Vermont Legislature SmartTranscripts:

[Speaker 0]: Good morning. It is Friday, May 8, House Healthcare. Jen has been working furiously and thank her so much for everything. And we're going to look at some changes. If you recall yesterday on 01/1990, a group of stakeholders sort of got together to try to hammer out some of the differences in cleaning up the language. I will also say that yesterday's version of this bill contained section, I think it was four and 4A. I have that was around teachers help benefit land. And I've removed that from the bill and kept the reference based pricing in there for them. And I just want to be really clear. We value, we deeply, deeply value our educators. We balance things in this committee because we are looking at the system as a whole. And we have to be able to look at all the systems within our entire state and how they work together. I will tell you, I put that in there to start a conversation, and I am really glad that we had the conversation, but it doesn't mean that we value our teachers any less. So, I just wanted to be really clear about that. Since I am the one that put it in the bill, I removed it from the bill. So, thank you everybody, and I hope we can continue the conversation as we look to trying to make our healthcare system in Vermont more affordable and sustainable and ensuring that everyone has access to high quality health care. Jen, are you Yes. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: I'm just kidding. On the Zoom. I just sent the language to the classroom. So the same Zoom as the center of your classroom? Are

[Rep. Brian Cina (Member)]: we not going to discuss that issue any further because it was removed from the

[Speaker 0]: Discuss it in terms of

[Rep. Brian Cina (Member)]: reference based pricing. Okay. I'm glad it was removed, but I had a thought about the issue. If we have to wait till another time to talk about it, that's fine though.

[Speaker 0]: I think I'd like to take a question. Okay. Thank you, Bill. And thank you for your thoughts yesterday. You had something really good. And we learned a

[Emily Brown, Executive Director, Green Mountain Care Board]: lot yesterday.

[Rep. Brian Cina (Member)]: Well, when the time comes, I was thinking a lot about what might be other solutions for it so we can come back to that.

[Speaker 0]: FBioxin Committee, we have Jen until about 11:05. So hopefully she can walk us through the language. Let's keep our questions for Jen contained to the language so that she can then go and we can have committee discussion. Wonder if

[Rep. Brian Cina (Member)]: we could use AI to screen our questions in advance, and then could decide if they get asked. We typed in

[Speaker 0]: our computer even. Couldn't we make shuttle legal?

[Rep. Brian Cina (Member)]: Done. It's supposed to ask for clinical advice.

[Jennifer Carbee, Office of Legislative Counsel]: Alright. Good morning, Jen Carvey, office of legislative council. And I think this draft is going up on the website. Natasha, if you're printing copies, can I have one too? Okay. Just I think I can get it. So this is a new draft of s one ninety. For the most part, I have highlighted changes. There were few places we're trying to show you the strikeout, and the new stuff was confusing, and so I got rid of some of the strikeout stuff. And in one case, just deleted a whole section. So it starts off with the reference based pricing section, and I think the there's a couple couple of changes here. One is to add a version of that that intent language that you looked at from Health Care Advocate yesterday. So I actually put in the beginning of the subsection on reference based pricing and proposed adding so adding a and there's currently an a a subdivision a and Refresh. B. So Subdivision E 1 a and b. I've put in a new b and made what was b c. So this would now say that the board shall utilize reference based pricing to reduce hospital prices incrementally until they are equal to national median median prices by hospital type by, I think the language said, 2030. So I took a guess and said calendar year 2030 since we talked a lot about fiscal and calendar year February. The board shall use the highest quality nonpartisan data demonstrating hospital prices as a percentage of Medicare. I think that's what it meant to evaluate progress toward reducing hospital prices in Vermont to the national median. So those who were involved with or in favor of the language, I hope will let us know if we have missed something in putting it into the bill draft. Then I changed the language around provider contracts with hospitals and health insurers showing beginning to express the rates as a percentage of Medicare or another benchmark and to move that date at the request of Hospitals and Green Mountain Care Board from 10/01/2026 to 01/01/2028. Next, I have deleted section two. Section two, but replace it with some other stuff where you've asked too much about that. So section two of the previous version had been the reference based pricing qualified health benefit plans and plans covering school employees. It was a session law provision because it applied to 2027 and maybe later years. Instead, I have put it into the statutory language. And so I've, and I've combined it with what had been in section three on hospital budgets and budget review. So we're, we already have the definition of Medicare adjusted base rate added, but then I've, you can see, put it in as a new section ninety four fifty nine and incorporated the provisions that were being proposed as ninety four fifty nine in the previous draft. So we have definitions. So I I tried not to highlight things that have been defined in previous section two because you had looked at them at least a little bit and just flagging the changes. So the definitions, definition of hospital, as we had seen in the version we looked at yesterday, it excluded critical access hospitals. This also excludes a hospital classified as a Medicare dependent hospital under federal regulation or a hospital that is participating in the rural community hospital demonstration program through the Centers for Medicare and Medicaid Services. My understanding is this is really applies to Broward Memorial. Currently, I think may fit both B and C, but it's the only hospital that is reflected there. So that is what that is carving at due to their financial financial.

[Unidentified committee member (female)]: So then this would only apply to the PPS hospitals. Yes. That's what I'm interested here.

[Jennifer Carbee, Office of Legislative Counsel]: Alright. And then this would do some specific things for fiscal years 2728, and '29. These are hospital fiscal years, so that's starting October 1. So in establishing the fiscal year twenty twenty seven hospital budgets, this would allow the board so it wouldn't be required, but it would allow the board to direct an amount equal to 3.5 percent of the hospital's combined commercial net patient revenue based on approved fiscal year twenty twenty six hospital budgets toward reducing commercial reimbursement rates for qualified health plans and the plans offered to school employees based on a percentage of the Medicare adjusted base rate determined by the board for each item provided and service delivered to Vermont enrollees in these plans. And then in establishing fiscal year twenty eight and twenty nine hospital budgets, it would allow but not require the board to limit commercial reimbursement rates for those same plans by a to not more than the following percentages of the Medicare adjusted base rate for each item provided in service delivered in Vermont to enrollees in these plans. For hospital fiscal year twenty twenty eight, not more than 300% of the Medicare adjusted base rate, and for hospital fiscal year twenty twenty nine, not more than 250% of the Medicare adjusted base rate. Then it would

[Speaker 0]: Do you have a question on language?

[Unidentified committee member (female)]: I do. I did. You you said combined. You used the word combined, and I just wasn't sure who was being combined.

