SmartTranscript of House Healthcare - 2025-02-06 - 2:00 PM

[Owen Foster ]: Technical difficulties. Chair Foster, if you'd like to continue. [Speaker 1 ]: Yep. To representative Paige's question, no one would own there's no entity that would be owned in the ahead model. It's just a different way of budgeting. One thing I would note though is I I heard some testimony, and there's discussion around, well, should we have a cap on revenue? And is a revenue cap a care cap? Just to make clear, the global budget is a cap. It is a cap on revenue. It's just how you come up with a cap is slightly different, but they're both caps. Real briefly, I think I touched on this. The this is a bill, I think, in the committee that's been discussed or introduced maybe at this point. But, it's just my point about that we need to make sure that the incentives are aligned with what we're trying to do. And ninety three seventy one is our statute of our principles of health care reform. And are those on which are those what decisions on bonuses are being made on? And I think that that's important to get to the ground level to incentivize the executives to drive towards what we're trying to do as a state. Next slide. There's there's a lot of, discussion about different health care forms, act one sixty seven and transformation you've heard about. There's There's discussion of having a division of planning, reference based pricing, c o n changes ahead, global budgets, prescription drug regulatory options. And I really think that it's critical we have our system operating efficiently. And I don't know that any payment reform will necessarily impact things very quickly. And we wanna make sure that we have the right system that we can sustain. I think is very important to do in connection with anything that you choose to do in terms of a reform. And we also want to make sure we're choosing reforms that fit our problem. So we really need to be conscious of what is our issue. And then if we're gonna do a reform, pick the one that fits that problem as well as we can. Go ahead, Lindsey. Running. And this just goes to, the Oliver Wyman report that was discussed a little bit. And in their opinion, and keep in mind that the physician who ran that project, was the chief medical officer, and really an architect of one of the most successful hospital systems in the country. And he was very disturbed by what he saw about how our system works. And so we're going to have to fix our system if we're going to fix health care in Vermont. Next slide. There was some disagreement, about the report from various places. I think the report was really, really well done and has an incredible menu of options state to consider as to how we can move forward. I know that that's being done at many different levels. But this came out in November sort of after there was some disagreement about the report and reports conclusions. This is from Beckers had an article about a study of hospitals at risk of closing in the country and Vermont had the highest I think is the highest or second highest level of the number of hospitals at risk of closing and at immediate risk of closing the next two to three years. And this was pretty consistent with what the Oliver Wyman team had found and discussed. So I just thought it was interesting that it was pretty well in alignment that we really do have a problem, with sustainability. And these at risks, I think, can change very, very quickly if the Blue Cross situation doesn't abate and if there are changes at the national level that impact reimbursement. You referenced the reference based pricing with with SKILL. This is linked to that report and and the findings of the report, and I'll I'll just speak to it very briefly. We have some of the highest commercial prices in the country, and that's difficult to sustain, especially with continued large rate increases and requests for additional rate. There This study was really just as to the VSEA and VHII members and it found an enormous enormous amounts of savings potentially available if the state were to reference base price some of the hospital prices. There would be pros and cons to doing that. One pro would be it would, help us with the affordability problem and people could access more care because they could afford more care. It would reduce the amount of money certain hospitals had, and it actually might increase some prices at other hospitals. Some are very very high, some are not quite as high. So there would be a change there in how much money they would get from commercial and having less money is challenging. It would also free up additional dollars that the commercial payers could pay to other providers in the system, whether it be, primary care providers, long term mental health, whoever it might be, would have a better ability to access dollars need to sustain their operations like an FQHC. If you look at the rate increases at FQHCs, they're really quite modest and that's that's very difficult for them. Next slide. Oh, and, is [Owen Foster ]: Yes. I'm here. [Speaker 1 ]: Oh, hey, Kate. I think this is you. [Owen Foster ]: