 Welcome back to the afternoon committee meeting of the Vermont House Human Services Committee on Tuesday, March 22nd. We've just had a very successful floor. Congratulations to the reach-up team. unanimous support. That's great. We have one last bill that we have been working on that is on the calendar for action on Thursday. We are taking testimony tomorrow morning, some additional testimony from Docs tomorrow morning around whether it's preauthorization, whether it's a study, but trying to understand more about it and what we can do. What we can do this year is dependent upon the fact that by end of the day on Wednesday, if we have an amendment to the bill, it needs to be on the calendar for reporting on Thursday. That is where we are in terms of that. Some people are beginning to read the bill and expressing some interest in it. We're working with other members of the House of Representatives, Donahue's looked at it and wondered whether things need definitions or not, but what I really wanted to do with us right now is Dane had come on in. Come on in and join our committee meeting representative Peter Fagan. If you want, you can sit at a chair. That smells really good. We are on Zoom. If you want someone or if you'd like to join us, you could sit in the witness chair or you could sit in Kelly's chair. I do appreciate that. I was really just hoping to borrow representative Whitman for about three to five minutes just for some clarifying questions. Okay, so we are still up for... I could also wait a little while because I will be downstairs and you could join me when it's capable. Would that be possible? Because he was about to clarify some things for us. Perfect. Thank you very much. Okay, my mother. You've got to try that. If you don't mind, I'm Mikey. You've got Mikey to try anything. He'll try anything that kind of thing. Three hundred thirty five dollars. Okay, I'll do it. I can talk to my daily. Okay, thank you. Sorry. My compliments to mom. Very good. Thank you. So, folks, I believe that the amendment that Dane worked on with Legislative Council is now on our webpage. I also do see that Legislative Council is with us. And my question to you, Representative Whitman, is should we go over the amendment and would you like Legislative Council to do that for us? I believe that Legislative Council would be very good at doing that. So I really appreciate it. Katie would be able to do so. Okay, thank you. Thank you, Katie. If you could walk us through, it's up on our webpage. And part of me is just trying to bring the committee together in terms of where we are. Okay. Good afternoon, Katie McLean, Office of Legislative Council. Let me make sure let me pull up the document for myself. Okay. So we are looking at language. If you remember, maybe I'll take a few steps back. The bill that passed out of committee had four sections dealing with prior authorization for MAT and house appropriations, house appropriations remove that language. And so now we have some unnumbered sections in the bill that would just appear as deleted sections. So this amendment is instances of amendment. And the first instance is adding new sections three and four to fill in two of those deleted spaces that would be left by the house appropriations amendment. So first, there is language in section three, that reads in subsection A, the AHS shall provide coverage to Medicaid beneficiaries for medically necessary MAT for opioid use disorder when prescribed by a healthcare professional practicing within the scope of the professional's license and participating in the Medicaid program. And secondly, upon approval of the Drug Utilization Review Board, the agency shall cover at least one medication in each therapeutic class for methadone, buprenorphine, and naltrexone as listed on Medicaid's preferred drug list without requiring prior authorization. And it's my understanding, although Representative Whitman would correct me if I'm wrong, that this sort of codifies the existing practice of how Diva maintains prior authorizations for these drugs. And then, oops, did I interrupt somebody? Katie, I would, as a, Katie, Dane and Taylor and I met with, oh, and Jen, to sort of talk about these things, I mean, and to get sort of clarity. And it was our understanding. But maybe we need to clarify that, that this is just, this is codifying what is in rule, that this does not change what they are doing right now. But it codifies it in rule. I mean, in statute. With which portion? This one, but Katie just referenced. Section three. Section three of the bill. Right here. Apart to Medicaid. Yes. Thank you. Then moving on to Section four, this is a report back. So that's sort of happening in two parts. In Subsection A, we're having the Drug Utilization Review Board collect certain data and submit its findings and recommendations to Diva. And then in Subsection B, Diva is reporting to the General Assembly. Usually the Drug Utilization Review Board doesn't report directly to the General Assembly. That's why there's this intermediary step. So in Subsection A by December 1 of this year, the Drug Utilization Review Board shall review the following and submit its findings and recommendations to Diva. So it will look into the quantity limits and preferred medications for buprenorphine products, the feasibility and costs associated with adding monobuprenorphine products as preferred medications. And lastly, how other states Medicaid programs address prior authorization for MAT, including the 60-day deferral or prior authorization implemented by Oregon's Medicaid program. So looking at what other states do, including this very specific ask about what Oregon does. And then