 All right. Good morning, everyone. This is the Senate Health and Welfare Committee meeting on Thursday, August 27. Thank you all for being here. We're continuing our work. And we're now beginning to look at the COVID relief fund expenditures and how that's going, how much is left, where it's being utilized. And Sarah Clark is here from the Agency of Human Services. Sarah, thanks for being here. Why don't you do we have something from you on our webpage? Yes. Yep. There's a PowerPoint presentation. Why don't we pull that up? Are you able to share it with us on the screen or maybe Jen or Nellie? Can we have that shared up on the screen? And I can make Sarah a co-host and she can screen share. Perfect. That's good. All right. She's now a co-host. Okay. See my screen. So just, just Sarah, you're going to give us the, the, the summary and overview. Maybe why don't you introduce what you're going to give us and then we'll know where we have to go next. Sure. Sounds great. So for the record, my name is Sarah Clark. I'm the chief financial officer for the Agency of Human Services. Today I'm prepared to give you an update on the various coronavirus relief fund programs that the agency has, has stood up. So the, the slide that you have before you gives a kind of quick overall summary of the appropriations that AHS received from the coronavirus relief fund. If you look down at the bottom of the screen, you'll see $500 million has been appropriated to the Agency of Human Services through either the joint fiscal committee process or through the various bills, but the legislature passed last or earlier in the session. Half a billion dollars. That's a lot of money between, you know, when the pandemic started and the end of December. So the agency has, you know, been hard at work trying to stand up a variety of grant programs. So, as you'll see in the kind of top box on the screen. I've isolated for the various joint fiscal committee meetings beginning back on May 11 when the agency received 115.7 million dollars of appropriation authority from the coronavirus relief fund across all of our departments for a whole variety of programs. Of that original appropriation through June 30 of 2020. So the end of state fiscal year 20 the agency spent roughly 91 million dollars. And our work is ongoing related to those original appropriations subsequent to that original meeting on AHS received a few other JFC approved appropriations for some targeted programs including 10.2 million on June 8 for the brettal moral retreat. $500,000 on July 29 for a suicide prevention program. And just earlier this week, almost $12 million for a remote learning and school age care program that the Department for Children and Families is working hard to stand up in advance of school starting in a little bit more than a week. So across those JFC approved amounts that's roughly $138 million. His presentation is going to focus more on the second box that you see before you, which are the various grant programs that were appropriated across multiple vehicles during the earlier legislative session. So to include in Act 109 which was budget adjustment number two for state fiscal year 20 the agency received $3.6 million for both an EMS relief program as well as some funding for community investments at the Department of Corrections. In Act 120, which was the one quarter budget for state fiscal year 21, we received almost $7 million in appropriations across a variety of programs to include legal aid, the blind visually impaired program adult days, micro business and a variety of miscellaneous appropriations for the Department of Corrections. In Act 136, which was essentially a coronavirus relief fund bill that was focused on health and human services programs, the agency received by far our largest appropriations of $323 million. Of that $323 million, the largest by far is the $275 million for the healthcare stabilization program, and we'll talk more in detail about where we are at with standing up that grant program. Another important component of that $323 million is a $28 million appropriation for an essential hazard pay for essential workers program, and I will give you an update on the status of those programs in future slides. In addition, Act 137 was a coronavirus relief fund bill that was focused on broadband and housing programs. The agency received a little bit more than $17 million in appropriations. The largest of included in that amount was $16 million for a homelessness program. As you are aware, we experienced a kind of surge in the homelessness problem as a result of the COVID-19 pandemic, and this program is designed to transition individuals out of the motel programs with these funds. And then I've also included here, though it's pending because there's almost $11 million in appropriations that were submitted in the FY21 restatement budget that the governor provided to the appropriations committees earlier last week. Within that $11 million, there's funding for reach-up caseload, which has seen a surge as a result of the pandemic, some funds for corrections staff that are substantially dedicated to the COVID-19 response, as well as some miscellaneous funding for the Department of Mental Health. So, all in all, within those bills that we walked through, that's roughly $361 million of appropriations. So, that's a lot of money to spend. There's a lot of guidance, not a lot of guidance actually, but there is guidance related to the coronavirus relief fund that the U.S. Treasury does kind of continually update. Part of the administration at large, one of our priorities is making sure that we're spending these funds in compliance with the guidance. Towards that end, the agency of administration created the COVID-19 financial office, CFO for short, to oversee the distribution of money from the coronavirus relief fund. Any agency or department that received an appropriation from the coronavirus relief fund must receive approval of their grant program prior to proceeding and requesting applications. Towards that end, the CFO designed and implemented a grant program questionnaire to understand the details of each program to help warrant compliance with CRF guidance and regulation. It's essentially a risk assessment of the program. The items that we must provide details on include COVID-19 related expenses, any revenue losses that provider groups could have experienced as a result of the pandemic, as well as how the departments and agencies plan to administer these grant programs. It's a very helpful process for the agency because it helps frame for us how we're going to proceed with these important grant programs. One of the questionnaires was reviewed by the agency of administration and at CFO office, as well as with Guidehouse, who is the administration's consultant on the coronavirus relief fund. They actually issue a formal response to agencies and departments questionnaires prior to us moving forward. With less or any questions I plan to kind of jump into the status update across multiple programs that we've stood out. Actually, I'm going to suggest that we hold our questions until after the presentation and if you all could just maybe write your questions down I know I have a number of questions but I think it might be better to allow Sarah to get through all of her slides. That works for me. I'll also point out that this is organized by department and the secretary's office in terms of where the funds were appropriated and who's administering the programs. So there may be some areas that is not necessarily under the jurisdiction of this committee and so we can kind of move quickly through those unless you want me to go into more detail. But so let's start with the secretary's office. You can, and I think those things that are more directly related to our jurisdiction are important but secretary's office is part of it. Yes, definitely. And that's we receive really the bulk of the appropriations because like the health care stabilization program is is appropriated to the secretary's office. So we'll get into that one shortly but the first two on this list and folks are able to see it. It's big enough to make it a little bit bigger here and our two appropriations to legal aid. One is directed to to legal aid to provide some financial support to provide access to justice services for Vermonters. The current tranche of funding to legal aid was related to providing legal and counseling services for Vermonters who are or are at risk of experiencing homelessness. For both of those pots of money, grants have been executed between the secretary's office and legal aid, and we are in the process of reviewing the financial report and the invoice for July expenditures. I anticipate that we'll be making a payment in early September. So those those programs are up and running and flowing. The next program is $3 million was appropriated for EMS providers. Of that, essentially there are is $900,000 that was earmarked for the Department of Health to provide training programs for paramedics and EMS personnel. Broken down that $900,000 in two tranches, $400,000 for EMS training and then $500,000 targeted to paramedic training. That $900,000 has been transferred from the secretary's office to BDH to carry out these programs. For the paramedic training program, the Department of Health has stood up that grant program. They have received 26 completed applications to date, though it is an ongoing process. However, they do expect with 28 awards those funds a half a million dollars will be fully obligated. We expect to fully spend those dollars by December 30 when the coronavirus relief fund, at least as of right now is set to expire. Related for the EMT and AEMT programs, they have received 35 completed applications to date. I think that is there is still significant capacity within the funds for that program for more applications to come in. They are experiencing an issue in that there are not as many licensure programs available right now for these types of training courses. And so the health department is kind of continuing to work that issue to make sure that the training is provided for the legislation and that we obligate and spend those funds in a timely manner. That was $900,000 for training within that $3 million appropriation. In addition to the 900,000, there was $2.1 million that aside for the secretary's office, 100,000 where we were to work with the Department of Financial Regulation to hire a consultant who would be able to promote EMS providers with the application process. DFR was an amazing partner in that process, and they actually issued a simplified bid, even though we had authority for a sole source for the legislation, we felt it was important to issue a simplified bid to make sure that we got the, you know, the best consultant available to help our EMS providers. So we have done that and executed a contract for this technical assistance. The health department is taking the lead on distributing the $2 million that is available for financial assistance to the EMS providers. Those funds have not gone out the door yet, though we are quickly working to stand up a program and distribute funds as quickly as possible. So I expect, and this applies to a lot of the programs that we're going to talk about today, I expect that in the next three or four weeks, we're going to have more information for you in terms of awards that have been issued and relief that has been provided. So that is the EMS provider program. The next one that I'm going to talk about is the $28 million that was appropriated for a hazard pay for essential workers program. The legislation surrounding that program was fairly prescriptive in terms of the types of employers and employees that were eligible to receive hazard pay for the period of work from mid-March to mid-June, kind of the heart of the pandemic. For this program, as well as the health care provider program that we'll talk about shortly, the Agency of Human Services working with ADS stood up a Salesforce grant application program to help facilitate the collection of applications from the employers on behalf of their employees for this program. That application opened on August 4th. On August 14th, which this is a little bit dated, we have received 460 applications. This is a first come first serve program in terms of obligating the $28 million. We've received requests of roughly $30 million. However, not all are necessarily eligible for the program. This is a new committee that is going through all of the applications for completeness as well as eligibility standards. We anticipate that the review of the applications that we've received will be completed in mid-September. However, because it's a first come first serve program, we expect that we'll actually be issuing some grant awards for this program, likely by the end of next week. And so that is moving forward. I think there is, and you are likely this committee is aware that there are some conversations happening in the Senate now about some potential technical corrections to this program to, you know, clarify some eligibility in terms of employer types as well as maybe potentially expanding. But I wanted you to know that this program is really well underway. A lot of work has been done. Wendy Trafton is the lead in the secretary's office and has done really a remarkable job standing up this program. Great. So the next program that I will provide an update to you on is the $270 million that was appropriated to AHS for establishing the healthcare provider stabilization grant program. There has been a lot of work that has happened over the last month and a half to stand up this program. So similar to the hazard pay program we developed a Salesforce application working with ADS. I think this committee is aware that Salesforce was the foundation for several programs across state government, ACCD, agriculture, the tax department, as well as these two programs within the secretary's office. The application opened to providers on