 Okay, we are now on the record and good morning. We're looking for additional testimony on S290. We do have some time issues with folks, but I think we're gonna try and go in order that we have people listed, except I might move, I'd like to move Devin up, because I think you might have to move. Jen Carby has to leave at 11, so the more testimony we can get by 10 o'clock, not that we don't aren't going to ask questions and have full engagement, but that's my own agenda at this point. But we'll do what we can do to get everything out there. Welcome. Good morning, senators. Mike Fisher, healthcare advocate here. And before I talk about S290, I wanna make this resource available to you. It's a document that my office produces that reviews the attempts on one page from then back to cover all state, sorry, all state programs eligibility and benefits. And if you ever want to have a more deeper dive about what this is on this document, I would love to provide testimony. Excellent. But it's not needed. Thank you. And now you've shown it to me before and it's very helpful. Yeah, that's our resource page. So thank you for S290. I think that on a high level, you will hear from me a general agreement with the position of the Green Mountain Care Board. I think that as I go through the bill, you'll hear maybe some differences in tone. But substantially, I think the positions that the Green Mountain Care Board put in front of you are reasonable. And so I, for one, have gone through those pretty thoroughly and looked at how they might improve the bill. So there are some very helpful suggestions from the board. So, and then on a high level, I do wanna say since I mentioned the Green Mountain Care Board, we have set up a regulatory structure. It is the, it is imperfect, but it is what we have. And I think it's better than what we have had in the past. And you will hear from me. I don't have anything in writing. I don't. Will we get something? I can provide you some details in writing because I am gonna make a few suggestions. I think that what? We will be here next week. So if we can get it, the sooner we can get it, then the more it will influence our thinking while we're thinking next week. You will hear from me disagreements about the decisions that some of the decisions that have been made by the Green Mountain Care Board, but I support the structure. And I think that there's some aspects of this bill that the Green Mountain Care Board is actively involved in regulating. And I just wanna sort of recognize the tremendous efforts that's already underway. So right up at the top of the bill, the recognition of the human service over a lap with the accountable care operations, organizations efforts, I think is an interesting issue. And one that I've heard in the halls of this building plenty of times, this recognition that the human service sector has been involved in doing efforts that we now call, that we now recognize as affecting people's healthcare. As many of you know, I spent 20 years as a early childhood home visitor, doing things like helping children get immunizations, helping families get primary care docs, helping people get housing, drug treatment, speaking of which thank you for your work on S.263, the parent child center bill. I think that's an important bill. But it's a recognition that the human service sector has been in the community doing this work for a long time. It and the agency of human services focus on measuring our activities has ebbed and flowed over the years. There's been great efforts. Remember the community profiles under Conhogean? Those were good times. Those were good measurements and good efforts. We have over the years built such things and then dismantled them. Today we're trying it in a different way and the effort to tie these efforts together makes sense to me. So I agree with the effort there. On a high level, the bill's request for some recognition for data collection. We too have had frustrations with data collection in and data reporting in the all care model in the accountable care in the budget review. An example of that is the quality, year over year quality standards. I understand and would be first to recognize that it's hard to compare year over year quality when there's so much change year to year. Yet if we don't do year over year quality, how do we track it? And so that there is an example of a question that my office has asked. We've gotten some answers in. But I also do wanna say, if you'll allow me a moment, I have not had an opportunity to talk to the committee about the all care model. And if you would like me to hold off on that. I think if you would stay focused on the bill today that would be very helpful. And we'll come back to more general discussion later. Just because of where we are in planning and we have a lot of folks who need to. So let me just say at a high level, I understand some of the focus of the bill and trying to drill down and get some more detailed data. I too have had frustrations. I'm not sure I land in exactly the same places as the bill does about deficiencies. But I recognize the impetus for some of those questions. So let's speed way ahead. Section nine, the board reviewing healthcare contracts. The Green Mountain Care Board currently, recently has been getting healthcare contracts between payers and providers. It is something that they've had to fight about. I don't agree with the concept that the board should review every single contract. I do agree that the board, that it makes sense to have a clear recognition that the board has the authority to look at contracts at their discretion when they feel it's necessary. So I think that position is very much in line with what the board said. I will call out one detail there that I don't have a clear answer on. The authority to review contracts is one thing. The authority to approve contracts is quite another thing. And I got to admit, I'm not there. I again understand the reasoning for such a request, but it's a different level of authority for the board that I haven't seen a reason for at this time. And as a public advocate, I like the concept, but I don't feel it's warranted at this time. Section eight of the bill, the great setting authority. Thank you for putting that language back in front of me. I spent a lot of time on that language a few years ago. It was developed in the context of a different vision for where our healthcare system was going. Nonetheless, I think the board's rate setting authority is important. And the board has chosen not to go there at all. And if you read the healthcare advocates' comments over the last couple of years in various places, you'll see that we say start to develop what it looks like to do some rate setting authority, provider rate setting authority, bring together the right people to the table, start to set it up. It has to be done right. It has to be done carefully. And so I thank you for your focus on that part of the statute. And I wanna suggest that the bill that is on your wall, that's 246, the prescription drug affordability concept fits here that the Green Mountain Care Board not having any official duty to do prescription drug cost containment is a deficiency. I was at the Green Mountain Care Board's advisory council the other day, maybe a month ago, and heard some very interesting conversation from providers about areas where we could really evaluate prescription patterns and opportunities to save money. And I think it makes a lot of sense to task them with appropriate resources to start to work on it. Section 10 defining unjust, is that what that does? The insurance rate review calls on the board to evaluate proposed rates as to whether they are affordable, promote quality care, promotes access to care, protects insurer solvency and is not unjust, unfair, inequitable, misleading or contrary to the laws of the state. Defining those terms is a good idea. We have fought with the insurers and argued in front of the board about this term affordability for a number of years. Does affordability mean that the rate doesn't have too much administrative costs? I don't think so. I think as a consumer advocate, affordability means consumer affordability. Can people actually buy the products? And so there is an example of a place where we, where I think in an effort to have the legislature define some of those terms is useful. So, and then I have a few suggestions to add. None of them are without controversy. Oh, good. I'm not surprised. Welcome, Senator. You should see what he's been doing in our community. So much fun. The, it is interesting for us to recognize that the state of New York requires insurers to give notice to their members when they propose a rate increase and to inform their members that there's an opportunity to give comment. And we think that's a good idea. We think consumers have a, should know, rate payers should know when there's proposed rate increases, should know in a way other than the news and the efforts that my office have. And then, so we would propose that insurers be tasked with letting their members know when there's a rate height proposed. And then I would also want to call your attention to an old issue when I've raised before. The other day in front of UVM's community breakfast, were you there? I was. Don George called me out and said, hey, don't worry, because the advocate's gonna scrub my rate, my rate violence. There's gonna be a public advocate at the table and he's gonna put us through the paces. I feel both proud, had it on the back for good work and also, wow, the David and Goliath aspect of insurance rate review, the amount that my team is out resourced by the carriers is phenomenal. Now as a legal aid employee, we kind of pride in the David and Goliath aspect, but we don't get to ask questions. Of the insurers. We do get in hospital budgets and in the ACO budget, we do get to ask questions. The board can't limit what questions we have, but in the insurance review, we get to suggest questions. So you tell attorneys to develop a case, but you don't let them make the case. You don't let us develop the case. So there might be details in the budget that we wanna bring forward in the rate filing that we wanna bring forward because we're gonna argue about them. And we don't get to ask those questions. We have dynamics where, hey, we hire an actuary. Actuaries are expensive. We hire an actuary sometimes to help us develop questions. We spend money on developing a question that the board doesn't let us ask. So I know that the carriers will say, this insurance rate review is too expensive already. The advocate's gonna ask too many questions. He's gonna waste our time and our resources with the kinds of questions I'm gonna ask. And I would give you a couple of ideas of the kind of questions that are on my mind for the next insurance rate review. But I would be starting to argue the case. Which is coming before us. And I don't wanna start to do that, nor do I think we have time. So that is another area where, second area where I think we will have a suggestion and I will provide language. Senators, I had a few more concepts, but I think reading the room, reading the table, I think I've... You know what? I think if you can provide us with your comments and writing, that would be helpful and the sooner the better. Because seriously, I for one have gone through the bill and based on testimony already started thinking through some adjustments we might make and the more information we have to put into the hopper, but the better off we are. Thank you. Thank you very much. Any questions I should have drawn around the table? We're all good. All right. And Jessica Barnard is here. Good. You were put off last time. So you are next. Hey, good morning. Thank you for being here. Popular room. And look at it. It's quiet out the hall. It's getting quiet now, I know. Everybody's so interested in what's happening. They keep stopping by and looking at the agenda. They're missing out on the most exciting business happening this session. Guess what? They are. I know. The bill is on the house, right? Exactly. Well, thank you. Thank you for giving me some time this week. I know you're very busy. Jessica Barnard with the Vermont Medical Society on behalf of our physician and physician assistant members. We don't have comments on all sections of the bill and some of them are fairly high level, but a couple of recommendations for the committee to consider as you're working on 290. On sections one through three regarding the ACO oversight and reporting, again, our comments are pretty high level on this section. We know that the hospital association and OneCare and Green Mountain Care Board are doing a lot more detailed work in this area, so I really largely defer to those organizations to give you feedback. I simply wanted to give the general comment that what attracts our organization to the ACO model in general is that it is intended to be provider led and providers coming together to find ways to give coordinated and high quality care. And so while we certainly support oversight and transparency for Vermont's ACO, we don't want that to get in the way of flexibility and the ability of the providers really to be able to troubleshoot, problem solve and come up with ways to improve care. So that's sort of a general just caution about sort of the level of administrative requirements being put on the ACO through the regulatory process. On section six regarding a healthcare professional on the Green Mountain Care Board, this is an area we do care about. We've worked with this committee to pass this language twice, I believe. We certainly do think that the work of the Green Mountain Care Board would be better informed by a healthcare professional having an official role in that discussion when the range of issues from CLN to hospital budgets to great review. We know that the board has benefited from a physician or nurse member since its inception until just a couple of years ago. Because we know this language has passed your committee and this body several times and has not made it across the finish line and just an alternative suggestion that we have discussed with the Green Mountain Care Board though I don't know that they yet have an official position on it would be a part-time or full-time chief medical officer staff position. So rather than requiring a member of the board to be a clinician to have that be a staff input position so that again they would have access to all of the information and deliberation and those conversations be able to provide input and feedback while they wouldn't be a voting member of the board, at least it would help inform the work of the board in a way that we believe is well beyond the current scope and ability of the advisory committees. While we appreciate the board has advisory