SmartTranscript of House Appropriations - 2025-02-28 - 10:00AM

[Chair Robin Scheu]: Good morning. This is the House Appropriations Committee. It is the last day of February, February twenty eighth twenty twenty five. Friday morning, it's ten o'clock, and we are delighted to have with us Doctor. John Saroyan, if I'm pronouncing your name right, and Addie Armstrong to talk to us a little bit about the blueprint for health. We have a lot of requests and things in the budget, and we are not the health care committee. So we're gonna be educating ourselves today. So we're we really are grateful that you were able to come today. We'll go right and introduce ourselves because I don't believe you ever been in our committee. So start with Dave. [Member David Yacovone]: Good morning. Dave Yacoboni from Morrisville. I represent the Royal Washington District. Greetings. [Member John Kascenska]: Morning and welcome. I live in Burke, and I represent the Essex Caledonia District. [Chair Robin Scheu]: And your name is? [Member Michael Mrowicki]: Doc. That's what we're thinking. [Member John Kascenska]: Oh, you you you you said that [Member Michael Mrowicki]: in you? In you. [Member John Kascenska]: I represent. [Member Michael Nigro]: Mike Nigro. I represent Bennington and Pownall. [Member John Kascenska]: It's really nice to see a doctor. Tom Stevens from Waterbury representing the Washington Chittenden District. Good morning and welcome, Jim Harrison from Chittenden and also representing Megan, Kellogg, and and Steven. [Chair Robin Scheu]: And I'm Robin Shai from Middlebury. Tiflin Lee from Burlington. [Member Tom Stevens]: Now, Franklin, I represent Heidi Franklin, Berkshire and his district. [Member Michael Mrowicki]: Good morning. I'm Mike Borwicki, and I represent the Wyndham Ford district of [Member John Kascenska]: Yeah. But he's not. [Chair Robin Scheu]: Next to Mike is representative Dickinson, Linda can sit for the state office town. And then just in time to introduce himself. [Member John Kascenska]: Trevor Squirrel, on your Hilton, Gerald. [Witness John Saroyan]: Thank you. Good morning, chair Shah, and thank you for inviting us. I'm John Saroyan. I'm the executive director of the director of the Blueprint for Health. Just briefly about me, I live in Norwich, Vermont. I'm a pediatrician by training. My subspecialty training was in hospice palliative care and pain management for children. In two thousand thirteen, I left my academic practice at Columbia University and moved to Vermont to do adult hospice in Vermont and New Hampshire where I continued through twenty twenty two, when I joined the blueprint in, in in twenty twenty two. So, doctor Armstrong? [Witness Addie Armstrong]: I'm Addie Armstrong, and I'm a PhD in math. I got my PhD from University of Rhode Island. And then after that, I taught at Norwich University. I've taught at the community college in New Hampshire, and I worked in consulting for a soft factory that we've all heard of in the state. I worked for the DOD. I joined Dale in twenty twenty two to run the data for money follows the person, and then I moved over to Sprint in twenty twenty three where I've been able to work on operations research problems. Yeah. [Witness John Saroyan]: Very lucky to have doctor Armstrong. We have three program managers, Michelle, Emmy, and Connie representing Burlington, Milbury, and Barry. So they're here and listening in and supporting us. So I'll start. Okay. [Chair Robin Scheu]: Please. And we all have, on our desk with them. [Witness John Saroyan]: And you've got it there. Thank you. Please don't hesitate to, stop me if if needed. The aspects of the blueprint that I'd like to leave you with today that I'm gonna say at the beginning, I'm just gonna move this part of my screen so it doesn't block it, is that blueprint for health focuses on building best practices in primary care practices and subspecialty practices across the state. Their practices in all of the districts that you represent in all of them. The services are accessible to patients regardless of payer. The two core aspects of the blueprint for health that I'll describe in greater detail is the patient centered medical home, which are very high national standards for the practice of medicine and multidisciplinary community health teams. Other initiatives that have developed, I will review. And lastly, again, if I leave you with just a few things, Medicare, Medicaid, and commercial insurers make payments to support these initiatives. It's a multi payer model. At the center of that model is the Vermonter who goes to a clinic, a practice. It could be a federally qualified health center, could be a private practice, it could be a naturopath, it could be a hospital loan practice. And for the most part, all the concentric circles and and other circles that are surrounding that person to support them, they're usually not aware of the blueprint for health, the funding mechanisms, and the other teams that are provided. So, for example, we have program managers here today, which oversee