Mike Johnson (Host): Welcome back, podcast listeners. And welcome to another episode of Crushing Healthcare. We're tackling more Connecticut-based policy related to healthcare and their impacts on the provider community. I'm your host today, Michael Johnson. I'm President of Accounts and Services at Sullivan & LeShane, which is a government affairs and public relations firm in Hartford.

Today, we're pleased to have Lisa Trumble, CEO and President of Southern New England Healthcare Organization—SoNE Health for short—Joining us back. As a quick reminder, Lisa's background is in clinically integrated network-focused population health and value-based care. Since joining SoNE Health in January 2020, Lisa has led the development of infrastructure, partnerships, and performance strategies that have delivered significant cost savings for health plans.

Prior to joining SoNE Health, Lisa has held senior leadership roles, including at Cambridge Health Alliance, where she designed and led population health and ACO initiatives. Lisa is known as an empathetic, strategic, and visionary leader. Charismatic and articulate, she also frequently speaks on value-based healthcare across the nation, and is an active contributor to healthcare policy initiatives, as well as a staunch advocate for the physician autonomy community in Connecticut specifically.

So Lisa, thank you so much for joining us again. Looking forward to a followup conversation on a very familiar topic for us, but just wanted to see if you had any opening comments before we kind of jump right in.

Lisa Trumble: No, Mike, thank you so much for all the kind words. It's good to be back here again to talk about the progress we've made over this last legislative session. So, looking forward to the conversation.

Host: Well, physician autonomy and the provider network itself as to how it fluctuates in Connecticut is actually one of the prime subjects we'd like to talk about today. The Certificate of Need Bill, House Bill 5045, was adopted by the House and the Senate, and is expected to be signed into law by Governor Lamont. This was a major piece of legislation that has been the most sweeping regulation of CON laws probably since the '90s.

Just as a reminder, the Certificate of Need laws in Connecticut are the main regulating body of regulations that provide oversight as to whether or not healthcare providers can expand into certain markets in Connecticut, and if there is a sufficient need for the care that would be provided by that specific network or specialty.

So, there were major pieces that were modified, and primarily the driver of all this was expediting the level of transactions and approvals or denials that would be overseen by this body in Connecticut. So, the major piece, right, is that the Office of Healthcare Advocate, in addition to the Office of Healthcare Strategy, were the driving entities prior to the CON bill passing this year that would decide the fate of whether or not a Certificate of Need application would advance or not advance.

So now that model has been shifted in the policies that we see in this bill, where it's now a three-body panel that's decided by the Office of Policy and Management, which is the governor's extended budget office, the Department of Social Services, and the Department of Public Health.

The criteria means essentially the same as to what the evaluations are based off of, but it's those three panel members that now make the decisions for whether or not a CON application can advance. Some of the other pieces that were also put forward are streamlining the very lengthy application process that is now aimed to be cut down on the median time for applications. So, that's an estimated goal of 50% reduction in time for applications for CON.

I think also the major driving force of this are the hospital termination of services and acute care services, whether or not that advances in the same light. The oversight of that has been significantly scaled back—in some places, strengthened—based on the type of specialty. But for mental health expansion and behavioral health services, expediting the CON process for that, given the critical need and the value-based assessment of having expanded behavioral health services in Connecticut was added as something that could be streamlined.

I think for the conversation we're having today, something that I know is very relevant to the physicians that are listening, it's requiring anyone buying a large group practice of eight or more physicians, which was the previous standard, to report to the Department of Public Health information of what was being acquired, who the owners are, the locations, the clinical services provided, and that there are no new CON requirements that have been added to that we thought that, on behalf of the physician community, those were important safeguards to make sure that you had a clear and cut definition of the corporate practice of medicine.

And finally, before we get into more of the discussion, I think the expanded Department of Public Health's authority to impose conditions on the certificate of need and to make sure that they are playing the main driving role as to how that criteria is assessed and what is going to be considered by the three-member panel.

So Lisa, I'll hand it off to you first just to see if you had some immediate takeaways on the legislation that passed, and something that we could probably jump into right away are, you know, some of the takeaways that you think specifically are going to be the most important for the physician community.

Lisa Trumble: Yeah. Thanks. You know, I think a couple of the takeaways from this session, Mike, we ended up in a good place. I'm very grateful for the fact that the governor's office and the legislatures have listened to us about the potential challenges with some of what was being requested be applied to physicians.

I understand, certainly where we're coming from, we're in a state where we've had issues with private equity and venture capital that have actually harmed some of our institutions and potentially harmed patients in the process in addition to economically deteriorating these facilities. And so, there was an attempt to really put some teeth into this part of this particular bill, to address some of the private equity concerns. And I think at one point it went far to the right, I think, in terms of the requirements for small physician practices.

And so, I'm thankful that we were able to talk through that and bring it back to something that is more sustainable for smaller practices to consider and would allow them to continue to be innovative and flexible in this ever-changing environment of healthcare in the state of Connecticut.

Host: Fantastic perspectives and I couldn't agree more. It seems that the legislature and the governor's office really prioritize maintaining small group practice autonomy, and that is something that I know is part of your value-based experience as well. And hopefully, that'll be something that as the CON law gets kind of "tweaked" over the years, it's something that's a continual work in process to make sure that autonomy is maintained.