committees, the general advisory committee I believe meets three or four times a year, the primary care advisory committee meets a little more frequently but really focuses kind of on a narrow set of issues and none of them are privy to the confidential information behind these decisions. None of them really have input into the official decisions of the board. It's more again advisory rather than informing the day-to-day work of the board. So we do think that would be a meaningful difference from simply having advisory boards. On the sections, generally nine to 11, sorry, seven to nine and then 11 which relate to provider rate or contract review, we absolutely appreciate and share the concern that I believe one of the intent behind this language is to help balance negotiating power between providers and payers. We do feel like especially our smaller practices and frankly I believe even the community hospitals are often provided what we would consider more of a take it or leave it contract with insurers without the ability to negotiate the terms of those contracts. That's actually one of the reasons we have a bill 309 pending in the Senate Finance Committee down the hall. The insurers are one large entity able to hire attorneys, actuaries and other experts to determine contract terms and individual position practices don't have the staff, finances or capacity to engage in lengthy negotiations. Frankly, I don't even know to what extent they're able to understand and read in detail the contracts that they sign. We hope they do but and then under federal antitrust law you're probably aware independent physicians are actually prohibited generally from collectively negotiating with insurers and we are concerned that the imbalance in size leaves most physicians in a very weak bargaining position relative to commercial payers. We could fix that. I have a proposal that would allow you potentially allow you to fix that which I believe would be a large skit rather than having to come before DFR or you on individual one off issues it would in a way allow larger conversations to take place outside of this building. So you may or may not know that actually in statute already and I've quoted it at the bottom by testimony 18VSA 9409 there is state statute that allows healthcare provider bargaining groups. Currently this is limited to bargaining with state payers, the text of the language so we can negotiate with the secretary of administration, secretary of human services, Green Mountain Care Board or commissioner of labor regarding regulation, provider reimbursement, administrative simplification, information technology, workforce planning or quality of healthcare and the Green Mountain Care Board actually it's old I believe maybe even goes back to Bishka rules that Green Mountain Care Board has adopted this authority was transferred from Bishka to Green Mountain Care Board and so there are rules governing that process what the application looks like, what you have to show in your application what the negotiating process is and so a provider group can apply for status to be a provider bargaining group but the current constraint on that is that it does not apply to commercial payers and we think rather than requiring every contract to go we have some concerns with the current proposal which is every contract go before the Green Mountain Care Board there may not be a problem with many of the contracts, it may delay entering the contract and in fact actually I think inadvertently add to provider administrative burden to say that you may have to go defend, explain, discuss every contract your practice enters rather if the statute was extended to provider bargaining groups it would allow physicians or other healthcare provider groups to collectively enter negotiations when the need arises with a contract again we wouldn't anticipate this would be every contract but if provisions come up it would allow us to have a group discussion with the payers that we're not currently allowed to have I believe, and antitrust law is a very complex area our interpretation is we are currently allowed to discuss non-financial contract provisions which is why we're discussing a referral policy with S309 but it is again a complex area to navigate and this would if there were state supervision through the Green Mountain Care Board process of this collective bargaining we believe it could be an exception to antitrust prohibitions and again be a way that providers could work on these issues together rather than again each individual practice having to submit their contracts for review or approval by the Green Mountain Care Board. So thank you, those were my comments that's my food for thought on this bill and happy to be available to answer further questions or provide further information to the committee. Questions? Thank you. Thank you, thanks a lot. So yeah, we'll be pondering a lot of this stuff so we'll have to figure out what's next. Okay, good. So, Sarah Berry is here from OneCare. Thank you for driving down. Weather's not bad today. It's beautiful there. It is? Well, it's above freezing which I'll take and I'm feeling less sick so that makes it a good day. Okay, that's good, we're glad to hear that. Good morning, I'm Sarah Berry I'm the Chief Operating Officer for OneCare Vermont. First, I wanted to acknowledge that we did submit a letter to the committee yesterday and I just wanna briefly summarize a couple of the points. And we have it on our webpage here, you can call it says Dear Chair Lines and Committee Members. Thank you. So thank you again for the opportunity to testify on this bill and provide some feedback on sections that specifically relate to the regulations or requirements for accountable care organizations and I'll limit my comments to those areas today. And I'd like to start just by reminding us that we still are very early in the infancy period of the all payer model in these healthcare reform efforts. And so from our perspective, we all need some time to let this program mature, to learn, to collect some data and understand more about what aspects of it are working and what the aspects are that need to be revised or modified in order to improve results. And so in that really spirit, we are requesting the committee consider not making dramatic changes at this time to the regulatory aspects of the accountable care organizations. There are three specific areas though, I'd like to highlight and are reflected in the letter that we submitted yesterday. The first is that I'd like to clarify that one care Vermont does currently have multi-year relationships with our participants and those agreements actually span the entire life of the all payer model. What is unique is that each of those entities has an option each year to not renew and that is a protection for those participants, particularly as we think about, as we increase scale in the number of remanters that are in this model, the amount of financial risk goes up for our community hospitals and others. And so they need to do their due diligence through their boards and make determinations every year about whether they can continue to sustain those financial prepayments as well as the potential liabilities. We have gathered feedback and we've heard that this overarching mechanism works quite well for our participants. The second area I wanted to reflect upon is with respect to the Green Mountain Care Board potentially only approving ACO budgets with salary increases if the ACO achieves shared savings and quality targets in the prior year. And I wanna be clear that one care does not support this approach to make our workforce's salary increases dependent upon shared savings. And the primary reason is that shared savings in and of themselves are not the actual outcome measure that we should all be focused on. Instead, what we're really focused on under this healthcare reform effort is trying to get to a place where we have predictability and stability in those cost inflation factors in the growth of healthcare expenditures. And so what we should be all looking at together is whether we're able to maintain that cost growth within the range of three and a half to 4.3% as is reflected in the agreement between the state of Vermont and the federal government. So to tie salary ranges for our workforce to something arbitrary like shared savings or losses which we do expect to fluctuate from one year to the next would actually cause us to constrain opportunity for our workforce and could make it more difficult for us to hire and retain talent that we need in order to help facilitate the transition into the delivery system reforms that we are encouraging our provider network through. Further, we do understand that the remount and care board has put forward some proposed alternative language that would tie management compensation to those measures. And for the same reasons, we do not feel that that is the appropriate approach. I do want to acknowledge that OneCare currently provides salary band information to the Green Mountain Care Board through its requirements under ACO regulation. And we are also preparing to submit an application for 501C3 status. And that would make all of our top officer and director salaries publicly available. And we are very much in support of the request of OneCare to be transparent about this information and we are working quickly to make those things happen. Finally, OneCare does appreciate the bill's contemplation of a two year budget and reporting cycle. And we propose adding language that requires an annual review of the existing requirements that would identify opportunities to continually align and streamline some of those requirements. So as this is all new and a learning process, it should be inevitable that some of the things that we think we need to provide or that the Green Mountain Care Board thinks they might need in fact, aren't the helpful pieces of information and those should be stopped while other requests for information are adjusted. So in a two year proposed cycle, we would hypothesize that some information would need to be provided every year of course and other aspects could be reported on every other year as we get deeper into this model. We also are supportive of an evaluation framework that would proactively look every year at that information and determine whether there are additional abilities to reduce the burden on both the provider network and on the Green Mountain Care Board as the regulatory entity to create efficiencies and streamline some of those processes. So overall, we feel that these are really early efforts in our payment reform trajectory and that we need the chance to let them mature before we add more regulatory burden. OneCare continues to support the idea of transparency and providing necessary information, not only to this committee, but to our regulatory entity and to the public and we look forward to being able to share information as we proceed. Thank you all. Thank you. Questions? I have a question. So a lot of the things that you have identified in the bill may appear to be premature because of where we are in the process and I think there's some agreement around the table about that and some of that, but we also know that 2.0 is gonna be coming up pretty quickly and so some of the issues that we're looking at might need to be evaluated as we go in the next five year. So some of this is anticipating that whether and whether it gets implemented, we don't wanna change horses in the middle of the stream. I think that's what we're hearing you say and I think that's probably a key comment for all of us to keep in mind. On the other hand, there are some things that we might identify that could improve the system going forward and improve the linkages and keep things moving in the right direction. So I think that's some of what we're learning about all of this. I think you're absolutely right that we are a question but please answer. I'll just comment back. I think what we want to be careful of is that we protect the fidelity of the current model so that we can all learn more about what's working and what might need to be changed as we move into a 2.0 version of the all payer model. At the same time, we very much want to be at the table bringing ideas and reflecting back with all necessary parties about what those improvements are that could be made in time for 2022. There is a robust process in place through budget orders with the Accountable Care Organization, the Green Mountain Care Board right now and I think there's some new work emerging from that in the 2020 budget orders that will help with some of the evaluation that you're describing. Thank you and then my other question relates to, I know you said one of the measurements that we would be using, for example, the salary piece and you were saying there are other things. We know that the three important outcomes that the ACO is being, and all payer is, possibly all payer is being evaluated on and maybe we should identify those or other goals and I go immediately to thinking about quality metrics and outcomes and I know you've done a lot of work on that. So how do we know that the protocol, the patient protocol improvements that are being made because you do have evidence that they are being made, how are those shared within the medical provider and hospital community? How do we know that they're having an effect out in the real world? That those successes are being shared from one entity to the next? Yeah, so a blueprint has done a lot of that work. Yes, so we've been working very hard for the last couple of years with the blueprint actually to look at where there was potential duplication and as a result, the blueprint has shifted some of their focus and evaluation in some new directions and that was a partnership with us to say here's a unique space and opportunity to look at the impact of people that are in the ACO versus not and understand care delivery changes and outcomes. So I think that's actually a great strategy that's been working very effectively. One care partners with the blueprint and the distributed staff across the state all of the time to help share the results of the changes that are being made and so we put those out through committee meetings. We have a network newsletter. We hold webinars and informational sessions and then we have staff through one care that actually go out into the community and are sharing those things as well. So it really takes a variety of strategies. I can't point to any one kind of easy solution there. There's questions. What's that? Thank you very much. Thank you. Thanks for driving down. My pleasure. This beautiful day. You're welcome. We might serve us on. It's not. You're okay. You're okay. Yeah. Rebecca. We're super-sounding. You're okay. I'm gonna dance with you first. It