July 17, the first round of applications closed on August 15. And we do anticipate, depending available funding, that there will be a second round of applications that would open up in October. To give you kind of a sense of the timing with the two different phases, phase one focused on expenses really for the time period, March through June. We anticipate would focus primarily on expenses or less revenue for the phase July through September. And so that's why we're taking that phased approach. You know, pending the availability of funding, though we do anticipate that there will be sufficient funds available for a second round. In the first round we received 343 applications from eligible providers. Of those applications, 78% were new to AHS, meaning they did not come through the door in our early relief efforts that we stood up in the kind of immediate response to the pandemic. So 22% had participated in our early relief efforts. The applications have been submitted across a wide variety of provider types. Just for a kind of point of interest, 22.7% were dentists based on the number of dentists. We are reviewing the applications now, it's actually a pretty complicated process and so there's been a lot of work done to arrive on the methodology and how we are going to review the, the significant amount of documentation that providers submit as part of this application process. We do anticipate starting to issue awards within the next two weeks. So similar to the hazard pay program I think in the next three to four weeks, we will have more information to provide to this committee and the legislature on amounts of award that were issued and to which providers. So, Sarah, I will, we will come back. I will have a question about this and in particular the complexity of the application process and the outreach provided for folks. So we'll come back to that but that is an important question I think a number of of us have heard about two questions. Yeah. Okay. So the next grant program that I'll talk about is that the agency received $2 million for distribution among populations made vulnerable by the COVID-19 public health emergency. The Department for Children and Families is taking the lead on this program on behalf of the agency. The kind of current plan is that we would be issuing one time stipends to reach up households to meet the intent of this legislation. The questionnaire that I referred to earlier that the agency of administration has stood up for these CRF grant programs is in process has not been submitted yet, but we do expect to stand this program up shortly. The next program I'll talk about is that there was a $700,000 appropriation to AHS to be split equally between the Association of Africans living in Vermont and the US Committee on Refugees and Immigrants Vermont Refugee Resettlement Program. The grants to both of those providers have been executed. And we are in the process of reviewing their July expenditures for payment. So those programs are up and running, providing services to Vermonters. So the next, that's kind of it for the agency of human services. The next are some programs, funds that were appropriated to the Department of Corrections. You know, they are still in process, but very kind of prescriptive in terms of how those funds should be utilized and corrections anticipates getting those funds out the door shortly. In the Department for Children and Families, there's also multiple programs that were stood up there. To include $1.4 million that was appropriated to the Office of Economic Opportunity for Micro Business Recovery Assistance related to the COVID-19 pandemic. So DCF has executed a grant with Brock Community Action on behalf of the five community action agencies. Brock is going to administer this micro business application process. The businesses will apply through Brock. We anticipate that a million dollars will be dedicated to grant programs for these micro businesses. $400,000 will be set aside for counseling support for these micro businesses. It's a rolling application process that's first come first served basis. The awards are smaller reward amounts between $2500 and $5,000. The next program I want to talk about is the $4.7 million that was appropriated to DCF for distribution to the Vermont Food Bank. Again, this grant has been executed with the Food Bank. The Food Bank will be granting these funds to its network partner food shelves and meal sites along with other partners to provide food, nutrition assistance, and other necessities to needy Vermonters related to the pandemic. That program is up and running. DCF also received an appropriation for a $12 million childcare program focused on providing restart stipends to childcare facilities, summer camps, and after school programs. As well as support to the parent child centers and to children's integrated services providers for telehealth training. The application process for this program commenced on August 7th. Instead of a Salesforce application applications were processed via web forms as well as through paper applications depending on the provider. This application process closed actually yesterday. And we plan to issue notice of decisions and award by September 11. In addition, there is a $16 million program at DCF that's designed to help. Before you jump down to that last little box there. A clarification I want to make sure that that we're all aware of and that is that that $12 million is separate from the joint fiscal money that we've been talking about in this committee with respect to childcare so there's an additional tranche of money available as schools open for school aged care that may also go through the after school programs and others that we're, we're still looking at. Thank you, Senator Lyons that's an important distinction. So the last program that I'll talk about for DCF is the $16 million that was appropriated for kind of state stabilizing housing opportunities for those experiencing homelessness as a result of COVID-19. That program is underway. And there's a variety of components to that program. I think if you, you know, for all of these programs that I'm talking about today, trying to give you a high level overview of where we're at but if you want more details bringing the department representation and will be a good idea. Okay, so I believe Dale is also a department where this committee has jurisdiction over. So there are two Dale specific programs. One is $100,000 to be granted to the Vermont association for the blind and visually impaired that grant has been executed and the program is underway. In addition, there was a $2.45 million appropriation set aside specifically for the adult day providers. In that legislation we actually had to execute the grant agreements and get the dollars out the door by July 20. And so I want you to know that we have executed those grant agreements and the dollars have gone out the door to stabilize the adult day providers that have not been able to be open because of the pandemic. The Department of Mental Health also received two, excuse me one targeted appropriation and one please let us know if you don't get that SAMHSA grant. We'll talk about the SAMHSA grant first. So as I think this committee is aware, the Department of Mental Health had applied for suicide prevention grant from SAMHSA. At the time, when you last adjourned, we did not know the results of that grant application process and really in short order we found out that unfortunately we were not successful with that SAMHSA grant. The good news is we came in to the JFC process in July to request a half a million dollars of coronavirus relief funds to be able to implement a grant, a suicide prevention program in state this year. Commissioner Squirrel provided some updates to House Health Care earlier this week that we are also in the process of applying for a grant from the CDC a five year grant from the CDC for suicide prevention. But if we if we do receive, we'll have a sustainability plan for this important work over the coming year. In addition, there was a $200,000 appropriation made for the pathways program to operate its peer warmline 24 hours a day seven days a week. That grant is being routed for execution and we will be staining up that program. Within the Department of Health, they also received two specific appropriations. One is a half a million dollars for addressing COVID-19 related health disparities. In response to that grant program the health department established the health equity and community engagement team to consider the needs of vulnerable Vermonters and any sort of resulting health disparities created by this crisis. The WHO has issued awards to a variety of providers to meet the intent of the legislation surrounding this grant program. I've included in this presentation a link to the report that the health department provided the legislature that provides you some more details in terms of which providers received funding related to this appropriation. There's $800,000 that is to go directly to the Vermont program for quality and health care. The purpose is to support equitable access to telehealth services. BDH is working to execute this grant and we anticipate it will be up and running shortly. And that's a quick snapshot of the programs that the agency has stood up. Thank you. What an amazing amount of work in a short time and just one comment about the 800,000 that went to VBQ HC. I think that was a finance committee. Recommendation and after we and our committee had done some work so it was a nice collaborative process to see that happen. I think all of it is I see that Senator Westminster's hand is up. So I know there are a lot of questions. I have a number of questions, but we'll we'll start out with Senator Westman. Unmuted here. So Sarah, this is a great list. Thank you. What I have for a problem because all of these appropriations were best guess and estimates in the beginning. When we look at this, can I tell where the requests were way over what what we appropriated, or the applications that are coming in for these things are not as great as what we appropriated. So how do I, in this list, look at it to try to figure out how to true this up. Is there some way to have a another column that says, here were the requests here's what we've been able to fill. How do I from this vantage point, figure, answer that question in the overall you muted yourself. I think it's a great suggestion for me to add a column to this spreadsheet to be able to kind of give you an indication of adequacy of funding. I think the reason that I didn't incorporate it just yet is for some of our largest programs it's still a work in process, trying to determine if funding is sufficient or not. But I think I could quickly provide to the committee and to you, you know, my initial assessment and where we are from an adequacy perspective of funding. That would be helpful. Good, you go ahead. Sorry. I'm sorry, I, I, what I don't, and what I don't want to do is I want to make sure that if we put money into an area, and there are applications for it. We can get applications out the door because as we know, none of us want to leave any of this on the money behind. Yeah, and it's shocking, but there's four months until the end of the calendar year, which shocking because that the time is just going so quick. And it's, you know, September is next week, but I, so if so if somebody, so if you've got something and we've appropriated and there's, there's only requests for half the money, we might want to take a look at that. Actually, that that that is a question that I had as well and I'm glad you brought it up so if we could look at maybe a rolling account of how the funds are being expanded and what's left over where is extremely helpful because we hear, we hear different things for different constituents about there's not enough money for this or there's, you know, some of the, some of the issues that are really critical. So, yes, having that what hasn't been expended what has been expended and what the need appears to be based on the individual grant. I think in large part from a cash perspective money hasn't gone out the door, but we're in the process of it but you know one of the things that we are focusing on is trying to estimate when cash will go out the door, how much will go out and what that balance is. Okay. Good. Any, any updates that you can provide for us we don't. I'm not necessarily wanting to drag you in every other day but it would be really helpful as the money goes out to get a sense of where things are. Definitely and like I said I think in the next three to four weeks I'll have, I'll have better information for you and just for context. Karen scheduled me for three weeks from yesterday to come in for an update so. Oh well maybe we'll maybe we'll try and do a joint so you don't have to do it twice. We'll we'll talk about. It's a great idea thank you. I have a couple of questions, and I know that others may well. But let me ask. I said in the EMT grant for applications or EMS application you have support support contractor $100,000 available to help them and I've the the issues that I've heard about really are related. So slide number four which is Act 136 provider stabilization and then the special needs folks at home services. And what I've heard Sarah and maybe this is a more discrete question when we bring in some folks from individual departments. Is it some independent physicians and docs and providers other providers just are not making the application because it's so complicated and they don't have the time to dive into their prior year data. Is there any consideration of providing contractor support for them, their independent businesses I mean again looking at some of the micro business discussion that you had the giving them help. Was there any, is any of that available and how do we get to these people who are small businesses, the small provider businesses independence. How do we help them. Yes, and so I think