 Okay. We are back. This is Senate Health and Welfare and we're continuing our discussion today on January 6. And the discussion before us now is a fairly critical and important workforce development report that was embedded in H-155, a bill passed Act 155. The bill passed through the House and the Senate, and this committee did a significant amount of work on that bill. And it was in the 2020 year, so it's not, if you look for it, it won't show up in 21-22, but it will show up in 2020. Thank you, Director of Healthcare Reform, Bacchus, for being here with us and to walk through the workforce development report. Give us a kind of, if you don't mind, give us a quick picture of the work and the folks who've been working on this. And the, I think the executive summary and recommendations would be extremely helpful. I don't, you know the timing of this better than we do and what it will take to get through everything, so I'll leave it to you. Good morning and happy new year. My name is Ina Bacchus. I am the Director of Health Reform at the Agency of Human Services. If I could, I'd like to share my screen to walk through the information this morning about the healthcare workforce development strategic plan. If I can adjust my settings here so that you're able to see the slides. Can you put it on a full screen like a slide, slide show? Yeah. Yes. From beginning, you've got it, yeah. How does that look to you? You, good. Okay, I think we can see you've got, you've got your next slide up as well and I don't know how you get rid of that one. You can, I think there's a place you can click underneath the first slide and now that's your, that's your, those are your comments. It's a change in the display settings at the top. Yeah. Oh, there it is. Yes. Thank you. That's why we have Aaron. I think you want that one. If that one doesn't work, try the other one. There you go. Great. Thank you. You probably have heard that we use a teams platform and so I'm not so used to zoom. I appreciate your patience. For the agenda this morning, I, I think it's important to review the primary charge for the healthcare workforce development strategic plan, as well as the process to date regarding the plan. I would like to provide some background and context for the current healthcare workforce challenges as these are certainly rapidly evolving as the public health emergency and the pandemic continues. And finally, to review with you the recommendations that we arrived at with the advisory group that informed the healthcare workforce strategic plan. First, as Senator Lyons explained Act 155 of 2020 asked that the director of health reform, maintain a current healthcare workforce development strategic plan, and that plan be informed by an advisory group of 11 members. The advisory group and with those 11 members is represented here for your review. There was membership from the Green Mountain Care Board's primary care advisory group, the Vermont State Colleges, the area health education centers, federally qualified health centers, Vermont hospitals, physicians, mental health professionals, dentists, naturopathic physicians, home health agencies, long term care facilities. I also want to thank those subject matter expert experts that participated from across state government. They were not designated members of the group but they provided much needed expertise and content to the advisory groups. And those include participants from the blueprint for health, the Department of Labor, the Division of Vocational Rehab, Green Mountain Care Board, the Office of Professional Regulation, and the Office of Rural Health and Primary Care. I thank them again for their participation with the group. The advisory group informed the strategic plan that we'll review today. That plan was submitted to the Green Mountain Care Board on October 15th of 2020. And this was in accordance with an amended timeline that was amended through last year's big bill to allow for more time for the group to meet again in light of the public health emergency. The plan was presented to the Green Mountain Care Board on October 20th. I apologize, there's a typo here. It was actually presented on the 20th of October and not the 15th. The plan then with feedback and public comment, there were some revisions that were presented to the Board on November 12th, and it voted unanimously to approve the November 10th, excuse me, and it voted unanimously to approve the plan on November 12th. You know, was that in 2021 or 2020? Oh goodness, it is 2021. Thank you. All a mistake here. 2021, thank you very much. It would be very prescient if it was in 2020. I wanted to provide some current context for the health care workforce challenges that will serve as a background for the recommendations in the report. As you are aware, we're experiencing what has been turned the great resignation for the workforce on the whole in our country. This has been prompted by the pandemic. Americans are quitting their jobs in record numbers. The US Chamber of Commerce reports that employers in South Dakota, Nebraska and Vermont are experiencing the greatest challenges as the total jobs available outnumber the total workers to fill them. And importantly, unlike past recessions where the health healthcare sector saw jobs growth stable and continue to grow. In this recession, the health care job sector is falling alongside jobs in other sectors. And that is, at least in recent history, unusual to see. And of particular concern, as we are, as you all know, confronting the COVID-19 pandemic. Here in this chart, you can see that health care that health and human services employment in all sectors is below what it should be. And the percent difference in November 2021 for health employment by setting versus what's projected to be at the inadequate level of employment in the absence of the pandemic is represented here. Again, for every area of the health care sector, the job, the employment is below what it should be. And you can also also appreciate where there is is significant differences in employment for certain types of health care providers. This is national context. I don't want the committee to apply these numbers to Vermont. But I think this is important background because Vermont is experiencing trends similar to the nation, but these are not Vermont specific numbers. You can also see that over the last decade, between 2009 and 2020, Vermont's home care workforce has declined. And Vermont's home care workforce has declined, interestingly, where it