has been worse. Okay, I'll do that. Every day is better. So hello. Do we have anything in writing from you? No, you don't. We do not. For those of you who don't know me, I'm Rebecca Heinz, general counsel for Blue Cross Blue Shield and I have to apologize. I'm covering for Sierra Teachout this week and I'm sort of coming into the middle of a conversation and so I could see from the testimony there's been conversations that I'm not privy to and discussions that have happened in front of committees. So I apologize if I'm covering. Groundless been covered or slowing us down. But I'm only mostly gonna focus on the healthcare provider contract provisions but I did wanna make a comment about a big picture comment about this bill and about the Green Mountain Care Board in general in the sense that we've given the Green Mountain Care Board some very big goals of improving the healthcare system and we keep giving them more day-to-day tasks to accomplish as they attempt to do that. I would encourage the committee to think about giving them tools that they can use when they need them as opposed to obligations that they have to do when they don't need to do those things in order to achieve their goals. That's just my big picture comment on sort of the ACO approach and also you'll hear that theme through the healthcare contract issues. I will respond to the collective bargaining suggestion that was testified today by BMS. My biggest first thought would be is that going to reduce costs? Are we talking about making sure that the rates paid to providers are high enough if that's what we're talking about? Maybe we give some sort of mechanism to the Green Mountain Care Board to mediate disputes on issues like that but not necessarily have them prescriptively involved in every single such conversation. Again, I haven't really had a chance to respond to that collective bargaining. This was the first I had really heard of. It's the first we've seen in two so anything you can provide back in writing would be short. So this is section seven which has the Green Mountain Care Board approving healthcare provider contracts. Again, from a big picture, I think we want to understand how is this advancing our reform goals? What are those goals in the review of these contracts? What standards would there be applied? It's not clear to me what's intended to be accomplished here. And then technically, there's thousands of these contracts. Some contracts are for one case. There are contracts with lab providers, DME providers, other types of specialty providers. Would the expectation be that the Green Mountain Care Board look at each and every single one of those contracts that's I don't think a workable option. Looking at the templates, I'm not sure that that gets us anywhere necessarily. It did occur to me as I was looking at this that having a place to go when there is a dispute and giving the Green Mountain Care Board tools to mediate that dispute is perhaps a good opportunity for everybody. I know from the payer only perspective, we feel often that we are really up against the tidal wave and an arms race of reimbursement increases that we wouldn't mind some assistance and partnership and some more transparency into that fight. So I think something that's less every single one and more, hey, if there's an issue, here's a place to go and you can work through that. But I think while you're talking and thinking, I'm hearing you say that the dispute that's kind of at the end after the contract has been not only in place but implemented until then or proposed or proposed. So I guess how can you think about how we can avoid those kinds of disputes? So kind of at the other end, but you don't need to respond right now but just think through that. I think that's one of the concerns that's here is try to sort this out, have something in place that doesn't result in World War III every single time. And I should be clear, I was thinking more about on the front end. So here's a proposal, providers don't like it. They don't feel like they have an appropriate forum. This would be an option for both the payers and the providers to sort of get an independent third party to weigh in on the discussion. This sort of the way I'm thinking. The other thing, and this is a perennial blue cross but should remind issue is we tend to be considered the payer, the commercial payer. There are a lot of other commercial payers and providers have to interact with those other payers as well. And we would really hope that if we're going to impose this type of burden on our local payer, we could impose this type of burden and cost on our national payers, which are our biggest competitors in certain markets. Any more questions on the healthcare review process? And then, on the, and this is in section 11, where administrative, or section 10, where a rate is unjust if administrative expenses exceed the consumer price index rate of inflation. It's important to understand that admin is by and large controlled by things controlled by the government. So admin is often the biggest increase on admin on QHD rates, for example, is often taxes. So taxes tend to go up with no necessarily tied to the CPI. There are wages, but there's also IT spend that's required for rules that are imposed on payers. So you have to pay a claim this way. You have to educate a dispute this way. So we would be very nervous about this. We do see the Greenmont Care Board does look at the administrative expense. I think that's a very valid role. It does require payers be transparent about their admin expenses and where those things are going. And so we don't have any problem with that, but tying it to an arbitrary benchmark that is not related to what's driving those admin expenses up is problematic. I do feel like it compelled to mention on the affordability discussion and the rate setting, premiums are driven by the cost of care and what you think the cost of care is going to be. It's so ironic to go to the Greenmont Care Board and fight about the cost of care, do something about the cost of care, do something about the cost of care. And then we come in here and we hear about why the providers and the system aren't getting adequately compensated or this benefit should be covered without a cost share, et cetera. Those things are all good things, but they're related to higher premiums. So we're going to have as affordable and insurance premium as we're going to have an affordable delivery system. They're just tied together. On the questions issue, I think where there runs into some problems is that an actual premium rate is really just a math exercise and it's a math exercise that's performed by experts. And sometimes there is a policy discussion that doesn't have to involve the math that's associated with that premium build. So we could work with the HDA to maybe clarify what would be an appropriate use of the appropriate type of resources, but at the end of the day, what goes into a rate is A plus B plus C and just complicate that by a thousand fold and that's building premium rate. So those are my only comments. And can we get those in writing? Sure. Or at least a summary of them. That would be very helpful. Questions? In that, before you have the lead. Yes. One time I fell over and the only thing around was Kevin Mullins-Lapel and I had to grab onto it. I had to grab onto it. Grab onto it. Grab onto it. Grab onto it. Grab onto it. Grab onto it. No, which I did. Devon Green, Vermont Association of Hospitals and Health Systems. Thank you for having me here today. So in preparing my thoughts on S290, I looked at this through the lens of what I spoke about before, which is stability and predictability going forward in this healthcare reform. And what I've done is I've responded to the Green Mountain Care Board's proposals because I think those went a long way in working with this bill. And so I'll go through the various sections and then if there's something that I don't mention, that means I agree with the Green Mountain Care Board's proposal and you have it all in writing so you can go back and look at it. So the first part in section one where the original bill said that the ACO should consult with AHS and VDH about public health and population health goals. The Green Mountain Care Board came back and said that you could require DEVA to include its language in their contract about coordinating with public health and population health goals. And so all of this, I say, we have our goals. Our goals are set out in the all-pair model. Those goals are increasing access to primary care, reducing deaths due to suicide and opioid overdose and improving care for people with chronic conditions. So to set up a system where it's required that those goals, that new goals be introduced or that the goals change from year to year at each contract, I think would destabilize what we're trying to do. We don't have $1.5 billion the way California does to deal with 300,000 people and solve all of the population health and social determinant of health problems. But we are making progress on those current goals. I heard yesterday about how a primary care physician's office looked at its own practice and realized that one reason why people weren't getting into their appointments was because they had a requirement of receiving their records before seeing the patient. And once they realized that that was a barrier, they took that away. So I'd get those people in for these appointments, get them started, and that has gone a long way in increasing the access for primary care for folks. So we have very clear goals. We're working towards those goals. We don't see the need right now to set in places to somewhere those goals can change from year to year. So that's section one. In section two, with the annual reporting, we agree with the Green Mountain Care Board that this is largely duplicative. They mentioned something about public outreach efforts and reporting on public outreach efforts. And I just, if you're going to go in that direction, I think it'd be worth defining what that is. If it's the internal efforts of trying to get the, trying to get good information to providers, I understand that. But if you're talking about a statewide public relations campaign, again, I feel like that's resources that may be diverted. So I want to understand what that is a little bit more. That's most funny. Yes. But it's a combo. I mean, the media has been so filled with negative articles about the ACO and the all-payer model. I didn't know discrimination between the two. That I think it's become very frustrating for those who are engaged in making that system change. So how do we accomplish both of those things? I guess that's a question. Yeah. And it's a great question because I could see the media knocking one care for spending money on a public outreach campaign. Oh, yeah, it was. Yeah, it was. Yeah, it was. So I think that's something we all can work on and figure out. I'm not sure about the reporting requirements on it, though. And then the rest of section two, we agree with the Green Mountain Care Board's positions. And then in section three, we agree with the Green Mountain Care Board's position. In section four, this pertains to us. And we agree with Green Mountain Care Board in part and we disagree in part. So the part we disagree with is the consideration of reimbursement rates in the budgets. Again, I think this moves us backwards. It gets into the Green Mountain Care Board micro-managing around fee-for-service and looking at reimbursement rates. And it's unclear to me what the Green Mountain Care Board would do to change the reimbursement rates. And so I don't think it would be helpful to remain in that fee-for-service reimbursement rate world and have the Green Mountain Care Board in that area. This is an interesting place to look because if we go to 2.0, I'm going back to the budget, the two-year budget thing. Maybe that's something that explored for 2.0, I don't know. But then the reimbursement, will we ever be a totally all-payer? Or will there continue to be fee-for-service? And in a world where we have both of those, then you wanna make sure that things are equitable. It's not that we would like to stay at fee-for-service. That's not the point. The point is that if we got to scale in every single attributable life within the all-payer model, then you see that. That's a conflict. I see that applying to independent providers who choose not to participate in the model. All of our hospitals are participating. That's true. And that's exactly true. And so what you wanna make sure that if they're, anyway, so this is helpful. And then the part that we agree with is confidentiality around the Green Mountain Care Board's work on hospital sustainability. So the Green Mountain Care Board has set in place requirements for hospitals to come up with sustainability plans. Our hospitals are happy to work on those plans with the Green Mountain Care Board. But as you've heard from them, it can contain some very sensitive information that could harm the hospital. And so we would like that information to remain confidential. How confidential? I mean, suppose a healthcare advocate requested to see that information because of its effect on patients. Would that then, would this kind of language preclude them from looking at that plan? I'm thinking about the people who are involved in the decision making here or the questioning process. And I think it's a matter of when the information is happening. A lot of this is speculative, which wouldn't necessarily hurt the patient. So a lot of this is the Green Mountain Care Board saying, hey, should you be eliminating service lines? Should you be looking at this? Should you be reorganizing that? Which is all very speculative and not concrete. And what we're worried about is that speculative information getting out and becoming rumor, becoming fact, and providers leaving hospitals and patients going elsewhere and creating this whole sort of... But it has to be a system built on trust. Yeah. And I think there's a lot of trust between, like I said, the Green Mountain Care Board wants to make sure that it sees another spring field coming. And our hospitals want the Green Mountain Care Board to see another spring field coming. We want to work with them. We are with you. It'll be very hard to work with them if we have to, if the information about, that is in the planning stages or the possibility stages is made public. Okay, so the question is the confidentiality question. We heard loud and clear that that was important for hospitals in being able to work within the system and the board and decision-making. And then there will also be questions about how confidential and during the process. So that's something we'll have to think about. Yeah, thank you. No, this is very helpful because