in the instances where we did engage a consultant to provide technical assistance it's it's because the legislation called for that specifically as it relates to the health care stabilization program. The staff at the agency of human services have spent a considerable amount of time on outreach to providers answering questions providing information really working with the provider groups that you did experience some challenges with the application process. I think that I know in house healthcare earlier this week, Laura Pelosi was, you know, was complimentary to the efforts of the agency and providing that technical assistance. It's challenging with the program of this magnitude, finding the balance between needing to meet the standards and requirements of the guidance surrounding the coronavirus relief fund and the documentation and validation that we have to do with meeting the needs of a large provider group that the kind of skill and size really vary in terms of the ability to respond to this application process and so we have really tried to provide that support within the agency of human services but recognize that it perhaps has not been a perfect process. Well my I guess I guess the concern that I've heard is that the larger or organizations have, they have the resources to complete the application and go through the financial data appropriately, but the smaller sole proprietor. The smaller clinic doesn't have that capacity, because they're trying to gear up and see patients again. So, this is a concern I think we're going to have to have a conversation about this as we talk directly. I don't know who we talk with who's in charge of that provider program. So we have Commissioner Doftison, as well as the director of health care reform. Okay, we'll do that. Then the other question that I had was with regard to folks who are home so the disabled who are home or special needs kids who are home and they've had parental care. They've been able to access I've heard in particular from people who have children with autism, or our move transitional with autism and so we will talk with Dale about that I think but off the top of your head. What kind of support is being provided for them and I mean it's a small amount it's a $2 million piece I think it links in with. A number of other things but. Yeah, and I would say for this this $2 million appropriation, and we'll, I think based on the comments you just made we'll take it back to the agency and have maybe a bigger conversation about it because the current focus was on reach up households but I think maybe we need to bring in Dale to the conversation before we move forward. But as it relates to, you know, the developmental services system, Commissioner Hut certainly can provide you some more information but we did issue in the early phases of relief. Some payments to families to help provide to allow them to be able to have additional supports at home. But as you know, you know providers weren't able to go out in the kind of initial endemic frame to provide. And I don't know the extent to which that's continuing but it might be worthwhile exploring, especially, you know with school starting and some of some of these folks having to continue the care. So thank you for taking that message back to the Commissioner and we will, we'll try and bring her in at some point. And then the other question I have. Obviously thank you for the comments on adult day I think that together with appropriations we did a good job there and getting them back up and running. And we'll we'll hear from them. The first question I have was related to the application and the allocation of funds for the parent child centers. The parent child center network and whether, do you know, and maybe this is a question for DCF. The funds will be allocated through the network itself the parent child center network, or is that going to be something that has to go through individual PCC's. I do not know that level of detail but I will follow up with DCF to let them know of that question. Okay that's good and I, I think I've brought that up previously. It won't be a new idea but it's something I think important to share. All right. And then as I said before we will be looking further at the child care issue with AOE. So that's a, and I know human services has been looking at that. That's going forward. Yeah. Okay. All right. A lot here thank you this is terrific. Committee members questions for Sarah Clark. Oh, you are lucky. Senator McCormick, you're still lucky. Yeah. I'm sort of a review, I'm a little embarrassed to even need this but just the real relationship between homelessness and COVID. Is it that the COVID actually make for there being more homeless people, or is it just that homeless people had particular vulnerabilities to COVID. I think and certainly Sean Brown and Sarah Phillips from DCF can provide you some more information, but because of the pandemic and the inability to house homelessness, homeless individuals in shelters, because you couldn't have congregate housing. It created this, you know, need to house individuals in hotels and a core corresponding costs and so now with this kind of elevated number of homeless in hotels where working on the plan to move them out of hotels and into housing. Yeah. Thank you. That's more that's more review. They just it's been a while since I've dealt with it. Thank you. Yeah, we've been, we've been just overwhelmed as I'm sure you have with all the different issues. Any other questions. Committee or comments. Okay, that's terrific. Very early in going through this we've gone through it very quickly but I think our, we were so embedded in working on especially act 136 that this is a good reminder of some of the things that we did and where we are. But I will reiterate it would be terrific to have an update on how much is still left where it's gone, and what the perceived needs are going forward and I think you've heard some of the concerns from from each of us so be great to get that info. We'll do or send the message back because we will bring people in. As we go ahead. All right, let me just see if I have any other questions. So, you know what would be good as you're updating is for us to know the number of recipients and even, especially in the stabilization piece of health care stabilization piece to know the size of the organizations that are receiving funding, because then that gets at the sole proprietor cons idea and the independent practitioners. Yep, we'll do what I think like I said we should be starting to issue grants in the next couple of weeks so when you know we come back we'll be able to provide you with that information. Okay. All right. And I personally have heard of at least one or two smaller organizations and proprietors physicians who have gone out of business as a result of coven and I encourage them to make application and get support. I don't know if they've done that or not, but it's been, it's been a real challenge in many ways, not just for medical business but for other small businesses as you know. Okay, we are good. Thank you very much. Thank you very much at your time. So, see you soon. Thank you. Committee we're going to take a five minute break. And then we'll be ready to move on to the next topic. Nellie you can put the screen up and we'll stay live but we'll take a break. Don't forget to mute yourself if you haven't. Why don't we move on our agenda. To age 795. And what I'm going to suggest is we have we do have some time. I'm going to suggest that Jen walk us through the proposal amendment. And then that we have some comments from the Green Mountain care board. This amendment is one that I, I think it should not be unfamiliar to the committee. It is a result of a lot of conversation that we've had on S2 90 and I know that the house health care committee has also had some conversations about the, the, some of the pieces or most of the pieces that are in the proposal. So, why don't we have Jen walk through at a, at a fairly high level. And then we'll have some testimony and I think we'll find some things that relate to the issues that we've been discussing right along. So, does that fit with your schedule. Robin launch and Kevin Mullen. It does. Okay, good. Let's do that. Okay, good morning Jennifer Kirby legislative council. So I will share my screen and put the amendment. If that works. All right. So you should be able to see my screen with the amendment. So I'm going to put this together as an amendment from Senator Lyons because it's her proposal, but at this point, the committee does have the bill. So if you wanted to move the amendment, we could make it a committee amendment. And what I've done is strike out the effective date section from the underlying bill, which as you may recall deals with hospital price transparency. And then put in there's a new effective date at the end, but put in several new sections section for that. So I'm going to put this together as a report requirement or study and reports for the Green Mountain care board to consider ways to increase the financial sustainability of Vermont hospitals. In order to achieve population based health improvements while maintaining community access to essential services. So I'm going to go to the board consulting with a number of stakeholders, the director of health care reform in the agency of human services, that position is currently held by in a back as Vermont hospitals, the Vermont Association of hospitals and health systems, ACOs, the office the healthcare advocate and other interested stakeholders. So there are some progress reports updates kind of moving from how the consideration is going to developing recommendations and then a final report would be due by September 1 of 2021 so there'd be updates to the health reform oversight in November, and then to this committee and the House Committee and the Senate Finance Committee by April 1 with the final recommendations do by September 1. Section five is a separate report this would have the board in collaboration with DFR diva and the director of health care reform, determine ways to increase equity and reimbursement amounts between providers for delivering the same services, regardless of setting or hospital affiliation with those findings and recommendations do by January 15. And then the next set of sections sections six through nine deal with first in the context of health insurance rate review and then hospital budget review, having some information provided to the board on reimbursement amounts, and then making that exempt public inspection and copying under the public records act. And so that in the first part here for the health insurance rate review in conjunction with the rate filing would require insurers to disclose to the board provider reimbursement information, including fee schedules payment methodologies and other information as requested that information then would be exempt from public inspection and copying under the public records act and kept confidential except for releasing it in summary or aggregate form. And then also allowing the board to examine and discuss confidential information outside of a public hearing or meeting. And then some similar language that we had looked at earlier in the, much earlier in the year in the context of s2 90 that would allow the hospitals would require the hospitals to report reimbursement information as part of the board's hospital budget review with some additional language on that. And then having that information again exempt from public inspection and copying under the public records act. And kept confidential, also including in their financial information that the board collects to address financial solvency or sustainability issues that could be disclosed to the board, and not subject to public public records request. And again the board would be able to examine and discuss confidential information outside a public hearing or meeting. So I would like to recognize the effective dates, both to address these new provisions but also to move out some of the effective dates that we're going to take effect on July 1, which is already passed. And having those instead take effect on November 1 and then I proposed a potential renaming of the bill as an act relating to hospital price transparency hospital sustainability planning equitable provider reimbursements and regulators access to information. Take that. Okay. Why don't we do this. Committee members you have questions for Jen I just as a reminder we did look at some of the financial confidentiality issues earlier in the session and would provide significant benefit I think and we'll hear from the board they can tell us. It allows for the board to look at information that perhaps they haven't been able to in the past, as they're looking at rates and budgets and so on. Questions for Jen. Okay. So I'm going to turn it over to I just muted myself sorry. Turn it over to chair mullen and member lunch and do you have something in writing for us. I don't necessarily have something in writing but what we have is slides that we've put together that is already up on your site in robin can load them on to the computer, but basically what you'll see in those slides is just a compilation. One of the slides is from a discussion that we had at the board when deciding the framework for sustainability plans, and then there are other slides that robin will talk about at the end but basically, it's really good timing. The language that you have proposed and let me start with. I'm sorry to interrupt but would you like to have the slides up on the screen so that everyone can see them. I don't know if it's necessary I think robin could put things up as we're speaking and then. Okay, that that will help. So for example, one of the things that I want to talk about in section four. Well, we're really rural hospitals throughout the country have been in financial struggles for most of this current century, and since 2005 170 rural hospitals have closed. And