again, Subsection B, Step two of this is that by January 15th of 2023, Diva is to submit a written report containing all the information in Subsection A to the two committees of jurisdiction. And then in your underlining bill, the bill is introduced because it was a committee bill. You had a Section 7 that had a report section on prior authorization for MAT with regard to Medicaid. So this amendment strikes out that whole section. And then it basically puts the whole section back in without many changes. But because there were a few changes here and there, it was maybe easier to see as a strike through than as inserting a word here and after this line and after this line. So just to refresh your memory, this is a series of three annual reports from Diva to the committees of jurisdiction regarding prior authorization processes for MAT in Vermont's Medicaid program during the previous calendar year. So first, which medications required prior authorization that was in your original version. Subdivision two is new. The reason for initiating prior authorization and subdivision three, how many prior authorization requests the department received and of these, how many were approved and denied and the reason for approval and denial. So this latter half of the language, the reason for approval and denial is new. And then lastly, the average and longest length of time the department took to process a prior authorization request. And that is it. Thank you. Thank you for that walkthrough, Katie. I need to go and turn this over to Theresa. Perhaps it will be quick. It's supposed to be a quick check in. Okay. But Taylor and Dane may have some updates. And we are starting at 9.15. What time are we starting tomorrow? 9. Starting tomorrow at 9. Okay. Thank you. Just in case I don't get that right. Do you know that you don't know? Okay. Thank you, Katie. For that review of Whitman. I guess it's just us, right? So Taylor and Dane, any thoughts about how you came to this and where we might be further headed? Yeah, absolutely. I'll take a shot at it. And thank you again, Katie, for walking through all that. I think that's an excellent sort of introduction. And yeah, I think the best way to sort of describe how we came to this and Taylor feel free to jump in if you have another idea, but really in collaborating with the department, Diva on scene where they sort of saw a path forward to address some of these issues that we agree where we want to make treatment as accessible as possible. Right. So I think that really the first page of this amendment that you see was proposed by Diva essentially saying, let's use the existing process in place through the Drug Utilization Review Board to sort of review our current practices and revise as necessary based on the latest and greatest information that we've been collecting and the everything that we've been bringing to this topic. I would say that section four on page two was really with Taylor and I working together trying to make that sort of process a little bit more direct and specific and far as what did we want to hear back from through that review process? And when did we want to hear back about it? And what exact specific components did we want them to consider and report back on? So you'll see 123 on page two lines six through 12. You know, we want them to consider the quantity limits. We want them to consider mono super norfing and where that fits into the picture. I'm interested in hearing from the committee after the testimony we received today. If we have any updated thinking about how to best phrase how do we want what do we want them to consider in light of the mono super norfing product, right? When you say consider it says feasibility and costs. Are we talking about feasibility and costs still requiring prior authorization? Or is this feasibility and costs with relaxing prior authorization? Relaxing prior authorization. Okay, so I would suggest that I think that could be a little more specific. Yep. Yep. If I may interject on just that one. The preferred medications do not have prior authorizations except for dosing. I see. Okay, so that's inferred. I would say so, but I'd like to dame. I think that if we could be more specific that so you're essentially saying that I'm just I know that perhaps now that things are on the preferred list don't have a prior authorization requirement. But I'm just I guess I would wonder explicit. Right. I would just wonder given the at least current opinion that we should, you know, should not do this, at least from D those perspective. I guess I just would I think it would be better served to be explicit. I think I think in general, one way to look at this feedback, Teresa is for section four. Yeah. Submitted finding and recommendations shall review the following and submitted finding and recommendations. I think we need to really spell it out that we're talking about prior authorization here. Right. That's not exactly in the language as is. And I think that as we look at things like quantity limits, we're talking about what's the limit at which prior authorization is triggered, right? I would kind of just do a minor correction. Taylor, like to say that a preferred medication doesn't have prior authorization may not be completely accurate. Since we saw, for example, Suboxone is a preferred medication, but there's a large number of prior authorization still taking place. So I think that this is sort of what we're asking them to come back to us is where can they relieve prior authorization pressures? What's the feasibility of that? What's the cost implications of that? And one of the I think clinical implications, but I think that's sort of captured