I know that Mike Fisher is standing behind you and he's ready to say, we have to be there. I don't know, no? Will you say that? Mike Fisher, healthcare advocate, I was gonna say I agree with the hospital's perspective on the importance of confidentiality here and the healthcare advocate has agreements with Green Mountain Care Board where we get to see confidential documents all the time. And so I don't see this as blocking us. I see it as protecting the hospitals from the public. Good, I feel good. Good, you like that, right? Thank you. Okay. Section five, which is the Green Mountain Care Board oversight of the DAs, we're neutral on this. We would just request that this doesn't come from hospitals paying because it doesn't touch on hospitals the way some of the other Green Mountain Care Board work touches on hospitals. Section six, having a provider on the board, we support this and we're happy to take into account the Green Mountain Care Board's suggestion of figuring out a backup plan if no qualified people apply for the board. Section seven through 10, which included that contracting provision section where the Green Mountain Care Board is supposed to approve of every contract. The Green Mountain Care Board proposes doing a study of what it would look like to rate set for fee for service and global budgets. They did point out that this impacts only, their powers go to 92,000 Vermonters. I like to remind the committee that the all pair model includes Medicare, Medicaid and commercial insurance. It goes far beyond the 92,000. And so again, I would like to move away from, even if it's just a study, but something in the fee for service world that does not align to what we're trying to do with the all pair model. So we would not support a study on rate setting for a fee for service. And then the section 11, this also contains the Green Mountain Care Board approving of all contracts and we would not support that. And then section 12, we are neutral. And then we also have a proposal, which is to add one thing in the hospital budget process where the Green Mountain Care Board would tie its decision making and tie back whatever decision they make to a standard that they set out in their hospital budget guidance. So they provide hospital budget guidance to all the hospitals. Within the hospital budget guidance, they say that hospitals take into consideration national, regional, or in-state peer group norms according to indicators, ratios, and statistics established by the board. So the board sets out these statistics. We're just saying when they make that decision, we would like them to include findings of fact around those standards that they previously set out. So tie their decision back to those standards. And that's it. Questions. Thank you. Thank you. Very well. All right. I don't see Susan. Bear it. When I leave Susan to last, do you mind? I was gonna bring Helen Laban in. She's in the hall. Yeah, okay. Susan, there's a chair you can sit in for a minute. You get Helen's testimony time. All right. That will actually work well because mine's on the Green Mountain Care Board. Our folks. So, Helen Laban from Bi-State Primary Care Association. And I'm also gonna walk through, you have my testimony, volume two. And it is going to track the original language that's supposed to be a Green Mountain Care Board proposal. And I'll try and tie it into what other folks have said. So in section one, we agree essentially with all the Green Mountain Care Board recommendations. As Sarah Berry explained, there is a system right now around the multi-year nature, but that does not lock providers into multi-year contracts which the FQHCs would not be prepared for at this time. So we agree with those recommendations. On section two, the annual reporting. I agree with Green Mountain Care Board VOS and one care analysis from previous testimony that this is redundant to existing requirements. We too had something to say about the reporting on the ACO's outreach efforts to educate the public about the ACO. This had come up previously with our members independent of this legislation as you know it in somewhat in response to the media reports. And our providers feels if there are a lot of communications needs out there that they would love to have ACO support in primarily around achieving the goals of the ACO around getting folks in for primary and preventive care about reaching people who do not currently have a primary care medical home and they, you can imagine the grumbling at the suggestion that that money be spent instead on promoting the ACO. Certainly we understand the concern about clarity with the public and media reporting. We too see the reports see the negative and often inaccurate reporting and it feels terrible. But I don't think this fixes it. It would be great to resolve it. It's an issue then. It's an issue and I don't wanna dismiss it as an issue. This just doesn't seem to be the venue in which to resolve it. Yeah, the question is who paid for it and how's it done? I think it's my idea. I just wrote an idea about it. Okay. We were neutral on the two year budget cycle that whatever BMAG care board, the ACO would say we're good with that. And then on section four, we were neutral. We saw the BMAG care board propose a language as raising two issues that are kind of thematic issues. And one that I know has been discussed is the availability of confidential information that allows for accurate assessment but also remains confidential when it needs to be. And we're neutral on whether or not the correct balance is achieved by the proposed language. And then the other question is that question of how much of our public resources we're putting towards systems that rely on a fee for service payment when we went to move away from fee for service. And we were concerned that some of the BMAG care boards proposed changed language in section four, trends towards entrenching further that fee for service system and putting more resources towards that. Which you'll hear me mention again in section seven, I think. Section five, which is the Destiny and Specialized Service Agency, as you previously heard from me, we recommend striking all references to preferred provider organizations that has a particular meaning in this context and we don't think it's appropriate for the intent of this legislation. We're neutral on the format. We do have concerns. I do wanna sort of highlight that questions about the funding sources because I do think it is a bigger issue that needs to be thought about. So we agree with the overall philosophy. I know that the healthcare advocate also pointed out that many elements of this healthcare system are linked. The goals of the Green Man Care Board are achieved by looking at those linkages. We certainly recognize that the Destiny and Agencies are an important part of that system and a vulnerable part of that system. So in that philosophy, we agree with it and certainly in the World Health Services Task Force Report, we looked at the Destiny and Agencies Report to different components of the Agency of Human Services but who's doing a complete fiscal review of them. So with that shared starting point, the question that comes to me is whether or not the right information is being provided to the Green Man Care Board to do an analysis that goes beyond and might reach different conclusions from what's already done at the Agency of Human Services and I'm neutral on that, that's between the three of them to figure out. But now we're getting into the territory for the funding mechanism of if we're going to go down the road of asking the Green Man Care Board to look at all these expanded components of the healthcare system in order to have a holistic or in-depth view of it or even if we're just asking them to be an arbiter if you want a second opinion from the current folks who you're reporting to. If we are opening that door, then clearly the statute that's in place right now doesn't seem to match it in terms of the funding. So I would suggest that that requires some amount of thoughtful consideration and review and just wanted to highlight that element of it. Section six, which is the provider on the board. I say here, we're supportive of the idea of having a provider on the Green Man Care Board. We're just simply neutral as to the mechanism by which that occurs and trust those with deeper familiarity with the system to recommend the correct process. Section seven through 10. And here we'll see as I flagged some of that question about what we're looking at come up. So we agree with the Green Man Care Board's recommendation of shifting to a study. You know, we just wanted to re-emphasize that the focus of the study should be on regulatory systems that are entering a value-based and global budgeting environment. And I know my previous testimony I read right here, we see some areas that might require a second look. Certainly one the Green Man Care Board themselves have highlighted around the tracking total investments in primary care and how those trend through the system in a value-based environment. Looking at investments in prevention and best practices for matching those investments with the next generation ACO structure and aligning those indicators, especially with some of the timing issues for changes that take a long time to in fact take effect. And then that question of the process of translating and managing total cost of care into lower cost for consumers, which certainly comes up again and again. And probably that is as the health care advocate pointed out, going to include looking at the question of pharmaceutical pricing and how those get managed, which I know is a separate point of conversation with S246. So we certainly see many values to a study and we do agree with the Green Man Care Board's assessment that this will require funding to support contracted consultants. And again, the only point of difference there is that some of the recommended areas for review, particularly around the rate setting, seem to further entrench that fee for service model when the goal is to move beyond that. Also, we're not shared concerns about tying administrative expenses to the CPI, which Blue Cross, which you spoke to more eloquently than I, I was just recognizing that there are many different rules coming through where you could in fact legitimately need to increase your administrative expenses to match the goals that everyone shares and support the Green Man Care Board review of trends in this regard. And then the fair contract standard, section 11, we do recommend striking the changes. As others have said, we do not believe as we're in this reasonable to implement. It also now is no longer, if we were to take the proposed changes in section seven through 10, it no longer aligns, so it also wouldn't make internal logic. The Vermont Medical Society's proposal on collective bargaining rules, we actually had internally brought that up advice that we were first reviewing this because of the way FQHC's are structured, it's not as relevant to us as to other provider groups just around the credit release around reimbursement, but certainly open to reviewing their proposal. We didn't talk about it further just because for our specific membership it wasn't the most important element, but we recognize that there may be very valid points to be made there and would be happy to look at a proposal. And then on section 12, which is the public employee attribution report, we agree with the Green Man Care Board that this, that report should be delivered sooner than later if it's going to be performed and would support a fast turnaround time, which is easy for me to say since I don't have to do the analysis, but the Green Man Care Board also said it, so we would agree with that as well. Very good, questions for Helen. All right, so I know Jen is in the room, but I think before we go to Jen, we're going to hear from Susan Barrett. And Susan, do you have additional testimony? Or did you want to go through what we had previously? I know some of us have been through what you gave us a couple of times. I was wondering who you've heard from so far as I had another meeting. I'm sorry, his cause gone already. We've heard from everyone. Okay, I'll go out of the last of the group. Okay, so Susan Barrett is our Green Man Care Board. I only have one point to make on some of the language that Boz proposed under, and I don't have the Boz language in front of me. Okay, and I'll try to do it from memory. But it is, do you have it, Devin? Oh, I don't want to see your notes if you don't want to. They're not legibles. Okay, great. So this was on the additional proposal under hospital budget decision transparency. What section? Well, it's after, on this document, it's at the very end after section 12. It doesn't have a section. Oh, this is a recommendation? Yes, reacting to the language that we proposed. The concern we put, we have with this language is we are already using national benchmarks, regional benchmarks, system benchmarks, for instance, days cash on hand, metrics such as that to make the board in its, when they make their decision on the hospital budgets. And we feel that this would constrain those decisions. And in terms of, we are already doing it. I can appreciate where Thaz is coming from in that there is turnover on the board. And sometimes when the board is newer, they are maybe not as familiar with the process as others who've been on the board for a longer time. And I feel like it's a very, it's a direction from our regulated entity to us. I would prefer to get the direction from all of you. And on top of that, we are already doing this in our decision. So that's the only statement I have. Is there any other question? I'm sorry to give the room earlier, but Elaine goes here. One of the things that we're interested in is as we move forward with the all payer model and the ACO, and we're trying to reach scale. And we're also going to be looking at 2.0 and the development of 2.0. And then all of the issues, some of which are identified in the bill and probably there are 100,000 others out there. And how do we build that system? How do we look at it between now, our transition time? We don't want to change horses in the middle of the stream, although that's the way the bill feels to people. You can't just do things categorically that interrupts the process. But what can we do? How can we look at this either through analysis of some type? And I do think of external analysis to build the system. So that's what we're looking at. We're looking at this little transition period and all these things are falling out and landing on us. And then we don't want to throw the baby out with a bathwater. We don't want to kill the golden goose. We don't have all those things, right? So any thoughts there? And I throw