because of that, and seeing the five year cager for operating losses for a number of hospitals last year the board in the budget orders, ordered six hospitals to create sustainability plans, and we ran into a few roadblocks that were closed, obviously is COVID-19, where things have had to be put on hold and changed. And throughout that, there were struggles with hospitals feeling comfortable with giving us all the things that the boards at the local hospitals were considering because they couldn't have that information in the public domain so say they were having a conversation with setting up a multiple hospital system with another hospital in their area, and there was going to be one leadership team, and certain specialties that were done at one hospital and others at the other. They don't want information like that out there that would jeopardize some real key money makers for their institution, starting to worry about what their long term future is, and so there's personnel issues there's contractual issues. We believe that under existing statute we probably could create confidentiality, but this would make it very clear rather than the process where they would have to make an argument for a piece of information being confidential and then a rolling on that. This would make it much more clear. Before we really in support of what you have put out there because what of course nothing is certain until it's done but I'm fairly confident that what we will require this year is those hospitals that were not required to last year will have to be brought into the sustainability process and will be part of their budget orders for this year and we're knee deep in those budgets. We've heard from 12 of the hospitals, the last two are tomorrow, and then we'll start to try to make decisions but I'll tell you that this is an unprecedented year, where there is still information that is not known that would factor into a hospital's financial picture. So for example, what dollars will they get in CRF relief, the couple hospitals they got PPP will those be able to be forgiven. So there may have to be some conditional orders and we may have to come back to that. But all that I'm saying is bringing it back to the fact that we believe strongly that every hospital should have strong strategic planning and for the most part they do. It's a rare exception that they don't but we want to basically make sure of that and be able to have a concept of what they're looking at moving forward. So the only thing on section four that I would suggest Madam Chair is the timeline may need to have some flexibility language in it. So for example, we've made it very clear to the hospitals, Robin, maybe you could pull up either slide 16 or 21 on the timeline. But we've made it very clear to the hospitals that if there is a shutdown and hospitals have to focus on, you know, creating more negative pressure rooms doing whatever is possible for patients not allowed to do elective surgeries that we understand that that has to be their first priority and that we would put a pause into this. And so this is the timeline that we have been looking at at the Green Mountain care board and we've brought it into four phases. And so you can see that the last phase really ties it into their budget submissions and we heard from Mike Del Treco at the hospital association that really they would prefer to have some tie into the budget process as well. And so you have in there a date of September one for that final report. I don't want to to basically be pessimistic but September one is right at the time that we're finishing all the hospital budget hearings. And it might be better if you gave us till October 1 on that and also added some language that allowed for some flexibility, should there be a surge in COVID cases or for any other unforeseen circumstances that could occur. Obviously the the other two timelines that you have in there are updates to you and we can certainly give you the updates. That initial update will will be pretty slim. It'll be basically you know the very beginnings of the sustainability process but we're very happy to always keep the communications open so no problems there. Is there anything I'm missing Robin. Sorry I wanted to unmute. No I think that you've covered it all for section four. So I'm going to let you take section five Robin if that's okay. Absolutely. So section five, which is I want to which is that equitable reimbursement report we're happy to continue this work further and work with the executive branch agencies on continuing the work. I would want I wanted to do just a brief historical recap because there have their this work started in 2014. Two jobs ago I did a report on payment differential in primary care practices, which was the 2014 started the conversation. And with the most recent report being received by you in 2017. So there's quite a bit of history on this work. What what I also wanted to just kind of touch on is some of the technical challenges that we've had in the work. So that everyone is coming at this with a reminder of some of the challenges. So what we found when we submitted the 2017 report and again we've included links to all of the reports in the back of the slide deck that we gave you. But what we determined when we looked at payment differential to primary care practices. Again, these are blueprint practices because in vcures the only way to identify a practice is with the blueprint for health practice flag. Otherwise we can't tell which claims are connected to an individual practice right now. But what we determined in terms of primary care. And this is as of 2015 so the data is a little bit old at this point is that if you look at the average allowed commercial charges. The FQHC actually have the lowest per member reimbursement rate with the academic medical center having the highest and independence and community hospitals being in between. If you look at the average allowed combined including public and private payers, the community hospitals. Robin, do you have a slide that we should be looking at. I can pull up the it's from the 2017 report if it would be okay I can pull that up. No, that's okay to do that. Well, we can look at the report. Okay. We're just on that Robin you should let them know that one of the pieces of our deck that we sent over is a whole listing of all the different reports that have been done on this so if you all the links are there and you can click on any one of those reports. Absolutely this is the August 28 2017 PowerPoint presentation which has this summary on slide 11. For when you look at for primary care across all payers public and private. It's actually the community hospitals that have the lowest reimbursement rate with then independence. The academic medical center and FQHC is having the highest rate. So there is definitely some variation based on practice type and we know that for primary care. But because of the data limitations. We don't know really a comprehensive look at the practice variation for other types of services. So that's something that we need to solve to really delve into this more deeply. The other thing I wanted to mention is that in fiscal year 2018 in the hospital budget process the board did cut UVMMC's professional fees. So the information that I just gave you may have changed since 2015 because we did cut their professional fees to address this issue. So that's just a little update on kind of the data that we've and the findings that we've had in prior report. I think so the other thing that we talked about in the 2017 report that I wanted to expound on a little bit is it would be helpful to have a little bit more feedback from you in terms of what you're looking for. Both in terms of which services are we supposed to look at data because as you know fee for service codes there are tens of thousands of fee for service codes right so narrowing the scope would be helpful and allow for a more targeted review. And there's and so that's one issue that I think with the language is very broad so we could certainly you know take a stab at picking an area but if you had preferences there would be helpful to know that. There's basically two different ways to tackle fee for service reimbursement differentials an insurer based approach or a fee for service rate setting approach. And I'm going to talk about each of these approaches because again having information about what sort of your reaction to that would be helpful in terms of designing this. If we are to look at it from an insurer level. I think the main limitation there is that it of course the state can't change Medicare fee for service amounts and Medicare does pay differently based on sites so from an individual practice perspective. If they have a high number of Medicare patients those patients reimbursements would not change regardless of what the state does moving forward. In prior legislation you told Medicaid not to do this type of reimbursement so those patients the reimbursement should be addressed. So then we look really at the commercial sector and as you may recall there's been a movement in the market away from the insured products into the self insured market. So we currently have less than 100,000 Vermonters who are insured privately insured across the entire state and we certainly know from the hospital budget process that there are many years of the state where there are little few or no independent practices. So you have to understand that that 100,000 people then gets diluted, diluted when you look statewide and then look at it at the number of independent. So, again, one of my concerns here is that from an independent, any given independent provider. Is a change in the commercial market, the insured commercial market going to impact either their revenue or really their feeling that something has changed because it could be a handful of patients. And that is of course because the largest part of the commercial market is self funded and the state doesn't is not allowed to regulate self funded employers under arrest. So those are some of the challenges with the insurer. So the commercial market getting it more expansively, taking a fee for service rate setting approach could address it. That will be complicated as you know, and also expensive because it requires additional government infrastructure to do that rate setting this is where identifying the high priority areas is important because you could do it on a limited, on a limited basis or you could do it rolled out over time. The other thing that's important to realize there is we have virtually no information about independent practices. So as part of the rural health services task force. Last year one of the efforts I made what with the group was to try and identify common sustainability metrics which are basic business metrics that we currently use in the hospital budget process. So look at the financial health of an institution. We weren't able to get that information from independence and so we weren't able to do that apples to apples. But certainly if we were to move forward with some sort of fee for service rate setting we would need there needs to be a clear understanding that it requires regulation of independent providers and that requires data submission by those independent practices. So I just want to be clear about that because certainly folks may be interested and willing to do that to address the reimbursement issues but it is a higher level of regulation and information provision than those providers have had to cope with in the past. And certainly there may they I don't want to speak for them obviously but they may have some confidentiality concerns if it would involve collecting tax returns or, you know, maybe, you know, we'd have to look at different ways and different information necessary certainly in the Medicare and Medicaid space cost reports are used which are information on expenses that separately collected so that's another potential program. As I said, happy to continue this work it would be helpful. Now that you have a little more background to get some narrowing of the language so that we had a better idea of what you really wanted us to tackle. With that said, certainly happy to jump in and try and take it to the next steps. The other thing I wanted to say about this is in terms of the data analytics I think in the previous reports we've taken it about as far as we can without hiring a contractor or an actuary. So, if we really want to tackle looking at code level practice level information we're probably going to need to both get some information from practices to be able to identify the claims for that practice, and we're going to need to be able to do some actuarial or contractor support. Now it's possible that diva or DFR may have contracts in place or money available to do that without an additional appropriation I don't know. And certainly I don't want to speak for them in tight budget time, but I think to really take it to the next level that's what we would need to do. So that's really my comments about section five. Let me ask you this question. Currently, do we require a reporting of distinction between the facility fee and the, and the actual and the, and the clinical fee. We, those are built separately. Yes, so they are sorry. Sorry, so they are reported separately. And do we have that data up as part of our transparency process. So they are built separately so the claims will be in vcures. And so certainly being able to identify those claims is possible I think the challenge becomes bringing it back to one practice because you need to be able to identify that practice in some way. Okay. Yes. So we were using blueprint that flags for example for for the, for the primary care level. I did reach out to our data team to ask this question to see if since we lasted that report if there's been any improvements in the data collection of vcures to be able to identify practices. Okay. And I don't know more distinctly like you could