the administrative entity, which enacts our our program in a health service area, which I'll show you a map of next under the guise under the rubric of the Vermont blueprint for help. The state, for a blueprint oh, this is so straight that I have screen in the back. Is is divided into hospital service areas. We've listed not only the name of the hospital service area here for you, but also the federally qualified health center or the hospital in that area that administers, the program. Planned Parenthood of Northern New England is considered a fourteenth health service area since it serves the whole state. Okay, so I'll go through the initiatives and then go into greater detail on each of them for you. As I said at the outset, patient centered medical home is a model of providing high quality primary care. That's national standards that the practice has to follow. The clinic that's the site. Community health teams, that's the first part of blueprint that I ever heard about, when I first moved here and started practicing as a hospice physician. The this is just an example. The community health team in Rutland thinks this person needs a evaluation for hospice. The community health team in Windsor thinks this person I'm a hospice provider. So it for me, it became part of my vernacular right away. I I didn't even know what the blueprint was, which is okay. I knew that there were community health teams that were referring people that needed a higher level of care because they were approaching end of life. The hub and spoke system of care, which is a model not just for Vermont, but also for Vermont to treat individuals with opioid use disorder. So individuals who've become dependent or perhaps even addicted to prescription pain medications to fentanyl. And the hub and spoke model is something that I'll dive into a little deeper too. More recently in twenty seventeen is the pregnancy intention initiative, which I'll also speak to, which supports pregnancy intention and family planning. And then new in twenty twenty three, there is a a mental health integration initiative embedding support specifically for mental health, pressing things like housing, transportation, into primary care. So patient centered medical homes at a very sort of direct, concise level are national standards that a practice must attest to for their standard operating procedures, access, coordinating care, preventive care, and really making sure they're taking care of their whole practice population, not just going problem to problem to problem. That model of care nationally and in Vermont has proven to have had improved clinical outcomes. So for example, management of certain chronic conditions, greater patient engagement and follow-up in treatment, getting to their appointments yearly. And some of the data that doctor Armstrong is gonna share that we've been fortunate enough to have her do with with our population decreased utilization of the emergency department. Our community health teams, appear to a patient as a social worker, a nurse care coordinator, a community health worker, a nutritionist. We've just diagnosed this with you. We want to pair you with this person who's a member of our community health team. Some of the health service areas label that blueprint, Some of them don't. And I'm not I'm fine either way as long as as long as I know that the funding is being used the way it's supposed to be being used, tailored to that committee. They can do brief short term mental health counseling. They can support management of chronic conditions. They can coordinate care and and look at that whole person to let the provider, whether it's a nurse practitioner, a PA, an osteopathic physician, move on to their next patient and know they've got a team taking care of them. The spoke initiative is the aspect of opioid use disorder, that the practices that we we have among the blueprint can participate in. And then they get extra team members. They get additional community health team members, no problem, to to serve that person so that the person has a counselor assigned to them. They have a nurse care coordinator that gets funded from blueprint dollars. So not only are they there for their primary care, but they might be, getting treatment for, opioid use disorder. Across the state, there's ninety one practices, many of them that are already part of our patient centered medical home that also provide this level of care. Also there's addiction specialty sites or clinics that also participate in the bespoke program. The pregnancy intention initiative, very similar to, focusing on opioid use disorder in terms of being very much embedded in our primary care model, spans the gap, not only from primary care. So that extra support, that other level of, screening for social needs, in primary care, but also in obstetric offices. So this is actually where blueprint has been able to move beyond simply primary care, which not is not simply, but but also to specialty care so that individuals can receive counseling and screening, that