One of the things I also wanted to touch on that seemed to be very important, specifically from the governor's office when this was introduced, was that no certificate of need application would be required for the termination of services by hospitals. I know we had briefly just mentioned that. And instead there would be a new "wind down process." So, what that means is that there's an expedited pathway that can be requested for four different categories as currently written, and more can be added via the regulations in the future. So, those categories can be amended with a little bit more license than the traditional regulation process. Normally, right, there's very strict statutory guidelines that navigate how agencies can implement regulations. I think one of the most important things that was included in this legislation is those determining wind-down processes for the four categories can be amended without having to amend the statute through a regulation process similar to the CON process.

So, I thought that was a really good addition to the bill. And in addition to that, it provided stricter guidelines as to how you define hospital satellite locations that are incorporated under healthcare facilities. As we know, freestanding EDs are also incorporated as hospital satellite locations, but in the past have not traditionally been included as traditional healthcare facilities by statute. That's now been changed and modified given kind of the growing model of medicine, if you will.

So, I think those were all really important categories and places that we start to see this shift. But I wanted to also jump in, Lisa, if you wouldn't mind just providing perspectives into are physicians as a whole more careful when they're entering the CON process? Are there barriers that you believe could still be addressed in legislation moving forward? Are there things that you hear from physicians on a daily basis that they hear the word CON and they get immediately scared because it means that they have to go through a process that they're not as familiar or fluent in? Are there other things that you think over a course of time would be valuable to kind of implement?

Lisa Trumble: I think there needs to be a line drawn when we're talking about CONs and physicians, in looking at it from a perspective of large group practices versus smaller practices or medium-sized practices. Because I think the differences in the way they approach the business and what they can invest in and their degree of sophistication with the CON requirements is very different depending on those two categories.

And when you look at the situation with private equity as an example, it wasn't a situation with one or two small practices that created a problem. It was large group practices being contained in an environment that was also private equity. And the CON requirements, typically, hospitals are very active in this space. Larger organizations are very active in this space. They understand what's required to go through the CON process, have access to data, have the dollars to actually invest in what could be a lengthy process to get something approved. That degree of sophistication and capability doesn't exist in a smaller practice. And they don't have the financial wherewithal necessarily to invest $150,000 in whatever might be necessary to go through the process of a CON. And so, they're less likely to do that. And I think that that stifles innovation in the state because I think some of our more creative innovators are the smaller organizations, the level of a smaller group practice. And it also has the potential to impact whether the individual independent practices could continue.

At some point during the process, some of what was being suggested, I think would've prevented or made it harder to survive as a smaller practice if you can't consider what a business partnership or relationship that might be valuable to you might look like if you had to go through a CON process to get it approved.

That to me just seemed pretty onerous and stifling for smaller practices, which would then just do the opposite and create more consolidation in the market, which is not what we need. We need the opportunity to be able to maintain innovation in the state and to maintain independence in the state, because that's what's going to help us navigate healthcare in the future.

Host: I really think you touched on an important theme of 2027, and I don't know if you meant to do this, but you really did spot on provide what the Connecticut Option is aimed at targeting during the next legislative session. So, it was a terrific transition on your part, great planning.

The innovative model for healthcare delivery is something that Governor Lamont has prioritized for the 2027 session through what he's dubbed as the Connecticut Option. It was shared this week during the legislative session, but also this week by the Hartford Business Journal's Forum on Policy and Politics, that the Connecticut Option is something that he'd like to address in terms of the cost of care. As a very brief background, this stems from a 2019 executive order that was issued related to benchmarking prices by traditionally more expensive hospital institutions and comparing that to value-based medicine to see if there are growths the cost of care.

I think in partnership with that, there's been concern from the provider community that the costs that are adjudicated by healthcare carriers are something that's also going to be put on the table that the provider community would like to see as well. So, I do think that the innovative model of how value-based care is determined is going to be the primary factor for the Connecticut Option in terms of how there's a large differentiation of the cost of care for certain services based on where you're receiving that care, and how do you incentivize the innovative models that are going to be more efficient for both the patient and the provider.

So, I figured I would just open up the door there, because it seems like you have a lot of experience in this area from value-based medicine. If there are things that you're more ambitious and excited about the administration taking on during the work group discussions that are going to take place this summer and fall in transition of potentially seeing legislation introduced next year.

Lisa Trumble: I think it's an interesting concept to consider. Having watched this session and watched the discussions around the Connecticut Option. You know, I think it is important for us to have a solution like this, but I don't think it needs to be the only solution. At the same time, we need to have competitive models like the association health plans that could also add a level of innovation at a very different level and a different approach entirely.

We're looking at different ways to be innovative, certainly a Connecticut Option is an option. It's an alternative for us to consider along with association health plans. And with both options, being able to wrap in some form of value-based care makes sense. And the question becomes where is the devil in the details in terms of how it will be constructed, what provider groups or communities will be at risk?