probably do it based on the tax ID number or something like that. But in order to know that you would have to know that that tax ID number was an independent practice. Okay. And I don't know that we can do that today. Okay. I have another question. The rates setting process could be considered as part of this so and but that is we have taken testimony on that we understand there's an expense and time involved with that but the Green Mountain care board does have the authority to do that. But, but it is expensive we understand that. That is one option. The other, the other option might be, as we currently have all payer model, particularly for primary care. If we looked at a global budget process and expanded that further for larger organizations and hospitals. That's also an option that might be approached so the language in section five is not to go out and do it, we should change it to the, I mean it does say ways to increase equity so one of the ways to increase equity is to build more of a global budgeting process overall that's one, or one of the things that we do is rate setting you brought both of those up and I guess the question is, what are the specific, what are the details and doing that and what are the costs associated with doing that one of the legislative or other barriers to doing some of those things and I think that's, that's really more what you were hoping for. So, you know, and the, I think the interest has continued to be primary care. The issue of going into specialty services gets very difficult I know I understand that. So, those are some comments, and maybe there's some help you can give us on clarifying the thinking there. Sure, and I apologize if I misread the language although I suppose that that is helpful in terms of clarifying what you were looking for. This isn't exactly what we were looking for but I think your presentation has helped clarify some of this and I think other committee members may want to add into that. This is a very difficult spot, a place to be. And we fully understand the self insured issues. We fully understand them. It's difficult. And what vcures can post and what vcures can't post with relative to that based on the court decision so. Committee questions for Robin I thought I think it might be helpful to ask questions at this point I think section four might be less fewer questions but if you have questions on section four or five. Senator Cummings. I'm muted. No, I'm not. I don't know if it's a question or comment. I mean, I get all these studies, and they just keep coming. But we just had an auditor's report that said consolidation is the leading cause of the increase in health care cost overall. And then yesterday there was a story that said I forget it was 11 or 14 independent primary care practices were getting out of one care because we're proposing to cut their reimbursement rates. This doesn't seem like a really good year to do that. But, but it's almost like we've got two tracks going here, and we're studying and we're studying but meanwhile the world is going on and doing what it's doing. And it's frustrating. And I'm not sure how to how to put a stop or how to do it we just keep. We're studying but it keeps on going like maybe we should just do nothing. Go back to the market sister. Let me, let me, I'd like to make a comment first and I'll go to chair Mullen. Jen Carby shared an article from Nash be about vertical integration and the effect vertical integration and health care has on competition and on costs, and Vermont was cited as having some of the solutions in place including an ACO, and our, and our board, the Green Mountain care board. But as we move through the process we're seeing that this hasn't solved all the problems. So for me the next, I will, I'm going to ask Jen if you don't mind putting that article up on our web page that that I read it last night it's very good it has some suggestions for how to get at cost, cost issues. Well, when when there's when vertical integration takes place and that is the purchase of practices by, by hospitals. So, let's put that article up and we can look at it. But then some of the things that are here in this bill including this how do we get to equitable reimbursement. I agree with you it was a little bit. We haven't heard from AC the ACO yet. And we know that they were saying that the reduced payment will be based on quality but how can you do that during a time of COVID so I won't go any further on that one but I do think, Chair Mullen you have something you want to add. A couple of points and Senator Cummings brought up some really important issues. The first one on the auditor's report. When it when that information that you're seeing a national study that talks about the effects on consolidation and the fact that the parent organization that the costs go up. And, you know, Vermont is a little bit different than other areas of the country in that we don't have competition within our eight. We have four private hospitals. And if you take a look at what consolidation has occurred in Vermont. If that consolidation hadn't occurred. These were institutions that were in financial trouble so if you take a look at Porter and Middlebury. It was a miraculous turnaround of a very bad situation that that hospital was in. So, I would be cautious when you look at national studies to compare them necessarily to Vermont because in Vermont. Things are very much different. And then on the second point Senator Cummings on the change that one care put forward. I agree with you that I think the timing is way off. Let me, though, make sure that the committee understands that the board of managers at one care was trying to create a system that would really put laser focus on the goals of what's trying to be accomplished through one care in the all payer model. And that's really, you know, improving quality and you know, making sure that certain events aren't occurring and others are. If I was a doctor and was given the opportunity to make more, which is what this program would allow you to do. I'm a competitive person I would seize upon that and try to make the, the four and a quarter but I agree completely that I think the timing of this is is a little bit of miss and people are up against the wall dealing with COVID and having to deal with additional change is very frustrating for them. I completely understand that statement. And I'm just hopeful that com or heads will prevail between the negotiations between one care and these independent docs and this can be resolved because it's really in everybody's best interest to move forward because our option is to move backwards to a fee for for service system that we know is broken. So I still remain hopeful and optimistic that this can be worked out. If I might also just add one point related to that. The other opportunity for independent providers is the comprehensive payment reform program which provides capitated payments to the practice and actually you receive the full amount of the additional payments plus so it actually addresses some of the underlying fee for service payment differential issues. As well as providing the quality payments up front so that is another option for providers independent providers as well if they're uncomfortable with the pay for performance quality program I would remind folks that in Medicare Medicare has gone to a fee for service pay for performance called MIPS which is a 9% up and down side depending on your quality so it is the way that fee for even fee for services going on the federal level. I guess this is all good. But if our goal is to get everybody into one care and this has got to be a significant percentage of our independent docs are getting out. There's a problem there. And I think the other thing we may be different than other states where hospitals compete. But I still find it annoying now that when I go in and tell them my ancient knees are aching they are going to make me go through six weeks of physical therapy. I've had this done to my husband with his wrist that I've had it that's you know I'm no other people you go in for six weeks for they'll take a picture you pay a facilities fee when you go in and then you come out they take a picture and they say oh yeah your are worn out or oh yeah like your brother and your father you have rheumatoid arthritis in that wrist. I'm not. But they are the hundred pound gorilla. And so they can do that that's the new protocol. I'm not sure that we're actually saving money doing that. I can see lower back pain maybe. Okay. There's a substantial amount of power to set protocols and to find ways to make money. If you are the only game in town. And that that to me is concerning that's becoming a utility. So this is the this is exactly the point of the article. I think that as you read it you'll see some of the comments that are there and then the comparison of Vermont with other states and Vermont actually as chair Mullen has said has is doing better overall. But we're still not doing good enough. So it's a matter of how do we what are our next steps forward. It is it's extremely difficult and we hear from everyone outside of everyone has an opinion about how to move forward. Right. And so I think for me, I want to understand how can we put put in line, equal pay for equal work, whether it's through all payer or or some part of it will be continue to be fee for service. So how can we do that. That that's one of the things we have to get that. Obviously, a lot of the issues are going to have to wait until January but I think there's some things we can put into play that get thinking going and that that's that's the goal here. Senator Ingram has her hand up. Thank you. Yeah, another issue that I think we're very concerned about is, in addition to the independent providers of the world hospitals. And I was looking at your slide. Excuse me in your slideshow on page five. Sorry, I need to get tomorrow. I think that anyway, if I can eat this out. Okay, so the even before COVID the growth and operating expenses was very seriously outpacing the growth and operating revenue so I was just wondering if you could comment on what, you know what the Green Mountain Care Board was thinking in terms of how you know how can we address that, you know, beforehand what were you, you know what what sort of path were you following with regard to these hospitals. So that's a success story, Senator Ingram. If somebody had asked back at the time that Springfield first ran into the problems that they encountered. What I thought the next hospital would be that would be in financial trouble I would have said Gifford, and Gifford had just come off of a staggering operating loss, a couple years ago, and sat down, did strategic planning, came up with plans to reduce costs and really have right size the ship and if you look at pre COVID in 2020, they were operating in the black the whole year up until the pandemic yet. And so, too often, there's too much focus on the top line and then they build the rest of their budget from that. They don't really have to be focusing on their expense drivers and finding new ways for efficiencies. And that's really what we're looking at. Also on the, the call, for example, Germany won't allow you to do certain surgical procedures if you're not doing more than I think 40 a year. And it just, it's common sense if you don't do something very often you're probably not the best at it. And so those are the type of things that we would hope the conversations would occur at the hospitals, so that care is being provided to their community in one form or another. And that this kind of ties back into the whole parody discussion and I'm glad that Senator Lyons has started to focus it more on primary care because one of my concerns is that we expect hospitals to, you know, have birthing centers and do things that lose money on a routine basis and the only way they can do that is they have to make a little bit more on other things and what their actual costs are. And so we have to be careful that we don't use a big brush and paint everything that's being done into equal pay for the same work because otherwise we better come up with some type of funding source that's going to allow hospitals to have birthing centers and other operations that lose the money. And along the same lines just to, I don't want to carry the discussion on too much further because I think you have other information for us but if you have a clinic that is doing specialty care, and they're doing it regularly so they're doing their 100 procedures a year. So you should be equivalent with any hospital that's doing equivalent. So it works both ways. Yeah. It does. Okay. Yeah. Okay. One thing you have careful of those and in other states what you've seen. So for example with orthopedics, there's more and more of a move to ambulatory surgery centers. When that move occurs. Yes, you're getting efficiencies and you don't have to charge as much, but then you're not having that same revenue stream going to the hospitals to pay for the other things that hospitals are required to do. And that's exactly why we have you on the green ground and care board to keep all of that straight. Okay, is there something else should should we move on because we would just, yes, I, if you're ready to move on I just have a couple of things on the remaining sections if that would be okay. Please yes. Okay. So I think Jen did a great job summarizing section six through nine, which basically clarify our ability to collect financial information which otherwise would be confidential and to be able to maintain confidentiality of that information at the specific level where necessary. I think having more information and more details around the reimbursement rates and methodologies is incredibly important and helpful in both the rate review and the hospital budget process. So I was looking at the language again this morning. There was one very small change I was going to suggest on page six, which is the