that might get pregnant, that might want to get pregnant, and and and and look at those options related to it. New in twenty twenty three was a one time appropriation for the mental health integration into primary care. This was something that was very much recognized as a as a need in the state nationally, increasing suicides, increasing death from opioid use disorder, and an expansion of the hub and spoke model to include other substances beyond opioids. So take that model, but make it work for other types of issues, too, and and really grow that that aspect of our community health teams to counselors, social workers, and community health workers. And that's been a pilot that's just been a tremendous honor to oversee and and watch the successes come back come on. Just a couple of quotes, and then I'll I'll I'll I'll move to some, slides before I go into doctor Armstrong. This is from a counselor in Barrie, health service area, who works in that opioid use, setting. The work we are able to provide is critical to the support of patients and our providers and local spokes. I have had primary care providers tell me this is the most rewarding aspect of their job and patients say you've helped save my life. A community health team staff member in Brattleboro, we are able to meet people with people who need it. Again, the community health team can meet with individual regardless of their insurer. We are connected right to primary or even if they don't have insurance, they meet with them connected right to primary care so they feel comfortable with us. There also isn't a co pay for our support, so they don't have to worry about the money component. I know we are helping people. It wouldn't be possible without the blueprint. And finally, a pregnancy intention initiative worker in the Burlington area. Our wraparound care had the benefits of preventing an emergency department visit, a potentially lengthy hospital admission and increased hospital costs. I hear that story over and over when I speak to our our community health teams. What are the funding mechanisms? How are these initiatives funded? Two terms to I'm not gonna dwell on too much, but that I wanna say and and sort of put into context. Training as a physician, working in other states prior to I came coming to Vermont, fee for service. That's the that's the term. The service is provided. A fee is charged. Some of it goes to the individual person who was served. Some of it, if they have insurance, goes to the insurance. Blueprint is based on prospective. So ahead of time, value based population based payments per member per month payments. And the way that's calculated, and I'm I'm only gonna say this briefly, is by an attribution methodology, which Addie and her team helped to do, looking at which patients are assigned to which provider. And then these payments are based on that population within the practice. So it's not a fee for service based, model. It's a value based per member per month model for attribution. And this is important as I lay out some of the dollar amounts for you that come from the different payers. So Medicare, has paid, into that that national standard, that patient centered medical home model, as well as our central first community health team initiative. That's been allowed by an agreement with CMS that's ending this year. Commercial insurers, Blue Cross Blue Shield of Vermont, Cigna, and and MVP also pay into that that core patient centered medical home program as well as community health team initiatives, plans that fall under the federal law called ERISA, from the nineteen seventies. So this is self funded plans, Medicare Advantage, any employer basically that chooses to pay for their own sort of health care, rather than using an insurance company. They they do not, pay into blueprint. Those individuals receive services regardless of their insurance. And then some small shirt insurers, also do not contribute. And then Medicaid, the base, pays into each of the initiatives and is the only payer included in the the mental health integration. From this slide, what I find is most helpful. So if if you really wanna get granular, you can see the dollar amounts per program per type type of payer per member per month. But I think the example at the bottom is is the most important, part of this slide. And the reason I say that is because, I think depending on where one is seen or what practices are around, seventy five percent of blueprint practices have an attribution number of around a hundred or at least that size. So for example, that practice would be receiving payments between forty five hundred and five thousand dollars a month for participating in the blueprint's high standards, and their community health team team members whom they choose with their their local program manager would be funded about at about fifty thousand dollars per year to support the practice. About twenty percent of our practices are at least double the size, But this gives you, I think, a sense of magnitude in terms of those dollars coming