[Jennifer Carbee, Office of Legislative Counsel]: Oh, the hospitals combined. So of those hospitals

[Unidentified committee member (female)]: Hospitals combined commercial net patient revenue? Yes. What's that? Combined.

[Jennifer Carbee, Office of Legislative Counsel]: What's being combined? All of their net patients. So if you take all of the the hospitals who are within the definition of hospital and you add up all their commercial net patient revenue, and then you take 3.5%.

[Unidentified committee member (female)]: So it would be, you know, Blue Cross, MVP, United I mean, is that what we're talking about?

[Jennifer Carbee, Office of Legislative Counsel]: Believe that is their net patient what their rev I mean, that's the commercial of their net patient revenue as opposed to a public payer. So that's what it

[Unidentified committee member (female)]: means, that anyone that's not a public payer? Yep. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: Thank you. A public payer or private payer. I mean, commercial, I believe. I mean, you'd wanna hear from maybe the hospitals and the Remote Care Board how they define it, but that is a defined term in the universe of hospital budget reporting. And they report those individual numbers to Remote Care Board. The idea was to use a known quantity because know, a known set of data because it is based on approved fiscal year twenty six budgets.

[Speaker 0]: Thank you.

[Jennifer Carbee, Office of Legislative Counsel]: Alright. So then it keeps language directing the carriers. Our registered carrier health benefit shall not reimburse or agree to reimburse a hospital more than the percentage of the Medicare adjusted base rate specified by the Green Mountain Care Board Subsection b, if any, because it was permissive for the applicable hospital fiscal year, again, for items and services delivered to Vermont enrollees. And then carries over that language about what to do if there's a capitated or other non fee for service reimbursement arrangement happening, and then saying that a hospital or hospital provider reimbursed in accordance with subsections b and c, so can the show limit or the potential for limit from the hospital side and from the payer side cannot balance fill, cannot charge or collect anything else. It does and then I I wasn't sure what the where the committee would be on this or where the stakeholders were on this. I kept in language saying if a if a hospital is required by the board's budget order to reduce its commercial reimbursement rates further than what would be achieved under subsection B, then the hospital would reduce its rates that exceed 500% of the Medicare adjusted base rate. Or if they don't have any of those, the highest rates in relation to the Medicare adjusted base rate. And then leaving the ability except as provided in subsections B, C, and that previous E, a hospital may increase the commercial reimbursement rates for one or more of its service lines, such as primary care, as long as in doing so it remains compliant with the total budget order budget order for the hospital by the board. And then separating out as recommended by DFR, making it clear that it's the Green Mountain Care Board doing review of premium rates for the qualified health plans in accordance with ABSA forty twenty six and that it is DFR that is doing the review of the rates for health plans offered to school employees by Health Benefit Association in accordance with ABSA forty twenty six and twenty four BSA chapter one twenty one subchapter six. Want me to pause there or keep going?

[Speaker 0]: I would say keep going unless anyone has any questions.

[Jennifer Carbee, Office of Legislative Counsel]: Sections four and four a were are deleted. Share address those at the beginning. Those are the sections that were studying some actuarial value limitations on plans offered to school employees. Section five keeps the hospital outsourcing report. Section six keeps the exclusion of health care professional bargaining from reference based pricing. Section seven keeps the language on agreement care board appeals. Sections eight and nine keep the language on data infrastructure. Section what is now 10, it had been 11 around critical access hospitals. This one has gotten some changes. So and it in looking at this afterward, it may make sense to take out some of the intent language depending on where you go on this. But this would take out the language that actually requires critical access hospitals to reduce their rates. Instead, it would require critical access hospitals by September 1 to identify all outpatient services for which the amount the hospital charges equals five or more times the Medicare allowed amount for the service. And in new language, most prominently on its website and in outpatient departments of the hospital, information regarding the federal requirement that Medicare beneficiaries must pay 20% of the charge for outpatient services at critical access hospitals and that Medicare beneficiaries may be able to receive care with reduced out of pocket costs from other providers. And then it would continue to say to the extent the Green Dot Care Board engages in efforts to address the issue in hospital fiscal year '27, it must consider any proposals from the critical access hospitals and other interested stakeholders and ensure its actions are consistent with hospital transformation and principles for health care reform. The Act would take effect on passage in what is now section 11, and you may want to change the title.

[Speaker 0]: Great.

[Unidentified committee member (female)]: Leslie? So just for clarification, it went by fast. B5 is not included then in the reference based vaccine or did I miss it's not included anywhere. They are. They are included in the right place. Point me

[Jennifer Carbee, Office of Legislative Counsel]: to consent. So that's section two. That's a no. Section three. Okay. Thank you. Three. And so everywhere in b and c where we were looking at

[Speaker 0]: the

[Jennifer Carbee, Office of Legislative Counsel]: back up. Everywhere that we were

[Unidentified committee member (female)]: Okay. Thank you.

[Unidentified committee member (female)]: Six. Page

[Jennifer Carbee, Office of Legislative Counsel]: six. Six. So Page we're still keeping all those definitions and we're still talking about rates reducing commercial rates for qualified health plans and health benefits plans offered to school employees by Health Benefits Association. That is statute for BHI.

[Unidentified committee member (female)]: Okay. And one more question, but this isn't for Jen. But there are no other witnesses, so I just don't know where we're going with this. But I do have a question that's not for Jen.

[Speaker 0]: Okay. We'll have some witnesses. Okay.

[Jennifer Carbee, Office of Legislative Counsel]: There are other, maybe other selfie.

[Unidentified committee member (female)]: Oh, I'm sorry. Go ahead. I am concerned about the sufficiency of the notice, page 14, bottom of page fourteen and fifteen. And I was hoping for

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: a really clear

[Unidentified committee member (female)]: disclosure to each person that might be having an outpatient procedure with a critical access hospital. It's posed prominently on a drug slide and in the hallway. I'm just concerned about the sufficiency of that. And the language is a little vague, like what does this actually mean? It might cost more if you go somewhere else, you'll feel much more. And so I would be interested in seeing more effective notification in that section.