within feasibility as well. And so, so I guess just be devil's advocate a little bit in that sort of that introductory thing on 4a. So I get where you're going with that. And I think it's actually necessary thing because I think they could come back and say, well, the quantity limits and preferred medication for deprenorphine products with regard to prior authorization. Well, we already said, you know, we don't require prior authorization for, you know, this X product. So I think that clarification actually would be beneficial in that in that lead in paragraph. Great. And I think the building on that and rereading this, the feasibility and costs, well, the feasibility and costs would, we know the cost right now, the department has said it's going to be $4 million if we ask them to add a mono-deprenorphine into because it's not a preferred drug medication right now. But the question is whether or not they're willing to negotiate in those supplemental rebate discussions that they have on an annual basis about adding a mono-deprenorphine product in as a preferred medication. And it's, and, you know, to me, I mean, listening to Dr. Lord this morning, it's just as much about even if they said, well, we need to maintain a prior authorization process, how that process works, and what prescribers need to go through in order to get something prior authorized. So I mean, I think they could still sort of meet the letter of their contracts with these drug producers by figuring out some way to honor the expertise and the knowledge of the prescriber with regard to the patient that they're seeing right in front of them, you know, that, that was a part that sort of struck me about the comparison between, you know, what they had to go through in order to get this alternative medication, you know, when, you know, compared to some of the other, you know, more, you know, maybe more common, although this is pretty common, this is a pretty common issue, but they just come, it doesn't meet the common sense test. I mean, the straight, you know, we often kind of talk about the straight face test. It doesn't meet the straight face test. And so how do you modify it? And I think that I appreciate the work you're doing on this to sort of like work with diva to say, okay, you know, and I did hear from them that, you know, if there's barriers that we can remove, we would like to remove them. This kind of gives them an opportunity, let's just say remove barriers. I said, I heard them say that if there are barriers, and I'm not sure we have convinced them that there are barriers, but I think. So anyways, I don't need to belabor that. I appreciate that. I think Dr. Lord did a great job. I'm sure sort of an act of Congress to be able to get him on the roof. Well, I think that's that lies in rules. That lies in rules for the department of saying this is how you're going to navigate, you're going to try all these other drug combinations first. And I doubt diva would like us to put that into statute. Yes. But how are we encouraging them to improve their systems now that they're listening to their providers, saying that there are difficulties? And it seems like there's also a lot of review processes outside of diva and outside of Medicaid that are really watching prescribers when it comes to monobupenorphine treatment. So where is that balance in trusting our clients? I realized I came, I left and came back. Is there any, is there any support or any worthwhileness of somehow doing, encouraging them to, to, to work on their internal processes so that you don't have to go through that extra process that Dr. Lord was describing. I wanted to ask the committee of on page two of this amendment, where we have number two, the feasibility and a cost associated with adding monobupenorphine products. Maybe we want to build off of that too to specify this issue that we're talking about. So not, not only if, if added as a preferred medication and or review this process for needing to verify adverse effects. So maybe we could add some language along those lines as far as what we hope them to report back on. Review to make it, why don't we not have them report back? Why don't we ask them to review their current processes around that? What about the wording changes that Theresa had suggested that we're going to consider that? We were just talking about on page, on section four of being in page two at the top. So it's not clear. It wasn't clear to me. And I mean, I was inferring it, but I think it is good to spell about that. For a one, two and three are really all about the prior authorization process. So, so it seemed like the quantity limits and the feasibility and costs associated with, well, you know, they could list anything, you know, with regard to that, what we're really interested in are those things as it relates to removing or modifying the prior authorization process. Okay. And so we need lead in language in for a that connects it back to the prior authorization process. I think it would be important. Yeah. Yeah. Julie, have we formally invited diva for tomorrow? Whoops. Can we formally invite the diva? And if they can't dedicate their whole morning, the latter half would probably be better, because that's when we'll be discussing language and wording. But So I think we're on page two of the three page amendment. And yes, are there any other questions? We figured that it would be great to submit findings and recommendations for a 60 day deferral period. That was one of the proposals that we initially included. Oregon has done this and apparently they have made it work so that it doesn't reach their sort of contracts around preferred medications. So if we