SmartTranscript of Senate Finance - 2025-01-21 - 1:00PM

[Chair ]: This change in the agenda, miss is going to be get two, and then we will have a possible dose on the appointment of parent Johnson. [Speaker 1 ]: Sarah? We are live. [Sarah Teachout ]: Thank you. Sarah Teachout. I'm the director of government and media relations for Blue Cross and Blue Shield in Vermont, and I believe I know everyone here. So lovely to see you all. And I brought a couple documents to talk about briefly, and I know that I sent this one to everyone in the legislature. But you may not have had time to look at it. So I just wanted to start with saying that Blue Cross is the only and some of this will be repetition for many of you, but Blue Cross and Blue Shield of Vermont is the only local locally located health plan in the state of Vermont. We're not for profit right up the hill in Berlin. We have about four hundred employees covering all kinds of jobs. But, you know, we have a pretty big IT division, but we also employ doctors and nurses, lawyers, full finance team. So there's there's a whole variety of the type of people who work for our plan. So we are part of the Blue Cross and Blue Shield system. So this is what's a little bit unique about Blue Cross and Blue Shield of Vermont. Vermont only land, but there are thirty four companies, Blues companies nationally that works, I like to say, a little like a franchise. We all join together to offer coverage across the country, and we have essentially territories. So Blue Cross and Blue Shield of Vermont covers only Vermont. We can only sell insurance to individuals and businesses that are located here in the state, and we can only, contract with providers who are in the state of Vermont and one county in along all of our borders. So it's a little bit different than how other health plans operate, but it's really you know, things that are unique to the Blue system, and I think it's important to know that. [Speaker 3 ]: One county out of all the counties that are adjacent to our borders? [Sarah Teachout ]: Oh, no. No. No. No. Around our borders, one county in so in New Hampshire, we do one county in. [Speaker 3 ]: We gotta be on the command entrance. Mhmm. [Speaker 4 ]: Yeah. Mhmm. [Sarah Teachout ]: And then just so you know, it doesn't work over water, so we don't do it over the lake into. Anyway, I don't know. Blues rules. Canada. So We [Chair ]: have to buy travel. Yes. [Sarah Teachout ]: Like, what we do have is an agreement among Blues plans that you can travel anywhere in the country and internationally, that any Blue plan has a direct, you know, relationship with a provider and you're considered in network. They process the claim for us, and then we reimburse that plan. And the same works for people from California traveling to Vermont with their Blue Cross coverage. So Who's key? You know, all all you know, we're a very mobile society, so it's important. And then the most recent change that's happened is that we became affiliated with Blue Cross and Blue Shield of Michigan last year, and that's unique and different. Up until then, we were a single state only plan with no special relationship with other blue plans, in the country. We are now a subsidiary of Blue Cross and Blue Shield of Michigan, just to be super clear. But we're we still operate and and work just like an independent single state plan because, as you know, health care is really local. Health care laws are very unique to every state, and so we we still really operate the same. What's different is, and the reason we did that, is we really needed to be able to bring kind of all the back office operations that you don't see when you buy your health insurance plan to Vermont at a much bigger scale than we could ever achieve with our two hundred and twenty eight thousand members. So what it gives us is access to their IT systems, their software, their vendor relationships, all on a much, much bigger scale. And Blue Cross Blue Shield of Michigan has five point one million members and about three thousand employees. So they are, in the scale of Vermont, very big. They're not the biggest Blue Clan, but they're big. They are also nonprofit. That was really important when we joined with them, and they're a single state Blue Clan as well. So they only operate in Michigan. Let's see. So I I think I brought this up, and there were just a couple things I wanted to point out on it. And I wanted to make it big enough so you can see it. But anyway, one of the things that is also unique about Blue Cross and Blue Shield with Vermont is this health plans offered box, which is kinda small and you might pass it up. We offer health plans in every marketplace in the state of Vermont. And so what I mean by that is we offer qualified health plans on the Affordable Care Act marketplace for individuals in small group. For large group, we do fully insured self funded plans. We also do, federal employee plans, so that's a little bit unique to the Blues as well. And we have the contract nationally for all federal employees. And so Blue Cross and Blue Shield in Vermont covers the federal employees who live and work in our state, and that's true for every Blue Cross and [Speaker 1 ]: Blue Shield in Vermont covers the federal employees [Speaker 4 ]: who live and work in our state, and that's true [Sarah Teachout ]: for every Blue Cross and Blue Shield in across the country. And then we do all the Medicare sort of commercial plans that people purchase. So Medicare Advantage, Medicare Supplement plans, Medicare Part d plans. So we offer insurance in every sector here in Vermont. Most markets have different competitors in every [Speaker 5 ]: month. So [Sarah Teachout ]: and that's partly because we don't have much scale. We can't offer insurance to someone not living in the state, so our market's pretty competitive. And then the only other thing I wanted to bring up on this chart, and we could talk about it, I guess, in-depth later, is the for every dollar in premium. [Speaker 1 ]: Here, I'll go back up. [Sarah Teachout ]: So we paid more than one point five billion. These are two thousand twenty three numbers, twenty twenty three. In a couple months, I'll have twenty twenty four. One point five billion for our member's care. I'm showing you the amount in that chart that is claims administration. So that's the cost of Blue Cross to administer your plan and then taxes and fees that we pay to the federal and state government. So you can see here that the vast majority of the expenses we have is for our members care. And I should say right now that we are a very low cost health plan. We the cost to for us to administer our health insurance is six point two percent of all of the money we So that's a very low cost health plan when you compare us to others nationally. And then the other piece that's really big here is that at twenty twenty three, for every dollar we collected in premiums, we actually paid out a dollar eleven in costs. So that's not what you wanna do as a health plan, but that is what happened in twenty twenty three. And so we showed it here in this chart. So I think I was gonna turn to to take that and turn a little bit to cost because that's clearly what this committee has been asking about in the health care system. [Chair ]: Before you go there. Yeah. I heard you get the extra eleven cents. Yeah. Perfect question. [Sarah Teachout ]: Thank you. I appreciate that. It came out of our reserves. So we are required by the Department of Financial Regulation to maintain reserves. There are members money paid in in claims. We maintain our reserves, and it's for instances when we can't cover the full cost of people's care. It's supposed to be there's two reasons we have it. One is that nobody's perfect. And when our actuaries in the Green Mountain Care Award are committing the premium rates, and that's for the For Employer Care Act plans, but we also do it, you know, for other plans. No one's perfect. So what you would expect is some years would be a little bit high, what we collect compared to what we pay out. Some years would be a little bit low. Over the course of, a longer period of time, it would work out. But we have to hold those reserves so that we always have the money that so we can pay claims. It's also for unusual and unanticipated circumstances, like, about the I will leave it now, Rich. Yeah. Another thing I just have to pull up is I don't know if you all remember, it's a little bit ago, but when the Trump administration took over the first time, they stopped paying cost sharing reduction payments to health plans. But we were still required by Congress to offer those plans to our members. So we lost, I think, in the neighborhood of twelve million dollars in one year of that one piece of federal legislation change. So there's all kinds of things that can come up that affect the finances of a future. So I I think the other things here are pretty self explanatory. And the team up at the office who is much better at visuals than me gave you a lot of pictures. But we do have the big numbers about two hundred and twenty eight thousand numbers in our finance. You know, population of the month, six hundred and forty thousand, and about two thirds of that is coming from on on government sponsored plans. So we are the largest plan for the remaining sector. So so I was gonna turn the I was gonna ask a bit. Are you anticipating something similar might happen in In twenty twenty four? Yes. Yes. Twenty