in month over month, quarter over quarter that, again, are population based. They're not fee for service based. [Chair Robin Scheu]: Oh, yes, please. For you. I'm sorry. The community health team, is that one team? So is it fifty thousand dollars once, or is and if they have four people or groups I'm not sure I'm using all the right language here, but no. Is it fifty thousand per each subs member of the team or group? [Witness John Saroyan]: So the the dollar amount is based on the the attribution count that the insurer has has calculated. And so the dollar amount comes in based on number, sir. Go ahead. [Witness Addie Armstrong]: Joe. Yeah. Sure. So if it's essentially, we think of it as per practice. So for a fifteen hundred patient practice, we expect that practice the community health team is a broader organization that supports lots of practices. Yeah. That team would receive about fifty thousand dollars for that practice. If there's another practice that has another fifteen hundred patients, it'd be another fifty thousand dollars And so that's how they can support so many workers because it's kind of per practice. Okay. And, you know, it might be fourteen ninety patients, and then it's a little less, but it's it's a little different. [Chair Robin Scheu]: Okay. And then how how do you define an attributed patient? Sure. [Member John Kascenska]: Let me [Witness Addie Armstrong]: pop back one slide, [Vice Chair James Harrison]: I think. Yeah. Just See if we can There we go. [Witness John Saroyan]: So the number of members of payer is make to make payments on is determined by the insurer's attribution to a blueprint practice. Do you wanna go through? [Witness Addie Armstrong]: Sure. Yeah. So when we insurers actually are the people who calculate the average. We set the algorithm. We say, this is how you should count, and then they look at their data and count. And an insurer will look at the last two years of all the claims submitted by all the doctors in the blueprint and say, okay. Jane went to this doctor fourteen times. And did she have the right codes? Was it primary care? That's the most so Jane is attributed to this doctor. Now if Jane goes to two doctors, it'll take whoever she saw the most, basically. And so it's saying, okay. Who did you get the most primary care from over the past two years? And that's how someone is added to that count. [Chair Robin Scheu]: So it's related to primary care specifically. Right. [Vice Chair James Harrison]: There's a [Witness Addie Armstrong]: specific list of codes, of procedure codes. It's a very long one. I don't [Chair Robin Scheu]: know if you can or something. [Witness John Saroyan]: We we we review them every year. [Member Michael Mrowicki]: But [Witness Addie Armstrong]: We review them every year. We add It's a lot. And take away and [Chair Robin Scheu]: It's it's the focus is primary care. So if you didn't see if you just saw the dentist or you just saw the I dot Great question. [Witness Addie Armstrong]: Yeah. Or be [Chair Robin Scheu]: or you had a, I don't know, a broken wrist, but you never saw primary care. [Witness Addie Armstrong]: That didn't count. Yeah. Exactly. And because of that, there will be occasional patients who, you know, if they have arthritis, they might get a lot of their care from a rheumatologist. Yes. But they might see a blueprint physician every now and again Yep. They're not gonna be counted for them. [Member David Yacovone]: That was [Witness Addie Armstrong]: awesome. Most of their care and their rheumatologist, their annual physical, and all those things. Okay. Well, they might actually go, but they're not gonna be Right. Counted as attributed. And that's because we try to make sure that each provider's only getting paid for one patient doesn't get counted twice so that we're not, like, suddenly and, you know, you went to six different doctors. They all get money. That's a little complicated. Right. It's a tie breaker. Yeah. So I'm trying to [Member John Kascenska]: understand the chart you had up at payment. And looking at this real quickly, it looks like the lion's share of the payments are coming from the dedicated program, which is safe dollars. I assume plus federal dollars. Yeah. And I don't what's the hundred and sixty three dollars? Is that are we paying that for every Medicaid? No? [Witness Addie Armstrong]: Not every patient. No. So that's specific to the Spoke opioid use program, and so not everyone will have an opioid use disorder. And so it's only for those patients who are receiving treatment for that disorder at those practices. That's actually a very small [Member John Kascenska]: predicates pain or heart disease. [Witness John Saroyan]: If they have that disorder and they're being seen in a practice that's part of our program and they receive a prescription of either buprenorphine or Vivitrol, then that that triggers that amount. [Member John Kascenska]: Okay. So let me ask you another question which you may not have an answer for. Everything we're seeing in here is Vermont has now