could learn more about the logistics of that and the feasibility of that. And then yeah, basically that we'll get a report back. So are there any other questions for this page before we move on to the reporting? If you could just refresh my memory on what was like what we asked the question, if we remove prior authorization, what was the cost of it? What was that? If we were to and it was actually specifically based on what we sort of posed and all of those different levels and indefinitely, you know, not for a given time period, there's a lot of intersection and overlap. They based on the fact that it would have been in breach of their contract with their preferred medications, that would have been four million dollars. And then they estimated based on the uptake of the most, you know, costly medication available, it's sort of this assumption that people would be able to freely transition, they'd be able to choose the medication that they want. And that it would be a more costly medication that brought their full estimate up to 17 million, up to 35 million for that. And I think that what we're looking at in this case is first 60 days, seeing that that may be the most critical time for somebody engaging in treatment. For the first time, how can we remove a potential barrier so that they don't need to go through some of the processes of jumping through hoops using medications that are that they may have adverse reactions to etc etc. So I think that's the numbers or some adaptation of that. That one we're talking about here the feasibility costs associated with, okay, is that that's a portion of it? Correct. Does that lower it? Or I would say So for number two, I would say that that's a very specific medication. Taylor, Taylor, do you want to take a shot at this? Yes, I would love to. So feasibility and cost, we know what the feasibility and cost is if we were to put this statue today, or we say classroom food mono buprenorphine, it would be $4 million. They do an annual negotiation with the distributors on those medication rebates. And so they can renegotiate terms with those distributors. So that maybe there's not a rebate, but there wouldn't be a cost implication of having the mono buprenorphine. That would have to be a discussion with the distributors themselves to discuss rebates. But we're trying to encourage that push them to have that conversation so that we don't have a $4 million impact, and are able to reduce barriers. And I think what we heard today is that maybe the prior authorizations for mono buprenorphine are not the specific issue, but it's all the other hurdles before the prior authorization that are challenging. Sounded like the doctor was concerned with the fact that his prescription, you know, he's the expert in this area, and that somebody else was going to have to go ahead and okay his prescription. Those are way to I mean, the two doctors we heard from are experts in their area. Are there others that are prescribing these medications that may not fall into that category, but are working for some, you know, in other words, could we carve out those real experts and say, you don't need prior authorization because these guys said what it was. Okay. And I'll look to Dane on this one around the preferred provider network. Is that is that in that room? I would, I think that looking at a specific carve out as far as whether I mean, I think a lot of spoke providers, maybe, you know, everybody receives their, their same level of training through SAMHSA, right? And I don't know if you're suggesting that we say that it needs to be signed off by an MD instead of a nurse practitioner. Is that what you're suggesting? Or is it like, I mean, Carl, what I'm hearing you say is, I mean, these are two, these two doctors who were within the the Medicaid blueprint hub and spoke system. And so by virtue of that, may have more of an expertise than a physician who is doing, you know, it's operating under And so that kind of thing. And James, we're not ignoring you. And that, yeah, sorry. No, no, no, I'm just letting him know we're not continuing my questions. Don't worry, he wants to know. I'm done that. James. Well, I kind of, it's kind of, kind of what Carl was getting started on, I'm not sure. So when, when the doctor said this morning about their expertise, not being questioned, my first thing obviously was, of course, your doctor. But then I was thinking about it, because contrary to what it may seem, I do a lot of thinking. And we get into this trouble, because people who thought they were experts didn't question the history of opioids really starts addiction. The biggest part is in the 80s. And it goes into the 90s and 2000s, how it grew. And yeah, the pharmaceutical companies were sued and they, you know, obviously, we have bills about this, right? But they didn't get into patients without experts in the middle of compositions that prescribe them the people and believe what they were being told, including in their education. So I don't think there are vicious people at all. I'm gonna go do this. They didn't do that. They thought that they were experts. And in most cases, cases, certainly no more than I do. But when we're talking about this, we should never, this is not downgrading, but never just throw our hats in the ring and go, well, this person has this degree or that degree or some other degree, or they've been doing this for 20 years and just say, okay, they must know, because we got in a situation that we're in. And it's a pretty darn serious situation. You know, in this, this is such a big deal that I'm sure most of you, especially you guys know this, that our life expect to see in the country actually