twenty five, I guess. It'll be twenty twenty four, and then twenty twenty five is different. So twenty twenty four, again, our health plans lost money overall, and we'll all know the final numbers in March. I think March first is what we you know, we have to wait for the month now when claims come in and do the final. Let me step back. So when we file our rates with the Green Mountain Care Board, we have to be very explicit about what we're asking for our premiums for. So we put in all the details of what we expect the expenses will be for the health care cost for our numbers, so pharmacy claims. We also put in the risk of population, the age. You know? So all those things go into what the actuaries are doing when they're asking for money. And then we also put in what we call a contribution to reserves. So we typically ask for three percent, and, essentially, that's our margin. So we're saying, this is what we think it's gonna cost to cover the population's health insurance that are our members, and then we want a little bit extra for marginal. And because medical inflation is growing far faster than three percent, That wouldn't seem like it should be enough. But what we do is we take the reserves that we already have and invest them. And if we can make a decent return on Wall Street, not every year, but over the course of those investments, we can offset what Vermonters should have to pay in to keep up with medical inflation. So that's why we target the three percent. Now back to your question. You asked for this year, because of our financial situation, we ask that that be increased from three percent to seven percent. So we have asked for a seven percent contribution to reserves from people purchasing our health insurance in twenty twenty six to help, refill [Speaker 3 ]: our representatives. True question about the Trump action [Speaker 4 ]: from eight years ago? [Speaker 1 ]: It it's actually both. I am curious if that will happen again with this the administration that just came in. [Sarah Teachout ]: Yeah. No. It can't happen in exactly that same way because it actually turned out to be a policy when we, a year later, unmerged our marketplaces and did silver loading that we're now actually drawing down more in federal funds than we would have under the original. So it's turned out to be better for Vermonters, but what's unknown is whether or not the Affordable Care Act advanced premium tax credits are going to continue beyond twenty twenty five, and that's where Congress needs to act. Mhmm. And it would be nice if they acted in a timely fashion so we could all make a claim. Mhmm. But that hasn't been the way things have worked out That's [Chair ]: a point. I do. So remember, there's so many people that depend on those right now. It's wasn't overly popular. Or [Sarah Teachout ]: Yeah. We'll be talking to so there are a lot of Vermonters who receive advanced premium tax credit Yes. And it really lowers their cost to purchase health insurance on the on the exchange for individuals. And there's a bill coming to you. I know that we don't typically talk about house bills, but age thirty five would permanently unmerge those two markets. So going forward, we'd be in [Chair ]: the same place as we are today. I do know that that [Mike Fisher ]: bill is coming. [Sarah Teachout ]: Okay. Good. Excellent. So Blue Cross has strongly supported that bill. It helps position us for whatever may come, but if if the federal government stops the advancement of tax credits, the money's gonna come. And he was really tough. It's just not something that the state [Chair ]: It's not just for monitoring. [Sarah Teachout ]: Well, no. Everyone in this country [Chair ]: will have a free, really. I mean, get blacker than Texas already is in the slide we saw with with the uninsured. It was just a dark hole. Right. But so it will be darker. [Sarah Teachout ]: Yeah. So to jump back to why we had to ask for seven percent this year, and it's because our reserve levels are now so low that we actually have less than a month in reserves, which is not good. And that happened for a number of different reasons, but in the course of the five of the last six years, we've lost money. And, I mean, lost money, like, Blue Cross is not trying to make money, but we've paid out more than we've taken in, right, for five of the last six years. Generally, the Greenmount Care Board was underfunding premiums, which means they weren't giving us enough to cover our expenses. And then the second thing that's happened in the most recent few years is that they've tried to write that. So they've tried to say, okay, these are all the things that you expect as expenses and we're gonna give you enough premium to cover it. Then when hospitals go significantly over budget, I'm not talking a little over budget because everyone goes over and under a little bit. But when there are millions and millions, hundred million over budget, then our premiums definitely are not enough to cover the cost. And so then we dip into our reserves for that too. So that's been happening in the last And then pharmaceuticals. Pharmaceuticals are always a a pressure, but so far, they've been something we've with the exception of maybe, you know, coupons and certainly unusual ones, We are able to manage those a little bit better because we know what's coming. There haven't been as many surprises on the pharmacy costs. We just know what they are. They're gonna be really high, and we build them into the into the rates. So so everyone's talking, and I hear a lot of information about why health care costs are so high in Vermont. And I think I just wanted to talk through a few of those, and then I'll point to the chart. So one is demographics, and you heard from Robin and and Brandon about that. We would say, yes, absolutely. Vermont has an aging population, but you have to remember, we also have one of the healthiest populations. And people if you look at the numbers, it's people over sixty five that's growing faster than the rest of our population, and that has some implications with making the commercial pool smaller. But it doesn't make the commercial pool more expensive because actually, we only really cover people up to age sixty four. So that growth is happening in Medicare, but not on the commercial population. We've actually seen the average age of our membership drop recently. We think it could be the Medicaid redeterminations, could be a little bit maybe people moving into the state. There's not that many to make a big difference. But Yeah. Anyway, we're not a hundred percent sure, but our demographics have actually improved, like, on the commercial market. The other thing we hear about is that Medicare and Medicaid payments are too low, and so there's a cost shift over onto commercial. Certainly, that happens. I would say that the Green Mountain Care Board has a lot of very interesting reports and presentations that were made to them about how many hospitals, and we have it for hospitals, not for independent practices, are able to break even or make some margin on Medicare across the country, and that's one measure of hospital efficiency. Our hospitals here in Vermont have not been able to break even on Medicare. And the other thing that we've done through the all payer model is try to keep Medicare payments low for since twenty eleven. So we may be putting even more pressure on the commercial by participating in these [Chair ]: federal programs. [Sarah Teachout ]: And then Medicaid payments in Vermont, I have a I can send it to the committee. I didn't wanna overload you with a million charts and graphs because I have a lot. But the Pfizer Family Foundation has a really interesting chart of Medicaid payments across this country, and Vermont actually pays really well on Medicaid. This legislature and, AHS have done a really good job to try and increase those reimbursement rates for providers, to help them with sustainability. So, at least in Vermont, Medicaid isn't paying as low as it is [Chair ]: in other states. Yes. In this morning, we heard we were losing community based services and because the Medicaid rates were not sustainable. So we're high, but I'm sure everyone could always use more. The the the way that [Sarah Teachout ]: the Kaiser Family Foundation does it is they do it for primary care, they do it for hospital, and they do it for others. So you really should look at the breakdown because it's not across the board. Can you send me that? Yeah. I'll send it to the whole unit. [Speaker 1 ]: Yeah. I was just gonna add [Sarah Teachout ]: sort of what Sarah just said is that I think it depends on what Medicaid payments you're talking about. And what you're probably talking about are the the health care cover that you cover, not the payments to other kinds of providers that wouldn't necessarily be covered by Blue Cross and other insurance. I need to look to the rest at how what they've got in their data. Yeah. I would like to look [Speaker 1 ]: at it. [Sarah Teachout ]: I can't answer that. We could chat together. I'd be happy to do that. Thank you. So that I I have also heard that we need more money in the system. We just all need to pay more. And I think that you and your constituents and your, you know, families, employers will tell you we we are paying more, at least on the commercial side, than almost every other state in the country. So paying more really can't be our answer here. And we ranked number one this