that out generally to folks because we will be talking about this, about how we might support the work that's going on. Because I think around this table, there's really significant support for the all payer model for the ACO. The survival of critical care hospitals is absolutely necessary in our state. How do we make sure that happens? So, and I know there's a whole other next step about what happens. We've got primary and preventive care in the first iteration. What happens if we are looking at specialty care? So there's a lot of stuff. And then how do we get the good news? Bad news is always gonna make us worse. How do we get the good news out to the broader population? So I'll just say a couple of things. And let me just say one other thing. Yes, please. The comments that are all gonna happen organically isn't gonna fly. It's just gonna let you know. Well, I wasn't going to say that. No, that's okay. No, I think that I'm glad you said that before I spoke because I can't agree with you more and our staff, I point out Alayna Varaby who is the head of our all-care model and value-based programs at the board and is visioning exactly what you're talking about helping me and the board get there. I'll say two things. I think getting the employees of the state and the teachers, I know the teachers have said no to the ACO for this year. I think a focus on that from any and all sources that are appropriate would be supported by the board because we do need scale. And you have heard that from others that we need to have in order for the system to work across the board, we need scale in that system. So to the extent that you could support that, we are already talking about all-care model 2.0. We have started those discussions internally with our partners in the state. The board is responsible for the proposal for this agreement. We propose if we were to go to an all-care model 2.0, which is what we're calling it now, the board in consultation with AHS will propose that model. So we're focusing on that already. But in order to get there, we need to make sure that our critical access hospitals can participate in this model. There are some challenges there at the federal level. That's something we wanna work on maybe now, maybe in the next model. And then I'll put in a plug for our board meeting this afternoon. We're going to be talking about shamelessly plugging the board meeting. We're going to be talking about sustainability plans for six of the 14 hospitals. They were ordered in our budget process last year to work with staff, our staff, to produce a sustainability plan. We're gonna outline the framework. I'm happy to share the slides with Doria. I'd love for you guys to look at that and provide input and comments. But one of the things we're looking at in those plans is we need to hear from those hospitals how they survive in a value-based payment world. Because it's not just Romana who's talking about moving away from fee-for-service. Even with the transitions at the federal level, they are 100% committed to value-based payments. So we are committed to this as well. And anything, just in summary, you can do to support scale in the model. Anything we can do collectively to continue to focus on moving away from fee-for-service and supporting that. And then I guess my last point would be that gaining a holistic view of the healthcare system at the board level will be helpful. Thank you. Okay, that's good. And I will, I'm gonna leave you with a thought because the thought, some of the things that we hear, and I don't need a response at this point, but certainly something that is important to us. Two things that we hear, and this goes for folks in the room as well. One, the Green Mountain Care Board has a paradoxical relationship with itself. It's innovative, it's regulatory. How do we resolve that issue? And then the second thing we hear is this ACO thing is creating a monopoly. And so that's another important issue. So that's what we hear. Those are some of the criticisms that are out there that are missed, maybe it's misunderstood, maybe it's not. But those are the things that concern people. So that's it. So thank you. Thank you all in the room. Jen? Oh, do you want a question? Well, I just want to make that a request, actually. As we're deliberating on this, it occurred to me that there was a speaker at the UBM MC Breakfast, Dr. Sharfstein. Yeah, I got it. I'm sure you heard from there. Mine goes, yep. Yeah, I'm wondering if we might hear from him by phone, he mentioned in his. Let's talk, say that thought, we can talk about that, I mentioned. He mentioned regulations, being an important part of bringing health care costs down. I thought he might have something to say that would be. Yeah, good. Interesting. Cool. Thank you. Was it, my hesitation is our time. Yeah. So I think we've all, we all know the regulation piece. So maybe we can ask for some very specific testimony. Yeah, we're going to. Hi, hi. So you missed a little bit. Okay. A testimony. Imagine. Here's what I meant. So you fix it? No. Yeah. So, you know, and so the, so maybe we can send her, we're going to get him in on the telephone or something. And I don't know who'd be the contact for that, but Susan. I can help get that. Okay. We'll have to figure out exactly what testimony we'll want to hear. Cause we can't afford the full hour PowerPoint. I've gone through that several times. But it would be great to hear from him. So the testimony that we're hearing kind of leads us to the place where we're doing things too soon. Or that we shouldn't be doing any of this. And then there are the recommendations that have come from the Green Mountain care board that have become sort of the template for discussions. And which is good. And I didn't say thank you for the work that you did, but it really has been exceedingly helpful. Where is she? Thank you. And so we've heard comments from the healthcare advocate, the VMS and have recommendations from VMS and from VAS. My suggestion is, as a committee, I think we need to go through the, how many of you have you gone through the proposal from the Green Mountain care board a little bit? Yeah, not a lot. So I think we all probably have done it the same. Might make some comments, it feels good, but that doesn't feel good. Exactly. Go out and read this and read it through all the testimony. Right. So my suggestion is that we each do that and go through the testimony. And Dori, we don't have this on our agenda for the rest of the week, do we? 290. We don't have it. So I'm gonna just make a suggestion that we work, if you don't mind, I'd like to talk with Jen a little bit about some of the things we've heard and Nolan, some of the things we've heard. And then what we'll do is we'll schedule some time when we come back for all of us to sit around the table and to go through the Green Mountain care board proposal and maybe some other ideas, and I apologize, but the things that I talk about with Jen, if that's okay with folks, I have put my head to this a lot and I did write up a whole bunch over the weekend. Okay, not ready for time time yet, so now this new information is extremely helpful. So would that be a good, that would be a good path forward, I think, rather than sitting here and going through this one more time, I'm trying to think of it wise. All right, is this okay? Is this okay, senators? Okay, let's do that. And Jeff Hockberg is in here, Jeff. I know he is. Yeah, I spoke to him this morning. Is there anything that you wanna ask us or tell us that we need to get your act together? So I'll go ahead and say it. I would never say that. No, I don't think so. I mean, it sounds like you have a plan and you and I are gonna discuss. We will, that'll be so long. I don't know what to come back with. My other suggestion is going through all of this stuff, but as I said before, I really feel that some external lies on what we're trying to do through the whole all payer program and where we are. We are moving ahead of a lot of other places in the country. And so I'm thinking that there must be some folks out there who could help us evaluate how to take the next steps forward. So I'll be thinking about that. And by that, I need some external consultant and that means money and that means how we're gonna do it and if we're gonna do it, what it is, we're gonna put into that. So do some thinking on that as well. So as we move from a transition to a more 2.0, should be more solidified. Oh, the other thing I think that we need to do is to hear from the VSEA and education folks. We need to hear their concerns. And I think we'll try to schedule that the week after town meeting if we can and then have people in the room who can inform that discussion. So there's some concerns about what I've heard, which is very little. There are concerns about employees losing benefits if it's paid for through the all payer model. That's what I've heard. They're concerned about losing benefits. I don't know if that's totally accurate or not. So we do need to hear from them. Is anybody in the room representing NEA, VE HI? VSEA. Steve was here. Yeah, he was. VSEA was here. Okay, Dory, why do you think that is? Okay. So being a beneficent dictator, we've got a break. Is that an email to the debt is in the building? Yeah, so come back at 10 o'clock, please. We've got this just in the room. Are you going to go to the film office again? We've got three witnesses. We've already done through 246, so. Yeah, we did. Okay guys, it's great to see you. Great. We're on time. Katie didn't come in, did she? Okay, he's not able to join us until 11.30. Okay. 11.30. She got booked out to the U.K. Yeah, okay. All right, Jack, thank you for being here. My pleasure. We probably can close the door. Yeah, starting to get a little noisy out there. We have been through S-246 and it was a, I think it's an idea that has been around for a while, but we're also very interested in helping us understand how we can regulate prescription drug costs more effectively, so. Yes. Thanks for, do you have, we have testimony from you? Yes. Okay. So thank you for having me. My name is Jeff Hochberg. I'm the president of Vermont We Tell Drugists. First, thank you for taking a break from your last one as we dive into prescription drugs. The easier to do. The easier to do, right? So, you know, the fact that we joke just highlights that everyone knows. There is so much confusion. There's so much complexity to prescription drugs that we all want transparency. We all want to go after it. The question is how do we do it? And how do we do it without breaking the current system that we have in place? The bill that was introduced to S246 contemplates the Green Mountain Care Board setting rates for prescription drug prices. That would be fantastic. However, they don't have the information necessary to do the task effectively. And this is the number one problem that we wanted to highlight. It's something we should seek and we want to push for it, but we have to identify the hurdles that are going to come up as a result. The way we go about prescription drug pricing, the state has effectively two approaches it can take. You can reduce the pharmacy benefit managers' control over the cost through system regulation, the greater regulation. We're seeing a lot of states are following Angcoil, the National Coalition of Insurance Legislation. Their advice on regulation of PBMs, the federal government is looking to regulate PBMs more heavily, definitely an area to pursue. It runs into a lot of pitfalls with too much push on the regulation side. You just are going to see an instant increase in price passed on to every consumer and constituent paying at the premium level, which really highlights the problem. And if you go to the third slide on my presentation, the current pharmacy revenue path, this is a very basic map, but it's much more intricate than that. But I use this to really highlight the flow, particularly the flow of dollars. So the patient and the remote consumer pays the insurer monthly on their premium levels and Angcoil pays associated with that. The insurer pays a pharmacy benefit manager for administering the pharmacy benefits to every remote consumer. The pharmacy benefit manager reimburses the pharmacy for the drug product. The pharmacy acquires the drug from the wholesaler. The wholesaler acquires the drug from the manufacturer. And the manufacturer has some back-end rebates to the PBMs for formulary pricing and fees as such. It's a gain. And at each level, there's an inherent inflationary cost built into it. And we can count at least five, but we know there to be much, much more than that. The question that I think 246 begins to address is how can the state step in and start to get real eyes on this data? With all of our previous attempts to regulate prescription drugs, we run into hurdles and blocks of actually acquiring the real hard data. V-Cures is a good example of that with the gaps in the data stream that it's getting. The question then we have to ask ourselves, is there any player in this model that actually has eyes on everything? And the answer is yes. The wholesalers actually see every bit of data that is required to effectively regulate and control prescription drug costs. My wholesaler and my pharmacies certainly knows how much I'm paying for the drugs, as they bill me twice a month. They actually capture every claim that I transmit, and they see how much I'm supposed to be reimbursed by the pharmacy benefit manager because they actually contract with the pharmacy benefit manager on behalf of the pharmacies. And they follow reconciliation pathways to ensure that contracts are adhered to. They collect the funds. Send the funds to me, and I send them back. That's how it works. We know how much the insurers are reporting, as it's already required by statute. And we can, I think, certainly gain that through effective regulation. But all that bit in the middle we don't see. And the fact that the wholesaler is sitting there, this whole time they've been sitting there, seeing everything. Now, there's supposed to be firewalls between this and that, the other, because of inducement and the cost of a prescription, the invoice price at which they sell a drug shouldn't be based upon the reimbursement rate. But they still see everything. The current system is so broken, and there's so much trust in these publicly traded, very large companies, none of which reside in this data per month, from the wholesaler and PBMs, that we can't get that, we're not gonna get their data. And effectively regulating them, we can do some degree of measures here and there, and we put forward a few suggestions of some tidying up of current statutes and keeping us on pace with other states. But if you were to take all of what the federal government and ENQUO wants to ensue and turn