decreased several years ago for the first time ever. And it's because of overdoses. So my point is that we didn't get there because experts said, Hey, listen, you're this isn't working. And we're going to stop. They expert said, Oh, this sounds right. We're going to keep on keep on doing it. And now we have had the chicken come on the rooster, whatever the other exact chicken. And I messed them up all the time. So yeah, maybe we need to work on changing the process so it's not an act of Congress. We also should be making sure we have some kind of trigger mechanism failed and that they'll see what everyone thought that says, Hey, when you're moving to mono, especially since mono is the one is that we've heard us two years ago on our bill two or three years ago, whatever it is, in itself is used as a drug. It is. And there's a country, I forget 20, because I made a whole big speech about the last time when we had our bill two years ago, that the entire drug epidemic in that country is the month. So it is an issue. And it's becoming a state said this morning, becoming more of an issue that that is the drug of choice. So we have to be careful that we're not just saying and I'm not a hostess by the way, but I'm just saying, just be careful when you make any steps, something that's all working. Yeah, no, I appreciate you bringing that James. And I guess my question to you would be to sort of to sort of be able to give a professional that has expertise, some amount of license, but also having to check. How do you feel about what Dr. Lord was suggesting as far as if a patient's having an adverse reaction, and the doctor believes that the mono product would serve them better, that a doctor can sort of just write off self a test, this person's having an adverse reaction, and not need to first prescribe them anti nausea medication or first prescribe them because that does seem like a bit of a double standard. I agree with when they have those those issues. But maybe there should be some kind of follow up that has it like a check where they go Okay, let's, you know, the person now has this they're being treated. Let's let's double check that you know, because it's a huge issue, we got in a big issue. It's one of the biggest problems in the country. You know, so not to have any checks, you say, we will take your word for it. We got here because of that. So and I would say the check, as I heard from Dr. Lord today, I think the check is the dosing that they were saying that when you look at the research, when prescribing that 16 milligrams is the standard dose, and that over 24 milligrams, they're showing higher risk of diversion, or that it actually might not be the right prescription for the individual. So I'm wondering if that is the direction that we're going of following the research on this one, and saying if if that medication isn't working, you have no prior authorization up to this 16 milligram mark. And as noted, I don't oppose this stuff, right? I'm just saying that is your question of where that checking balance is what I'm saying is that the research also showed it was a great thing for chronic care. And now we know it's absolutely not a good chronic care. And, you know, you shouldn't have been getting it for what wasn't. So, you know, hopefully Very sure. Anyway, I digress on my point, but I'm just saying it's, you know, I didn't think I had it in me. I appreciate it. You raise a really good point. But maybe that's why the DEA has X waivers for people to prescribe. Because you totally do raise a good point that anybody could prescribe opioids. And that's how we got where we are. Not anyone can prescribe these particular drugs. You have to go through a specific that this X waiver through the fed. So is that the check? I don't know. I don't know. It's a good question. You definitely raise a good point. And, you know, and I don't know enough about how many patients you can have with an X and how much you can prescribe. And is there a series of checks already in that particular certification that the doctors that are treating people with opioid use disorder need to have? So If I could just interject for one thing, madam chair, I think that all of these are great considerations. And there may come a time where we want to legislate some of these things. What's on the table right now is sending this to the Drug Utilization Review Board for their recommendation. So I have a couple of questions. Drug Utilization Review Board. How often do they need? Who's on it? And how often do they did you already go through all that? No, but it's just what we've been asked about everything we do, right? You know, so we This is not a new board. This is not a new board. So in order for us to even talk to someone hours, maybe it's 20 18 hours, we need to know who's the Drug Utilization Board. Yeah, what do they do? And we need to be honest, we need to probably know it from not just reading about it. Okay, are you are you suggesting a witness or? Yeah, or someone on the phone. I believe that. I know that we heard in our meeting that it's 50% physicians, 50% pharmacists. And they essentially review at least every two years, the changes in clinical guidelines, prices of different drugs and things like that. That's just what we from our working group meetings with diva. That's what we've heard that from. So they do that already. Did we already talk about some of these things belong and in the prior author authorization camp? Yes. Okay, that's what we're talking about putting lead in language that essentially says that that's why I mean, I guess I'm going to play appropriations. Why are we asking for a poor re asking? Are these two separate