section on confidentiality and the hospital budget process. So in, which is to strike submitted by the hospital because for example if we've collected that information already. So if for example and can aggregate it at a level that is shareable then it wouldn't necessarily make sense to recollect the information so I just wanted to make sure that we could be as efficient and as possible and between those two processes because right now. When we collect something in rate review we can use it in rate review but we can't really use it in hospital budgets because it's often proprietary or confidential and there's competitive reasons that each insurer, you know, doesn't have the other person's information, but being able to cross be able to use that information between the two which I think this language helps us do would be helpful. To improve some of our rate decisions in the hospital budget process because we'd have better info. Yes, good. That's helpful. It would also also help in the other section that we were talking about. Yes, and I can I ask specifically where on page there you're talking about the in the list of what is confidential. Hold on in B line for. Notifying the information that will be exempt from public inspection and copying. So that's reimbursement information submitted by a hospital. Well, yes, but I think we could potentially get the reimbursement information submitted by a carrier. Not by the hospital. Okay, so I just wanted to make sure that this wasn't limiting us from using information that we might get from a carrier as opposed to from the hospital. It seems to me that having. Does that help Jen I don't want to I think so so would you take out the whole submitted pursuant to 9454 of this sub chapter because that's linking back to the hospital providing that information and just saying reimbursement information. I think that would be helpful. Yeah. I have no problem with it at the committee's fine with it. I don't have a problem with that I think it sounds like it helps significantly. The, I think what this does in many ways is it provides a green mountain care board with greater. Well responsibility but also authority and decision making I think it really will help you, and I correct me if I'm wrong in. And your regulatory responsibilities. It'll be a major help senator lions. Good. Okay. All right. And that's all I had on the remaining section. Okay. So if you don't mind. Communicating with Jen is some of your thoughts, and perhaps as a result of the conversation that we've just had here in committee on the sections four and five I think those were the two that you were commenting on. Maybe we can massage what we have and improve it. I'm sure we're going to hear from other folks who want to comment. But I think you need to put your. You need to have we need to have your input on this first so that's helpful. If you want to deeper dive into the parody question, you might want to invite in Marissa Melamed from our staff and Dr. Holmes from the board to talk about the most recent work that was done on pay parity and what was found. Okay, we will, we will definitely try to do that. We don't we're on a short leash right now in terms of understand how much time we have. But we might, we will do that and if we, if we can't do that and we can at least have something here. I think what we will add is an update to a truck at the same time we get the up the preliminary report. I think that we can have a truck take further testimony on this. Okay, that might be extremely useful to us, genuinely want to. We can put that a health reform oversight committee. Right, so you do have one, you do have an update coming to them in November. In this language goes to a truck. Okay, so that what you're saying includes four and five. Well, that's not specifically on section four section five didn't have an interim so you want an update. Yes, and we at that point we can do the deeper dive. I will have to think about it and we'll have to see how the language falls out. This is our first thinking through with the board so good. All right. Committee questions now for either Jen or, or Robin or Kevin chair Mullen member lunch or Ledge Council, Carby, or discussion. Okay. Is there anyone who feels that we should not proceed with with the amendment. Senator Ingram. Thank you. Well, I mean, you know, as you know, I was skeptical of some of this in January, and I'm still here this August, but I still feel the same way. So I am interested in hearing more testimony. I mean, I, you know, section six, I think I could get behind. I'm. Yeah, I'm not sure whether I really even support four and five even with changes. But I am trying to keep an open mind. Good. And I do encourage you to read the Nash be article that Jen is putting up for us. And then, and then the deeper dive into the 2017 report that Robin was talking about. And the issue here is that there continue to be expressed concerns by independent docs and concerns by others. So we're trying to get at the basis for some of those and how can we, how can we help so maybe we won't. I just worry that we create more, you know, work and effort and kind of bureaucracy that actually adds expense to the system rather than help, you know, helps in the long run. So, okay. That's my concern. Thank you. Good comments. Senator Cummings, and then Senator Westman. Before we vote on anything, I know we went over the amendment, but can we just get a 10,000 foot walkthrough of the original bill because January was a long time ago. I think yeah, I mean, I remember discussions but actually don't know that we did a walkthrough because this bill passed right before. COVID changed everything passed from the house. So you may not have actually seen the. All right, so I think we should. Yeah. We had, we had a fairly thorough look by Lucy Rogers with her PowerPoint. And we did talk about it, but you're, but we don't, we will. We're going to be on the agenda again and we'll have a chance to go through the whole thing and then make any changes that we want to the underlying bill and or to the proposal amendment. We're with you, Senator. Senator Westman, did you have a comment or question. The comment was. Exactly. I just brought up that I needed to back up and you know, Lucy came in a long time ago. Yeah. Okay, this is good. I just wanted to say to be honest with you was to put this amendment out there so that people who are more familiar with the bill perhaps and we are and the issues can we'll have an opportunity to, to weigh in going forward. Senator McCormick. Thanks, just. I heard my speech. I think the United States as a fundamentally flawed approach to health, providing health care, good health care but fundamentally flawed system for providing it. And I've been doing some home improvements this summer and I've been reminded again of the corollary to Murphy's law. Once you screw something up, everything you do to fix it makes it worse. I think, I think that Kevin and Robin are heroic. I appreciate your efforts. I think you're doing the best you can under the circumstances. So, yeah, I, I, you know, one of the problems is that we're in the middle of a process and it makes it really hard to step in and change what's trying to prove itself. And we've got everybody and his brother and sister doing coming in and telling us what's wrong. Yeah, so I do do read that article and do go through the bill and the proposal and think about what we've been what we have been hearing through the session. All right. Thank you. You're, we're all in the same place right you know it's like limbo but what do you do to get yourself out of limbo right sink or swim. Any other questions, comments, terrific. Okay, so Jen will be reaching out probably to Robin to you and Kevin to you and trying and we'll be I'll be we'll be talking with her as we look at the bill again next week. And trying to sort out what we finally keep in it so appreciate your time on this very much. Thank you anytime. Terrific. Okay. All right, so we are going to take a break until 1059 so we've got a five minute break in our, in our spirit of finishing early so Nellie you could put the, the sign up and then we'll, we can mute ourselves and go off screen for a little while. So why don't we start and I think Senator Westman and Senator Cummings are here and why don't we talk about and go through H663. So we have as passed by the house and then we have a proposal of amendment that's on our in documents from yesterday. So yes I did not send a let me just send Nellie the new version but I can also share my screen and show it to you. Okay, let's do that. Do folks want to go through the entire bill and the amendment sequentially. Probably good way to do it. Okay, we'll do that and I'm thinking if if there's any time at all before 12 o'clock we might go through 795 briefly. You're muted Senator Cummings still muted. That's a strange things. I have 1215 with joint fiscal. Okay, we'll try and I need to, we'll move, we'll move efficiently. Okay, so let's Jen you want to walk us through the bill and then the amendment. Sure. So I will go ahead and share my screen again here. All right, so this is H663 as past the house this is an act relating to expanding access to contraceptives. It starts with a purpose section talking about the steps that Vermont has taken to improve access to effective methods of contraception. And then finding that some of these provisions have not been implemented consistently across states of the request to DFR to investigate compliance with existing state and federal laws take and take appropriate enforcement action as needed. But then says the bill seeks to provide further opportunities for reminders to learn about and obtain contraceptives in order to prevent or reduce unintended pregnancies and sexually transmitted diseases in the state. Section two. This is getting into now the sections on expanding access to contraceptives section to is mostly just existing law. This is insurance coverage and insurance requirements for contraception. And it would add a provision saying that the coverage requirements of the existing law shall apply to self administered hormonal contraceptives prescribed for an insured by a pharmacist in accordance with changes that occur later in this bill allowing pharmacist to prescribe those contraceptives. And also, and we're, we're, we are consulting with the house and figuring out how to move these forward but if the, if the provisions in this bill end up getting pulled out on pharmacist prescribing in favor of the broader OPR provisions, this section still works. So this section would still refer to pharmacist prescribing provisions that would be added in 26 vs a 2023 so this section can stay as long as that is the intent of the committee. Section three modifies the definition of, or the application of the definition in the education statutes of comprehensive health education. So it's clear that the definition applies across all of title 16, and not just in this small sub chapter on health education, the impact of that is in part to carry over this definition of comprehensive health education into other statutes that do things like specify what has to be part of the curriculum in public schools so right now the statute uses the term comprehensive health education but it doesn't say whether it pulls in this definition or not. And a lot of the language was included in here, because there had been interest in seeing what language, what provisions were already in the existing law so the house had been interested in showing some of that. Section four adds a new provision in title 16 looks in the same chapter. That would have in order to prevent or reduce unintended pregnancies and sexually transmitted diseases would have each school district required to make condoms available to all students and secondary schools free of charge secondary schools are defined as grade seven and up so seven through 12. The school district administrative teams in consultation with school district nursing staff will determine the best manner in which to make condoms available to students at a minimum they must be placed in locations that are safe and readily accessible to students, including the school nurses office. Section five is in goes in title 18 the health title, and this has again in order to prevent or reduce unintended pregnancies and sexually transmitted diseases, the Department of Health in partnership with health care providers and health insurers required to communicate with adolescents and other individuals of reproductive age information regarding contraceptive access and coverage. The next section or two sections deal with creating an exception to the mandatory reporting of suspected child abuse or neglect for school employees to make condoms. So just based on the way some of the definitions and other provisions in existing statutes work. You could make an argument that as school employee who was aware that that someone under the age of consent was engaging in sexual activity by taking a condom would be required to report that. This specifies that a mandated reporter as described in subdivision a to which is all of the school employees shall not be deemed to have violated the requirements of the mandated reporters section solely on the basis of making condoms available to a secondary school student in accordance with that requirement added a couple of sections earlier. The next several sections deal with pharmacists prescribing self administered hormonal contraceptives, as we talked about a bit yesterday. These are, this is a narrower version of what's in the OPR bill that would allow pharmacists to prescribe a number of different types of medications, either based on an agreement with a physician or as part of a using a state protocol. This is a more limited version of that that would allow pharmacists to prescribe self administered hormonal contraceptives. That term is defined as a contraceptive medication or device approved by the FDA that prevents pregnancy