year, and I have it on this other handout that I'll be [Mike Fisher ]: able to pull up in a [Sarah Teachout ]: minute when I figure it out. But we ranked number one in the country for health care costs last year, which is not a great place to be on the spot side. We want that for access and quality and all the other things. Another thing that I've I've heard about is that Blue Cross is not being well run or well managed, just to address it straight up. That is not true. We have some of the lowest administrative costs in the country. We're very well managed by, like, the typical measures of of how a plan operates. I'd say [Chair ]: if we cut out all your administrative costs, it wouldn't You're [Speaker 3 ]: still in a lot of [Sarah Teachout ]: a lot of difference. It doesn't. And and to be to just tell you, we have been cutting our administrative costs. We can't cut a whole lot because we still have to, you know, offer all services. [Chair ]: Like you need well administered. [Sarah Teachout ]: But but we are doing what we can to cut back on our administrative expenses. May I ask you a question? Sure. [Speaker 3 ]: I heard you just say that Vermont has the highest health insurance in the nation, highest most expensive. Yes. My question to you is, can you point to things that this legislature and our predecessors have done over the last twenty years that would be a direct line to driving up up those expenses? [Sarah Teachout ]: I could point to some too sure. But it's those won't be the only things. There's there's a lot of pressures, but there's certainly been thing decisions made here that increase costs. [Speaker 3 ]: I would love that list of things that you would identify as things that this legislature has chosen for the health care system in the state of Vermont that have led us to be the most expensive private private health insurance market. [Chair ]: I just from my experience at Encore with with legislators, we tend to start with what we think people should have, and they start with how much money they think they should spend. It's a joke. We the state wide time. Some states do not do the Medicaid expansion. So if you are working for minimum wage, you don't have health care in the in those states. And we have defined effort to make sure that you do have access to it. But it adds up. [Speaker 4 ]: Well, I think also the issues about states, how they define health care. We had a a bunch of things to health care that other some other states don't. We other states don't. And so many states don't have coverage for natural gas, for example, and other kinds of medicine. Kind of. Many states don't impose specific standards or dollar signs in the amount that can be done for a particular procedure, but we do quite often. So I I think that one of the reasons I would suspect that our costs are higher is because we have more things that we authorize to be paid. Yes. [Speaker 3 ]: That's a conversation I I welcome because I feel like we our voters, our constituents are asking us to have that conversation. [Chair ]: Do you have quite a few afternoons on the co pay for chiropractors and this commitment. It was unbelievable. It is very hard to cut something once you've done it. But we have done it. Thank you. So couple of questions. [Speaker 1 ]: So, yes, I heard you say that we're number one for health care costs, because I'm wondering if you might be able to get us data as to Yeah. What the impact of Medicaid is on that. [Sarah Teachout ]: Oh, okay. Yeah. So this is the one I'm citing. It's consumer affairs, January ninth twenty twenty five. So Right. It's it's this link right here. [Speaker 1 ]: Okay. There's lots of data sources, but that's the one we use for this. Okay. And my follow-up is we we kinda got to this in the last presentation, but I guess I'm interested in teasing it [Sarah Teachout ]: out a little bit more. [Speaker 1 ]: I think we're making the assumption here maybe that fewer people or fewer services that are covered under insurance equals less cost. And I guess I wanna know if that's true, Because my sense is that when folks are not insured and they don't get care early on in their illness or whatnot, they end up actually driving costs up by showing up at the emergency room. And then by that point, they need really invasive procedures that are more expensive. So I don't know if that can be quantified, but I'm wondering if Yeah. [Sarah Teachout ]: I mean, that's absolutely true. We all know that. I'm not sure if it can be quantified, but I can look around. The other thing is, I mean, costs are three things. Right? It's price times utilization and also the type of utilization. So what how intense the services are. So if we got, you know, everyone just going to see their primary care and they're not using very much more. They could go to a lot more visits and they still wouldn't drive up the cost. But we have the other thing that we have here in Vermont, I think it's pretty broadly recognized, is that more care is being delivered in the hospital setting that could be given somewhere else. So that's another thing. So we have high prices for our hospitals and then more care happening in the hospital setting. So that's kind of two things driving up costs. Okay. [Speaker 4 ]: So just a so community hospital, that's like MBRH or Mhmm. And then freestanding facility would be [Sarah Teachout ]: We only have the we have maybe two. It's the one up in Chittenden County. [Mike Fisher ]: Okay. Yes. [Chair ]: The Chittenden Street. Surgery. [Sarah Teachout ]: We have an I one too. [Speaker 3 ]: Private medical provider specializing broadly. [Sarah Teachout ]: Right. There's one in Colchester, Green Mountain Surgery Center. [Chair ]: Okay. So Yeah. Vertical center. Yeah. Yeah. We have two. Still We [Speaker 1 ]: want to sell it all. [Chair ]: So I've [Sarah Teachout ]: done this to everyone in the legislature again. What we're really trying to do is just provide a few snapshots of information that we hope will be more useful than, you know Yeah. We have in the past. So this is all self selected information. [Speaker 1 ]: Do you have a question? About past. Yeah. Okay. That's okay. No. [Sarah Teachout ]: That's okay. Go ahead. And and I wasn't gonna read the whole thing for you, but we thought it would be helpful to show you for some very common services the differences in price at the universe. And this is now all because of the transparency laws, all the stuff is available online. And this is for Blue Cross and Blue Shield Vermont members. I could give you the zillions of caveats as to how we chose the number, but we were consistent in what the services are. But so we can show you for MRIs the difference between UVM, Dartmouth, community hospital, which we've averaged across all of Vermont community hospitals, and then freestanding facilities. There is open MRI, so that's really the freestanding facility for MRIs here in Vermont. We made an announcement last year that we were eliminating prior auths if you went to open MRI because we were trying to direct people to lower sites lower cost sites of care. So I've just given you first some common things. These aren't complicated. You know, I'm sure you could say, oh, there's a lot of variation in health care, but this is meant to be consistent. [Speaker 3 ]: Would you reflect on the notion of reference based pricing as to how that would be overlaid with what I'm seeing here, the general topic that's percolating from the auditor's office and elsewhere. [Sarah Teachout ]: Yeah. So reference based pricing would be a way to kind of rationalize some of this, because the Green Mountain Careholder, whoever you choose, would set a price for a service. So I'm gonna do colonoscopy because it's a little bit easier. And they would say, you know, we'll pick the middle price, you know, two thousand five hundred dollars for a colonoscopy no matter where you go, or they could actually say it might be more at a hospital and less at a freestanding center. I don't you know, there's different ways they could do it, but they would say that's the price, and then the provider could decide we're gonna offer it for that price. We're gonna be more efficient in the way we can do services. Yeah. But there wouldn't be this variation across providers that you see right now. So that would certainly it depends on the price they pick, but if they pick lower prices, it would certainly save money. The only thing I wanna say about the reference based pricing is often a percent of Medicare. It's fine. You can reference off any number you want or you could set it as your own number. The only thing that we feel strongly about Blue Cross as an organization is that we don't pick and do it just for one hanger, so or one employer. So if you could just do it for the state of Vermont employees or you just do it for the Beehive Trust Fund, those costs are gonna come out on the rest of the commercial marketplace. And that's, you know, we're very concerned because we cover everyone who paid for. So we're supportive of the concept, but we really want it [Chair ]: to be broadly. And the other issue would be the impact in hospitals' budgets, clearly, and whether or not it would get cost shifted on to whoever wasn't covered or put some of our hospitals that are in the red belly up. So I find it. Good now. Essentially, change your money out of the system. [Sarah Teachout ]: For us and hospitals, we would never recommend doing it flush overnight. We definitely think you would