things? Correct. And why? I mean, sort of why are they two separate things? I mean, who's going to I guess, are we changing? We probably don't want to change the function of the drug utilization review board. So whatever they do, if there's something that we can be specific with them, and maybe consider moving some of these things with the drug utilization review board to diva doing a report where they may have to consult with them. I mean, I you know, I think one of the things I'm hearing some people also talk about is it's not it's the process. And so how do we get them to review the process? And that's not the drug. I mean, since I don't know what the function of the drug utilization process review board is, if they're only saying certain drugs, yay, certain drugs, nay, then it would be the other to review that. But that's us playing nicely with others, which is saying, okay, if you're going to keep prior authorization, make it easier. Right. And we don't really say that in the second one. We don't. If I may, the second report is a continuation of that report that we received and went through on prior authorizations, which was sunsetting this year, we got the last one this year. Oh, we're saying we want it to continue. And we want to add we want some additional information for clarity. Yes. Totally. I just wanted to explain that that second one has already existed. I thought I had this straight now. So I look at the first report is the sort of the experts on the drugs saying these are the ones that we think could change that that we could recommend to diva that has a change in process. That's what we're hoping comes out of it. And then I look at the second report as in addition to whatever you have here of saying, not only what did we do, but how did we modify the process to be more accessible to prescribers? We don't ask them to do that. But should we be asking them to do that? Could you say that? What should we maybe be asking them to do? Should we be asking diva to so take what is learned from the drug utilization board into so if they come back and say X, Y and Z drugs, we believe either don't need prior authorization anymore, or we believe they do still need prior authorization, but only under these circumstances. How do we address what Dr. Lord was talking about this morning, which was not the fact he wasn't really actually belaboring the fact that he had to get prior authorization. He was belaboring the fact that he was required to go through so many steps, and they wouldn't acknowledge his as the prescribing physician, they wouldn't acknowledge his expertise of documenting that the patient had the adverse reaction, and instead had to go through all these ridiculous processes. And so that's the part that I feel like we don't get at in either of this. I would recommend building that into the first report through the Drug Utilization Review Board, and then potentially maybe adding something through diva administratively. It has a huge I just it has a huge thing. Responsibility and I may meet monthly. I think part of the idea is that technically this is under their purview now, but we are charging them to get back to us within a timeline on these specific topics in the form of a report so that we can really take another close look at this and see, OK, like here's this change and here's this cost associated with this change. And this will be able to have impact. But I still do agree. I agree with Teresa on that the physician, Dr. Lord, really made it clear that it wasn't that he was against prior authorization. He just wanted prior authorization like he does with other drugs. That was quick that they believed, you know, when he said Medicaid was one of the best prior authorization across the board, right? But he felt they got back pretty quick, but they're not being treated the way that they should as physicians who work on this all the time. And that seems to be a pretty big issue for the field. Yeah, tomorrow. And then and then I would say just in case of somebody was wondering about the second report, that is I see that as you know, whenever I was in committee and I was reading off of that sort of numbers that I was saying there have been 3,000 prior authorizations for Suboxone, you know what I mean? This is basically building off of that recording process that already exists. It was put in place in 2019 for three years. It's now sunset, but really so that we're able to say, you know, why were a thousand of these prior authorizations approved? Why were the other 50 denied? And that data would already be encompassed within the report. It said, you know, denied because of a quantity limit or denied because we want them to choose this medication instead or denied because it was two eight milligram doses and we wanted to be so there's less room for interpretation. And this is something that Diva expressed support for taking up. I feel we're at a place where we sort of need to think about how we do this. What our goals are and, yeah, and be prescriptive but not being so prescriptive that they're used and we're going to hear some more. Now you, did you send this to them? What, this latest? Yeah, I just sent it to Julie. You've been working with them, sending them drafts. They're getting more nervous every time we send a draft, but if this is something or, you know, I mean, I guess between now and nine o'clock, right, we're having nine o'clock. And that between now and nine o'clock at nine o'clock, we're having three or four people come testify. And three people testify. Two doctors and a nurse practitioner. So we will. And then we have committee discussion around finalization around what this is going to look