by using hormones to regulate or prevent ovulation, and that uses an oral transdermal or vaginal root of administration. And it has the language itself that allows a pharmacist to engage in the practice of clinical pharmacy including prescribing self administered hormonal contraceptives that must be done in a manner consistent with a valid state protocol approved by the Commissioner of Health after consulting with the director of OPR and the Board of Pharmacy and the ability for public comment. It talks about how the state protocol becomes valid if signed by the Commissioner of Health and the director of OPR and has the Board of Pharmacy feature the active protocol on its website. And there's some requirements around what must be in the Board of Pharmacy's rules about prohibiting conflicts of interest and inappropriate commercial incentives and establishing minimum standards for patient privacy in clinical consultation. And then it has some rulemaking have it has the Commissioner of Health approving the state protocol by January 1 and the Board of Pharmacy adopting rules this may be a date that needs revisiting but at this point by January 1 2021 the board would be required to adopt rules. And if the board is unable to adopt rules by that date then it must adopt an emergency rule while it works on the rulemaking. So I guess that that could still work. Section 10 would require the Agency of Education and Department of Health to report by January 15 to this committee the House Human Services Committee and the two education committees. About their continued efforts to support schools and school districts in providing comprehensive health education to Vermont students, including sexual health and safety. And then finally there's effective dates. Some provisions with the provisions around the pharmacist prescribing take effect. And actually there's there's an error here should be section two. It will take effect on January 1 2021 the remainder will take effect on July 1 2020 and that's one of the things that gets addressed in the amendment. So if you want me to. So I don't know if you want to stop there. If you want to pull up the amendment and look at that any any questions to this point well and then we'll pull the amendment up. Okay, and I'm actually going to make sure I fix that numbering a shy. Okay. I think we're all good we can go right to the amendment. Okay. Then is the amendment and we looked at most of this yesterday. This would strike out the effective date section. And it's reader assistance heading and putting in some new sections. The first two sections sections 11 and 12 deal with wellness program. This includes comprehensive health education. And we looked at this yesterday it makes some changes to the membership of the advisory council on wellness and comprehensive health. It requires the secretary of education to collaborate with other officials including the director of trauma resilient prevention and resilience development, and the substance misuse prevention oversight and advisory council. And requires by January 15 at the agency of education in collaboration with that advisory council update and distribute a model wellness program policy. That complies with relevant state and federal laws and reflects nationally accepted best practices for comprehensive health education and school wellness policies. And a new section 13 would require school districts and approved independent schools to make menstrual hygiene products available at no cost. And a majority of gender neutral bathrooms and bathrooms designated for females that are generally used by females in great any of the grades five through 12. And each school and the school district or independent school in consultation with its school nurse would determine which bathrooms to stock with the products which brands to use. And specifies that the school districts and approved independent schools would bear the cost of supplying the products and allow them to seek grants or partner with a nonprofit or community based organization. And then we have the effective date section I just marked this one in green, I will go back and revisit the recheck the section numbers and fix them. But the sections that would have taken effect on July 1 would instead take effect on November 1. And so those are the highlighted changes, and then I added a potential new bill title and act relating to contraceptives school wellness and menstrual hygiene products. Okay. Questions for Jen. Comments. I just wanted to assure everyone that we went through the previous sections with the Senate Education Committee, and they were supportive of parts that pertain to your six education and terrific. Thank you. Thank you. That was that. Did you do that recently or before we went on recess so it wasn't like, you know, February that it was. Okay, words that'll be great. It's good I think. Excellent. Thank you. Any, any, any further questions. I think the proposal of amendment the effective dates. So you're just looking to make sure that the sections correspond with the bill. Exactly. Right. So that they reflect so that I think I had not renumbered in the effective date section after adding in that purpose section in the house version. So I'm actually changing what had said sections one, seven and eight should really be sections to eight and nine. So I am making that change right now. Okay, that's good. Committee discussion on the bill. Do you feel that you're ready to to vote this bill out. Everybody shaking their head. Yes, that's that's a pleasure. I would accept then a clerk. We, we can do this. I'll move the bill favorably. Thank you, Senator. And there's a second there from Senator McCormick. And so Nellie, I want you to help keep track of this for Senator Ingram as well. Nellie was already on the ball and yesterday she sent me the form. Wow. Okay. That's why she's here. That's right. Okay, further discussion on the bill. The motion has been made to approve the bill as amended. Senator Ingram. Hey, I'm Sarah Cummings. Yes. Senator Ingram. Yes, Senator McCormick. Yes. Senator Westman. Yes. Sarah Lyons. Yes. Senator Ingram as someone who might be interested in reporting the bill. Yes. Yeah, I'd be happy to. Terrific. And so that will. So you have to send a note to the secretary's office. And general have a clean copy of the bill with. Right. So I'm actually just sending it for a final edit. And then I will send it to you. Senator Ingram and I will copy. The secretary and then if you can confirm to, or you can forward it to him or whatever you want to do, but. That way I make sure that everybody's in the loop, but he does need to hear it from you. So this will be a strike all. No. No, it's not a strike all. Okay, so the amendment will appear in the calendar and then. Everything else is the same except the title. And then the date of the date of the date of the date. That came to us from the house. And the effective dates. Right. Right. So you're, right. So you're changing the effective dates and the title and adding on these provisions. Okay. That's good. All right. Okay, good. So we're clear on that. Thank you. That's a great vote. And we'll get that. That bill will show up on notice as early as tomorrow. And then it may be that you're reporting it. Okay. Okay. Okay. All right. I will prepare. All right. So let's move on to S. 252. Which is the bill that is currently on the calendar. And we just wanted to. I guess we want to make sure that Senator Westman is comfortable and that we have. Everything we need. There is a small amendment. Because again, of effective dates. So. So we look at that. Do you want to look at the amendment? Do you want to reminder of what the bill is? Well, let's look at the amendment and then let's look at the section by section. Rich is that what it's up to. That's fine. I haven't been gone through the section by sections. In a while. But I will be ready on Tuesday to do this. All right. Well, we'll see how that goes. So there's the, so Jen walk us through the effective day and then the section by section. All right. So the first thing we're looking at here is the. Amendment. And it is in Senator Westman's name because the committee no longer has the bill. So it would be a floor amendment. Okay. So there were two date changes because there were two July 1sts in the bill, one of the, or two, I guess earlier dates. The first required the department of health. To amend its rules around advanced directives. To, and it required that to happen by January 1st. 2021. This point, that's not enough time for rulemaking. So we're going to put it six months later to be July 1st. 2021. If that works. And then the second instance is striking out the effective date, which was July 1st, 2020, and making it instead November 1st, 2020. Any questions or concerns on that? Otherwise I will pull up the section by section. All right. I'll share this one. Okay. So it is a section by section of as 252 and act relating to stem cell therapies, not approved by the U S food and drug administration. So, which is what the amendment would change the title to be. So it adds a new sec, a new chapter in title 18 on stem cell products. It has definitions. Healthcare practitioner is someone licensed by the board of medical services. And it also has the term stem cell products. And so it says the term has the same meaning as human cells, tissues, or cellular or tissue based products in federal regulation. It ties it to the specific federal regulation. And applies to both homologous and non-homologous use. The term also includes homologous use of minimally manipulated cell or non-homologous use. And it also includes homologous use of minimally manipulated cell or tissue when used in applications that are not FDA approved. The next section requires healthcare practitioners who administer stem cell products that are not approved by the FDA to provide each patient with a written notice before administering the product to the patient for the first time. And the bill specifies the content and the format of the notice. So you may remember it had specific language and also information about what size it needed to be and what font size. And requires that include information on methods for filing a complaint with the licensing authority and for making a consumer inquiry. The bill requires the healthcare provider to prominently display that written notice and the consumer protection information at the entrance and in an area visible to patients in the practitioner's office. It requires the healthcare practitioner who administers stem cell products not approved by the FDA to have the patient sign a disclosure form prior to each administration of that unapproved stem cell product and to keep a copy of each signed form in the patient's medical record. It requires a healthcare practitioner to include that same notice in any advertisements relating to non-FDA approved stem cell products and addresses both print and non-print forms of advertising. It exempts from the section healthcare practitioners who have FDA approval or clearance for an investigational new drug or device for the use of stem cell products and practitioners who administer the products under a contract with an institution that certified by certain listed national organizations. And it specifies that a violation of the section is unprofessional conduct under the board of medical practice and OPR statutes. Then sections two and three add that failure to comply with the notice disclosure and or advertising requirements for administering non-FDA approved stem cell products to the OPR unprofessional conduct statute in section two and to the board of medical practice unprofessional conduct statute in section three. Section four directs the Department of Health to amend its advance directive rules and the underlying bill. It's by January 1st, 2021. The amendment would change that to July 1st, 2021. To further clarify the scope of experimental treatments to which an agent may and may not consent on behalf of a principal. And finally, the effective date originally would have been July 1st with the amendment would be November 1st. Okay. Questions for, for Jen. Senator McCormick. Thanks, Jen. Did you just. Review for us. Homologous and non-homologous. I am going to. Perfectly defer to the chair. Has considerably more scientific background than I do. I think generally it sort of has to do with whether it's related to the same organ. Or tissue or a different one. Exactly. Okay. Thank you. Thank you. Thank you. Thank you. Can we make the definition? Can we, if we look in the bill itself. That may be helpful. Yes. Did I pull up the bill itself? Otherwise I will. Let me just open up. Do we have. I think it's on your. Web page. I have it. But sometimes it's. Doesn't have. I don't, I don't think we define. Those terms, but I think the federal regulations do. It's defined in federal regulations. I don't, I'm. It autologous means the same individual homologous means. Similarly, but. I think that the definition is something that we're going to have to ensure is available. Senator Cummings. Yes. All of the problem that we got all the emails on of people who. Centrifuge your blood and put it back in. Yes. Okay. Yes. Any other questions on that? I'm, I'm, I'm not going to be the expert on this. I even though I. No information. I think it's important that. Senator Westman, I'm, I'm asking. One of our. One of our witnesses. To help. Senator Westman. With the, with the bill. And so under the federal regulation. I'm not going to be the expert on this. I'm not going to be the expert on this. But. Homologous use means the repair reconstruction replacement or supplementation of a recipient's cells or tissues. With a human cell tissue. Or with a cell tissue or tissue based product that performs the same basic function or functions in the recipient. As in the donor. So it's human cells. So, right. So it's sort of. Using cells or tissues that did the same thing. I think it has to do with whether you, whether you're taking