has grown in many other states. Here in Vermont, we have experienced decline with this workforce. The home care workforce is defined as combined employment counts for two occupations, which are personal care aides and home health aides. These these two types are what are represented here. And you can appreciate that we have seen fewer of those workers available per 1000 people with disabilities over the last 10 years. In order to maintain Vermonters access to health care services amid this amid this unprecedented shifting in in the employment sector. Health providers are relying on traveling staff and traveling staff from staffing agencies are necessary in order for continuity of operations and to provide high quality care. But those traveling staff do do come at a cost that is many multiple times more than the cost of employed staff from hospital fiscal year 2020 to projected 2021 the hospital Association reports that the use of travelers has increased 26% from 270 to 341 positions, while hospital costs associated with the services have increased 50% from 50 million to 75 million. And similarly skilled nursing facilities expenses for traveling staff have also increased in this time period. So with that context in mind. I think it's important to note Vermont was experiencing pre pandemic and declines in certain that excuse me at workforce challenges in certain areas. This is, this is information that was reported by the rural health services task force, and is also familiar to this body, but that has been exacerbated by the global health pandemic. The workforce development strategic plan makes recommendations to it to address challenges with the health care workforce in a number of areas. These areas include recommendations for financial incentives, education and training, recruitment and retention, regulation and strategies for regulation to invite more participation in the workforce. And the practice of providers in the workforce and federal policy. The workforce strategic plan also recommends that there be some organizing aspect for these recommendations and recommends that there be a state collaboration, collaboration across agencies and departments to organize around the objectives in the strategic plan. It also recommends that the advisory group that maintains the strategic plan be connected to the state workforce development board, and finally recommends that through collaboration across state agencies, there be an established entity to serve as a health data hub to bring together disparate pieces of data and information that inform our understanding of the health workforce, and that also would allow for supply and demand modeling, so that we can better anticipate needs for the health care workforce. So those structural elements are also recommendations in this plan. Financial incentives for health care workers to live in Vermont, to live as permanent employees in Vermont, again is one of the sections of recommendations in the plan. And here we recommend broadening and expanding existing loan repayment programs based on an evaluation of existing data and potential new sources of data. The agent, excuse me, the area health education centers should develop a proposal for expanding its service based loan repayment program to include more health care professionals and increase current program offerings. And recommendation should include the funding necessary to increase existing loan repayment programs as well as funding for including additional professional types in those loan repayment programs, and considering how those programs can adequately include critical access hospitals, employees of FQHCs, and the increases necessary for nursing faculty in its programs. We also recommend the plan also recommends increasing scholarship funding created by Act 155 of 2020, the same act that enabled this plan, and identifying a permanent source for scholarship funding. The recommendations also include evaluating the effectiveness of the existing scholarship programs, making financial assistance, and making financial assistance options for health care workforce clear, transparent, and easy to find. And the plan recommends elevating VSAC as the wayfinder for information about health care education, financial planning, scholarship and services service opportunities. We also in recommend in the category of financial incentives promoting permanent health care employment and residency in Vermont with financial incentives by revisiting tax incentives incentive proposals. In we recommend revisiting proposals and evaluating incentives that have been utilized by other states to recruit young professionals and health care workers to live and work as permanent resident states. The teams, but we also recommended considering tax exemption for preceptor income to encourage more health professionals in Vermont to participate in educating new professionals, and consider whether tax incentives should be offered to employers who are offering housing or other benefits to full time employees. And that is an important overlay for all of these recommendations. Certainly that housing childcare are equally important for the health care workforce as the workforce broadly and are certainly key priority areas when we think about our recruitment and retention efforts for this workforce as part of the broad workforce. We also recommended identifying barriers to the recruitment and retention of the non licensed workforce, but this includes home care providers. And we recommended specifically that the state interagency task team should identify and propose remedies to the most significant barriers for recruiting non licensed allied health and direct support professionals to participate in Vermont workforce. We also recommend the consideration of one time funds for health care employers to attract permanent employees. And here we recommend retention bonuses relocation assistance and housing support for permanent employed staff. I want to pause here because there has been in the budget adjustment part two and in the budget adjustment proposals to fund retention and recruitment activities for the health care workforce. And in total that's a $33 million investment that has been proposed here consistent with this recommendation. I also recommend the consideration for a longer term grant incentive program, a program that would entice health professionals to seek permanent employment and residency in the state of Vermont. And here a program could be modeled after or expand upon a program