it on tomorrow, it would just come back at the premium level without some sort of buffer in there to really create a stop gap to protect consumers. And that's what we're looking to seek out. And that's what I think S246 begins to do, okay? It puts, if we could somehow get the board, or a different department, whomever, but I think the board is best suited to have real data, to truly know what is the most effective program or cost saving measure that we should institute, whether it's importation, whether it's 340B carbon, how those programs affect consumers directly at the premium level and can then effectively sit there when the insurers are talking for rate adjustments to have a clean and solid discussion. That's fact-based. That's what we need. So before we begin to regulate and seek what everything in S246 does, what we suggest is that we really take a step back and we say, who here has the information that we need and can we work with that to get the data that will allow the board to, in a next step, start to institute some rate reform and start to get real eyes on what's going on. To highlight a couple of the discrepancies, there's a big push between several groups nationally that have done work for New York, in particular, and the state of Florida recently. And it's a company called Three Access Advisors. And the slide that I put out is for a drug, Omephrazole, Esomeprazole, which is the Jennifer Nexium available over the counter. Okay, and there's three lines on this chart. You have the lining yellow is the managed care costs. So that is the price to which the state of New York through its insurers for the state programs is paying for this drug. The lining red is the actual pharmacy revenue that is paid to the pharmacy by the PDM. And the line in blue represents the national average drug acquisition cost. That's NADAC, which is a publicly available platform and you can go on that any day. Great in theory, still in development and there's current federal legislation proposed to help beat it up. But you see that difference. There's a huge gap between what the pharmacy is actually paying for the drug and what the insurer is paying for the drug. And that's what we need to be able to better articulate that difference so that we can understand what's going on in prescription drugs. That the pharmacy's profit. So the difference between the red and the blue line would be the pharmacy's profit. And the difference between the red and the yellow line is the PDM's profit. The next slide is from another group. It's actually started by two pharmacists in Ohio. It's called 46 Brooklyn. And they, in working with the Columbus Dispatch were probably the instigators of the biggest pushback on PDMs nationally. And it came with an expose into the Ohio managed care system for their Medicaid. It looked at one drug in particular, this drug of matinib, which is a generic for a very high cost drug, which is typically steered towards special pharmacies. And they looked at the reimbursement versus the cost. And you see that chart. You see how it's completely diverging away. The blue line representing the NAIDAC cost per unit and the state cost per unit. And you see that divergence is getting greater and greater and greater. That's a problem. If we don't understand, if we can't see what the people in the middle are actually making, then we can't effectively regulate. We learn from, we all know that Medicaid gets supplemental rebates. And there's a difference between its net cost and the prices that it actually pays. What would happen if, and like the Trump administration has even proposed and other CMS administrations have proposed is carving out rebates. Telling drug rebates would make a clear system because everyone would be able to see just based upon long revenues of what's going on. But it would absolutely crumble everybody. This state is so dependent upon drug rebates from the manufacturers that if you were to turn a switch and turn them off, our drug spend would nearly double. We also have an access issue. This was a, the slide that I have is from Navitas prescription drug coverage. And it was put forth by Nashville recently in testimony. And it shows how we have different co-pays for Vermont consumers at different pharmacies. We have less than 35 individual pharmacy groups in this state. The number of independents in this state is decreasing. There's 25% of the independents in this state are actually for sale. But with only 35 different groups, why do we have such discrepant pricing between access? We have a major access to care issue and yet we're determining that the co-pay at various institutions is different. Why are we allowing that? The next slide I had actually comes from NCPA, the National Community Pharmacy Association. And it's a comparison of state statutes regulating PBMs that are currently in effect. And I highlight where Vermont is, we score four out of seven of their major, major targets. I wanna highlight Arkansas. Arkansas is probably the most progressive state in terms of reform and prescription drugs, story-wise. And there's a major case that's going on that the Supreme Court is actually gonna hear on April 27th. It's called Rutledge versus PCMA, the Pharmacy Care Management Organization. And it really begins to tackle the question of whether or not the PBM is a fiduciary and a risk of preemption truly exists for those entities. Did that court case is in Vermont? No. It's in the United States. Rutledge versus... Rutledge. Oh, Rutledge. Sorry, sorry. So the question naturally went to the local court. It is a national. Definitely something to keep your eyes on. Okay. I think we hear all the time about, oh, there's an orisa preemption to this or that the other, that may not be true anymore. I think we should probably hope not to since the orisa prancer. We'll keep our eyes on it. Yes, you might see me on the steps. I highlighted a few things that I think the committee should, if they wanna take up the time to really dive in, there's a link to NCOIL, the National Council of Insurance Legislators, their guidance for Drug Pricing Transparency Model Act that they pushed out last year. They've been a pretty conservative organization. Yes, they have. And they've been behind a lot of the recent regulation. New York state had a bill S6531, which made it to the governor's desk. That is a very comprehensive representation of that guidance, effectively regulating. Kansas just put out a House bill 2598 that does effectively the same thing. But again, there's concern in that. Just the more pushback you get to the PVMs at this point in time without any control, that's where we can potentially have things fall apart. So bear that in mind. But the highlight is, of really everything that I wanna talk about is the data. The data is so key for us to move forward safely, conservatively with true reform that's gonna be sustainable. And evaluate any programs that we wanna do here on out, whether it's importation on 340B. And the data equals the power. The manufacturer, the pharmaceutical manufacturers, want two things. They want formulary status and they want the data to show their drugs are effective. That data is already being sold left and right. Vermonter's data is being sold left and right. There's rebate programs for Vermont insurers about selling the data. And there's another middle-media entity that exists. It's called the Switch Company. But between every pharmacy claim and the PVM, there's an entity that takes the pharmacy data, correlates it into one format. Every single, there's four Switch companies essentially that operate and they all work into one single format for this data and they capture it, they sell it. The number one data miner is called IQV, a formerly IMS. It's a $57 billion in your company just for data. We tried to stop it and we lost the money. We lost that court case, we lost that suit. That data can be bought, that data can be sold. The question is, can somehow the state step in and either become its own Switch so that it controls the data, works with the wholesalers to better control that data, turn around and use it to fund other, other, and work directly with manufacturers in the actual release of that data. If we were to capture that Switch data today, you would be able to expand VPMS system because instead of just control substances, you would see the entire context and breadth of prescription drugs that's being dispensed in real time on a daily basis. You would know, hey, there's a coronavirus outbreak. Oh, we better do something about it and let's shift some resources that way. But in real life, there's a flu outbreak and there are constant shortages of Tamiflu and the generative of Tamiflu and the other products used to treat flu. What if we had more control and work directly with a wholesale distribution chain to say, hey, allocate some extra resources down to Bennington County because they've got a massive outbreak and we want to curb it now? We'd be able to identify the 340B price. Wholesalers distribute product, whether it's regular prescription pricing or whether it's 340B, it's the same wholesale. They know the real 340B price. They would be able to fill in that missing gap as to whether or not the supplemental rebase that Medicaid was receiving actually justified not carving in the 340B price at some of these entities. And to highlight 340B, 340B focuses on those brand-name drugs that take up 80% of the actual drug spend and they are the one that you constantly hear about. Comparison basis of NADAC to current 340B pricing, I'm gonna put some of that in the slide. This is as of January 15th, data. You see the drug Humera representing the NADAC price of $2,700 and the current 340B price of a penny. Insulin, the number one insulin product, Lantus, $27 per unit, that's per ML, typical box is 15mm. The current 340B price, three cents. We need to be, somehow need to be able to capitalize on those savings without jeopardizing certainly funding to the hospitals and the impact in there. But we need to be able to evaluate that. Exactly. That's what we got when we were looking at the insulin though. The, well, and to go into insulin, even entities, PBMs, I mean, there's effectively, this is kind of on topic, but the insulin pricing and diabetic medication, I would say diabetic medication pricing, there's no reason you couldn't set the price to zero. Several states are instituting laws where it's a $100 cap on 30 days supply. CVS, CVS camera is announcing a plan that will cost zero to their clients, i.e. the payers and plan sponsors, zero increase cost for a zero cost of insulin products. If they can do it and they're the number one PBM out there, then why not go for zero? The question that is, where do we go? Where do we turn? How do we be able to, you know, I can't come here and showcase what I know on a daily basis so that we can regulate this. What we need to do is we need to turn to somebody and I want to point this community in looking at the wholesaler. What if we had some kind of working group with the wholesaler? We would know true manufacturer price, the true list price that they're selling the drugs. We would know how they're changing them. We would be collecting rebates directly from the manufacturers to help subsidize things. There are three major wholesalers in the country, McKesson, Amerisource, and Carbon Healthcare. They effectively set, those three companies effectively set the NADAC price to which, from a Medicaid basis, about 90% of its reimbursement rate's off. Why can't we work with them on that? And where do they get their profit margin? It's not in the big ticket drugs. The big thing that everyone comes in here and raises fear about the specialty of this drug that costs $20,000 a month. Those drugs are coming directly from the manufacturer and there's rebate dollars in the back end, but there's little swing in the actual profitability between the individual members of the supply chain. Generic drugs, however, are significantly different. They represent 90% of every claim that are dispensed to Vermont consumers. They represent only 20% of the cost, but the price difference between entities is huge. The price that I effectively pay in my pharmacies versus the price that I'm reimbursed at versus the price that the insurance company pays versus the price that the patient only pays at the premium level or the copay level is drastically different. And that's what we need to come out a solution to. Now, wholesalers depend upon generic drugs. That's their bread and butter. And that represents the biggest book of control. If we can work with a wholesaler, we can effectively control generic drugs. We can negotiate better prices that are passed through all the way up to the premium level directly to the patient's pocket. So that everyone makes a fair market value for the services that they provide, but and we can continue access programs, but we know the real cost and we can see it and control it and we can work with that entity to better negotiate with the manufacturers directly. I like to liken this model to what we do with the control. Drugs are a commodity. The prices change so drastically on a daily basis, knowing unless you had some vehicle in place to truly monitor in real time what's going on, you would never be able to affect meaningful regulation. So you have to turn somewhere. There was a proposal several years back on S140 that contemplated the state partner and the wholesaler. I would turn the committee to looking at that language again, possibly leading it into the what's S246 creates and intent of creating the green on care board to regulate prescription pricing by setting rates, but as an initial step, maybe working towards that model so that we can find real data. If you had money, I'd say go out and hire one of these companies and have them do a top to bottom research of what's actually going on. We don't have money to spend. So let's see what we can do and let's try to get real data. That's what I wanna go because what we really want this state to do is to sit there in a position where they can truly regulate and monitor programs to reduce cost for monitors at every single level of the supply chain. We have to do that by inserting ourselves somewhere in that chain. So you had, in addition to your slides, you have some other, you have suggested language. Yes. Ken, do you wanna go to that? So yeah, I went through S246 and I kind of broke it down and this certainly would require working with the green on care board more closely on this one, but the underline in red is where I basically redacted a lot of it from the price pointing and rate establishment to more of its data aggregation theme. In particular, I would point you to E, where the board shall identify and model any potential partnership, cooperative association or further