the highest insurance rates for health care in the country. And the trajectory is going in totally the wrong direction. Should he be suspect of all our best intention efforts that, you know, we have the great mountain care both we have, which is for care. We have the blueprint for both our involvement. Are these saving us money or are they just adding to the cost? Yeah. I don't expect you to answer all that, but specifically on the Blueprint Sure. Which part [Member David Yacovone]: is I [Member John Kascenska]: wanna say back when Jim Douglas is Two thousand five? Yeah. We we made it worse. Just I I don't know if there's an answer to that. [Chair Robin Scheu]: Okay. [Member Michael Mrowicki]: I mean, how do how [Member John Kascenska]: do we justify whatever the whether it's three dollars a month or whether it's, you know, five thousand dollars. [Witness John Saroyan]: There's a whole section at the end of our slide presentation to shed some light on your question. Yeah. [Chair Robin Scheu]: Okay. I'll wait. So Mike, Marathi, and then Mike Nyberg. [Member Michael Mrowicki]: Thank you. Thanks for coming here. I'm probably segueing a little bit from what [Member John Kascenska]: Jim had to say that I go back [Member Michael Mrowicki]: when I was on human services committee. My understanding of the blueprint at that time, from what we've been doing over, we had identified a cohort of people who were regular users, especially of emergency rooms. And the idea was to bring teams in to to focus on that. And try and update me. I'm trying to understand who who you're serving here. [Member David Yacovone]: Just [Member Michael Mrowicki]: everybody in the practice that's identified. Is it people who are identified as heavy users? And and then my second question is going back to what I've learned about trauma through my own work and are these identifiers, whether it's adverse childhood experiences or other trauma identifiers that help identify people who are getting extra extra help service. Sure. [Witness John Saroyan]: We can. Thank you. We can shed light on the emergency medicine or emergency room question in doctor Armstrong's slides. And the answer to your second question. And I don't think we'll go into as much detail today as you might like, but the the individuals are identified right now mostly by their clinicians, but also by screening instruments that are administered to identify what you're talking about exactly. [Member Michael Nigro]: Just a clarification. The commercial insurers that that are paying into blueprint, is there something that requires that, or do they Legislation. Okay. So I was gonna say [Witness Addie Armstrong]: that instead. [Member David Yacovone]: Thank you. [Witness John Saroyan]: Statute. Yeah. Thanks, Maria. So this is an overview, slide, again, of what what the amount was in twenty twenty four. As the representative mentioned, Medicaid supporting all the initiatives, commercial insurers, and and Medicare supporting those those core initiatives. And at the bottom, just to label it a one time appropriation for that mental health integration. May I turn it over to you? Okay. Oh, sorry. Yeah. [Member David Yacovone]: Go ahead. [Chair Robin Scheu]: Integration was one time. And how long is that going for? Or [Witness John Saroyan]: The it was a two year Twenty pilot for which there's language to make it a three year pilot. So any remaining funds may be used. Right. With and we just instead of having an end date just until the funds are used up. I believe yes. That is correct. [Chair Robin Scheu]: I've seen that one. Okay. And now we know what that's for. [Member Tom Stevens]: We Just, just wanna again, on that chart with with follow-up, follow-up. He's actually here. So what's the mix of patients? What what's driving the attributed money? Sure. [Witness John Saroyan]: Sure. Doctor Armstrong has a slide exactly for that, beautiful pie graph, so we can show you that. [Witness Addie Armstrong]: In fact, I think that's the first thing that you'll see. Oh, true. So this is I I like this part. I guess, talk a little bit about the impact, the data, the numbers. What are we doing? What does all this buy? And so this shows you who's paying into the blueprint initiatives per quarter. And these numbers are based on all the commercial, and these are our our initial we know that Medicaid is the only payer into spokes and pregnancy intention. So I'm not going to show you a chart that's just the center right blue bar that says Medicaid. I'm going to just show you this one. The the green bar is Medicaid in this chart. And as you can see, it's been going down a little bit. Why did it start going down? If you recall, we started determining whether or not people were eligible for Medicaid last year. That's what's happening. So we can see that green bar shrinking. The central bright blue bar is our commercial insurers, between a hundred and a hundred and fifty thousand a year a quarter. And I don't have the data for last quarter yet. They're a little slower to report to me, so I'm waiting