like the remote worker grant program. Moving next to the group of recommendations that are focused on education and training to strengthen the health care workforce. The first recommendation is to increase enrollment and nurse in nursing programs. We recognize that there are barriers to increasing enrollment in nursing programs and the advisory group recommended further work on this issue to be facilitated by the office of professional regulation and to include the schools of nursing and the clinical sites and health care organizations, working together to establish a preceptor model of clinical training so that opportunities for student nurses could be maximized so that the required clinical time could be realized. And that the work group would consider preceptor ships across the care continuum, including home and community based settings. The work group would also evaluate any gaps in compensation between academic faculty and practitioners, identify possible solutions and make any further recommendations necessary, including funding. This working group would consider how nurses transitioning to retirement could be incentivized to work as nurse educators, and the working group would identify any additional barriers and recommendations for increasing enrollment in nursing programs. The advisory group also recommended support for transition to practice programs for professional roles, exploring funding to make investments in transition to practice programs. These investments could help to offset the cost of hiring new graduate clinicians and support for instructors. We recommended evaluating the opportunities for funding program of this kind. We see this as a training initiative and within that $33 million that I just referenced, we have included an activity of this kind, support to transition to practice programs for professional roles. We also recommended strengthening incentives for preceptors for all professions. We also recommended exploring opportunities to expand family practice and residency programs, modifying the curriculum in the university, modifying the medical school curriculum to introduce primary care earlier in medical school. We also recommended advancing a coordinated approach to promote healthcare careers through the K-12 educational settings. And here we recommend leveraging our existing resources with the area health education centers, Vermont Student Assistance Corporation, Vermont Afterschool, Vermont Career and Technical Education Centers, and vocational rehab programs, all working together to clearly document and develop a plan to actively promote healthcare careers in K-12 educational settings, and ensuring that there's adequate funding for these entities conducting this work. We also recommended establishing a physician assistant education program. Here we recommend that the state colleges should study and provide a report to the legislature on the potential to offer a physician assistance education program, including an analysis of the employer demand for such a program. This study would include a timeline to implement any physician assistance program, as well as lay out the resources that would be necessary to develop, equip staff and operate the program, and include the timeline to attain the accreditation that would be necessary to set up a program to support a first cohort. The advisory group also recommends modifying curriculum to prepare students for work in interdisciplinary teams, developing and identifying strategies to streamline the advancement through the nursing career ladder and to upscale existing staff. Here the advisory group recommends that healthcare providers should convene and develop and identify needs for on-site delivery of training and education programs to upscale existing staff, for example, to provide incentives and opportunity for LNAs to move to LPNs and beyond. We also in the advisory group recommended that we ensure that the healthcare career education is offered to all students before leaving middle school, and that there be further advertisement and recruitment of existing apprenticeship opportunities that are supported by the Department of Labor in the health sectors. Moving now to additional recommendations for recruiting and retaining health professionals to work as permanent employees in the state of Vermont, the plan recommends inventorying and highlighting state programs that support recruitment and retention of health professionals. For example, here the recommendation would include that the Department of Labor can clearly advertise its role and availability to assist Vermont organizations that are seeking international staff members through the foreign labor certification programs. Also, recommending here that the Department of Labor can promote the apprenticeship program, as just mentioned, and also its efforts to recruit current or former armed forces members with healthcare training. We also recommend modifying or expanding programs that support living and working in Vermont for all folks coming into the Vermont workforce broadly, certainly, and where appropriate to highlight particular opportunities for healthcare providers. These strategies would include highlighting and identifying opportunities for healthcare employers such as the Vermont Rental Housing Investment Program and recommending how these programs and others could be modified, expanded or newly implemented to have a greater impact as we seek to draw more workers into Vermont. We also recommend, the advisory group also recommends a marketing campaign to promote healthcare careers in Vermont and to do so by capitalizing on existing incentives to live and work in Vermont and also capitalizing on existing platforms and modalities for recruiting and for elevating Vermont as a place to live and work largely. We also, the advisory group recommends promoting healthcare careers to new Vermonters and here recommends that the refugee resettlement program work with healthcare employers to incorporate education and resources to encourage new Vermonters to work in the healthcare field and that the refugee resettlement program promote the interim administrative rule for assessing foreign credentials because this is a speedier avenue to licensure. The advisory group also recommends developing a cross system strategy to utilize. This is, I apologize for the language here. You may be more familiar with the home and community based services 10% F map increase. And here, we recommend again utilizing these dollars for implementing