cells like from a particular organ. And one person and using them for the same in the same organ on the other person or using cells that might come from a different. Different part. And using them. And a different part, part in the recipient. Right. Discussion of the changes. I'm not sure what these changes are. Does that sound like GMOs? Pardon me. Wait, hold on a sec. So Senator McCormack and then Senator Cummings. Go ahead. As I, if I, if I hear, hear right. This language explicitly says that we're not making the distinction. That we're treating them both. It's a homologous or non homologous. Right. So you're talk right. Yes. So the bill declines to make a distinction. Who does make a distinction? And how is that distinction used out in the world? So let me just back up to the language of the bill. Language of the bill says stem cell products has the same meaning as human cells, tissues, or cellular tissue-based products in the federal regulation and applies to both homologous and non-homologous use. So that's the not making a distinction. It also includes the homologous use of minimally manipulated cell or tissue products when used or proposed for use and one or more applications not approved by the FDA. So in one case, it's homologous and non-homologous. I think the minimal manipulation happens in the homologous use context. So that's why it's specifically called out as that in here. Okay. Who makes the distinction? It occurs to me that there are there practitioners out there who we're regulating who would want to make that distinction. Is there some, well, maybe it's not okay in this case, but it is okay in that case because, and we're saying, well, no, that doesn't let anyone off the hook. What's the loophole we're closing, I guess, but I think at the, so you're requiring notice and disclosure requirements that are currently not required. So you're not, you're not getting in the middle of whether something, you're not getting involved in the approval or disapproval of a particular product. That's up to the FDA, but you're saying if it's, if it's non-FDA. You've got to notice that. We're not, we're not banning anything. No, I didn't say we were banning something. This is a notification requirement, but are there people who are making the distinction that we shouldn't have to notify because it's this, not that. And we're saying it doesn't matter. So I'm wondering, what is the this, not that all about out among the practitioners? The practitioner is making that decision about whether or not it's FDA approved. There's no other way to do, we don't have, we don't have FDA police, but if someone doesn't provide notice and something happens, then there are consequences through the medical practice board. You're sort of explaining to me what the bill does. I know what the bill does. I'm talking about this particular distinction that we are stepping back from and we're saying we don't make this distinction. And I'm wondering why that needs to be clarified, that we're not making the distinction. Presumably somebody somewhere is. And I'm wondering what their thinking is. I presume that there's certain practices that they're saying, well, we shouldn't be subject to the notification requirement because we're non-homologous. And I'm wondering what, what is, how is that distinction used by practitioners? I think. I'm not sure that distinction is. So I think, right. So I'm not sure that distinction, I'm not sure that there are practices that specialize in one or the other. I think that the idea here is that it's encompassing both. Yeah. Right. So I mean, as you may recall from earlier this year, this is not an uncontroversial bill. There are people who object to the bill and to certain language in the bill. That's what I'm asking. Yeah. But I think, I think that has more to do with potentially how they, either how they view the application of this bill to their practice or, or their discomfort with some of the distinctions that are being drawn. I'm not sure, I'm not sure that there came to be a way to please everyone. So Jenny, you, you mentioned that one of the witnesses I should be in contact with. Oh, well, I, I don't know whether I copied you. I think I did and a request for some help in understanding and asking questions. So you should be getting that. Yeah. I will, I will check. It's just today, today is like crazy. I don't know. I completely understand what you and Dick are going through on appropriations. And it's well, well, as in, we'll tell you, we have joint fiscal at during lunchtime. I'm on the floor one, we have appropriations from 130 to four. And then we have that hearing. And the hearing will probably go till seven or eight. So that's today. You're doing good work. I want to eat. Well, we're going to, we'll try and give you some time. So I hear Senator McCormick's question. I think it's the, it is the confounding question of, you know, what is, what is this, who is this bill affecting and how? And I, I know that we've been through this with the testimony and, and tried to fix the notification piece. That's what the bill is about. So it's about notice. And that is important. Senator Cummings. Oh, this is, I'm flashing back. It's amazing how things change so quickly. This was the full page ads in my local paper. Do you have anything from, well, this week, it would be flat feet. Next week, it would be hypertension, the weekend, come down to the local hotel. And we've got this stem cell that will cure you. And it, I mean, they were right up there with the Oriental Carpet Salesman. And the same process, come down to the local hotel, we'll do a presentation and you can sign on. And all we were saying is you got to tell them this isn't approved. People were desperate. I mean, if people are desperate, they don't care. But we had the example of the two women who went blind, trying to cure macular degeneration with having cornea cells implanted in their eyes. So there are some serious consequences. And I think this is just, you should know that you're being experimented on or being victimized, being victimized, depending on your point of view. But it's full disclosures, all we're asking. Yes, that's it. And it gets into some detail about what's allowable and what's not allowable. And it's, I think, I have a chronic that will cure any ailment that you have, Senator Cummings. Is it a snake oil product? I've tried those. So in the late 1800s and early 1900s, there was something called proto-nuclein that was guaranteed to cure all your ills. And I think it included in it some, a derivative from the coca plant. Oh, that should work really well. It did a lot of good. It took away all pain, regardless of the height. For a short amount of time. Right. Listen, we have 20 minutes left. And are we feeling okay now? A little more comfortable, I guess, having had this discussion. That was one of the reasons I wanted to have it. We've been away from the bill for a while. We okay then? And Senator Westman has it up on the calendar. I think I will, if you don't mind, communicating with Senator Ash about when you're comfortable reporting the bill and just copy me on that. So I don't want to get in the middle of your. Yeah, I'll text him during lunchtime and tell him that I'm ready to do this on Tuesday. Okay, that's good. And you do need to get the amendment, you'll need to get the amendment to the secretary. Yeah. Okay. I'll leave that to you. Do we need to vote on that amendment? Or that's a, that's a Senator Westman amendment. Okay. Senator Westman amendment, he may want to report on it. Can I see a show of hands that people on the committee that are in favor of the amendment? It's two date changes to remind you. Good. The committee was unanimously in support of it. Good. Okay. Jen, Jen, did you say you were going to email me the new copy of H663? Yes, I'm having it edited right now. Just I asked them to take a final look. And then I, yes, and then I will send it to you. Okay, thank you. Yep. And then Madam Chair, I had a question for you. I was thinking that the, you know, the chart that we got from Senator Clark this morning was a really nice succinct and easily understandable way to see where, you know, quite a large sum of money has gone. And I wondered if you would, I think it would be a good idea for me as the clerk to send that, just to email that link to that to all of our colleagues just with a little paragraph saying this is what we heard. This is what's going on with all this money. Yeah, that sounds like a very good idea. Very good idea. If anyone disagrees with that, let me know. But I think if it's going to become obviously it's going to become out of date pretty soon. But I think it's a great place for people to see what's been happening. Okay. All right. Sam McCormick. Yeah, I would still like an answer to my question. I think the discussion from my question kind of drifted into an explanation of what the bill does, which I already knew. I'm curious as to how the terms homologous and non-homologous are used by practitioners. Okay. Well, I think that's a question that can be asked of one of the witnesses. And I guess I might leave that, Senator Westman, if you're in contact with someone who's helping you, can you ask that question? Sure. Okay. That would be helpful. Good. All right. All right. We have, we have 18 minutes left. And I'm thinking, Jen, that we probably could look at age 795 briefly and at least the 4000 foot level and go through that bill. Just had to find it. Yeah. So you want to look at the house version? What passed the house? Okay. So this is age 795 as passed by the house. It was an act. It's called an act relating to increasing hospital price transparency. And this requires by February 1st, the Green Mountain Care Board to report to this committee Finance and House Healthcare regarding its progress in developing and implementing a public interactive internet-based price transparency dashboard for use by healthcare consumers. And it's supposed to include the results of the board's effort. They're working on validating vCures data through comparison with hospital discharge data and with information from health insurers and the status of the board's work to incorporate location information into vCures data. Then it also requires the board to include in the report any information it gets from the validation process about payments for services by patients without health insurance coverage and the information hospitals track relating to self-pay patients and how the hospitals might be able to provide the board information in the future about actual amounts that the self-pay patients pay for their healthcare services. Section 2 adds a statutory provision on an interactive price transparency dashboard. So the first was a report on how they're doing and developing it. Second is the requirement to develop and maintain a public interactive internet-based price transparency dashboard allowing consumers to compare healthcare prices for certain healthcare services across the state. They're supposed to use vCures data and have the dashboard provide the range of actual allowed amounts for specific healthcare services showing both the amount paid by the insurer or other payer and the amount of the members out of pocket responsibility and allow the consumer to support to sort the information by location, healthcare provider, payer type and the specific procedure or service. It's also supposed to have a link to the statewide comparative hospital quality report published by the health department and it requires the board to update the information on the dashboard at least annually. And then it required by February 1st, 2022, the board to provide a demonstration of the dashboard to the same committee, so this committee, Senate Finance and House Healthcare. And in addition, by February 1st of 22, the board must provide recommendations to those committees on ways in which the dashboard could be expanded to provide quality information and information on actual amounts charged to self-pay patients after any charity care policies or other discounts are applied and on other information that's not currently collected by vCures. And section four would have the most of the provisions take effect on passage but the statutory provision take effect on July 1st and that's moved out in the amendment with the dashboard becoming available for public use as soon as operational but now no later than February 15th of 22. So that is the bill as it came over to you from the house and then this morning we looked at that amendment with the Green Mountain Care Board. Okay. Questions for Jen on the bill, underlying bill. And I think we heard from the board that this was something that they can do but will. Yes, on the house side the information had been developed with the board. Right. This is the next step in the price transparency bill that we passed last session, 2018, 2016. I think you had one last session and you've had a few others. Yeah. So it's an ongoing process. All right. So good. Why don't we consider this as a full day's work unless someone has, we'll leave the homologous, non-homologous question open but the way I would look at it would be the practitioner needs to understand the definition based on federal law and what is approved and what's not approved by FDA and the responsibility would fall on the professional to make some judgments. Okay. So we finished our work for the week. We are not going to meet tomorrow. Yeah. We work so hard from March through June. So what we'll do is I'm trying to keep Fridays open. We still are on the floor at 11.30 on Friday but this gives some time for us to do our work and preparing for committee or getting ready to present bills. Okay. Is there anything else that anyone wants to bring up? We're going to have a full agenda next week and some of the issues that we talked about the other day will be coming at us. So we'll keep working. Thank you all. It's been a good day's work. Take care. Thank you. Nellie, we're good. We can leave.