[Speaker 0]: I would love to see all that too, but I think it would be operationally impossible. First of all, outpatient services are like all outpatient services. If you're getting a lab drawn, should you get notification of how much it might cost you if you're having an office visit with a doctor. I mean, single service that's done on an outpatient. So, I mean, it would literally mean every single last thing that's done, which I'm not sure how you would operationalize that. And the other problem is how would that individual hospital be able to determine what it might cost somewhere else when they don't know what that somewhere else is charging or what other somewhere else? I mean, would they have to have a listing of the charge masters and what possibly you'd be paying at every individual hospital in the state or No, I mean I agree, I mean, certainly could be a little bit more specific about the information, but I'm not sure we can

[Unidentified committee member (female)]: be too prescriptive. Right. So, no, not practicalities.

[Unidentified committee member (female)]: Not to that extent, but I mean, if a patient is having some kind of interaction about a procedure, whatever it is, they're already in communication and contact with their provider. And so to sort of generally post it somewhere that they may or may not see when they're actually in direct communication with them, I would think one of the things I could imagine is because this is a critical access hospital and you're having an outpatient procedure, you may see substantial savings if you have it in the hospital or you go to a PD. Yeah, one of those hospitals. You might want to look into it. And then they can decide. They have enough information to look into it and make an informed decision. So I don't know, that's my fault.

[Unidentified committee member (female)]: I'm struggling with that too because there's a sign on the ball, but where do I go? I don't, Okay, I may be able to find it, but what does it mean? I have no clue. I'm struggling with who's in charge of that problem. And what I'm wondering is, should we direct them to Vaz, as someone who has oversight of the entire system to help direct people. I know you're gonna hate She gave me the face, I got the face. But it's sort of like who's in charge of the problem? And I'm trying to figure that out.

[Jennifer Carbee, Office of Legislative Counsel]: Just put that in a cell number.

[Unidentified committee member (female)]: I know the right person for you. So I'm just wondering that we need to help people, we can make a sign, but I would read the sign and say, now what? I don't know where to go. Who's going to help me discern the best place for me to get this? And it's

[Unidentified committee member (female)]: a very narrow category. It's outpatient critical access. Not everybody's

[Speaker 0]: is actually not a narrow category. That is a very modest category.

[Unidentified committee member (female)]: It's every outpatient procedure, but

[Speaker 0]: it's not just outpatient procedure. It's every single thing in a hospital that's done on an outpatient visit. If your primary care doctor is at is a critical access employed, that would be that office visit, that blood draw, that removal of cerumen impact ion.

[Rep. Brian Cina (Member)]: I love when they do that.

[Speaker 0]: Yeah, it's good. So frustrating. Confusing.

[Unidentified committee member (female)]: Is it worse than, I mean, I'm just trying to think of a person who is there to say,

[Speaker 0]: for more information, please call patient financial services. Absolutely.

[Rep. Brian Cina (Member)]: There you go. I was going to say something like that.

[Unidentified committee member (female)]: But that means financial, they need to know. I mean, they'll have to have to There be informed has to be like,

[Jennifer Carbee, Office of Legislative Counsel]: we can direct them, and there is some onus on people to be able to know where to go as well. So if we say, contact patient financial services, if you're getting care, you're going to know that there's a patient financial services. Think we need

[Unidentified committee member (female)]: to be more. Fine with contact patient financial services. I think that's the right thing. So thank you for that. It's just I think they need a place to go.

[Speaker 0]: You're welcome. We

[Unidentified committee member (female)]: have to train everybody.

[Unidentified committee member (female)]: I think we'll be getting more actual information on these categories. So we'll have more data, which particular procedures are really impacting people.

[Speaker 0]: I will say, and I'm sure that Devin can testify to this and I will say that Vaas did receive information from CMS regarding this issue yesterday. And there is there are limitations on what we as a state can do on this issue.

[Unidentified committee member (female)]: Is that something we can hear about or not?

[Val [last name unknown], committee member (remote)]: It does.

[Speaker 0]: Okay. I'd be curious. But

[Unidentified committee member (female)]: disclosing to patients so they have informed consent, hopefully it's not one

[Unidentified committee member (female)]: of those things. Correct. We're not. That's what

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: we're talking about right now. Is

[Speaker 0]: there can we have in here that the hospitals shall develop the communications and the board approve, like in development. I mean, I know often sometimes we do things and then DFR will sort of approve it. I don't know how to write that, obviously,

[Jennifer Carbee, Office of Legislative Counsel]: you know. Do you want them to, for what they're postdining in places? Okay. Yes. And have it by board approval. Same way

[Unidentified committee member (female)]: we did with how to get patients financial assistance. So it's the same product, that's what I'm thinking.

[Speaker 0]: Does that work for everybody?

[Unidentified committee member (female)]: Does it include Leslie's suggestion about a real

[Unidentified committee member (female)]: Yeah, there would be a real context.

[Speaker 0]: I'm sure the board will ensure that it is comprehensive notification in a manner. Okay. Any other questions on language at all? Have questions for you.

[Val [last name unknown], committee member (remote)]: Oh, you weren't!

[Speaker 0]: I was hoping that I'll have people come up and speak to this latest version, but we have bumped the healthcare advocate multiple times. And I promised him he got five minutes yesterday just on the end of tail end of it. But I'd like him to come up first and testify on this bill because I don't think you have other than your few minutes. You've upset that you keep getting bumped, and now all of a sudden you don't know what you're gonna say.

[Rep. Brian Cina (Member)]: We fixed everything.

[Val [last name unknown], committee member (remote)]: It was a very effective five minutes you had. Thank

[Speaker 0]: you, Jen. Yeah. Thank you. Great work. And and your proposed language? Oh, yes. Yes. Responsible.

[Mike Fisher, Health Care Advocate]: Thank you, Mike Fisher, health care advocate. Yes. I actually do think that in my very brief five minutes, it was actually

[Val [last name unknown], committee member (remote)]: efficient. Yes.

[Mike Fisher, Health Care Advocate]: So I did that was significantly what I wanted to say. I I guess but I'll just go to big picture for a second. Boy, this is the time of year where we all have to do deep breath. Nothing is perfect. There are probably there are many things in this that I might draw your attention to and suggest changes that are not appropriate to do at this time given the timing, but I think this moves us in a good direction. On the last piece, I do wanna say, and I know that that the hospital association will clearly list patient financial assistance in their notice, but that is the tool that many Vermonters will benefit from who are experiencing this. I don't think we should write anything in here, but I'm struggling with how to inject my office's support for this very tough question, boy, we are telling people to go here for this type of care, go there for that type of care. And guess what? Most Vermonters just want to get care.