evidence informed cross system strategy. And again, these dollars are contributing to that $33 million investment that the Agency of Human Services is seeking through budget adjustment and budget adjustment to as a total package to support recruitment, retention and training for healthcare employers in Vermont. We also recommend promoting wellness and peer support programs and leveraging existing appropriations to ensure that there are resources available to address the issues of clinician burnout, which are were issues prior to the pandemic, and certainly, like many challenges pre pandemic, those challenges have certainly been amplified by the global health pandemic. And the final recommendation in this group is to reduce administrative burden for healthcare professionals. And here we recommend that the legislature should review the results of the reports being submitted pursuant to act 140 of 2020, and take further action to implement recommendations included in those reports. The reports call for a review of how electronic health records can better streamline prior authorization. How the all payer ACO model can align and reduce prior authorizations and ask for an analysis of divas prior authorization waivers and updates on commercial payers and their implementation of the gold card pilot programs to reduce administrative burden. In the category of regulatory strategies that can help to address the healthcare workforce. The strategic plan recommends advertising and promoting the fast track for healthcare professional licensure for all OPR regulated professions and advertising and promoting this work again through existing platforms and avenues for advertising about employment in Vermont, such as the think Vermont program. The advisory group in this report also recommends differentiating Canadian healthcare workers from international healthcare workers, so that there can be an even further expedited to licensure for Canadian healthcare workers interested in working in Vermont. This strategic plan also recommends reducing licensure licensing barriers for telehealth practice, taking into account the recommendations that are forthcoming from the workgroup created by act 21 of 2021. The further recommendation is to evaluate further opportunities to remove barriers to licensure for mental health and substance use disorder treatment professionals specifically and the plan asks that within the next five years, the Office of Professional Regulation undertake a systematic review of the licensing process for mental health and substance use disorder treatment professionals and make recommendations to address barriers to licensure for these professionals specifically. And finally, in this group of recommendations, the advisory group recommends consideration for temporarily waiving licensure fees for first time licensing licensed nursing assistants, essentially to remove a further potential barrier to moving into the healthcare workforce in Vermont. The advisory group also discussed modifications to the practice and how providers practice healthcare that could help to address the workforce challenges that we are confronting. And here recommend maximizing flexibility for reimbursement under and utilizing in order to do that, the potential flexibility that we have via our all payer model agreement that allows for Medicare to pay differently in the state of Vermont. This is a very specific recommendation, and it was also a recommendation from the Royal Health Services Task Force that the AHS as well as the Green Mountain Care Board negotiate for more flexible reimbursement policy to address service site and geographic restrictions that Medicare has and including reimbursement for audio only services that are more expansive that and are certainly being used more expansively after the and during the public health emergency. As as examples. We also recommend developing commercial reimbursement models for audio only services, expanding telehealth coverage, making telehealth billing requirements clear and establishing a statewide telepsychiatry program in emergency in emergency departments. In this recommendation, we recommend that we explore a telehealth telepsychiatry program that is similar to that in North Carolina. North Carolina has a statewide telepsychiatry program that would help treat and divert psychiatric patients that seek care in emergency departments. And finally, I want to highlight the the report does include quite a quite a significant number of federal policy priorities that rise to the federal level. But I'd like to highlight specifically today the advisory committee's recommendation that there be federal action and support for strategies that would minimize the increasing trend toward travel staffing. This trend as I highlighted earlier in my presentation is resulting in unsustainable cost increases for healthcare employers. We in the report recommend exploring anti poaching provisions that would be directed at travel staffing agencies at the federal level exploring price gouging prohibitions and reforming federal tax incentives where that are beneficial for the traveling staffing and traveling staff health care organizations have a very difficult time competing with these staffing agencies due to the federal tax benefits. These benefits include non taxed housing stipends non tax per diem such as meals and incidentals and non tax travel reimbursements. And certainly the recruitment and retention proposals that have brought forward that have been brought forward to date, do recognize the environment for healthcare employers to recruit, train and retain permanent staff has become much more competitive. It's become much more competitive between the states and the nation that are working to attract and retain health care staff during this during this pandemic and this unprecedented time of healthcare workforce decline. And as well as states competing with one another and employers also competing for staff with these staffing agencies that that concludes my overview of the workforce development strategic plan. And I'm happy to stop screen sharing or you know, thank you so much, you know there's a great deal of work in this and the, the advisory group has done an exceptional amount of work it looks at and somewhat an extension of the work from our previous rural health care task force, and some of the other conversations that we've had in the legislature but it's a huge step forward and thank you for bringing this to us. So I think it would be helpful. I