May I before we go on to prescription drug regulatory, I actually have a question, specifically regarding, I guess, reference based pricing, but also, you know, some information that we heard this morning. We had the, president, CEO of UVM Health Network in, and he seemed to lay out an awful lot of challenges that they face in meeting the requirements to limit their net patient revenue. And that's currently as as our regulator, Green Mountain Care Board, that's the tactic that we take to try to control, costs at our hospitals. So number one, is there the authority to rather it seemed to me that maybe if we just set rates, that would be easier, since it was too challenging to limit your revenue. Is is that something that you have the authority to do, or is that something that statutorily, are you required to use net patient revenue as your tool for controlling hospital costs? [Speaker 1 ]: Yes. So we don't agree that a revenue cap is a care cap, and I'll I'll tell you why. So first, there is a significant amount of, ED utilization that is what they generally consider, movable or they could be done elsewhere. So if you want to comply with a revenue cap, you can take steps to try and move care to a more appropriate location out of the ED to primary care. And that would reduce your revenue because the revenue coming in through the ED is higher than it would be, in a primary care setting or a more appropriate setting. And I'm not speaking specifically to UVM. I'm just speaking generally that is a strategy to lower revenue. Second, if expenses are reduced and, at an appropriate level, you can reduce your commercial prices because you don't have to cover for those expenses. And a a revenue cap is price times volume. So if you reduce your expenses, you can reduce your prices. If you reduce your prices, you reduce your revenue without sacrificing care. So there are strategies and options to do that without, necessarily limiting or stunting on care. And, your second second part of your question was about rate setting. We do have the rate setting authority in our statute. We would need to set up, the program to do it. It's not none of these things are a a light switch. AHEAD global budgets, reference based pricing, rate setting, none of it is. We would need to to put in the time and the work and the resources to create that program. [Owen Foster ]: K. Thank you. Prescription drug regulatory options. Yep. [Catherine O'Neil ]: Hi, everyone. For the record, I'm Catherine O'Neil, and I'm the director, prescription drug pricing at the Green Mountain Care Board. I, have worked at the Green Mountain Care Board for a little over eight years, but this is a new position. And a couple of months ago, I transitioned to into this position and, we hired a policy analyst. And just, in December, we, got the, contract in place to help support this work. Just a process question. Do what time do I go to? Am I just gonna overview this slide super quick? Overview. We've done there's a lot of interest in this [Owen Foster ]: in our committee, so Okay. [Catherine O'Neil ]: I just didn't know how long I could I could go for it. Well, so just a a really quick overview, Act one thirty four that was passed last year directs the Green Mountain Care Board to, explore and create a framework and a methodology for implementing a program to regulate prescription drug costs. We submitted our preliminary report in January of this year, and we are continuing to do research and, analysis and evaluation with the intent to, present a final report next January. That final report will include recommendations. The preliminary report does not. What the report that you have now really does is provide you a landscape overview of the different kinds of strategies that other states [Mari Cordes ]: are implementing [Catherine O'Neil ]: or applying right now and a little bit of understanding at the federal level. So that's the landscape review, and we're doing it to understand what strategies are out there, but in terms of what's going to make most sense for Vermont. And what makes sense for Vermont is, as Chair Foster said, you know, it this is part just one part of, the big picture of the problem in affordability in Vermont and access in Vermont. And so, you know, we wanna look at options and strategies that are going to make sense, that are, going to result in savings, not be too, administratively burdensome, and that and that kind of thing. So, it means understanding the landscape and the sort of the policy landscape and then doing analysis on the most feasible policy options. So, if I can go just a couple minutes longer, I'll just give you a super quick overview of current state strategies that we are just learning about this now. There are experts out there. We hired OnPoint Health Data. Lindsay mentioned OnPoint Health Data. They are our database manager for VCURES, our all payer claims database, but they also do, they have a whole analytics shop, and we hired them to, help us with the analytics. We think that's a good fit in large part because they know our data, they know our database, and that's where we're