like. But I don't know whether we're in a place to go further tonight. Carl. I just have a question of these two that they might be able to clarify this for me, but when prior authorization is requested or there's a problem like the doctor said this morning, and I asked him to come to the food. What medication is it primarily? Is it the number one, you know, we call mono? In other words, somebody wants that. I'm just looking at, can the system be manipulated by the old patient in a way? In other words, like that the patient says to the doctor, you know, I'm having side effects to the combination. And can you do something for me? And so is that why these companies are saying, you know, we want there to be a prior authorization to possibly stop that from happening? You understand what I'm saying? The combination drugs are the ones that seem to cause somebody's side effects, right? Yeah. So, I mean, the doctor, he takes the patient's work or something else. And now that medication didn't work for the nausea. Eventually the doctor says, go on the mono. Okay. All right. And I think that's, you know, I'm just trying to rationalize why did they spend so much time on this prior authorization unless they're trying to stop something. So anyway, just the thought by throwing it out there. And I don't know how to deal with it or find somebody that could tell us how much of that do they see on manipulation of the system to some extent. Yeah. And I don't know if we will know that answer, but I think what we've heard from testimony is that it's two fold. One is that concern about diversion with the mono buprenorphine product. And that's why suboxone is the preferred drug. And then the second is cost. So they have to have a prior authorization in place for the mono buprenorphine. Because the suboxone, the combo is the preferred drug where they get more expensive or not necessarily less expensive, but you get the most rebates for a bigger thing for their buck on that one. I just compared to buprenorphine. I never just thought, I don't know. Yeah. It's a great question. And I think what we heard today is that folks are getting buprenorphine the mono product on the street. And so then they're getting inducted through buying it on the street and then getting into health care to then be on stabilized treatment. So it's already out in the community. As we did with our bill last year to help lower the threshold so that folks are able to get inducted by any way necessary so that they're able to retain on treatment. So it is a difficult balance. I totally see that. But I still hold that that really distinct concern around overdose deaths and rather see someone on treatment by any means necessary. I actually found it promising. That was it. Dr. Luconus said that he had a lot of people coming into treatment for the first time, but with buprenorphine in their system. So it sort of suggests to me that somebody who may be receiving prescribed buprenorphine is also open to treatment. I mean, I guess the thing that's going to be hard for us. Is that we wanted something a whole lot different and we're not going to get that. So we got to let go of that. Because otherwise we're going to waste our time. And two, we got to keep focused on what it is we are looking for in a. In a report that will move us forward to identifying how to remove the barriers. And one, we, we have heard that one barrier is pre authorization. That's not a shared belief. So that's, that's a bit challenging. We've also heard that. This mono. We like, you know, we, you know, I'm being. Short-hand pre authorization is, is helpful and supported because of issues, maybe that you're bringing up Carl and others around. Who can do it and it's a risk. It's a risk. It's a risk. Or risky. Product, perhaps then some others for diversion. But that, what did he say? You have to move mountains. An act of Congress. An act of Congress. So how do we make it not an act of Congress. Or not we, because we're not going to do that. How, you know, and so, and how do we say that in a way? I think. Please. So this doesn't take an act of Congress, but that's, I mean, right now those are. And I, I, but I get a little. Some of the people were testifying this morning. They were. I want to keep us focused on those things. Yeah. Not on the bill we passed before. Not on who's fault it is that we're where we are. You know, but that we see barriers. And, and we really don't quite understand. Prior authorization for Medicaid when it appears that there is not prior authorization for others. And that may be money. And that may be. And that may be. And that was the other way around it. There is no prior. There's limited prior authorization for. That we heard from the major insurers. That are the major private insurers that are in Vermont. And there is prior authorization for medic. For. And. One, there used to be prior authorization for everything. And two, there, you know, it's a way to support. Healthcare. For the Medicaid population. It's a way to keep, you know, and so that that's one of those. Realities out there. Right now. So I feel like, I feel like asking the drug utilization board. To, we just, I feel like that's a good step. Because we're asking the people who are experts in the field. This is part of their charge. I just was reading their charge as part of what they're. Okay. It's supposed to be doing. And we just need to make sure that we have the right questions, you know, that the questions. Right. And that seems to be something that. One, both divas on board with. And two would give us additional information. And. The thing that it feels like it doesn't. Go. Sort of that final step is, which is. How. How