have one question on the last screen. Before you take your screen down and that is the federal tax. I guess my, you know, if we were to step out and put some taxation on these things at the, at the local level that would put us out of step with the rest of the country, and then we would lose. And if we put restrictions on our traveling staff regardless of nurse we hear mostly about nurses. So we put restrictions on them and said for every, every amount of time you spend as a traveler. We look for a commitment as a resident that you know some something like that. This is out of step with others and I'm questioning whether or not your you and the administration has reached out to coalition of states to begin to build a pushback on the traveling staff and on traveling nurses, because it's going to take a critical process to, to make that happen. Now, for me I have former students who have become traveling nurses and they do exceedingly well, but it, it is not at this point it is undermining our health care resources so the question I have for you is, is, was there a discussion about any kind of regional or broader statewide connection to look at reducing numbers of travelers, you know by reducing the, the payment scale, whatever. Thank you for the question. I'm fortunate to be able to connect with with several national health care organizations I think you're familiar with the National Academy for state health policy. I'm fortunate to be able to participate in, in discussions and to share information. I have shared with the National Academy for state health policy, this workforce development strategic plan. I do know that that is an area that other particular to traveling staffing agencies, other states have also come forward to, to bring this issue forward. What next steps there may be. There is still an open question, but I have used those forums that again I'm fortunate to have the opportunity to work with to bring this message from Vermont, and to seek out whether or not other states are experiencing this issues and they are. Yeah, they sure. Yeah they are. Why don't you take your screen share down and we can come back to it if we need to we also have this on our iPad so this is helpful. And so the, just to continue with the thought on multi state initiatives I know a lot of this might be on the shoulders of our vase, and having those folks get together with their counterparts in other states or have the national participation come up with some policy on travelers that would help Vermont, you know, it's, it's not going to help Vermont if we step out all alone. Just, and I would think probably, I'm thinking that some of the vase folks are listening on YouTube and I, they'll probably tell me they can't do this. It's a difficult time I get it, but having some coalition building outside of our borders would really help. And this is a, this is a, this is a long report and I don't know if you've had a chance to read the entire report. But I would recommend that you do that. And there are some very tiny places where the legislature has some recommendations, knowing that all of this started. And we feel a strong obligation to continuing our work and responsibility. I do have a, I had, I do have a couple of questions. And I, so I'm going to go forward with those and then if other folks have questions and we'll get into some discussion I hope that it, the interagency task team that you've talked about and then merging with a workforce and build a board seems like a very good idea. My concern is that that something that is an administrative step. And if it happens administratively, then we know that administrations change. And we might lose that my, so my question is, was there discussion about having that task force be embedded in statute, even if for a short period of time to ensure that this work continues. No, we did not. The group did, did not discuss that particular question. And certainly the coordination effort, I think, is one where we are among agencies and departments, particularly having had, you know, consistent coordination to address the public health emergency and throughout this pandemic, a truly cross agency and department response. We really sought to in this recommendation we really sought to continue that track record of working together to address these sorts of issues. I think we're all for that. But you know we are legislators so we look for ways that we can help promote that work. And so that might, we might put that on the table for discussion pros and cons there. And then looking at the advisory task force, obviously there were no legislators on it was more of a outside work and we're, we're pleased that that happened. Sometimes when we look at these things we understand that there might be some more discrete legislation needed to keep this stuff going. And I included that some of the funding pieces, the housing pieces that you mentioned all of those things fall on the shoulders, so that we can keep keep going, not not the lease of which. When you start talking about doing some kind of a market analysis for increasing the number of PAs in the state. And there and I, I do have a couple other things so just just sharing with you as a legislator. When when I go through this I see places where we can place our hands and help. It's not a matter of intrusion it's a matter of support. So, will, as we work on this, our committee, in particular since it's health care. Hello. I hope we'll have a lot to to provide in in help, because we want to do that. And some of us have a long history of experience in the health care environment and, in particular with the work that a heck is doing and then with programs at the collegiate level and others so we'll be working on that. I do have a couple questions. And they're that that the data indicates in the report itself that there's, and we know this has been a drop in our primary care providers in the state. At the same time, we've seen an increase in PAs. And the, the recommendation is to have a PA program in the state. I find that really important. I myself worked to build a PA program a long time ago. And it didn't happen but maybe this time it will. And, but they're the Education Committee and the Health and Welfare Committee can work together on this with our state colleges to ensure that some kind of a clinical placement program is there. It's not going to happen if we don't have the primary care offices. So your recommendation on increasing primary care incentives is absolutely key and