starting. There there's other data, you know, pharmaceutical data out there, manufacturer data and and the like, And we're expanding our reach in terms of access to data. But they could hit the ground running, and so we thought that that was great. They're subcontracting with Horvath Health Policy, and I don't know if Jane Horvath, testified here last year at all, but she's a policy expert in this field, and she's, done work with other states across the country. [Owen Foster ]: And so, we've got access to her expertise, so we're [Catherine O'Neil ]: really excited about that. Prescription Drug Affordability Boards was one of the callouts in the legislation. And so, we're looking at other states. We did a summary in the preliminary report of eight states that have prescription drug affordability boards or PDABS, Colorado, Maine, Maryland, Minnesota, New Hampshire, New Jersey, Oregon, and Washington. Their authorities, their meeting schedules, the staff positions that they have, and the budgets that they have to do the work, it all varies. But for the most part, these PDABS are active. They're up and running. Though we've noticed, we've learned that they got off to a slow start, and that's in part due to the startup and implementation that's necessary to get a PDAB underway, including the steep learning curve of the board members that get appointed, but also in part due to strong opposition from the industry on PDAB activities. That's an important acknowledgment, I think. Some other strategies that states are looking at or working on do include building on the Medicare drug price negotiation program through CMS. That program is to create a maximum fair price or MFP. You may hear it referred to that way. That's the negotiated price. So, PDABS are, you know, in these states that have the affordability boards, they're looking at how, you know, is it possible to create a statewide payment limit, for the drugs for all residents beyond, you know, just the Medicare or or a subset of residents, perhaps. So that's or it's early now, certainly, with that, but states are looking into whether and how it's possible to expand on that program. In terms of market transparency, that's to have a goal of better understanding the prescription drug market by collecting data that could be useful potentially for policymaking. Vermont does already have some market transparency laws and data collection in place. We're learning that there are other states that collect additional and different kinds of data than we do today, so that's good and interesting information for us to have. We're kind of exploring, like doing a gap analysis on that and would it make sense to bring in more data, and how would we do that? Some other strategies, caps on out of pocket costs. Many states limit insured consumer prescription cost sharing for certain drugs with different limits and apply to different drugs. An example, we do this in Vermont for insulin, so we have a limit of one hundred dollars per thirty day supply. So, that's an example of that. I won't talk a lot about international drug importation because we do have a law on the books, and the Agency Human Services has a program in place. But I will say, so I would defer, certainly defer you to them for a progress update on that. But what we are learning around other states that are doing this work, including Vermont, is that there are challenges with importing drugs, including the application approval and implementation process at the federal level. It's fairly onerous, and it has limitations itself. We're learning on a smaller scale, some states and local governments are designing programs that would incentivize personal prescription drug importation for limited populations like state and local workers. There are multi state drug purchasing pools that states are looking at and thinking about, And a new area that we don't know a whole lot about, but there are new market business model innovations. This is where we're really relying on ORBA health policy to help us to understand what are some new market innovations that could, be promising. So that's just a super quick overview. Our preliminary report highlights these various approaches. In the next phase of our project, we're going to be narrowing down some of the potential options and then doing some more in-depth analysis. We really want to understand what's going to work best for Vermont, where are the potential challenges, what are the market impacts to it, How does it fit with the whole healthcare reform landscape that the Green Mountain Care Board and others are working on? [Owen Foster ]: With that, I'll turn it back to you, Chair. Any questions on this? Sorry, I can't believe that Mari doesn't have a question. I [Mari Cordes ]: guess I just want to, like, warn you. I did have a bill introduced that's, I mean, a controversial, bold, and it came from Arkansas, who's, as you know, has been a leader in PBM reform. And they had introduced a bill that prevents vertically integrated companies like CVS or PBMs that own and operate pharmacies in that state from having those pharmacies in the