would that information be used? You know, so if they make the right. Recommendation that something should be done. Is incumbent upon diva to do it, or they just like take it under advisement and decide. You know, because of the contracts they have for the utilization of certain. Drugs that they. Not going to do it. Or. That's the part that seems. That feels. Like. A hanging chat. Perhaps. It's like it's hanging out there. I mean, isn't part of it. They get information. They may or may, and we, and that information is also shared with us. They may or may not on their own make some changes. If they don't make changes. I guess we invite them back next year. Yeah, we invite them. You know, and we invite them back in January. You know, right. With, you know, and. Work with. Appropriations in terms of this is. How much can we, how much can we lose? You know, and do some of those kinds of things. All right. I wish one of us. What were the acts of Congress or whatever. Like an act of Congress. To get approved. Maybe those things could be simplified. And what I'm thinking. What I'm anticipating it would be. What I'm thinking is that. His office probably gets called back and says, did you prescribe. And. And those sorts of things. And maybe that could be done on the front end when the guy writes prescription. It'd be like an addendum to the prescription that says. We checked this, we checked this, we checked that. And so they don't have to call. Like they have from the doctor. The answer is that they're probably. You know, they don't have to call the doctor. You know, they don't have to call the doctor. You know, they don't have to call the doctor. You know, they don't have to call the doctor. And then you're busy doctor. And somebody calls from the pharmacy and says, did you prescribe. And I vomit medicine or something. And that's probably what he's thinking of. Congress. Anyway, just. I think you're right. Cause I mean, part of what he said is he would like. Them to accept. His medical. Opinion. Or his medical. That's. You know. Right. He said rash. nausea. That's what I'm sorry. Sorry. My brain. There was swelling. That's very sweating. Those sort of things. So. You just didn't want to put his patients through all that. The other thing I know that's not in this amendment, but I wonder about that. He brought up that really had an impact on me was the transportation. Issues. And I know we have the van and I think that's great, but what about the. I can't think of the name of the organization. We can't. We need to stay. Stay in this land. We need to stay. We need to stay in this land. We need to stay in this land. We need to stay in this land. And. Talking about the. The pilots and whatever. We can't. I'm sorry. There's no money. We can't add another. For this bill. I didn't. I didn't want to suggest that. I'm sorry. Did I cut you off? You're not going to say. No, no, no. I was just curious how much this bill was really. Yeah. I think it's like under. Bring up going back to the transportation and the mobile. Dr. Lord today kind of commented, you know, can't just be the medication. It needs to also be the case where our budget. The way that we budget included a case manager. Is that something maybe we should specify in the language or. I don't know. I don't know. Because the model that we based on that was. You know, included a case manager and a nurse. I think when we reported on the floor, you say that. I want to. Yeah. Reporting on the floor. Because then we'll get into what kind of therapist. Yeah. Yeah. Yeah. Yeah. I mean, I mean, I mean, it is sort of as he's talking about the things. Child care transportation. It's like, those are the other things that we've been working on. I mean, I mean, I mean, I mean, I mean, I mean, I mean, those are the other things that we've been working on. And so whenever I sometimes get frustrated and people say, they're not doing anything about this problem. Right. You know, those, and I'm aware that two of our, three of our members will need to be somewhere else in five minutes. I'm going to, you know, I'm going to keep sort of going. We need to keep this as simple as we can. I'm looking forward to hearing from the doctors tomorrow. Or at least one of them. The first one is the first, the first doctor is one that Eva asked us to hear from. And so we're going to hear from, and then we have one from the community health center. Who I don't know if that's probably not a spoke. Maybe it is. I don't know. And then someone, a nurse practitioner from the safe recovery program. So we will hear. I think that'll be helpful. Three diverse people. Hopefully. It would be really great if someone from diva could come. So we could ask them questions. And so they could provide us some. For the record, it is a spoke. Oh, good. Yeah. Okay. Good. We all have that. So thank you all. And this is, you know, this is going to be one of those bills that we will do the best we can. And then we will. Rely on the good work of the Senate. Perhaps with our help. To if we need to, if, you know, for any kind of massaging and for other people to come and testify and do something different with it. But thank you all. Thank you. Thank you. And tomorrow. Bring our good moods. Because at least our caucus said we were going to be here late. Right. Yeah. So. Realize that. And if you have not. Those of you who don't always go home. Make sure you made your reservations. Okay. Thank you. Thank you. This is, this is, this is mother and speaking. And now that's. And this is the. Tonight, tonight's. Meeting. And on a good note, we did great job today. And a great presentation, little history lesson. On the floor. That was helpful.