building greater primary care presence in the medical school curriculum is is probably key and I'm pleased that Charlie McClain was on the advisory group so that message perhaps we'll get back to the med school. We don't legislate the curriculum. We can make recommendations, and that's for all of this, this whole area, we want to make people available to do the teaching and the conditions available but we can't say teach X, Y or C. Well, maybe the Education Committee wants to get involved with that, but Senator Hooker, you can. We can do that. I'm really glad that you're, you're bringing these points out, Senator Lyons, because it occurred to me as we were listening to his back is that we've heard all of these points in various parts of our legislative lives. And it would be important for us to know exactly where we can affect the change. So, looking forward to that I really like the idea of highlighting healthcare careers in elementary school, you know, and all the way through and there is a lot that we can do. And that actually that's a question I had, and I'm Senator coming to your next I got it. As you're going through, and obviously elementary middle school by middle school you need to have something extracurricular activities is critical for careers and in earlier ages. But the, the question I had is, there's a lot in here about healthcare, and there is a mention of DAs and a substance use disorder and mental health, where, for me, the continuation of a of a strong healthcare environment, it goes into counseling. And so our job in here is going to be to look at mental health and substance use disorder folks as well as the PAs and the PCs and so on. So, can you mention talk a little bit about any conversation that you had around mental health or substance use disorder counseling or extending even into the recovery or other areas. Absolutely. The, the committee did include, it did include membership that were also involved with workforce development, planning and conversations, but focused on the designated agency workforce particularly so we had that cross section of membership in the committees in this advisory committee and the designated agency focus workforce workgroup. And I think you can see the particular in some particular places where recommendations are specific for mental health and substance use disorder workforce professionals, such as the example with licensure and barriers to licensure. I think that there are some significant barriers in how credentials are assessed for that group of professionals that does make licensure more obtaining licensure in the state of Vermont more challenging for those professionals. That's one example. However, there's some other important work that the advisory committee recommended to evaluate the opportunities for alone repayment and scholarship for a broader range of healthcare professional types. And in that recommendation we were thinking specifically of mental health and substance use disorder provider professionals in evaluating what opportunities there might be for inclusion of again a broader range of health professional types. And I also, the report does have the recommendations regarding the non license workforce or the direct support professionals or direct support workers. There's a lot of acronyms that are competing right now and I'm not sure which is the best one to use to describe that workforce. But that is certainly a workforce that designated and specialized services agencies employ and we do recognize the particular challenges in that workforce. Yeah, the support staff. So critical. I have other questions I'm going to ask Senator Cummings to go ahead. You're muted Senator. Okay, I'm as bad as my committee members. In recruiting, we should get a TV show with the latest TV, pre adolescent heartthrob starring as an LNA, which would probably do more to increase the profession than anything, or what are they influencer blogs. But, yeah. Yeah, what what I'm interested in is we've had testimony in the past about the reimbursement rates. We've got the reimburse and primary cares where it hits the reimbursement rates for independent practices that are not affiliated with our one mega teaching hospital. We've also lost a whole slew of pediatricians up in Franklin County. We've heard testimony from other doctors that if you were located in an area that is primarily reimbursed with Medicaid rates. You cannot make it, which means that we have a wide disparity and a lot of this is in a lot of areas is coming. It is coming down to dollars. We're talking about reimbursing the rates for the, the last bill we looked at for a home and community. And I think we all know yes we have a crisis there it's dying. We need to talk about that and again, every year I get three, four bills in my other committee asking to tax the rich for a new program. But if we're going to reinforce this we need to talk about ongoing revenue and right now, the reason many of these programs are underfunded is, we don't have the revenue. We're going to put it here, unless we come up with new revenue, we're going to take it from somewhere else. And then, in five years, we'll be looking at that crisis and I know you're going to send that down to that and that just is the reality. But Senator you are you know you you're on target and these are the things that we continue to talk about in here and we're going to we're going to take some steps, I guess. Yeah. The overarching issue is maintaining some sustainable funding and but but I do have a question for for Ena on this director back us. We have this whole health care crisis whether it's substance use disorder counseling, mental health, nursing, primary care, whatever it is it's exacerbated by pandemic. No, no question. And without the pandemic, we would be limping along and okay you know we're going to do this that the other thing now we're looking at a statewide strategic plan that we initiated during the early stages of the pandemic. So, we do have federal dollars coming to us, or here, and we must be able to coordinate some investment of those federal dollars into a lot of the things that you've listed I could see. So, it's not a simple work to build a PA program or to enhance primary care education, substance use mental health education to build out some programs. I don't even know what the guidelines are relative to an endowed chair at a college for a specific program and sometimes it's the endowed chair that brings the star faculty member that then highlights that program