want to phase it in both in the percentage [Speaker 4 ]: Yeah. [Sarah Teachout ]: Or the reference that you're doing, but also the services you're doing. I don't think this is the kind of thing we could do overnight, reference based pricing for every single thing we pay for. You'd probably wanna phase it [Chair ]: in what kinds of services. [Speaker 3 ]: So I'm really intrigued by this subject. And, what I understand that the treatment of care board discussions and capping the equivalent revenue from the hospital, that seems counterintuitive to me to what we wanna achieve because then you're motivated to extract or or achieve or offer the most return over both, richest margin services. Whereas reference based pricing, if I'm a hospital, then I'm motivated to achieve more greater economies of scale or I wanna provide more with lower administrative expenses. So I'd be really with your Blue Cross Blue Shield network and that this has been done in other states, I would welcome how this worked in Montana or elsewhere and how this might actually look. I know there's a bill coming, but it seems like there's there's fruit to bear from this this discussion tree. [Sarah Teachout ]: Yeah. I I think Blue Cross and Blue Shield of Vermont would agree. It's it's a good thing to pursue. And the total cost of care is kind of the or or global hospital budget is this big picture number, and this would provide some structure within the the pricing system to achieve that total number that they're going for. And like I said, there's just also some rationalization about this for consumers. Like, they would understand more what the price is. Instead of not knowing what the price is for where they go. And I would echo everything that Robin said about people using the cost tool. You know, we have a cost tool on our website. I'm not sure if it's operational right now. We didn't get a whole lot of complaints about it not being operational because it's rarely used. People really don't shop. When you're sick, [Chair ]: you go, but your doctor sends you. Right. [Sarah Teachout ]: And, you know, the only way it could be useful is for things that you go, you know, your mammogram or your colonoscopy or your MRI if it's not an emergency. Those are really the ways that you may be able to use it, but people are, you know, reluctant to drive far for care, and they're reluctant to go somewhere that their provider hasn't recommended or isn't, you know, part of the provider's network. So it's it's not something that's common. So I didn't wanna sync up a whole lot more of your time. I can send this to you and Okay. People yeah. [Chair ]: I will not know. I was feeling that hospitals may have a different way. I can't remember. [Mike Fisher ]: It's great. That's definitely understandable. [Sarah Teachout ]: Well, thank you for for your time, and I look [Chair ]: forward to working with you all this year. Thank you, We'd like to see more of you. Alright. [Speaker 4 ]: Good afternoon. Good afternoon. Good afternoon. [Mike Fisher ]: I guess, I need to sweep at the end of the day. Were we talking about not doing health care if lastly the debt? [Chair ]: Health insurance over to you. Health insurance over to you. Alright. And and three of them. [Mike Fisher ]: Yes. So I am Mike Fisher. I am a health care advocate, and I have not come to a presentation or particular talking about a few points I wanna make with particular scripts, which means I'm sure to get myself enrolled. [Chair ]: Yep. [Speaker 3 ]: I do that all the time. [Mike Fisher ]: So, you know, first, just very briefly, I think most of everyone knows this, but I think I just seem to say it. You know, the health care advocates office is a physician. The the chief health care advocate physician in the office is in the office of the finance statute and through a RFP process, landed at Vermont Legal Aid in nineteen ninety nine and has been there ever since. And I've been in this role since seventeenth, I think. And we have two major parts of our office. One part of my office is a helpline. We have eight play advocates every day working with people who are having some kind of problem with some part of the system that's not working for them. And then we have a policy team that is at this ominous task of rep interest in front of every place that health care is being discussed and decided upon. We're out of state government, we have a care board, and even the private entities. We do our best to be a part of the decision. We're at our best when our policy team and our advocacy team are informed by each other. And so, like, cases come in the door. People raise concerns. We try and use that to inform what we have to say about. [Chair ]: Hi. [Mike Fisher ]: The the HCA as a part of that representing Vermonters, we're we're on the Green Mountain Care Board, and every time they meet, we're there every time they meet. But we have a particular role in insurance right here in Vermonters. And so we've got two attorneys who argue on behalf of Vermonters at each qualified health plan rate hearing. [Speaker 4 ]: Also, the large groups are in in [Mike Fisher ]: the full in the fully regulated market to and and, you know, what what we have to say, to not surprise anybody, it's pretty predictable. Vermonters can't afford it. This rate increase will price more Vermonters out of the ability to afford the care for the. That's you know? And and and we do our best to present effort. I meant to bring my computer on the show chart for us. I'll show it later. When you compare the rate of increase in premiums to real Vermont wages, it's a stark comparison. It it it you know, the costs of premiums not even accounting for out of pocket costs as compared to wages is, you know, one number go one one line goes like that, and the other one goes barely caught in comparison. So in a real way, I'm not surprised by what we're seeing today. I think I think I'll just say part of my job, I think, today is to, in a little bit more urgent way, wave the flag of of the crisis we're in and to to state it more clearly from where from where we see it. Everywhere we turn and look around our health care system, we see tremendous vulnerability. Can Vermonter can Vermon businesses afford another twenty percent rate increase next year? I don't think so. Is there, you know, you know, it's been referenced to the number of hospitals that are, at risk. Or you look around at other parts of the health care system, the FQHCs, we you know, we're at at at real risk. And, you know, to some degree, it well, and and let me just mention Blue Cross. I appreciate Blue Cross's presentation just now. And I, you know, I do wanna recognize a few communications from the Blue Cross. Last week, maybe, we received a email from Don George quantifying some of the recent losses. And and one detail that Don George recognized was that at least in one month, it lost thirteen million dollars. The claims were thirteen million dollars more than the premiums paid. So and I'm aware that that trend has been for a number of months at the end of a number of months in in twenty twenty four. So I wanna recognize that Blue Cross is doing a lot of it's gonna stabilize itself and that but I also wanna recognize a low risk there. The hammering report that happened this past summer, the act one sixty seven process. You know, the the the the big takeaway I had from that is, hey. If we keep doing the same thing we're doing without intervention, we're gonna see hospitals close. I'm pretty frustrated that after that report, there was it it sort of a response from the industry was to attack the messenger and attack the report as as having you know, the data was wrong. It was they they've brought up, you know, details in there. I'm sure they're important details to them, but none of that pushback changed the overall message. And in fact, I think it confused us from the overall message. If we keep doing what we're doing now without intervention, the market's gonna take apart key parts of our health care industry, health care infrastructure, and, man, key parts of what keeps our individual communities healthy. And so maybe I'll just fast forward to that main, main takeaway of this moment. We have to have this theory considering the tax rating committee. We have to have a theory of how we're gonna pay for the system we have. And it's not even, like, that we need more money. When I hear about Hot Wheels that are losing their day's cash on hand and insurance companies that are losing their reserves, real estate is we're not paying for today. We're not paying for the health care system we have. And, you know, as the health care advocate, I should be sitting in front of you saying, we need the very best system in every community. People should be able to get the care they need without having to drive far, and I believe that. But my fear is that if we don't and I don't wanna see hospitals re repurposed or purposes changed and and reductions in services in in one community or another. But even more so, I don't wanna see a lack of action and the marketplace closing those same hospitals. I'd rather see a planful approach. [Speaker 3 ]: So I would really respect and appreciate your opinion. I've been hearing from lots of individuals, and I haven't heard anybody yet make case why we shouldn't raise the threshold for the certificate of need trigger to Okay. More competition in the marketplace. Who would be against that or Permian? [Mike Fisher ]: I think that there's