[Speaker 0]: Mhmm.

[Mike Fisher, Health Care Advocate]: And they're not thinking on that level of what kind of coverage they have or what type of hospital they're at. They just wanna be so it's really tricky to think of broad communications. But how do we help people maneuver through with their scheduling something? And it's pretty rare that someone calls my office and says, I'm trying to get this type of care. What are the legal dynamics sort of leading me to go to one place or another? How do I avoid a big bill? But it does happen. So having pushed to have a moment in the seat yes.

[Speaker 0]: With the bill in its current form as revised last night, what can regular Vermont residents, people you represent, be most excited about if this goes into law?

[Mike Fisher, Health Care Advocate]: Well, I do so I I do wanna recognize that we've sliced this thing in different ways because we're now doing these two markets. So it's qualified health plans and the teachers at PPS hospitals. It's I just wanna recognize that there are some promoters that are gonna experience some real savings, real savings, and there are some promoters that won't experience anything. And I guess I will I'll go back to one of the central messages from yesterday that focusing this legislative activity on 2027. That's sort of the task in front of us in this bill. And really very much I know there's some language here that's not permissive about '28 '29, but, really, I want to get to a place where the board has gone through rulemaking, and we are down going down our path of system wide reference face pricing that affects all of our mantras. That is a real value to me. Yeah. So I so there will be real savings. I think there will be real reductions in the QHP and for taxpayers paying for the cost of teachers' educators' health care.

[Rep. Brian Cina (Member)]: Actually, you had said something a minute ago that there were people who would directly benefit and then there were others who weren't, but I was going to actually ask about the indirect benefit to all Vermonters, including the public workers, because even renters may benefit if their landlords aren't raising their rent as much because their taxes stabilized. I do think that this bill is an important part of our efforts to control the cost of both healthcare and education. And I think the way we're doing it is respectful and measured. So

[Mike Fisher, Health Care Advocate]: can I

[Rep. Brian Cina (Member)]: Thank you? But I'm curious, but you and I don't know if you have anything else.

[Mike Fisher, Health Care Advocate]: Right. So this this may be gonna get me in some trouble. Uh-oh. This this has a little bit to do with my knowledge base of how it works. I can see in the QHP how this will iron right through to rates, and I will be at see at the table and watch the board do it. I don't have it worked out in my head so clearly how the reduced cost for teachers' health care works itself so directly out into reduced tax taxes. And Why? I

[Rep. Brian Cina (Member)]: yeah. It's Because you're not because I don't know the that process. So, I mean, I I I

[Mike Fisher, Health Care Advocate]: don't Maybe this is a question another witness can answer. But Yeah. It it so I'll say it is it is certainly my hope that there's a dollar amount that shows up at the end of this that once we've worked through and that we can we can see that result in in reduced tax burden.

[Speaker 0]: Oh, did anyone else

[Val [last name unknown], committee member (remote)]: I I have a question.

[Speaker 0]: Oh, go ahead, Val.

[Val [last name unknown], committee member (remote)]: Hi, everyone. Thank you. I don't know how to raise my hand. I'm sorry.

[Unidentified committee member (female)]: I I can raise

[Jennifer Carbee, Office of Legislative Counsel]: it at

[Speaker 0]: home. I can't see it. Can't see it anyways. So,

[Val [last name unknown], committee member (remote)]: don't know. I've just been studying this quite a bit. I still don't really know how to absorb all this. I do have a question. I'm concerned about every Vermonter being positively affected by this. For example, me and my husband self insured. I kind of want to know more about the subsidies and the waiver, the whether or not we just say, as a self employed family or business, if we are not reaping the benefits of this bill, or if all Vermonters are not, how does that affect us getting how does that affect the waiver, the subsidies in the future? Like, I I don't know. I'm just I'm having trouble with this. Do do we not do do we we get money from the what is it? That's,

[Unidentified committee member (female)]: $13.32 only if I may want premium tax credits.

[Mike Fisher, Health Care Advocate]: Yeah. Yeah. So thanks for the question. I think it reminds me a little bit that I that I I went into the nuance of this bill, and this is a moment for sort of broader reflection. I know this is just a step in the path, but the overall path is a significant effort to right price our system in a way that we can afford to maintain it. And so it is well, it it is, I I think, the most important effort that is going on in the legislature right now. So this bill coupled with previous action. So I do think that it will help families like Vals. And I think I think families that are on the exchange, which I think pretty much all self self employed people would be. We'll see the results of this very quickly. Though I think I heard I heard the sort of relationship to the premium tax credit question. I do recognize that for the significant number, I think we've estimate it's been estimated something like 77% of the individuals in the exchange are getting a tax a premium tax credit. And that for them, all other things being equal, they won't see they won't see this savings or they won't see as much.

[Rep. Brian Cina (Member)]: And that's because they're expiring?

[Mike Fisher, Health Care Advocate]: No. No. Because because the way the tax credit works, it it sets a maximum amount that your family has to pay. I know

[Rep. Brian Cina (Member)]: what you mean now.

[Mike Fisher, Health Care Advocate]: And your size, and so a reduction in the overall cost just reduces the amount that the federal government

[Rep. Brian Cina (Member)]: Right. It's like because I get that, whatever that is, and whatever you just call this, a tax credit. It depends on the subsidy. It's a tax credit. So I get it, because it's like if I'm paying 33¢ a month now, then that's not going to go up, because that's the max already.

[Mike Fisher, Health Care Advocate]: There's been a healthy debate, I think, between me and many people and others about where's the right place to inject these savings, and I have recognized that dynamic we're talking about. And then I also fully recognize the now 20 some percent of Vermonters, 5,000 of which many many of them are in the group that just left health insurance this year, who are, yeah, incredibly exposed, and harmed by the loss of the enhanced tax tax credits. And so bringing these prices with into a reasonable range is a key part of attempting to secure this market, particularly for those people who are above the tax credits.

[Val [last name unknown], committee member (remote)]: Go ahead, Brian.

[Rep. Brian Cina (Member)]: I don't remember if there was testimony showing any projections, but do you know, do you have any idea what the numbers might be for people, in other words, all tax credits aside, what would you call it? Not like the raw fee, but like the

[Mike Fisher, Health Care Advocate]: The total premium cost?

[Rep. Brian Cina (Member)]: Yes. The premium cost without any embellishments or help. You know? So like, it's like 800 and something now, I think, for an MVP bra.