construct, including a sole source, wholesaler acquisition and distribution that would further enhance the board's capability to analyze and monitor prescription drug products, the effect on consumer costs and the effect on other prescription programs. We need to be at the board to be able to identify what the manufacturer cost is, the wholesaler cost is, the pharmacies costs are, the pharmacy benefit managers cost are, the insurers and also the patients. We need to be able to categorically identify the metrics behind each and every one of those markers to establish rates. The other suggestion in that is some further tidying up of some current legislation for pharmacy benefit managers. And I think it's really not to remain to this, it's kind of a separate attack. You can choose to go after the PBMs or you can try to rewrite the model or both, depending on what your flavor is. But I would point to really what we suggested here is a very modest increase or improvements to what is already currently in statute. At the guidance of ENCOIL, but if you really wanna look at true reform, I would steer this committee to those two bills that I highlighted, the New York bill and the Kansas bill. They are truly reflective of ENCOIL's push for true PBM reform. And the other that I attached was the original language of S-140 that really contemplated this whole whole sort of connection. And that's what we should focus on because we have to be able to change this game. This game is so overly complex, there's too many players involved, too many large entities that are really more concerned about their stock price than the actual patients cost. And we need to break that apart. We need to somehow change the model without the whole thing collapsing on us. And if we were to somehow gain data from the same data that the wholesaler sees tomorrow, that wouldn't change anything. If we were to have a single wholesaler distributing products throughout the state, that necessarily wouldn't just change anything. But it would open the pathway for us to do some real reform. A lot there. There's a lot there. So a whole another couple of weeks of testimony. Yes. At least. We have, this is very helpful. I do remember the bill from 2017. We did discuss it. So the pharmacist role would be to supply data. What other role would you see the pharmacist playing? Pharmacies playing. The biggest role that the pharmacist need to be pushed for is access. Access. There's current framework for OPR guidance on increasing pharmacists to maximize their licensure. We strongly support that initiative. But one of the things that we have to realize when I sit here and I talk to you about improving the pharmacist role and giving them more work to do, at the same time, 25% of our independent stores are for sale. That goes to show that there's too much dependence upon a fee-for-product model. We're here talking about fee-for-performance and moving away from fee-for-service and pharmacies still stuck in a fee-for-product. Could we somehow unbridle the pharmacist role from concern about how much a drug costs and how much they're being reimbursed focus on what's gonna be the cheapest and most effective product for a patient? And that's what they were trained to do. That's them working at the top of their licensure. If they could do that without being concerned as to whether or not they had access to a product or whether or not they were being reimbursed properly, then that would change the game for them. And we could actually employ them in a manner most students for their training. I think it takes what the OPR bill is doing in conjunction with somehow this data and maybe some partnership with a wholesaler. What I envision is that if the state had a partnership with a wholesaler, you could effectively, instead of paying a pharmacist for the actual product, the state would be paying the manufacturer, through the wholesaler entity, they would be paying the manufacturer directly. You would be paying the list price. That's the first bottom inflationary point of any drug. If I could go buy something a wholesale, I'd go do it. Why should we not try to achieve that with prescription drugs? If we could remove those inflationary points, we could focus the pharmacist to their licensure, to providing better care, to improving the care of the monitors, and that's what we could do that. By paying them a fee based upon the services, they actually render rather than the products they dispense. Okay, questions. So, just takes tincture of time. Yes. I guess one of the questions would be knowing that the remat and care board is represented here in terms of looking at the bill, and perhaps the bill has modified thoughts. I just saw some of this thing. Yeah, first slide. So, Susan Barrett is my community director of remat and care board. I would just reiterate what we've discussed since our regulatory processes in the last cycle that prescription drugs has been the biggest cost driver both for rate review and hospital budgets. So, I don't feel prepared to say where we stand on the language, but we certainly will be open to talking with the committee and with Jeff and others. We should do that. I mean, it would be nice to be able to take at least one step forward in a direction to lower drug costs holistically. There are a lot of players in the room and outside of think about diva and what their role might be and so on. So, good, thank you. This was helpful. My pleasure. We will mull this one over and maybe we'll link with the remat and care board and sort out what might be a good step to take to keep it on the front burner. We do know drug costs are raising premiums and people are not buying their drugs. Exactly, and that's the last that we want is people that have been taking their medication. I just want to start to describe it perfectly. Okay. All right, thank you very much, Jeff. Yeah, this is great. Is Katie coming in? I'll shoot her a note and say whenever we have five minutes. 183 is the bill that we went through with Eric and Katie and our responsibility is on the mental health study piece, not on the insanity case. So, I just wanted to go, what sections are those Katie? Five and six. Five and six. I wanted to validate and verify and all the rest of that stuff that we were okay with those two sections as written. Want to review with us briefly what's there. Sure, Katie. Okay, Katie McLean, Office of Legislative Council for the record. Section five is a report back that would be due November 1st of this year from DOC and DMH there to jointly submit an inventory and evaluation of the mental health services provided by the entity with whom DOC contracts with for health care services. And that report would go to House Corrections and Institutions Health Care and Judiciary into this committee and Senate Judiciary. The evaluation would include a comparison of how the type frequency and timeliness of mental health services provided in a correctional setting differ from those services provided in a community. So that's the parity issue. The evaluation would further discuss how the MOU executed between the two departments impacts mental health services provided by the entity with whom DOC contracts with for health care services. At section five, section six creates a working group to look at the forensic population. And it's kind of a two-part evaluation that's being conducted. The first part is looking at policy. The second part is looking more at institutions and physical structures. So in subsection A this is saying that by August 1st the Department of Mental Health is to convene a working group of stakeholders including as appropriate DOC, Department of State's Attorneys and Sheriffs, Office of the Attorney General, Office of the Defender General, the Director of Health Care Form, Department of EGS, a representative appointed by Vermont Care Partners, a representative appointed by Vermont Legal Aid's Mental Health Project, the Mental Health Care Ombudsman, a representative of the DA's appointed by VOS, a person with lived experience mental illness and any other interested party permitted by the Commissioner of Mental Health. So then that first policy piece of what they're going to be looking at is identifying gaps in the current mental health and criminal justice system structure and opportunities to provide, to improve public safety and the coordination of treatment for individuals incompetent to stand trial or who are adjudicated not guilty by reason of insanity. The working group is to review competency restoration models used in other states and explore models used in other states that balance the treatment and public safety risks posed by an individual found not guilty by reason of insanity such as psychiatric review boards and specifically asked for a view of Connecticut's psychiatric security review board and also guilty but mentally ill verdicts and criminal cases, a model that's used in a few other states. And then in subdivision two, this is the institutions piece evaluating various models for the establishment of a state-funded forensic treatment facility for individuals found incompetent to stand trial or who are adjudicated not guilty by reason of insanity. Specifically, the evaluations to address in subdivision A, the need for forensic treatment of a forensic treatment facility in Vermont, B, the entity or entities most appropriate to operate such a facility and C, the feasibility and appropriateness of repurposing an existing facility for the purpose of establishing a forensic treatment facility versus constructing a new facility for this purpose. In subdivision D, the number of beds needed in a forensic treatment facility and the impact that repurposing an existing mental health treatment facility would have on the availability of beds for persons seeking mental health treatment in the community or through the civil commitment system. And lastly in E, the fiscal impact of constructing or repurposing a forensic treatment facility and estimated annual operation costs considering the IMD institutions of mental disease waivers available through CMS don't provide federal fiscal participation for forensic mental health patients. And then in subsection B, we just have due dates on the deliverable. So by November 1st of this year, DMH has submitted a report with findings and recommendations to joint legislative justice oversight and it shall include proposed draft legislation addressing any identified changes needed. On page eight, so on Katie, a line 13. The line actually reads representative of the designee in hospitals appointed by the boss. I think you read designee in agencies for these two different things. Yes, and you're right. This reads correctly, hospitals for boss, yeah. I know it's a shape thing. Oh, really? Yeah, it's okay. I'm in the practice of saying that. I'm just going to give you the answer. Yeah, I'll solve the memory. Okay, anything else there? Looks good. It does, it does look good. It's integral to the bill. And I know that this section of the bill, these two sections, have they changed at all since or just which one? Section five has not changed since introduced, but section six has changed, particularly the institutional piece. Right. Oh, and I would just report that the question I had when Eric Fitzpatrick was here about that language about findings. Right. Yeah, he did get back to me. He did get back to you, okay. And to the judge and the attorney that he consulted still thought that that language was fine and that it didn't need to be changed. Okay. Good. So the scenario that many of the public are worried about is someone commits a terrible crime is, and both in terms of the conflicts and the insanity, the one way or another, is not tried and convicted of the crime because there's a mental state. It's confined to a mental institution for treatment and is then let out because they're cured, the result being that they've basically gotten away with it and it offends people's sense of justice. Is, does this, they all not allow for that scenario? This bill, particularly with regard to that piece, is looking ahead at policy changes that could address that. The only change that that could potentially have, that this legislation could potentially have in that scenario is looking at victim notification. I think that's the piece where you'd see an immediate result. But I think as the committee took testimony next door, it became clear that until the institutional piece was addressed that the policy options were limited to address the situation here. So I'm wondering if we're getting ahead of ourselves. I'm wondering if that should be taken care of first. And that's part of the study. I mean the notification, okay. So the guy who killed your loved one is getting away with murder. But good news, we're letting you know about it. That's sort of a moving price. I don't know. I'm wondering if we should be, if maybe that's not the first thing that has to be dealt with before we even get to this. So which one are you looking at? I think it's more than Berge's, the judiciary committee. Oh yeah, yeah, it's the judiciary. And so it'll be important to listen to what the bill report is and the work that's going into it. This is, from what I understand, this has not been an easy piece of legislation to draft. And Eric Fitzpatrick would probably be helpful. Yes. No, but I'm wondering if the judiciary committee does that, I don't know if we want to get into this. Well we're not in the first part. We're only in sections five and six. I'm wondering if we want to be dealing with it at all. Oh, well, I mean, unless there are, yeah. And I am aware of the different committees have different jurisdictions. I sometimes wonder why they call it mansplaining. I didn't need to have that explained for you in a while. But the, so the issue that you're bringing up is whether or not we want to weigh in on this bill? Yeah, I'm wondering if, yeah. If we should be getting into the details of how this is handled, if you've still got that underlying fundamental problem. I can't answer that. To solve that problem, the way to make your constituent happy, you would have to say. I could stick to it since it's a plural and I would be free by myself. That either no one could ever be mentally ill enough to be incompetent or to be rational and I don't know what they were doing. And so you lock them up. You might lock them up in a state hospital, but once they, but if they have to be locked up somewhere, it does away with the whole insanity defense. Because if you're just finding them guilty and saying, well, okay, you were insane when you did it, but now we found a medication and I will tell you about the guy who is wandering around the streets of Montpelier in Waterbury who bludgeoned a young woman to death in Burlington. They can't find anyone for him to stay