on those numbers, which is why that last quarter has that star. The commercial beta is not yet available. And then [Vice Chair James Harrison]: the We have a question here. [Clerk Trevor Squirrell]: No. You can finish your evidence, and then we can call it. [Witness Addie Armstrong]: Yep. And then the bottom bar is Medicare portion, and that's pretty consistent in the seventy seven, eighty thousand range depending on the year. Go ahead, and then [Clerk Trevor Squirrell]: I will add Sure. Well, maybe you will address this later on, but I'm just wondering what you're thinking about what we're hearing from Washington about Medicaid and how this affects all of this. [Witness Addie Armstrong]: So there the a lot of the stuff is fairly recent, and I think a lot of us are still processing and thinking going forward what, as an agency, we're going to do. So, honestly, that's a much bigger question. It's not a question that I can pull an answer to and just say, this is how the agency is thinking, but we can take that back. I'll let John speak to it if he has better ideas. [Witness John Saroyan]: Following very carefully and listening to my leadership too, representative, I think that yeah. I welcome your input. [Clerk Trevor Squirrell]: Well, I guess I'm just wondering, is this particular type of programming especially vulnerable because it's a is it it's a kind of special Medicaid. It's not core Medicaid. Or is it core Medicaid? I [Witness John Saroyan]: Not not not in my view in terms of all of our policy work, but I I again, as as Abby said, there's a degree of, I think, unpredictability that I I can't see into, but not in my professional opinion. [Clerk Trevor Squirrell]: I totally appreciate that you you don't have a plan. And but I just I I I wondered if you knew about the moment the particular vulnerability of this program. [Witness John Saroyan]: Yeah. I I could certainly bring that back to our policy folks. But in terms of our approval and our policies, we're we're very up to date with the feds. [Witness Addie Armstrong]: Yeah. And so the eleven fifteen waiver is Yeah. Is Vermont's Medicaid kind of agreement. And as long as that's in place, this is part of the eleven fifteen waiver work. So it's it's subject to the same vulnerabilities as essentially all of the Medicaid services covered under eleven fifty, which is Vermont Medicaid as a whole. Right. But that's [Chair Robin Scheu]: the big question. I don't know the answer to that. [Witness Addie Armstrong]: And I [Chair Robin Scheu]: So it's it's vulnerable. [Vice Chair James Harrison]: I want the answer. Okay. [Witness Addie Armstrong]: So one more thing I'm gonna mention on the slide is, because of Medicaid's redetermination, we've been seeing those numbers go down a little bit. We have actually been seeing that central bright blue bar go up a little bit. It's hard to tell when they're, you know, stacked like this. But there is a little bit of lag time. So we do expect instead of the trend to continue going down, we kind of expect a little bit and then it to go back up because people, when we calculate that attribution, these are the numbers that are calculated, not just visits. So somebody's on Medicaid. Medicaid they get off Medicaid. Medicaid's not counting them anymore. They got on their commercial insurance. They got a new job, but they haven't visited the doctor yet this year because they visited the doctor while they were still on Medicaid, and so there's no claim in the system for them. So there's sometimes that little a little bit of lag time between when people change insurance. And so that's, I think, a little bit what we're seeing here as opposed to we certainly know that the number of people in Vermont is not decreasing, and we certainly know that the number of people visiting doctors is not decreasing. So that doesn't mean that we're decreasing here. [Chair Robin Scheu]: Another question or a date. [Member David Yacovone]: With One Care, no longer practicing at some point, the administration has recommended certain amount of funds to go towards primary care as well. British in in a sense. Should should those dollars that are targeted for primary care that used to go to One Care, should they be routed through the blueprint and directed toward attributed lives because we know those patients are getting best practice? [Witness John Saroyan]: I think we have yet to determine how those monies will be routed out of AHS. But my if I I don't I don't know the answer to to your question. Should they be? I think the priority is seen right now is filling the gap from the all payer agreement ending and those Medicare dollars flowing to primary care practices as they were. That's my understanding of how it's been written. Should it be turned into, blueprint payments after that? I guess is up up for discussion [Member Michael Mrowicki]: still. You don't have a recommendation. [Witness John Saroyan]: I I see I I see the answer to my recommendation being, tied to the ahead model, which is a significantly higher per member per month