all kinds of of of implications of what you just said. I'm gonna stick with the the main the main push. I think there's fraud support for raising the threshold for where there it should be a certificate of need review, I think, because there's a recognition that the administrative effort of CON is not is not worth it. We we don't get we spend more than the than the value of that review. From my perspective, as someone who's there to fight against bad stuff in the systems, you you're gonna hear me say, you know, hey, heads up. There are bad actors that want to take advantage of they wanna make money and take advantage of Vermonters, and we need some kind of I don't wanna do away with this to get a new system. We wanna make sure that there is still a level of level of review in decision making. But there's another implication. There's another thing you can just as senator, and that's create more competition and Put more options. Okay. More options is a different statement. You know, for sure well, I'll just say, when the when the Green Mountain Surgery Center, quite a lot of years ago now, went through the CON process and took a long time, at the end of the day, the health care advocates office supported it. A lot of local hospitals did not and pushed back hard on it. [Sarah Teachout ]: It was [Chair ]: heavily debated [Mike Fisher ]: Heavily debated. Here. And but but at the end of the day, we supported it because we didn't believe it represented as much deep stabilization as the hospitals argued, and we believe it gave Vermonters a lower cost after. And so so there's a couple yeah. [Sarah Teachout ]: Well, I was just gonna say that there are I mean, I I'm cosponsoring a bill that would raise the threshold on the COO, and I agree with what Mike said Yes. That they've got they're too they're too low right now and have kept up with the inflationary cost. But there is value in having a review of new, you know, bricks and mortar and high expensive equipment. And, you know, part of it is there was the if you remember from Robin's slide, the use of technology is one of the driving costs in American health care. So if we don't have some kind of check on the, you know, newest fanciest thing, then that could drive the cost potentially. There are also quality issues and placement issues in terms of where you cite things and how how they might compete with local community hospitals, etcetera. So there is some value to having that kind of review and there is more to it than just the cost threshold. There's the COM process is is more than about just the cost. So I think that, you know, don't throw the baby out with the bathwater. There's some value to it. It's just that what we have right now hasn't helped up with the times. And also the the profit motivation in American health care can be super damaging. And as Mike said, there there can be, like, bad actors that come in and try to, you know, sell sell health care services that are not necessarily helping or of good quality. [Chair ]: He had a rather robust discussion about birthing centers, and that's fine, but OB GYN is expensive because you have to have someone on call twenty four seven. A birthing center is fine for a normal birth. But if there's no hospital and they're closing them, Springfield's closing them because of the expense. If you have a birthing center, that's great. But what happens when there is a problem delivery? How far in the middle of a snowstorm can you safely, and how do you work that out? Chittenden County's got a certain population. Central Vermont's got some choice. But I think a lot of Vermont believe you now have to go to Dartmouth for chemo or infusion chemo from the kingdom. That's a long drive when you're suffering the aftereffects of chemo, but there's no place out there that does enough that feels they can afford to do it. So it, again, is a real balancing act in what Chittenden County could support the separate surgery center. And I was on health and welfare, and it was there. Maybe Central Vermont, but probably not any of the more rural areas because there just wouldn't be enough surgeries to support two centers. [Speaker 5 ]: You're saying there [Speaker 3 ]: needs to be nuance for the certificate of need. Is is there not some nuance now for the Well to that being any question? [Sarah Teachout ]: I don't There there is a nuance. Yeah. And that's what I was saying. Don't throw out the beer, bathwater kind of concept is that, you know, that I think there there definitely is time for tweaks, but it's not it's not something to say, oh, we shouldn't do this. There there are ways to make it better and more effective. Yeah. But doing away with it entirely, I think, would be safe. [Chair ]: Was doing health care regularly with the AI. It was just we bought an MRI machine. Once you paid for that machine with visits, it was gravy. And the theory was he would refer more people to get an MRI, would maybe it would be just health effective to do an X-ray, which is where some of the prior approval things came in. But it's that was the you know? Or I can remember hospitals just wanna create palaces. I remember I think it was the chair of this committee that said that pretty quickly. Not this one. But the idea was that you didn't and, you know, build new steel glass. You keep the old brick one and retrofit. So it's been controversial. [Speaker 4 ]: Just like to share kind of a background vision that I have on this. I've always been astounded by health care and how its cost for everything continues to rise. But every time I go into Best Buy and look at the new TV sets and video recorders, the price is lower than it was the last time that I went in. And you almost see that with every area of technology. You realize it's a lot it costs less now in inflation adjusted dollars to send a rocket into space than it does to get colonoscopy. The the inflation adjusted increase in health care is almost unique. And that, I think, is something that deserves a lot more study and analysis as to why. [Chair ]: Yeah. Mhmm. The cost of energy. [Mike Fisher ]: Yeah. And and I don't know the answer to that question. I it's [Chair ]: Well, if you said you pay the cost? [Mike Fisher ]: Well, indeed. I mean, it's a little bit to do with the slide that Robin had up a little while ago about sort of the complexity of this marketplace. And I think also getting health care is and then our motivations around getting health care are a different dynamic than our motivations around getting a TB. And [Speaker 4 ]: A neighbor of mine makes high precision medical equipment back in Swanton. I remember him testifying before one of our committees. So it's gotta be ten or fifteen years ago. And his testimony was you see this little piece of device [Mike Fisher ]: right here? Remember this testimony. Remember that? Mhmm. [Speaker 4 ]: And he said, this device, I made for seven cents, but put into a patient at Dartmouth that cost three thousand dollars. Why? Same same exact Same exact device. [Chair ]: Mhmm. Yeah. [Speaker 3 ]: The hospitals in because I'm sure they have an answer for that. [Chair ]: Oh, we will have the hospitals in before [Speaker 4 ]: I So so if you look at it and and again, this is one of the things that I don't know how well I got the job that everybody here does. I mean, somebody theoretically does it. But of of looking at the the whole cost structure and particularly the elements of it because it's so layered in terms of the participants. We certainly, you know, have the concerns about the pharmacy benefit managers and that process, for example. The week Of the number of middlemen who are involved Yeah. Taking a slice out of something. And and that is only a small piece of it. But just analyzing costs at various levels makes me very frankly, as I'm okay. I'm very, very suspicious of it. As you Yeah. [Mike Fisher ]: So so maybe this is close to reference based pricing Yep. And as we as what? This is close to reference based pricing, I'm just saying. Let me just say, I am supportive of the effort to move towards records based pricing. I have similar concerns that Blue Cross just mentioned about doing the segment for the marketplace. I think we could try to make sure that the costs don't balloon out to other parts of the marketplace, but I think it would be a try to. I'm not I I would have a hard time being assured. And further, yes, the taxpayer is really harmed by the cost of public employees public employees. But the small business person is equally armed today. And I think the prospect I'm not gonna admit myself to this because I think it's possible that the right thing to do is a segmented move towards universal a a full reference based pricing. But I just know that if you put in front of us in front if the legislature move forward on reference based pricing for public employees and didn't touch the small employer world. You you hear a lot of frustration. [Chair ]: They will be cautious. [Mike Fisher ]: I I also I wanna recognize a couple of other moving pieces. We do have a decision in front of you this year that needs to be made this year and rather quickly about small about merge or unmerge individual and small group. I was trying to remember how long ago it was that that happened. And I [Chair ]: Was it two or Two or three [Mike Fisher ]: years ago? In twenty one or twenty two. [Chair ]: We did it one year for a year. [Mike Fisher ]: And I [Chair ]: And then the because it was gonna run it was only one year