[Mike Fisher, Health Care Advocate]: That's the cheapest one or something. I'm aware that the chair carries the menu.

[Speaker 0]: That sounds so strange.

[Mike Fisher, Health Care Advocate]: Okay. Placemat.

[Speaker 0]: So so that Okay. So, Brian, would you like to know?

[Rep. Brian Cina (Member)]: Well, what I would like to know is Let's choose just for the for for the for, like, the experiment. K. And the second most expensive MVP bronze for an individual.

[Speaker 0]: Second also, if you really not have the

[Rep. Brian Cina (Member)]: It's on the right hand side. It's on the right hand side because I know that's my sec that's my section of the tank turret.

[Speaker 0]: Special thing.

[Rep. Brian Cina (Member)]: Oh, no. Maybe that's not it. I I MVP bronze was on the right, but they keep adding things.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Okay. Well, there is a

[Speaker 0]: Yeah. MVP bronze.

[Rep. Brian Cina (Member)]: It's expensive. Right?

[Speaker 0]: It's For like individual?

[Rep. Brian Cina (Member)]: Is it four digits yet? I'm not sure.

[Speaker 0]: 124

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: is

[Speaker 0]: the bronze five. $8.62 is the bronze one. And that is a that's an individual. Okay. Not a family.

[Rep. Brian Cina (Member)]: That's what I was aiming for to But but Yeah. Hold on. Okay.

[Speaker 0]: A $7,250 deductible. Wait. That's it? For an individual. I thought it was 15,000. But that's for

[Rep. Brian Cina (Member)]: Maybe that's the one I have.

[Speaker 0]: That's the other. Yeah. The cheapest plan. No, there is the anyways, you get that. There are ones over here, which are the health HSA ones.

[Rep. Brian Cina (Member)]: It's getting more and more complicated. But that being said, let's use the $862 a month one. What might be the savings on that? Do we have any idea? Are we just taking a guess or 100 less a month, 200? Are we talking

[Unidentified committee member]: like 400 less a month?

[Mike Fisher, Health Care Advocate]: I think it it may be that Blue Cross will be prepared to give an estimate of the percent reduction that this represents. I'm not sure whether

[Rep. Brian Cina (Member)]: You don't have that.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: It's okay.

[Mike Fisher, Health Care Advocate]: Given the way that we've spliced things a little bit differently for different hospitals, I'm not sure whether we have that.

[Speaker 0]: And it's also very possible that it wouldn't reduce it at all, but what it would do is instead of going up 10%, it goes up 10%.

[Mike Fisher, Health Care Advocate]: I actually think this is bigger than that. I think in previous versions of this, when it was all hospitals, and let's remember that the cause, while there's lots of them, are not a lot of the health care dollar. I think we were talking in the range of 15%. Now I'll get just my self control because I had no confirmation. I think that this may well be a significant reduction in

[Speaker 0]: PRINIMS.

[Unidentified committee member]: Did you have a question?

[Val [last name unknown], committee member (remote)]: Okay. You Scratch my notes.

[Jennifer Carbee, Office of Legislative Counsel]: Yeah. Sometimes you

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Well, I'm a new thinker. So

[Speaker 0]: I guess my one question started your testimony by essentially saying that this is not perfect. I acknowledge this is not perfect. I just wanted to get your thoughts as somebody who is in the stakeholder group coming to this version. Do you feel as though this version strikes the right balance?

[Mike Fisher, Health Care Advocate]: I think this version strikes a good balance. I think there was a good stakeholder group process. We didn't all leave happy for sure, but good communication. And I do wanna say this is about this one and about the bill that represent Demar delivered so well, today. Not easy to do a good stakeholder process at this time of year. Not easy. In the middle of the session when there's lots of time. So there's been some good some good process.

[Unidentified committee member (female)]: Thank you. Thank you.

[Speaker 0]: Okay. Yeah.

[Unidentified committee member (female)]: Oh, what's what is the timeline on this part, like, when the FCA gets in on this? And did did you discuss any of that? Like,

[Speaker 0]: Just wondering of a timeline. Reference based pricing, which we did last year, begin implementation in 2027, which essentially this is sort of that beginning because they're still in the rulemaking and so they can't implement actual things for 2027. So they will begin 2028 and beyond. That'll be the QHP. That'll be 2028 will be everything. 2028 and '29, and there is no end date to reference based pricing. Everybody thinks that, oh, we're going to get to Reference based pricing is not something that will ever end. Well, until another legislature comes in.

[Rep. Brian Cina (Member)]: When the robots take over.

[Speaker 0]: That will that affects the whole part. Wait a second.

[Jennifer Carbee, Office of Legislative Counsel]: Don't help me all of our I really

[Mike Fisher, Health Care Advocate]: need something that I wanted to say.

[Unidentified committee member]: Yes.

[Mike Fisher, Health Care Advocate]: We find ourselves in this place with the need to define record space pricing for '27. That's how this bill started to be. But one one lesson from this year on this bill for me is how much we we really we've set up a professional entity to do this work, and and it's, I think, really important that they be allowed to run with it as much as possible without constraint. What happens at this table, no offense, is sometimes influenced by other forces. And and I think in order to really be successful in this, I am really hopeful that we don't have to come back year after year to this table to be looking for exactly how to frame it. I'm hopeful that we can let it run under the direction of the board.

[Unidentified committee member (female)]: Think it's the rule making. I'm just trying to get a oh, my head around this. The rule making is Green Mountain Care Awards. That has started? Yes. There team?

[Speaker 0]: Part of the rule making process.

[Unidentified committee member]: Not sure Green Mountain Ward, Diane, and my firm, They are in the rule making process, but this interim step here, because it's not finished, it'll be a while, and this body and building, it has to be met with care board last year to begin in 2027. It was a beginning point, but there will be many years to come. The other thing that's important to take into consideration is that as price rolls out,

[Speaker 0]: if I can say it one way or

[Unidentified committee member]: the other, it needs to also be in step with our mission of making sure that

[Jennifer Carbee, Office of Legislative Counsel]: the hospitals, ratepayers,

[Unidentified committee member]: that all of this not an overburden in any one direction. As much as we would love, sometimes the Senate yelled at us to get it done yesterday, there is consideration to other entities and how this will affect them as we go.