across the country. My question is, have you looked at ARPA dollars and maybe strategic and creative ways of using those dollars as the plan is clear we were certainly looking to maximize the 10% increase for home and community based services providers that is a federal government program specifically to strengthen that workforce and as we've and we will continue to testify to impairing that in those investments with other funds to to really create a strong a strong investment in retention recruitment programs for the areas that you've named outside of those of those initiatives. I have not and the advisory group did not look specifically at ARPA dollars as as a source for those activities such as a K through 12 curriculum, you know design for instance or for the establishment of a physician's assistant, a PA program as another example, we did in doing our work. We did identify as you as you can just got the whirlwind tour numerous areas, numerous areas where we would recommend further work and study to evaluate those opportunities and and to identify potential funding sources. The plan is clear in a number of areas that the groups that would that would be doing the work to evaluate the need and would also be evaluating potential funding sources. So, I guess, I guess my concern and then Senator who has a question or comment is, we're on a fast track. You know, so can we wait. So, I'm, I'm interested in what can we do that will facilitate and there will, I'm going to send. When I go into talk with Senator Campion in education I'm going to say, you know what what money's what money's are available in our elementary and secondary schools to promote some of this and work collaboratively with a heck or others, you know, so we need to, we need to step on this so fast. Yeah. And I just think that, you know, we have to look at what the restrictions are on the ARPA funds, you know, is there a time limit, we're up against that time limit, you know what can we do that will get things done. Quickly, you know, I'm thinking as you spoke, Senator Alliance I was thinking about loan reimbursement, you know, as a this is a one time thing we could pay off loans for for physicians to come here we could pay off loans for nurses we and these are things that we've talked about in other other committees or in our committee and I'm just wondering what the what the group is going to do to push these things quickly. So, I guess, at this point, you know, first, before I ask my question. I want to say, thank you. Thank you. Thank you for all the work that you have done on this. The fact that you are stimulating questions and discussion means that you've really taken us to the edge of the cliff. And we greatly appreciate everything that you and the advisory group has done, and everyone else who's weighed in on this so the questions aren't criticism, the questions are next steps, and how can we promote the work that you've done. I probably should have said that in the beginning, say thank you. But I do have one question you you talk about cross system strategies. And are you thinking about cross agency department or system in terms of health care economic development housing. The systems that are in that embedded in that. And then Josh has a question, Senator Tarenzini has a question. It's an excellent question it's certainly a theme throughout the plan that there does need to be cross system approaches to the issue of workforce development and again workforce development is a challenge across sectors. It's only a challenge for the health sector. And so we do have an important opportunity that we must seize to emphasize workforce development across sectors to include health care. Very importantly, but in the realm of investments in or work to address the issues with housing. That we have the issues with childcare. Those are important cross sector examples of cross sector approaches and approaches that are applicable broadly and to the health care professionals as well that we would like to recruit to Vermont. We also talk in the report about cross system collaboration within the health care system and, for example, team based care being a way to, if you will spread our resources further to promote perhaps more satisfaction in care delivery on behalf of those professionals can benefit from being trained to work in teams and to be able to rely on one another as colleagues in providing the best high quality care to individuals so that's a that's a health system level. And in that example so we have a couple of levels where we're really through our recommendations here promoting collaboration across state government, broad sectors, and within the health sector specifically. Okay, thank you. I thought that was the case because it came up several different places in different ways. So that's helpful. Thank you. Senator Karen Zini. Senator Alliance, I just wanted to piggyback something that Senator Hooker said that was interesting, you know, we, we talk about all the problems we know we have retention problem we know that we have, you know, we can't, we can't place enough people or these students right now in clinical settings because of the, you know, the limited spaces and so on. You know, Senator Hooker I, you know, as you said we have billion dollars to billion dollars whatever the number is. And, you know, maybe, maybe it's something that we have a committee bill or whatever that says we want. I don't know what the numbers pick a number $5 million 10 million dollars whatever the number is set aside specifically for the repayment of student loans or the promise that you come here and nurse or you open your medical practice for the next 10 years will will pay your licensure fee will will do something to incentivize you to come here because whatever whatever we're doing right now and I don't mean us but I mean, whatever we're doing collectively isn't isn't getting the job done so food for thought. Yeah, good. Yes, very good. You know you, you raise the issue. We do have our acts six work before us and the other, the other laws that we put into place. And so that will be our kind of our short term let's get this work going but we then we also talked yesterday and we'll continue to talk about the workforce issue as a longer some longer So I think the act six falls into the category of telehealth telemedicine a little bit and well maybe we'll look and see if there's something we can add there. But then our longer term bill that we hope to get out before the end of the session. We'll