increase in the federal subsidies. And then they extended it to three years, three or four, and we extended it So in twenty one brought it out. [Mike Fisher ]: This at this table, I delivered a letter saying, I think we should look at this, and your committee moved in doing a one year Should [Chair ]: we say confirm that you get adamantly opposed? So Yes. Thank you. [Mike Fisher ]: I wanna recognize my position on this this change. [Chair ]: No. But this was never changed. This was before the change, before the subsidies. [Mike Fisher ]: It was the enhanced premium tax credits that made us say, this doesn't make sense to ignore it. And so that will come to you. And newsflash, I'm gonna I'm gonna keep it consistent at least this time. I think for a number of reasons, and maybe I can do it more later, I I I think it makes sense to continue with the unmerged position. Largely because Yeah. Because of the structure and the way the core vocab works and and because it's something that I'll just give you a review of today. Silver loading, our Vermont strategy on silver loading really worked this year. The Green Lantern Care Boards Actuary estimated that it was worth forty million dollars in increased buying power for people in the individual market. I don't know if that's exactly right, but whatever the number is is a increasing subsidy for Vermont lower income Vermonters to buy better quality plans without a need for a state match. And so I think given Silver Lilly in particular, DHC will support maintaining an unmerged market. [Chair ]: Washington does not mess it up. [Mike Fisher ]: Until messes it up. You know, then lastly, I think I I I do have to mention that and this maybe this goes back to reference based. The prices of our system are out of whack. And, yes, our demographics are part of it, but not part of it. But, you know, in media's open. And Yeah. There and there are many different reasons for this. It's not simply one thing or another. But the bottom line is remarks prices are adequate, and it will be painful, the right price, our health care system. So I'm not on any illusion that this has been some kind of simple fix out there. [Chair ]: We're gonna find out how the pain threshold on this committee is between this and educating the property. [Mike Fisher ]: But but but let me just say, if someone could deliver me to me, the theory of how we're gonna pay for it, I'm I'm on board, and I wanted to figure out a way another way to not have to live through the pain of of affecting our prices. Yeah. Somebody you know, if if the hospitals came forward and said, you know what? This is not important enough. We think there should be a increase in a broad based tax and how to pay for it. I might think you're politically not reading the tea leaves, but at least we would be saying we have a theory of how we wanna pay for it. Short of that, I think we're we're driving off a cliff and [Chair ]: Good. [Mike Fisher ]: We need to pump the brakes. [Chair ]: Education. Which she have I might find the money to pay for this year's increase, but if I can't bend the increased curve, the money I find this year is just gonna be gone this year, and it's it's bending. We've gotta bend the curve. We aren't getting that much better health care for that much more cost. We won't even talk about pharmaceuticals, which is I don't know if it's the first or second. I think it's the second now. Leading cost driver for health care. And we spent three, four years almost totally focused on pharmaceuticals, and we have not bent the curve. And you go how far is it? Sixty miles north, I think. And the pharmaceuticals are Yeah. Less than half the price that they are. Yes. And they're perfectly good pharmaceuticals, The same ones. [Sarah Teachout ]: Part of the problem with the pharmaceuticals is that they are federal Yes. Regulated for the most part. And Yep. Vermont state legislators have very little impact on them. And we have just this system that is completely based on profit of pharmaceutical companies, and that is the number one thing that drives up pharmacy costs in the [Chair ]: United States. Told they are the largest donor to political campaigns in the country. [Mike Fisher ]: And I understand the effort to negotiate those prices is Just when? Yes. Roadblock. [Chair ]: Yep. Yeah. Yeah. I mean, finally, last year said you Medicare could negotiate to the prices. Before that, Medicare was banned. Yeah. [Sarah Teachout ]: And that's true. Just were revoked [Chair ]: yesterday. Oh, it was revoked yesterday? Yeah. Oh, well. I have the email address for Canadian pharmacy. The two hundred dollar a week prescription, forty four dollars and seventy five cents, and that includes shipping from Mauritania, which is where all the name brand years are also made. But that's the And that's also fraud [Speaker 4 ]: in many cases in those Canadian mail order pharmacies that we've seen in the past that things aren't always what they're supposed to be because they're not looked at by the Canadian authorities. This is a company so this is something that we do have to be aware of. Now I know we used to have situations in which we we had buses in fact. But Mhmm. You know, from from all those that would go up across the border of Montreal to pharmacy. I bought them. I've had products in past years. I don't now. I remember one thing I had was tablet that cost sixty two dollars to purchase each one in the United States, and I got it in in in Montreal or pharmacy for less than ten dollars. And the only thing I had to do was go see a Canadian position and their their storefront positions that you can go to to get the prescription the same day. So it wasn't hard to do, but, you know, you you just have to go across the border to do it. [Chair ]: I mean, but it is that big a difference, and I haven't heard the can the Canadians were out there was having better outcomes and lower costs than we do. I haven't heard of my grandchildren being bad bad drugs. [Speaker 4 ]: It's not because it is useful right now for people here in the states that you have a prescription. It's a high value prescription. Just go online and see what you can get at a pharmacy in Montreal as opposed to the mail order pharmacies in in foreign countries that some of the mail order providers offer. [Chair ]: This is the Canadian pharmacy in [Speaker 4 ]: the line. But they call themselves that, but, you know, the [Mike Fisher ]: question is, are you radiologists. [Chair ]: Who knows the number? In a place that you [Mike Fisher ]: can rely on what you're getting. Yeah. So [Chair ]: we will but those are the two big cost drivers, hospitals and pharmaceuticals. We have had, I think, almost no effect in controlling the cost. We also don't have any manufacturers. We have very little hook in that market. [Speaker 4 ]: Well, it's also difficult here to get effective pricing for pharmacy. I know we have disclosure requirements regarding service drugs and so on, but it's it's it's not easy to get that from pharmacies. They're not that Fort Collins. You have to have a prescription in in some pharmacies like like Walgreens, for example, in order to ask what the price would be for it. They won't do it or give it to you unless you have prescription. And I know the law may not specify that that's the case, but that's the practical use of it. So if there are roadblocks, it's not easy. [Chair ]: They have to tell you if you could get a full price cheaper. You did that. Some things you can't okay. We have one more [Mike Fisher ]: Medicare, it's always an adventure to sit in front of our list committee. Thank you for holding on, and I'm happy to check with any of you. Individual members are back before the Well, [Chair ]: Thank you. Okay. Maybe we will we're gonna get this. We can't do it with health care because it's in the morning. Mhmm. But these are issues we're gonna be working on with them and try to get this through. We have one witness left, not left, but definitely not least, which is our second major provider on the market, MVP, and Jordan Estes with us. So, Jordan, welcome, and the floor is yours. Great. [Speaker 5 ]: Thank you, chair Cummings and and members of the committee. Can you hear me alright? [Chair ]: Yes. [Speaker 5 ]: So after a great discussion, and I'll keep this brief, but I did wanna share a couple of slides because I think it's helpful just to, you know, quickly paint a picture of who MVP is as it relates to Vermont's health insurance markets and our role in them. So bear with me for one minute. [Mike Fisher ]: K. [Speaker 5 ]: You see my screen alright? [Chair ]: Yes. Perfect. [Speaker 5 ]: So very quickly, just to contrast a little bit with what Sarah presented about, Blue Cross Blue Shield of Vermont. MBP, like Blue Cross, is a is a small regional not for profit health plan. Our footprint extends all of upstate New York and Vermont. So we're only in those two states, but we've got about six hundred thousand members. The bulk of our membership is in New York state, and New York has a different set of rules around its Medicaid program. So we are very heavily involved in partnering with the state to deliver, you know, their Medicaid, their child health insurance program, and their state funded, safety net programs. But we're also in commercial markets, the exchange markets, fully insured large group self funded. And in Vermont, as I'm gonna cover on the next slide, our membership is really only in the individual and small group markets. So