[Speaker 0]: You. I know you weren't prepared, but I would like to get your thoughts.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Thanks for having me. Devin Green, Vermont Association of Hospitals and Health Systems. And I am also thankful for the stakeholder process. I really appreciate all the parties coming together and working further on this bill. Mike Fisher's right. There was not total agreement on the bill. But I do think it is going in a better direction right now. I'll just first say for the reference based pricing piece, I think what hospitals are looking for are clarity and predictability and a long term goal. And we appreciate you adapting, Mike Fisher's long term goal. I think that will be helpful in giving us direction. We've really been looking for direction this year. The three and a half percent process, you wish that it could just say $50. That's or $50. $50,000,000, which is what we've said all along. It's a defined number. We know what it's gonna be. We can plan. We don't have a lot of time to plan at this point. We can just take that and run with it instead of spending time trying to figure out where that number might land. So we would argue for $50,000,000. And we realize that I don't know if this makes much of a difference. We appreciate the years going forward, '28 and '29, being a May instead of a Shell. We would like there to be flexibility there. And, again, hope that this can be done just through the budget process. So there's one process and

[Jennifer Carbee, Office of Legislative Counsel]: it's not

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: multiple processes on top of each other just for sort of planning purposes. So we would say $50,000,000, just leave it at that.

[Unidentified committee member (female)]: Where are we? I'm sorry.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I think page the three and

[Speaker 0]: a half percent.

[Unidentified committee member (female)]: That equals 50,000,000? Okay.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I see. Three and a half percent, I think, is more. We don't actually I don't totally know what the amount is, and that's why we're just saying.

[Speaker 0]: I just wanna ask the Led Councils that so we had discussed putting 59, but Jenny had concerns about it not being, like, statutory and taking sessions or

[Jennifer Carbee, Office of Legislative Counsel]: I mean, if we can do it now every month, I think it makes sense to codify some of this language because it's going on

[Speaker 0]: for a period of years.

[Jennifer Carbee, Office of Legislative Counsel]: It feels odd to put a specific, very large dollar amount in statute.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: But it's just for FY 2023?

[Jennifer Carbee, Office of Legislative Counsel]: That would mean we can't do it. So, I thought percentage was sort of more a percentage of a defined set amount, a full amount. No one really seemed more consistent with what we typically put in statute, but we can save $50,000,000 if we would save this amount. That shouldn't be the reason you don't move forward. People aren't supportive of And

[Speaker 0]: I will say, that is a known quantity, what that number is, and we spent a great deal of time with calculators. And that gets us very, very, very close to that 50,000,000, that 3.5.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Okay. We would like the final number. We would like to understand the final number so that we have agreement. Certainly answer my direction. So that's where we are in the reference based pricing piece. Then on the I start

[Jennifer Carbee, Office of Legislative Counsel]: back that before you go on?

[Unidentified committee member (female)]: You want it now? Or I can wait. No, you can I am curious and you may not know this off the top, but what percent of our system is PPS versus critical access? So this would represent four hospitals. Right. So what percent of

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: our system is Oh, in terms of money or Well, I know you gave a thing or

[Unidentified committee member (female)]: I'm trying to understand what not having a critical access hospital means financially and also for them.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I think that's like $3,000,000 or something. I'd have to go back. It's very small.

[Unidentified committee member (female)]: So that's what's interesting, too. So not having the critical access hospitals seems to be reasonable in terms of this process. I just want to understand the impact. I'm looking at impact. I think it is

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: reasonable, especially because I think it's easier operationally because with PPS hospitals, there are prices that you can look at and convert with critical access hospitals because they get reimbursed on a cost based reimbursement. That is harder to translate into direct percentage of Medicare prices, that sort of thing. And so it makes sense to start here and keep the critical access hospitals out for now.

[Unidentified committee member (female)]: Do we know how much would come from the if you said $3,000,000 for the critical access, what's the PPS? I don't know. I'm not

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: totally sure about the so the 3.5% inclusive of the budget, I think, is something like 56. 56. That's where that number is.

[Speaker 0]: Is that the total? Okay. Oh, but because we have well, we'll have Emily speak back. She just popped up. Oh, great. Perfect.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Then

[Unidentified committee member (female)]: yes, so that's the- Major orders of magnitude across the system, and that's what I'm just trying to understand. The

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: rest of it? So I'll hit the critical access hospital cost sharing piece, the most hated

[Unidentified committee member (female)]: You just read the thing that you received. So thank you for Yeah, that's very helpful. That was really important,

[Rep. Brian Cina (Member)]: I think,

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: from you. Yeah. And so I think our concern in this section is there are things that hospitals can do voluntarily, but they make it very clear that it needs to be voluntary, and the intent can't be to reduce the cost sharing. And so I don't know what to do here because the intent language is already in previous drafts. Like, there's been legislative history around it. But just, like, going forward, when hospitals are adjusting charges, I don't know.

[Speaker 0]: So you really just have a problem with the intent?

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I don't even know if I have a problem with it. I just think it sets things up for when we you know, like, if we have the intent and we report our over year or over five time prices and then those all come down, are the Feds going to look askance at that? That's the issue I'm grappling with. I don't know how to solve it.

[Speaker 0]: Although I still cannot wrap my head around. Understand

[Unidentified committee member (female)]: that

[Speaker 0]: the Feds say you can't do it, but reducing it to five times doesn't affect the Medicare payment at all. They get the extra money. It's not really about the payment. It's about what we're paying them for their back policy. They're not going

[Unidentified committee member (female)]: to hear about all of the stuff that we're

[Speaker 0]: We could

[Unidentified committee member (female)]: take it off the intent,

[Speaker 0]: need the intent.

[Unidentified committee member (female)]: That's where I'm going. Take it out.

[Speaker 0]: We could just have or before the state, you should identify all your services. You should have those at end?

[Rep. Brian Cina (Member)]: Who suggested the end? I'm trying to remember.

[Unidentified committee member (female)]: Oh, we're 14. Think twelve thirteen would start something. I think this committee was just setting the table.

[Rep. Brian Cina (Member)]: Yeah. Was it that you requested Ledge Council to write it based on our discussion? Is that how it ended up in there? No stakeholder told us to No, write it in,

[Speaker 0]: I think that there was language in the Senate version and then that it started. So this whole Green Mountain Care Board and the General Assembly have recently become aware. So that all came from the Senate. And then they said, don't look at it. Wasn't that in the original version?

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: They had the maybe. They had the work group in there. Okay.