payment than what it is now. So I I I don't I don't have a I don't have a good gestalt for you right now. [Member David Yacovone]: Thank you. [Witness Addie Armstrong]: I will add one thing to that, if I may. The the ten point eight million line item in the governor's recommended budget, half of that is to support blueprint payments. So those funds are already being routed through the blueprint in some way. [Member David Yacovone]: So they're both those are not the dollars, but rather part of what was coming through One Care? [Witness Addie Armstrong]: Yes. That was a part it was not all of it, but that was part of it. Yes. One Care did administer a lot of the Blueprints funds. Oh, the Medicare portion in particular administered all of that because it was very convenient for them to do the, essentially, check splitting. They got the big check for Medicare, split up in all the ways, and then now that big check has to go [Member David Yacovone]: Just a follow-up, if I may. So the various payers, they channel the cash, the dollars to you? [Witness Addie Armstrong]: Different weights. [Member David Yacovone]: And do you distribute the funds? [Witness John Saroyan]: No. It varies. It varies. But the there's not a no. We we direct the funds, and generally, we direct the funds as how they go from the payer to the practice or to community health and funding. We direct them. They doesn't come into a, like, a Yeah. We don't get a whole [Member David Yacovone]: pot. Maybe flip. Thank you. [Witness John Saroyan]: May I go to the [Chair Robin Scheu]: next slide? And then rep Stevens. [Witness Addie Armstrong]: I'm just gonna let you [Chair Robin Scheu]: know that three of us are gonna have a committee of conference at ten forty five. And so importantly, we're losing. Oh, yeah. So we actually have to that's right. Well, much more importantly than the committee of conferences that we're losing here. And so we're gonna we're gonna have to end this at, no later than twenty of [Vice Chair James Harrison]: I have several questions. I would like to hear about the emergency department because I know that's a huge issue. But one of the things that I I question at first, it looks like your paramedics just are looking ahead. It looks like there's about even between commercial Medicaid and Medicare. Otherwise, probably other types of that's actually not too bad. That's better than some hospitals have. Yes. And certainly, no nursing homes are bad. Yes. One of the questions and maybe other things. One of the questions I have is when we do the well, one question is that my understanding is when you go with a capitation plan, which is an attributed, that it isn't just like you give them the money. You actually do in the background a fee for service analysis because you have the codes and you have to know what was done when and what the intensity was and what the procedure was and what the details were. And that helps both the provider and probably BluePrint and anybody else who's interested to know how much it costs to treat these patients you've got attributed there. It's not just like I get five thousand dollars and I just give it to them and they do what they want. There is an accountability piece to that. So you're doing a double type of thing here. You're doing your capitation money. But also somewhere in there, everybody's still gotta do food for service to account for what their, like, their p and l was. How does that work? [Witness Addie Armstrong]: Or do you So the payments for the blueprint are not actually a capitation model for the services provided. Right. Those are all still fee for service. The payments for the blueprint are that additional payments to ensure that higher quality. We'll talk about the ED visits. The community plan. And all that. Right. The community health teams, these things. And so, yes, there is a fee for service model that goes on in the background that informs the attribution. That's how we find out who got their care and where they got it and how many people belong. And then And [Vice Chair James Harrison]: how much money it's gonna cost so that you can adjust accordingly. [Witness Addie Armstrong]: Right. Although we don't we have not had the opportunity to adjust our rates in recent years. [Vice Chair James Harrison]: Okay. Yeah. The other thing is is there was a an audit done by the by the auditor. And he seems to indicate that that that there was savings early on, but it's really hard to tell if there's any savings now. So have you reached your maximum amount of savings and now everything else is just, you know, just not there anymore? Or how does that work? [Witness John Saroyan]: I think we'd welcome the opportunity to, speak to that in greater detail in the future. I think there were some there were some distance on the conclusions and and where the blueprint stands on that statement, though we wholeheartedly agree with the recommendation. That would be a point by point that I'm not sure I'm prepared to go through right now. [Chair Robin Scheu]: I will not be talking about