state, which so I I like the boldness. I can also see significant problems with, like, how that would roll out because we already have a challenge in in Vermont, in many states. But in Vermont, with people not having access to their medications because pharmacies are closing, whether they're it's Walgreens or we know most of our community pharmacies have closed. So we'd we'd be shutting out access from people who need it most if we told CVS they couldn't function in in Vermont anymore. I don't know. I I guess I'll just leave it there. I I the reason I like the boldness of it is because the problem is so bad. And Vermonters are access to to their medications. The problem is so bad. Vermonters are are hurting. Mhmm. So I would be interested in [Owen Foster ]: Mhmm. [Mari Cordes ]: Exploring ideas like that that we could actually make happen without impacting access to the vacation. Precisely. That's that's great [Catherine O'Neil ]: and noted. And I will say that we have seen I have read some about the the issues of vertical integration and and PBM reforms that try to address that. I know that Vermont's not alone and Arkansas is not the only one looking at more PBM reforms. The Department of Financial Regulation is just getting up and running on the licensure process for PBMs, which is a really great endeavor, and other states have licensing as well. But it doesn't end there. It's a very dynamic landscape around PBM reform and regulation. [Mari Cordes ]: And I think the another issue with prohibiting them from a CVS pharmacy, for example, operating in Vermont would be that wouldn't stop their PBM from they still control the formularies of Mhmm. Some of the health benefit plans Mhmm. Of people in Vermont. So Mhmm. It there would still be problems caused by that through the formulary actions. Yeah. [Owen Foster ]: Any other questions? Alright. Well, thank you. Yeah. Thank you. Thank you. [Mari Cordes ]: Hope you like a huge job. [Owen Foster ]: Thanks for all your preliminary work. Again, I got sucked into a Green Mountain Care report. [Mari Cordes ]: Thanks for jumping in the role. Your video [Owen Foster ]: is excellent. Thank you. Hey. So before we finish up for the afternoon, we're gonna pivot back to CLN, Ping Ponging, and just a couple of providers' perspective. It's Devin. Devin wants to come up. [Devin Green ]: Hi, good afternoon. Devin Green, Vermont Association of Hospitals and Health Systems. And, yes, so, hospitals are in support of increasing the thresholds, the jurisdictional thresholds for certificate of need. And we are supportive of age ninety six. I would say that, you know, in order to make some of the changes that we're talking about with hospital transformation, it would be very helpful to have increased flexibility by increasing those jurisdictional thresholds. And so that's why we're supportive of this bill. And I would say surprisingly, my members, when I spoke with them, so I worked with Health First on some of these proposals. And one thing that actually came up separately from that with my members was the idea of proportionality for academic medical centers and tertiary care centers. So, the hospitals agreed with these thresholds. We thought that they were fair for themselves. I was surprised that some of them were advocating for increasing the threshold, even more for, academic medical centers, and their thought was basically it would be more proportional. So I would throw that out there as something to consider. There are certain projects such as EMRs that are based on per user, and so an academic medical center would likely need a greater threshold to meet that standard or it would be helpful for them. Go ahead, Mari. [Mari Cordes ]: There is is UVM Medical Center supplying human resources to help other hospitals begin to use Epic? [Devin Green ]: So UVM Medical Center and I don't I can I can get you this information, but I know that UVM Medical Center and North Country Hospital are in talks about giving North Country Hospital access to Epic because they had a lot of difficulty with their electronic health records? [Owen Foster ]: Remember what they had? I don't remember off the [Devin Green ]: top of my head, but I can definitely get it to you. [Owen Foster ]: Smart. Smart work. So, yes, giving them access to be able to use it or giving them access to be able to use it. [Mari Cordes ]: Access to the because [Devin Green ]: their records aren't working. And so it's a little bit of a lifeline to them to have working electronic health records. And then when there's relocation or just because a lot of spaces are bigger, so it's really just taking proportionality into account for the academic medical center when we're thinking about this. We think a lot of the other hospitals are pretty on par. And again, they agree with the jurisdictional thresholds proposed here, But it's something to consider, and we're happy to supply language for that. [Owen Foster ]: Yeah. That would be great if you could do that. But did you want to comment on S-ten a little bit, even though it's not with us in particular in in particular, the two items that