be putting some of this in and I, your suggestion is a good one well taken. That, and I know a heck has done credible incredible work on loan repayment. So, the expansion of that that suggested in the workforce report dovetails with what you're suggesting Senator Tarenzini. Good. And then the other one that I was pleased to see was the recommendation around the EHR that act 140 electronic health records. And can you just elaborate a tiny bit on that one. Is that possible or we can wait and get more testimony. And I can you anywhere on the floor. We 10 minutes ago. No, today's today's Thursday, Senator. That's right. It's one tomorrow. Right. Right. We're going to. I'm good. We're just about to wrap up but I want to make sure that we got all our questions answered and you know has. Yeah, no, I just saw the thing come up and for some reason I was thinking it was 1130 we were out. Tomorrow. I'm going to get, I'll get acclimated yet. I know it's going to take time. I think it was something about prior authorization related to EHR. Or an expansion of our electronic health records with it. And that, and I'm my question is, is that going to be more inclusive for different practitioners or. I've moved back in my, in my notes so that I can, I can review. Let me know if you can't see me. I can't see you for the moment, but I'll okay. We can hear you that's important. Okay. So in recommendation regarding the reduction of administrative burden. There are reports that are being submitted pursuant to act 140 of 2020. And those reports will will provide some insights into how electronic health records can better streamline prior authorization. So that's the report is anticipated for the legislature, the report, the charge in that report, if I understand clearly was to review how the electronic health records can be streamlined to promote prior to to address. To address prior authorization administrative burden. So how the electronic health record can help to reduce the administrative burden associated with prior authorizations. So that, and as I understand is a report perhaps that has been received already or that is pending for receipt by the legislature and the advisory group thought it would be important that the legislature review the recommendations within it. In case there were places for further action. Good. Thank you for that clarity. That's helpful and we will be looking at reports and hopefully get to that one. I do have one last question. That is, as the group was going through the whole. Improvement through the higher ed or any educational programs, knowing that there's a lot there I mean a certification programs or tech ed programs all of the that work and that we've been interested in the past. But what conversation was there about enhancing the remote learning environment for some of these more, more specialized areas. Did the advisory group consider whether remote learning could be an avenue for persons to gain education training. And I listen I know that it's being used for you know I know that some of the master's programs and V you are totally online. And I know that CCV is very much of an online environment. And I know that there are a lot of systems and to what extent other programs and higher ed institutions are utilizing remote. I know I know we've heard how difficult it is for high school kids but there might be some advantage for technical schools and others where there's certification, including childcare. And I think that that's a really creative way to think about the issues we didn't, and, and the groups, the group may want to keep me honest in my memory here I can review our notes from our discussions. It's occurring to me that we had that specific discussion but one thing that we did discuss and we did highlight as a future area for consideration, was whether or not simulation experience could be a way for people to gain critical clinical critical clinical that is, it's not remote per se but it wasn't that was an area of discussion that seems similar to what you were raising in whether the remote opportunities were discussed. Right, I do think that remote simulation is not a bad idea and of course it depends on what you're doing you're not going to be doing surgery that way but. You know, telemedicine started with some pretty hands on stuff but so just a thought, and this is something we might be talking about and exploring and as, as you and your team are interested in helping us with our legislative work, because we are going to work on this in here. It would be helpful, first topics and people who they may be listening in right now be great. That can help us formulate some of these ideas into a way that will push things forward and knowing that whatever we do I mean it's it seems like resources are at the bottom of it. Whether it's loan repayment or expansion of a of a program somewhere so. We look to you for your recommendations on who we can have in to help us on workforce. As I said before. Act six is in front of us will continue our work on that will be formulating a committee bill either we or the health house health care will be doing that. We will be formulating a newer long term bill and I I see workforce as being a part of that we might use a bill that we currently have and committee will just see, you know how that sugars off, but your insight and help with with this will be very valuable. Questions committee. Just one comment and I don't know if it belongs here or in education but an increase in apprenticeship programs. I think is really critical. Not everybody goes through the, you know, the traditional schooling to learn skills and you know that that's across the board I mean whether it's the trades or health care. And a stackable credentials, all of those things that we need to talk about so that we can encourage people and help people to get through to gain the experience they need to increase our workforce. We could use our little CEO bill to do that, and then send it to education. Okay, whatever it takes, Senator, you know it. Okay. And we could use a dental bill to do some of this. I mean there's a lot. All right. Any other questions for Ena. All right. Thank you so much. We appreciate your time and the work that you've done on the report and this is just the surface of the report will start diving in a little bit and putting together some thoughts and will rely on you for your help in doing that so. Thank you. Thank you as well for your thoughts and recommendations and your feedback. All right, terrific.