that right now. [Witness John Saroyan]: I'd be happy to in the future. [Vice Chair James Harrison]: But I'm trying to jump ahead. Can you talk about the emergency room issue? [Witness Addie Armstrong]: Absolutely. That is the next two slides. [Chair Robin Scheu]: We have way to the [Member Tom Stevens]: next two slides. [Member John Kascenska]: Okay. [Member Tom Stevens]: Just the next one. Just there we are. Next one's mental health and substance abuse. Then the next set of graphs down the next slide. Yeah. So let's do the emergency room visits, which is So the the graphs here no. [Member David Yacovone]: No. It's fine. [Member Tom Stevens]: So maybe it's the emergency room cases. And it looks like roughly thirty percent of the cases in there are either mental health or or [Witness Addie Armstrong]: So these are patients with a mental health or substance use condition. The slide rate before this one goes through kind of how people end up in that category. Yes. [Member Tom Stevens]: So so my point is that I wanna make is what I'm asking is what criteria for success and failure do you have with this program? And we have a great concern about emergency rooms being all filled up with mental health and substance mental health especially with substance abuse in some cases, but, you know, they're absolutely needed for medical care. But it is a a major problem with our positives. We understand to just speak to that. [Member David Yacovone]: So, [Witness Addie Armstrong]: I'm gonna talk a little bit about this slide, and then I'll add a little tidbit about something else that I've been able to do recently. So this slide shows you the proportion of patients who have a mental health or substance use condition, and there's a giant list that people throw it out through that the SAMHSA diagnosis codes, all those things, throw out. And, the difference is not huge, but it is statistically significant. And that's kind of one of those things that is important to us. Statistically significant means it's unlikely to be random. If we pull all these people again, we're gonna get the same answer. This is not a random difference. So one of the things that we're tracking is these people with mental health and substance use conditions tend to end up in the emergency room at a higher rate than people without mental health and substance use conditions. This graph on the right hand side shows the rate at which these people had those visits, the proportion of people with an ED visit in that condition category. The green dash line, of course, is the non blueprint patients. The blue line is the blueprint patients. You can see that apart from the COVID year when we had the snow stye when nobody went out, the difference is significant, and it's slower. Blueprint patients end up in ED visits less. That saved about forty five hundred to five thousand ED visits last year. And so I don't have, off the top of my head, a how much cost that is, but you can think of it we've avoided some ED visits. And that's useful. Go ahead. [Member Tom Stevens]: My my concern is when somebody says there's a significant difference, and they don't tell us what the p value is and what you're trying. [Witness Addie Armstrong]: So the p value on this is point zero zero one, which means it's a ninety nine point nine percent chance that it's not random and a point one percent chance, a tenth of a percent, that if we did this again, we would see a difference. And this has been that significant for the past five years. [Chair Robin Scheu]: Got your answer. Other question? Okay. Hold on. We we literally have two minutes. [Witness Addie Armstrong]: Okay. So I will mention this one. This is the number of encounters. So what are encounters happening? Community health teams are providing services about three hundred to four hundred thousand services a year. And when we say a service, we don't mean they called you and reminded you you had an appointment. We mean they provided a brief intervention. They did some counseling. They taught you how to manage your diabetes. Something actually happened. And so those I think I'll wrap it up there, and just kind of point out that that is some of the things that are happening. We see that as a significant contribute contributor to why our folks are [Chair Robin Scheu]: ending up in ED visits less. Okay. And then we have the payer mix. [Witness Addie Armstrong]: The next page. And the last page was who's doing this work and what what each item is paid for. [Chair Robin Scheu]: Great. Sorry, we had to rush you at the end. It's really interesting. We are getting a lot of emails from folks who feel and believe that this has been a critically important, program. And this shift from ACO to ahead is, has its challenges. So thank you for all you are doing. Clearly, you're making a difference in people's lives. So thank you all, and thank you for coming in. If people have other questions, you know, I don't know if we wanna stay around. We'll go up live, but if you, want

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