those markets, you purchase coverage whether you're a small employer or an individual through the state's health insurance exchange. We've been in Vermont since nineteen ninety three licensed as an HMO. We've got about thirty thousand members in those two markets in Vermont. So a very small slice of our total membership of six hundred thousand, but a significant presence in those markets there in Vermont. Very robust and comprehensive provider network across New York and Vermont with more you know, we were contracted and partnered with more than five thousand providers. And as a as a community based mission driven organization, you know, we take very seriously our role in the community, you know, and and in being a partner to providers, community organizations, policymakers like yourselves in terms of, you know, being at the table, being part of the solution and doing what we can to deliver, you know, affordable, high quality healthcare to, to not only our members, but the entire communities that we represent. This is just reflecting, you know, where MVP's market share is. Now share Cummings, you mentioned the MVP being the second kind of major player. And that's true as it relates to the state, what I would call the state regulated health insurance markets, which are individual small group and fully insured large group. There's about seventy two thousand members in the individual small group markets. We've got about thirty eight to forty percent of those members. And again, that is really where our our Vermont membership is. So we're a small small participant in the grand scheme of of all of Vermont and and and where, you know, Vermonters get their health insurance coverage. But, you know, I think a very, you know, relevant and important plan as it relates to the state regulated markets and a lot of the policy discussions that that you all have. You know, these slides I had actually prepared for kind of an introductory overview of MVP to the House Healthcare Committee last week. And I pulled these two graphs in particular and after listening to the conversation, you know, just now I think they're really important and certainly in line with, you know, a lot of the questions and what some of the other presenters had said. You know, I'll start on the right hand side because there's been a lot of discussion about cost and where Vermont is relative to other states in terms of, you know, the affordability of health insurance coverage here. And what this slide shows is in the again, in the QHP markets, individual small group, state regulated markets through the exchange, you know, premiums have been increasing everywhere across the state, but they've been increasing in Vermont at a greater level. And they, you know, they're starting at a greater level in Vermont. So that's, you know, simply not sustainable. And, you know, as as Mike had shared, you know, small employers in particular, individual families purchasing coverage in these markets are, you know, they can least afford, you know, the dramatic cost increases they're seeing every year. On the left hand side, you know, this is data I had pulled from an overview of the health insurance markets that Nola Langwell had given the legislature at the beginning of last session. The data only runs through twenty twenty, but this trend, you know, has not reversed. So what you see here is a change in enrollment between state regulated commercial markets and non state regulated commercial markets. So your self funded ERISA plans, federally funded markets or federally regulated markets and then your, you know, your fully insured state markets. So what you see here is that there's been a significant decline in the the number of enrollees in the state's fully insured markets and a big increase in the non state regulated markets. So, you know, as we talk about cost, I mean, part of the issue here is you put you know, we've got a small and shrinking pool of Vermonters that are in these state regulated markets and that, you know, increases the the volatility, you know, of the market. You know, the the the members tend to be, you know, sicker on average and it it tends to result in higher cost pressures and and volatility. And I'll just point out if you're not aware in these state regulated markets, particularly the exchange markets, there are only two carriers. So it's it's Blue Cross Blue Shield and MVP. Cigna has a small presence in the, in the large group markets as well. But really two carriers in, you know, these the the the these focal points of of state insurance regulation are are MVP and Blue Cross. [Speaker 4 ]: I'll tell you a question about that slide. [Speaker 5 ]: Yes. [Speaker 4 ]: If you go back to your bring the slide back. I'm looking into the two different categories. The the one the the last one that showed state regulated versus non state regulated. I just want a little try to get a little clarity on the non state regulated. Are those, employees who live in Vermont who are employees of businesses that are multistate businesses, or is there anything else besides that? [Speaker 5 ]: Yeah. It could be association arrangements. You know, there's innovative captive arrangements, my understanding, in the health insurance space. But generally speaking, this is gonna be your, what we call, self funded market. So the employer is is bearing the risk in those arrangements. You know, they're paying the cost and then they're partnering with a health plan like MVP, like Blue Cross, like United, like whomever to act as a third party administrator way where we are, you know, we're maintaining the network, we're processing the claims, but the financial risk actually sits with, you know, the the employers in those arrangements. Now I will point out this is not a uniquely Vermont trend. This is something that's happening across the country. But given the, you know, the higher premiums in Vermont, I think it's particularly acute here in that, you know, I think part of the reason this shift is happening is you've got employers that are just, you know, struggling with the burden of health insurance premiums and looking for more affordable, more flexible options to offer their their workers if they can afford to offer coverages at all. I mean, that's certainly a a piece of the the challenge here as well. Any other questions on this before I I move on? [Chair ]: Yeah. I have one more question. [Speaker 3 ]: And and to your point, so those employers can be set health standards for their employees. Like, they can have no smoking policies. And so you're saying that more of the riskier type, or the more expensive to ensure are getting shifted to the state regulated market while those are risks [Speaker 5 ]: Yeah. Remain remaining in that market. Right? Versus, you know, those that might there are affordable options elsewhere because they're got a healthier workforce. They can you know, their claims experience is gonna be better than the, you know, kind of the the overall risk that's shared in the in the state fully insured market. So it's a better, you know, it's a better it's it's a more it's a more affordable option for a lot of employers. And that's happening nationally and it's certainly happening here in Vermont. So, you know, why I wanted to raise this because I think it's it's an important policy variable to really understand. And I had shared this again with HouseHealthcare, a couple of policy principles, you know, we have that we would kind of urge the policymakers of Vermont to be mindful of. You know, the first is, again, it's it's protecting Vermonters against unaffordable, unsustainable health care costs. Then a lot of good discussion today, a lot of good questions from the committee members. Health insurance premiums are expensive because health care costs are expensive. You know, I always tell people that we don't wanna raise premiums any more than we have to. Right? The reality is we have to, you know but we have to charge premiums that cover cost. And in the in the case of a not for profit like MVP or Blue Cross, we're you know, when we're profitable, that's not profit that's going to, you know, benefit shareholders. It's it's being reinvested in in the business. So, you know, we have to have you know, we have to charge premiums to cover costs, but regretfully costs are simply, you know, they're they're they're uncontrollable year over year, and it's it's it's putting us in a position of having to raise premiums to levels that we don't want to and most importantly, to levels that, you know, Vermonters in these markets, small businesses, families simply can't afford. Number two, you know, and this is really kind of a general statement, but we would urge policymakers to really put individual Vermonters at the center of all of these discussions. I think, you know, the health care changing is the health care system's changing. It's changing rapidly. And, you know, as we think about a future state in a health care system that's equitable, affordable, resilient, and transparent, that is really built around in Vermonters individual health care needs and experience. There's a lot of technological advancements, a lot of opportunity, I think, to just move away from a healthcare system that has traditionally been very siloed, but very fractured, right? You've got your hospitals, you've got your pharmacies, you've got your health plans and all of these stakeholders that aren't really integrated in a meaningful way. I mean, again, not