And to your point earlier, Mike, is that also risk that is compounded when you look at the fact that the state has the AHEAD model, the Rural Health model, and then we have MSSP and the LEAD model and other commercial risks.

So, there's a lot of things to consider here that overlap with a potential Connecticut Option. additionally, I think we need to be very careful around how this is stitched together for employer groups. Is it going to be a fully funded or a self-funded approach? And I know the governor has thread the needle very carefully to not put the state at risk for the financial outcomes or for potentially being sued related to some of the Consolidated Appropriations Act requirements.

But if I'm an employer and I sign on to this and I'm self-funded, I still have an obligation and a responsibility to manage my health plan according to the Consolidated Appropriations Act. So, it'll be interesting to see how the legislature actually, works through this process, and how we take this next year with a potential work group to understand all of these details so that a thoughtful, option could be put forward for various employers in the state

Mike Johnson (Host): Great thoughts, and I do think that was something that was mentioned during the forum this week as well, that the Connecticut option could be more of an omnibus bill regarding workforce development and healthcare association health plans, other types of innovative expansion growth for the medical industry as a whole.

limiting it to whether or not providers are charging disproportionate amounts for the same type of service, I think would be a very linear approach to how this would be captured instead of the full picture of how healthcare is decided as a body in Connecticut. And I think that in general, while, healthcare costs are certainly a chief concern for every household in Connecticut, looking at the system as a whole and taking this as a major opportunity to expand all these different areas, I think will be the top priority for the legislature and the governor's office.

So I think that in conclusion, we wanted to see if you could provide additional thoughts on some of the things that have been expressed about association health plans, and specifically what I'm referring to is, the self-funded model, self-insured model, compared to having a fully regulated model that's, captured under the Department of Insurance for mandated regulations, all types of, health insurance.

That's very important, but it does increase the cost of care. So are there models that you think are more effective than not? Are there areas that you believe are worth more exploration by the legislature? And are there ways that you think should be collaborated with?

Lisa Trumble: that's a pretty big question, Mike. but let me make one more comment related to the Connecticut Options, because it's also relevant to association health plans. If we think that we're going to balance the economics of the healthcare costs in the Connecticut Options program by rate setting hospital rates across the board as the only solution, I think we're kidding ourselves.

We are dealing with a situation that is, of course, a per unit cost situation, but it's also a volume situation where utilization is increasing in certain areas. But if we do all of this and we rate set hospitals and we address the volume, but we don't address the pharmacy spend at the same time, and we continue with the same commercial-insured approach around pharmacy benefit managers, it doesn't matter what we do on the other side of the equation, because pharmacy costs are going to outstrip everything else that is done. We're seeing it right now in all of our value-based care arrangements. Pharmacy spend is becoming the biggest challenge that we have in terms of being able to manage the cost, trend for our various plans.

Now, association health plans, I think, the idea of association health plans is to allow groupings of like employers, aggregate their purchasing power and be able to purchase something or assemble a health plan that works better for them and for their employees. And generally, in a self-insured type of structure, you can make decisions at a level that you can't do today with traditional health insurance. You know, most of the small businesses have to go fully insured because they don't have the financial wherewithal to self-fund. And as a result, they've received 20%, 30% rate increases, but they can't make a decision around changing how the pharmacy part of their plan is approached or whether they even use the health plan's pharmacy benefit manager and look at a different avenue, like Capital Rx or Mark Cuban's approach to pharmaceutical structures.

So, an association health plan could be designed in a way to allow that grouping of employers to manage that more discreetly for the needs of their employees. And we know it can be done successfully because I've done it for our organization, our relatively small organization, and applied some of these concepts that are espoused in the Consolidated Appropriations Act to our approach to our health insurance, and we've been able to bend the curve and the cost on our spend.

And in the pharmacy area, you know, we've saved 30% over the last several years in our pharmacy spend. that's unheard of. But if we're going to use the same approach of let's take the typical commercial insured approach, and layer on top of that a Connecticut Options or an associated health plan and expect different results, then I think we're kidding ourselves.

We really need to tear apart the way we're providing the insurance, the way that the insurance is priced, and open up the option for new, innovative ways to approach care delivery or resourcing the needs of the populations that are being served, like approaching the pharmacy benefit structure differently.

So, I think both have opportunities and both have risks associated with them. But part of what we're required to do is to look at how do we do this differently to make health insurance in the state of Connecticut more affordable for people and to maintain great coverage for our citizens and if we think doing the same thing that we've done over the last 15, 20 years is going to get us there, then I think we're fooling ourselves.

Host: Really, really valuable perspectives, Lisa. And I couldn't agree with you more in terms of the models that need to be evaluated continuously. and it is refreshing at least to see that the governor and legislature have both taken a top priority in terms of addressing healthcare costs.

So, we are very thoughtful and thankful to be at the table trying to create those decisions and value-based propositions that will help both consumers and providers in the state. And I just want to thank you so much for your perspectives today. I really appreciate the listeners also from following our journey from our first podcast episode that started in February and extended through our legislative wrap-up podcast today.

It's been wonderful to be able to share these perspectives. Look forward to recording more of these in the future. And I hope everyone has a great rest of 2026.