Sheriff Foster noted, the the provision around depreciation and then the other emergency and non emergency ground transport. Yes. Not a helicopter. No helicopters. [Devin Green ]: I'll I'll start with the last one. Hugely supportive of that. So hugely supportive of exempting them. We know that transportation is a big issue, so definitely support that one. We also support the depreciation one. We, you know, our my members came to me with this concept, and I just had trouble figuring out the right language, and this captures it. So we are supportive of that. And then we're also supportive of the exclusion in this bill around excluding items that are contracted with the State. So things like the adolescent psychiatric inpatient unit, which was signed off on by the State but is caught in the CON process right now. One thing we may need to change there is there's a little bit of a catch-twenty two. The contract has not been awarded yet. So the language in this document, we thought the contracts had been awarded. The con the state contract has not been awarded yet because they're waiting for Southwestern Vermont Medical Center to get the CON in order to award the contract. So but the concept is basically if the state agrees that this is a need and allocates funding for it, we think that it should not have to go through the CON process because there's already been a statewide determination for it. [Owen Foster ]: So you're you're proposing we get rid of the word contract or come up with [Devin Green ]: yeah. Come up with a I will get back to you with the right language. [Owen Foster ]: Right? So [Devin Green ]: It could be something to the effect, like, of budgeted for, you know, like, something that's in law or in budget or but I will get back to you with the right wording. Which would be great. Leslie, I'm [Owen Foster ]: just thinking about the Bennington project. Yeah. Gets caught up in the CON morass. Can we help by making something retroactive to allow that to move on? Do we want to? [Devin Green ]: I would be supportive of that. [Owen Foster ]: I'm not sure that's the policy, but I'm just wondering if I'm having a question. So you mean, like, everything that's in the c o n High school. File folder or whatever they have [Mari Cordes ]: at the Green Mountain Care Board. Yeah. So we can definitely [Devin Green ]: And if you wanna just apply that I mean, maybe that's just supply so, again, if you wanted to do it broadly, great. I would support that. If you wanna just supply it to things that have gone through the state laws, state budgeting process. [Owen Foster ]: Approved by the state. Yeah. That would then, I mean, that would be this, right? Approved by the state, not required to see when. So does that apply in Bennington? I'm throwing that out as a question. To our legislative council. Yeah. [Mari Cordes ]: I mean, I think it's a word of conversation there. Yeah. [Owen Foster ]: And I didn't know if you were prepared or if you wanted to comment at all around what other states do with which what I'm calling reverse CON hospitals or facilities closing down without any sort of reverse I [Devin Green ]: can't get it made. [Owen Foster ]: Did you wanna comment on that at all? [Devin Green ]: I am I will not comment on that today, but I will prepare something and certainly come back. [Owen Foster ]: Great. Great. Thanks, Evan. Thank you. And Jessa? [Jessa Barnard ]: Good afternoon. Jessup Barnard with the Vermont Medical Society, the executive director, and we represent individual physicians and PAs, so potentially a little less directly impacted than the facilities or organizations looking for a CON. So my testimony will be very brief and that we support the concept of raising the thresholds and simplifying the the CON process [Owen Foster ]: or at least the number of instances in which [Jessa Barnard ]: it applies. But in terms of specific dollar amounts or thresholds, we're really deferring to [Owen Foster ]: the other stakeholders who kind of put a lot more thought, into the the pros and cons than than our organization has. So, again, we support the concept, but we're a little bit neutral on which specific numbers or exemptions you land on. I has anecdotally or any members of have concerns over, well, I thought about doing something, but it needs a CUN, and I'm just not going to bother. Or [Jessa Barnard ]: I have not heard that personally. Again, our members kinda work at both the hospitals and health first practices and by state primary care organizations. So I, you know, [Owen Foster ]: I know health first wants to come in and and talk to [Jessa Barnard ]: you about it. So they are probably, you know, hearing that at least on [Owen Foster ]: the independent side more than we we may have. So we haven't received that comment, but we've been from it through others. Great. Thank you. Thank you. Thanks. Yes. Alright. I before I say this, I think we're all set for today. So we can go off that line.

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SmartTranscript of House Healthcare - 2025-02-06 - 2:00 PM

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