just the Vermont challenge, but the historical kind of nature of the US health care system is it's not really built around the patient and their need. So, you know, I would urge policymakers to really, you know, prioritize that when we think about a future state that, you know, we it can't continue to look like it does today and that there's gonna be some pain, you know, in that transition. And I include health plans, you know, in this this statement. And then third, going back to the the the chart on the last slide, would urge policymakers to be mindful that, you know, there there is the state regulated versus non state regulated market dynamics and that be mindful that a policy changes that will continue to drive Vermonters out of the state regulated markets in favor of other options. You know, state law has a limited and shrinking reach on the private pay market markets and any changes that, you know, this legislature make really only affect the two local not for profit community focused plans at the end of the day. So, you know, I think that's a really important principle to be mindful of, you know, when we're working to ensure that Vermont has a strong and stable health insurance system. So I'm gonna stop sharing now and happy to take any questions. And just real quick on some of the discussion before I before I spoke. You know, I think price prices is huge. I think we have to look at costs. You know, the the data that's, Sarah shared about some of the price differentials between facilities was, you know, I think really important. And, you know, we see it because we're a multistate plan. I mean, the cost of some of these services just across the border in New York relative to what, you know, we pay in Vermont is dramatically different for the same service. Let's take an MRI, for example, lab services. You know, I think the lack of competition or choice for Vermonters around where they can get some of these services is definitely something, you know, to look at and consider as to why the prices might be where they are. And, you know, there was just discussion about prescription drugs. You know, another policy area to be mindful of or or to be thinking of when we talk about prescription drugs are medical drugs. So drugs that are administered in a hospital or outpatient facility, Those are, you know, have their own kind of unique, you know, pricing features. And, you know, we're seeing pretty significant trends around outpatient prescription drugs being that's where we see most of we're seeing some of the the highest cost trends in our data around prescription drugs. So those are, you know, a little unique because I we're probably gonna have a discussion around the three forty b program, which, you know, is is is an important program. It really helps the the hospitals, the safety net providers in particular. But, you know, I think it's important to understand to what extent, you know, that is there's that plays a role in increasing some of these drugs for the commercial markets. You know, for example, the PBM law that the legislature passed a few years ago and, you know, this was a head scratcher for me. There's a kind of an unnoticed provision in there that prohibits us or our PBM from even tracking on our claims when a three forty b three forty b drug is used. So we really have no idea, you know, how much, money we're spending on these drugs relative to what acquisition costs are and so forth. So, you know, these are really complicated discussions, but, you know, really important ones given where we are, you know, as as a health care system. [Chair ]: And Sanders has a question. [Speaker 4 ]: Good afternoon. General question. We were talking a little bit earlier about the differential in pharmacy pricing between Canada, Quebec, and Vermont. Is there any differentiation in pricing at the retail pharmacy level between New York and Vermont? [Speaker 5 ]: The retail pharmacy level, I'll have to I I can't answer that with any level of authority. I'd have to check with our folks. [Speaker 4 ]: You know, our Just send our our our our our our residents to Plattsburgh. [Speaker 5 ]: Yeah. Yeah. I'd I'd so in MVP's case, we we work with the PBM, and our PBM relationship extends, you know, across our footprint. So I would be surprised if there were significant pricing differentials for our members in our network across borders. But, you know, I think the, you know, the outpatient drug issue is certainly one that's that's worth exploring as well. [Chair ]: Other questions? Okay. Thank you, Jordan. That's been helpful. [Speaker 5 ]: Appreciate your time. [Chair ]: We will see you, I'm sure, again before we finish. [Speaker 5 ]: Actually, I'm I'm Claire's in the room. She's she reminded me real quick, two bills I think are important that, you know, we're working on the house with, right now. One is the the small group individual, merge market bill like Mike like Blue Cross, MVP strongly supports that. The other is an act one eleven kind of cleanup bill. You know, we've been working with stakeholders over the course of the, you know, the sum the summer and the fall, since that act was passage to, you know, make some clarifying changes. One important change for MVP is, and I don't think anyone envisioned this when the when the act was being considered is, you know, a limitation on applying the the claims edit standards within the act only to Vermont based providers. So, you know, the way it's written under insurance law, we have a concern that if I'm an MVP member in Vermont and I'm traveling somewhere in New York, because of where it sits under the statute, that that would apply to the transaction at the at Albany, Med in Albany. So that would be impossible for a small plan like MVP to ever effectuate, and I don't think that was a legislative intent. So we've had a lot of good discussions, and that is in, h thirty one, and we would strongly support, you know, advancement of that as well. So more to come on those bills. [Chair ]: It makes sense this way. Okay. Thank you. [Speaker 5 ]: Thank you. [Chair ]: Thank you, committee. If I find somebody to do it, I'm gonna have you have another wonderful day. And we can do PBMs one zero one. [Speaker 4 ]: This is great. Thank you, Melissa. [Chair ]: So Yeah. This just a background. If Sarah or Mike, anybody knows anyone that does PBMs one zero one, let me know. The pharmacy benefit managers are another What you're layer. Sometimes they work well. Sometimes they don't. I know we've been told don't touch Medicaid drugs because they were very happy with what they're if you have got them at the state level. But that it's just another big player as we get into this that we need to have a rudimentary understanding of. By next week, we will have the governor's budget. I think that's on Thursday. It's Tuesday. Tuesday. Tuesday. Tuesday. [Speaker 4 ]: But he's presenting on Thursday. Yeah. No. No. You said that? Thursday. Twenty eight. Thursday. [Mike Fisher ]: Twenty eight thirty nine. Twenty [Chair ]: eight. That's Thursday, please. [Mike Fisher ]: It's Tuesday. [Chair ]: Okay. So we'll move that down. Just. Okay. So we may not get to TPMs until Friday, but we will do a brief that's, I I think, the other big player that we need to know is in this health care world. And then if anybody else has any you know, anyone you wanna hear from, let me know. Any group, any questions, we'll get that out. I think once we get the governor's budget address, we're gonna be really focused on the financing section. I think I may get briefing on the I think that's what we're gonna get with all member caucus [Mike Fisher ]: Right. Right. [Chair ]: This week. Oh, yeah. Tomorrow Oh, yeah. At ten is emergency board, I believe. And then we will know what our revenue picture looks like. The rest [Speaker 4 ]: Anybody can go in the corner. Yeah. It's open to everything. [Speaker 1 ]: Yeah. The room is usually closed in [Chair ]: the governor's ceremonial office. I see. But y'all this is not the house. Y'all have roommates in the morning. House of the room only have five members, so the chairs react poorly if they're not there. And I won't be there, which, frankly, precludes anyone from health and welfare holding up. But we will get a briefing in the afternoon to talk to that. Yeah. And it will give us the system the census forecast. So they've arrived in agreement. Oh, there's nothing earth shattering at this point. [Speaker 4 ]: Yeah. But The [Speaker 3 ]: board will get it three [Speaker 4 ]: three hours before we do. [Mike Fisher ]: That's that's usually why I went [Speaker 3 ]: with today. [Chair ]: This morning because I can't get my calendars coordinated. I have two. One for here and one for everything else. And, apparently, I'm told they don't play well together. Play out? I've been able to [Speaker 4 ]: What are you trying [Speaker 3 ]: to merge? You got Outlook calendar and [Chair ]: I was trying to get my Outlook and my Google calendar. [Speaker 4 ]: Oh, that's doable. I'll just see them across pocketing. Yeah. That's doable for you, can we? No. I've done it. Yeah. Hey. I'm waiting. [Chair ]: Here you go. Yeah. Constantly. [Speaker 4 ]: Yeah. Yeah. [Speaker 5 ]: Seemed bad. [Chair ]: They did it once before. And then last year, they said, no. They could do it. [Speaker 4 ]: Oh, yeah. [Chair ]: Still Yeah. It's hard. We can go off live. We are off the topic of today. [Speaker 4 ]: This is great.

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