with. I'm not sure what his exact problem was, but he has been on meds for, I'd say, 25 to 30 years. I regularly see him around. He used to read the Fourth of July parade and red, white, and blue spandex. He kind of stood out. He's able to function. And if you want him locked up forever, then you're saying there is no insanity defense. I actually didn't say that, but I did not offer an answer to my question. I raised the question. And I think it's a dilemma, and I don't know if we as this community needs to get into it. I'm saying that it is, it's why it's a dilemma. Going back to the ancient Greeks, you don't hold someone morally accountable for something he doesn't understand. Someone who's not in his right mind. On the other hand, they're very, the idea of people getting away with horrible crimes. It's a dilemma. And I'm saying that the dilemma is still there and that perhaps the communities of jurisdiction are going to be dealing with that before we start going into the details. I guess he's going to be a great Florida bait. Uh-huh. Mm-hmm. Unfortunately, it's not ours. Yeah. So, I mean the question, the question that, the reason I brought it back up was we, I don't know that we ever said that we're okay with the sections five and six. We don't have to vote on this. This isn't in our committee for a vote, but if there's anything egregious that you see with those two sections. So, Senator, how would I express your concern? I don't know if you would. I just expressed it. No, I mean, if I were supporting this on the floor, I may have to say something after the bill, after judiciary presents the bill. And so, I can simply say that we reviewed sections five and six and their committee is okay with that. Yeah, I'm not opposing the bill. I do have a problem with it. Expression of it, because I think it's somewhat, and I don't know how you deal with it, you know? I just, it's been at least 2,500 years that people have been trying to cope with that problem. It is. Okay, so what I said before is that work, something like that. We reviewed sections five and six, always. Good. Now, S-243 is another little issue, and I don't have the email that was sent out from Beth Gavotny indicating that, and I have talked with the chair of Gavots, about 243. They no longer believe that they need to have us send the bill to them, and they will not be interested in working on the money piece. Okay. And then I heard, through the grapevine, I haven't had the, I didn't get an email from Beth, but supposedly she did send it, but did indicate that we should take the sections out on the funding piece and pass the bill with the commission, the wellness commission. So it would be, we would just pass the bill out in wellness commission, which feels a little more comfortable, probably, there. And then, will it get added somewhere else? It won't be added, it'll just be a little standalone bill. We'll get it up and run in there. We'll worry about paying for it. We'll worship it. And because the commission, the commission won't look about how to pay for it, maybe recommendationally, that would be different. That's what I meant to, I wasn't phrasing it very well, but that's what I mean. I hired board executive directors and saying, and if you can raise money, you can have a raise. Exactly. I mean, it's the life of small nonprofits. So here's my suggestion that Katie is here. Katie has put together a proposal that has taken off. Have you done that? I've removed sections two and three from the bill. So that is a wish draft. That's 4.1, it only has the commission language and the effective de-section. Okay. And I'll alphabet numbers. It does have your alphabet, that has not changed. And how far does it go? I told somebody the size of the commission. You can't do that. Would you be willing to add another one? Oh, did you learn another one? Voss, apparently, no, it's not on here, but. Voss? Voss, the representative of the Honorable Association. Did it? I'm fine with that. And I did talk a little bit about that yesterday. Okay, so that UVW, that means we have three slides left. Because, you know, big commissions are always on it. Do we have a larger slide, too? We could put a few later, so. Why not? No, we're not doing that. How many are we up to? 23. So if we add that, the Voss rep. And then does anyone disagree with taking the money, you know, okay, that is. Let's take the money out. Let's take the money out. And then we. We ate that horse yesterday. I'm sorry, you know, this little bill, this little bill, it's not simple. So, you want to get them established. Yeah, and then they can figure out what they need. We've given a basic clerical support. Right. They figure out what they need and we'll get into the training, what they figure out in the training sessions. I like that one. Tomorrow is Thursday. Can you bring, can you get us the next final draft? Yep. And then what we'll do is we will vote on it tomorrow. So maybe by that time, I will have heard officially from that Voss thing. Fantastic. Thank you. Thank you. I haven't seen it. I've been looking for it. I sent her another, I sent her an email to send it again. So, well, I'll just check and see if you just have it. I re-sent it. I just re-sent it. I don't find it. She should. I don't know about that. She should. She should. She should. Well. Okay, so we'll deal with this tomorrow. We'll deal with it very briefly tomorrow. Are you around? Are you in the meeting? I don't know. Where am I tomorrow? I think that you're backing up Cam on the bills. Oh, perfect. Perfect. We don't need a lot of time. Okay, and I think my commitment on the House is going to be canceled. So, that will work out well. Oh, good. Okay, good. All right. Then we have some folks coming in on Habitat for Work. Thank you. You're welcome. I'm with Habitat. Thank you. I don't know if you're ready. Hello. Hello. Are you here for Habitat? I certainly am. Excellent. Thank you for being here. You're welcome. Thank you for letting us share what we do. We have a few minutes and we would like to get done. Do we have it at Tessaloni? Are you Susan Sullivan? I am. Thank you. Do you know everyone at your table? I do not. Rich Westingford. From? Oh, great. Jenny Lyons, Chittany County. Dick McCormick, Windsor County Senate. Yes, thank you all. And Senator Ingram had to leave for appointments. Where is she from? Chittany County. Okay, great. So, we have your testimony in front of us. Why don't you share with us a little bit about Habitat for Humanity, a state name for the record? Susan Summer, S-O-M-M-E-R. I'm the Executive Director with Bennington County, Habitat for Humanity. Vermont has 10 Habitat for Humanity affiliates or chapters that are actively working. Our affiliate alone, for example, since 1999, has brought 28 people home who've worked very hard to become homeowners, putting in more than 200 hours of sweat equity for everyone in a family who's 18 or older, making a down payment, paying their closing costs, and then paying a mortgage. When we look at health and welfare, and we talk about life, which you cannot have without health and welfare, it seems that housing is certainly an essential factor to all of our lives. And our homes are entirely connected to who we are as people, and what type of a life we wish for our children, and whether we can ever realize our dreams of having a better life. In America, home ownership has always been called the American dream, at least for as long as I remember growing up as a child. So, I'm talking about home ownership. Habitat for Humanity's vision is a world where everyone has a decent place to live, directly connected to our health and welfare as human beings. I'm not talking about affordable rental housing. I'm talking about the opportunity to do something more for yourself and your family through home ownership. I'd like to encourage all of you to consider with deep commitment whether the state can do another housing for all initiative bond, and that may not be practical, but I want you to know it had a huge impact on our Habitat for Humanity affiliates in the last couple years. Because of that bond money, the Vermont Housing Conservation Board was able to give our Habitat affiliates more money to help build houses. The money they give to us through their grant award program reduces the first mortgage amount for every single home buyer. If a house costs 100,000 in the last couple years, we were getting $35,900 up from $22,500. $30,000 went to reducing the first mortgage for those home buyer families. That was critical for our affiliate. We were able to increase our house production from one house a year, and we were trying to do two and had to drop back to one, but when that money came around, we're now doing three houses a year. We're a small affiliate. The affiliates in Vermont are small. Only four of us have staff. The rest are all volunteer run, which is amazing the work they're able to do. But when you look at it in the scheme of things that in the last two years is six more families in Bennington County who've been able to come home that wouldn't have otherwise. Dawn needed a house because she was renting an apartment in Bennington that had two bedrooms in an upstairs, very small area of the house. She is raising her two grandchildren who are not safe with their parents and need to live with her. But they were so afraid in that apartment setting because it was with a number of other units, right next to one another a dinky little yard out back where the children couldn't play because there were other people with animals, dogs that would take them out there and it just wasn't a good place for the children. They would sleep every night on the pull out couch with Dawn, their grandmother. They are in a three bedroom house now and although her grandson still is getting used to his own room and might spend the night with her as well, her daughter is ecstatic. She's 11 years old, her granddaughter has her own place to live and they're not afraid any longer that either their parents are somehow going to come and find them and track them down. So for Dawn, safety was the key issue for becoming a home now and the reason she wanted to do that on behalf of her grandchildren. Donna is raising two children who are babies that she adopted in addition to her natural born teenage son. They were living in a double wide trailer where they had to use electrical heating units in the winter time. The wind blew through the windows. She could not afford to repair the roof. The doors were sinking in and now they live in one of the habitat houses our affiliate built in Jennifer and Lane Neighborhood of Manchester Center. We have a 22 home neighborhood development there that we're working on. Their concern was health directly related to health and welfare. They were sick all winter long in that double wide. Their little babies were cold. It was not a good place to be raising kids and now they've got a highly energy efficient house. Efficiency Vermont works with our habitat affiliates and we work with them. It's a fantastic partnership. They're paying less every month for a mortgage, property taxes and homeowners insurance than she was in the rent on the double wide. And same thing with Don. She's paying less than the apartment that she was renting in downtown Bennington for the house that she now owns. We also do affordable home repair. That has been a wonderful project we took on in the last couple of years because of the ramps that we're building. William lives in Bennington. He's a vet, disabled, was told he was gonna have to move out of his house. We work with people who are homeowners because he could no longer stay there safely without a ramp and we were able to partner with him and build a ramp and now he can remain safely in his home and he can come and go if he needs to with help. But he was going to have to leave if he didn't get a ramp. Can I ask you is it a ramp that can be moved to another house when he's finished with that home? No, these ramps are wooden ramps that we're building. Although someone did donate to us a metal ramp, we were able to use it at two different places actually because they had used it for their mother and when she passed on they called our affiliate and we were able to help a person out so that also works well and makes a lot of sense. It costs us on average about $110,000 to build a house with a family. A ramp project can be less than 2,000 so we are trying to do at least 10 home repair projects and continue with our three houses a year. When we work with Habitat for Humanity and we do the work that we do with affordable home ownership and affordable home repair projects, we are making the vision of a world where everyone has a decent place to live, a reality. So everything that we do here in the state with our Habitat affiliates and the support that you give us, again my ask is that you would please support the Vermont Housing Conservation Board, give them the funding that they're entitled to every year, if there's some way to get more funding and I'm talking about for affordable home ownership and home repair, please consider doing that. It's vital to our health and all of that. Thank you. You're welcome. I'm familiar with the Springfield. Wonderful. Yeah, actually. They just got a house phone. Actually I haven't done it lately but they used to invite politicians to come and actually swung a hammer. That's why you saw them. It's been a day working with them. Does everybody do the being super is that just for the good? We've had goulash. One of our home buyers actually brought goulash to the site. And it's one of my sites, they sell, they probably used to sell bags. Oh, to make, to dry their recipe. No, I think every single Habitat affiliate and there's 1,300 in the country have different ways of raising money. That sounds like a clever idea though. Maybe we'll do that. I've seen people who were sort of poor young couples starting out who have since really emerged. Yes. And that's the goal really is wealth creation and making, working with folks so that they're safe and healthy. The rentals in Vermont are horrible. And I know that personally because I went to look for it. I couldn't believe the people who referred me to certain places and thought that's a place that I could live safely. It was appalling, it was appalling. So I know what it's like first hand and I'm grateful for every family that can help. Well, I think many of us have had experiences with the Habitat folks and having sworn the hammer. So, and the work that you do is absolutely outstanding. Thank you. It really is, thank you. Yes, thanks for helping us out wherever you're able. I hope you enjoy the rest of the day. Oh yes, we always do. Good, the weather's holding up anyway. Any other questions? Okay, thank you very much for your time. Thank you for your time. Sure.