[Speaker 0]: Well, maybe in the very, very short, short, short time I have, I can work with Ledged Council to at least, maybe, we know what the antenna is, but maybe we should have it in there. Yeah.

[Jennifer Carbee, Office of Legislative Counsel]: But we still get the data.

[Unidentified committee member (female)]: Yeah, we keep the rest of it.

[Speaker 0]: We just wouldn't have the, it's the intent to provide some relief to Vermont's and other Medicare in the confinescence of the federal fire ban.

[Jennifer Carbee, Office of Legislative Counsel]: You probably shouldn't. And

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: you can talk to Legis Council about it. The fact that it's in the legislative record could potentially be a problem too. But But

[Rep. Brian Cina (Member)]: we decided not to put it.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Yeah. And I I don't know how that would play out. But but the other piece is and we haven't talked to the Green Mountain Care Board about it yet since the CMS memo, but we would still wanna make sure that everything complies with federal law going forward. I'm sure they will do that, but we would like assurances that this is not going to be dealt with in our hospital budgets.

[Speaker 0]: Hear you.

[Unidentified committee member (female)]: Thank you.

[Unidentified committee member (female)]: But the hospitals are aware of something they can think about on their own.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: Yes, and there are things that they can do on their own around payment policies and notification. And we're still in touch with the delegation. And if all of you want to get in touch with the congressional delegation, and if you get complaints about this, tell those folks to get in touch with the congressional delegation too. I think

[Speaker 0]: that would be helpful. Okay. I think there's

[Unidentified committee member (female)]: some suggestions in here about what we could do to help seniors, though. I'm looking at that memo. I'm wondering about some

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: of those. I mean, could we so about that. We're we are drafting out notification. And in what we have so far, what we're saying is we have financial assistance policies. Here's who to call. You can go to this website to find out more information about the Medicare Savings Program and your eligibility for that. But we're happy to add.

[Unidentified committee member (female)]: Yeah, there were four and five Medicare supplemental insurance covering, so ensuring robust Medicaid enrollment. So somehow involved getting, I don't know what steps that would require and where that's four and five in the memo, state Medicaid and low income assistance programs. So I don't know what action might be taken. It might not be today, I mean, but I wouldn't want to let that go if that's an opportunity for seniors.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: We're happy to continue working on it to the best that we can, and it may take us to a partnership in terms of helping seniors out.

[Rep. Brian Cina (Member)]: Yeah, no, I'm just twitching because I'm in pain.

[Speaker 0]: Okay. Lori, your pussy.

[Jennifer Carbee, Office of Legislative Counsel]: No. That's

[Speaker 0]: like Dave. Dave raises his hand by going like this, and then so every time I see his finger go up, think he's raising

[Val [last name unknown], committee member (remote)]: I do have a big hand.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I have a question. I have another question.

[Jennifer Carbee, Office of Legislative Counsel]: I just have a reminder that

[Speaker 0]: time is short. I know.

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: And just one more thing. Sorry. On the fifty six million, the percentage, I think that is fifty six million. But with the critical access hospitals in there, I think it's more like 59,000,000 total impact to the system. So I just wanted to point that out. Okay, thank you. Thank

[Speaker 0]: you. Emily, thanks for jumping on. So it is my intent,

[Devin Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: just to let you know,

[Speaker 0]: it's my intent to work with Jen for a few minutes over for lunch. And then we will go down this at 01:00 when we come back here. Okay. Sorry, Emily, go ahead.

[Emily Brown, Executive Director, Green Mountain Care Board]: Thank you. Apologies for not being there in person. Emily Brown, Executive Director at the Green Mountain Care Board. So I heard, was listening to the prior testimony from Vaun about concerns about the percentage somehow being not definitive or not identifiable. So the language, as I read in the latest draft, has the three point five percent based on the approved fiscal year 2026 hospital budgets. So those are approved defined budgets. Those happened last summer. The Green Mountain Care Board has done a calculation excluding Brattleboro, which I think is a rural community hospital demonstration program. So they're not going to be included in this rate reduction. And so the calculation that we have done without Brattleboro is $54,600,000 So the Green Mountain Care Board is able to define that number and, you know, has the approved budgets with which the 3.5 is based on. So, we have full confidence that we will be able to do this calculation if this is the version that passes through House Healthcare. And I just wanted to comment also on the CAH, the CMS memo related to the CAH cost sharing issue. I think one provision that stuck out to me was that there's an expectation that charges that are in use in the Medicare program, they're a reasonable relationship to the cost of furnishing services. I think what we have discovered through this consumer complaint is that many of the costs at the cause do not have an obvious relation to the cost of providing those services. So, I agree that this memo does raise some concerns about if it's the intent to lower charge master amounts to somehow, you know, induce Medicare to pay more, I understand that. But I also think there is an opportunity here for the cause to look at their charges to make sure and ensure that they are reasonable in relation to the cost of them providing those services to Vermonters. So, I think even without, you know, providing the intent to address the Medicare issue in the federal law, there is an opportunity here, I think, for cause to do some type of analysis to make sure that what their charges are are rational or reasonable in relation to the costs. So I just wanted to offer that comment after reviewing the memo.

[Speaker 0]: Yeah, I appreciate that comment. You know, mean, the requirement is that we not artificially change our to affect Medicare, but there's another component and that is that charges need to be reasonably priced. So, you know, both sides are

[Unidentified committee member (female)]: What it says is bear a reasonable relationship to the cost of furnishing services.

[Speaker 0]: So, mean, I think having the cause actually look at their prices is really important. Any other thoughts?

[Emily Brown, Executive Director, Green Mountain Care Board]: No, that's it. And I just want to also echo what Devin and Mike and others said about the stakeholder This has been really challenging, but I do appreciate everyone's ability to get together and discuss these really tough issues. Also wanted to echo that, thanks.

[Speaker 0]: And I appreciate all your work on this as well. Thank you. All right. Oh, yeah, I'm going have Blue Cross, if you want to just give a final thought on this version.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, I think just wanted to Courtney Harness, Blue Cross and Blue Shield of Vermont, Just wanted to talk to Rep Cina's question about the premium and expectation there. And so VHI plan is kind of its own beast, as we've seen, and our biggest client. But for the entire qualified health plan, we think a number like what we've heard, 55,000,000 is around 10 percent, which is a big deal. And so if that number is $880 a month on premium, then it goes, maybe it doesn't go down to $800 How it will work and you'll see our rate filing on Tuesday morning. If MVP and Blue Cross file a 10% increase, this would effectively make that zero. So I think that's a benefit.

[Speaker 0]: Are you giving us a preview? No.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: You almost had me. You almost had me. And I would say, too, just a question about the critical access hospital involvement. And so I would say this fantastic premium and cost relief for the entire qualified health plan. I would just first say from Canada to Massachusetts east of Barrie, there's not a PPS hospital. So folks in the qualified health plan will experience a premium reduction here, but the price at their hospital doesn't materially change. So I think my question is more around, probably for the care board after we're done here, the premium is good. We've had some deductible conversation as well. If people are paying out of pocket, then do we suggest that they drive from St. Johnsbury to Barrie for their service because Barrie is operating reference based pricing? Or do we suggest that they stay at their critical access hospital to keep their care local? It's decision not to make for them, but the where, when, and how much are the things that we grapple with. So I don't require an answer. I'm just putting the question out.

[Speaker 0]: I think that it is a great reminder of the lack of, even though we have price transparency, the actual real lack of transparency in the entire healthcare system in price. Because we also have Blue Cross saying don't use UVM. I mean, saying that and then steering to critical access hospitals where people may be now using if they're a Medicare beneficiary. And I mean, we're just telling people to go all over the place and shop around, which is not what we want in our healthcare system. Emily, did you something you wanted to put out?

[Emily Brown, Executive Director, Green Mountain Care Board]: Yeah, I actually agree with Courtney's comment in that by limiting this just to PPS hospitals, we are not providing this relief to a lot of our rural citizens who access care at critical access hospitals. They will see, as was mentioned, a premium reduction, but they're not going to see a reduction in their cost share when they access those services at a critical access hospital. I think the Green Mountain Care Board had supported implementing and spreading this relief across all hospitals. And I believe that's what the Senate version. So just wanted to, I think it was a good comment and wanted to echo our support of including this across all hospitals and not just PPS. I hear you.

[Unidentified committee member (female)]: I'd like to echo that too.

[Speaker 0]: Of course, if we could get the cost of premiums in their funeral, then people would be able to select plans that don't have $10,000 deductibles on them and maybe that would. Thank you.

[Val [last name unknown], committee member (remote)]: Yeah. Thank

[Speaker 0]: you. Right. Let's We got to come back to this at 01:00. I'm sorry, unless there's any discussion, does anyone want to

[Val [last name unknown], committee member (remote)]: Are you going to make the change to 50,000,000 or are you keeping that 3.5%?

[Speaker 0]: Don't think it's wise because of Jen's

[Unidentified committee member (female)]: clunkiness And of

[Speaker 0]: I did change, I will say that this concern was brought after stakeholder engagement and I did, I changed Cal to May. As our healthcare advocate pointed out, is this perfect? No. The thought, the calculation, let's just be clear, Green

[Unidentified committee member (female)]: Dot and

[Speaker 0]: Care Board doesn't need any of these words on the page to do anything at all, but what they do need these words on page four is they need the words to be able to target the savings to these two markets. Without this bill, they would do whatever they do and it would be spread across the entire system of care, which if it's spread out to the entire system of care, no one actually sees a significant reduction of anything. So that's why, and I did change child to me. I will work with budget council around the intent language in the new section test and to do some of that.

[Unidentified committee member (female)]: So help me understand if it's May and no one engages with it, what happens?

[Speaker 0]: Well, particularly with I think I got it's page six.

[Unidentified committee member (female)]: Line 11.

[Val [last name unknown], committee member (remote)]: Line 11 is Michelle Meng.

[Speaker 0]: Oh, I'm not looking at the right version.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Madam Chair, can I clarify my premium comment? Yes. Go ahead. 50,000,000 would be

[Mike Fisher, Health Care Advocate]: 50,000,000

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: would be 10% of our premium, so if it was savings of 50,000,000 to us, we're only half of the industry So we would look at about five ish.

[Speaker 0]: You said that, but I'm like, you're not a whole market.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Sorry.

[Speaker 0]: So no, it's not as though all 50,000,000 would be targeted to Blue Cross, although the majority of it would be because of the high level, but MTP is in there as well. So, can we, it would probably be about 75% of that savings. So, on page number six, lines nineteen, twenty, 21 and then on to the next page. I think the May is particularly important there because if after one year proves to be really chaotic, they can come back to us or choose not to move forward with that.

[Val [last name unknown], committee member (remote)]: Can we define chaotic?

[Unidentified committee member]: I

[Speaker 0]: spent two years trying to define the word transformation. If you want to come up

[Unidentified committee member (female)]: with a definition for chaotic,

[Speaker 0]: I'm happy to do that. I think that this bill was a very bright stakeholder process that got as close as we could possibly get in the time that we had on this bill.

[Val [last name unknown], committee member (remote)]: Can I make a comment?

[Speaker 0]: Oh, of course, Val. Go ahead.

[Val [last name unknown], committee member (remote)]: Hi. Thanks. So we're gonna vote on this?

[Speaker 0]: At 01:00.

[Val [last name unknown], committee member (remote)]: I'm I'm just I I wanna say thank you for all the work that everyone has done. I cannot I'm this bill scares me. It just does. And I'm not going to pretend I understand it completely. I would need more time with a new version to go through it and have conversations with people like my hospital in Rutland or I I just I I can't vote on this right now. I just, I'm sorry. I need more time and I know we don't have time, but for me, that's not a reason to say yes. And I really apologize for that.

[Speaker 0]: I completely, completely understand. And I know it is rushed. And unfortunately, this is what end of session is. And sometimes we do things in the end of session and get them through and then we come back to them next year. Okay. Any other comments? We will be voting on it at 01:00. I I don't have a choice on that.

[Val [last name unknown], committee member (remote)]: Do we have room to comment at 01:00? Sure. Sure.

[Unidentified committee member (female)]: Do you wanna comment now, Ed?

[Speaker 0]: No. Say I'm at 01:00. We also have to we have to move to one ninety seven. And so let me set the table for you here. One hundred ninety seven is pretty much exactly how it was when we got it. And there has been there are like some it's not I wouldn't even call it markup. There are some ideas that are sort of in it. But my intention is this afternoon, we as a committee are going to go through this bill and do through markup, which is we are going to create what the end result is going to be all together. Be prepared. Be prepared.

[Val [last name unknown], committee member (remote)]: So