SmartTranscript of Senate Health and Welfare - 2025-02-19 - 10:30 AM

[Chair Ginny Lyons]: Alright. Thank you. This is, senate health and welfare. We're back. Now we're going to hear testimony, regarding our proposed committee bill to draft framework right now, and we're seeking comments and for inclusion, how we can approve the bill. And we've got a number of folks to testify, so we'll listen. We'll do a lot of listening. And if you don't have your testimony on our red page yet, please get it to us because this is how we remember. And if anybody can remember the third thing that George Washington said we should be concerned about in our democracy beside political parties causing division and of someone who wants to be a king rather than a president. I don't know. I forgot the third one. It's really important. We're working on it, but, you know, send it to me. Okay. So now we're back on our committee bill. And, Debbie, you are here, and you'll have your testimony on great. Sorry. [Jessa Barnard]: Hi. Good morning. Thanks for [Devin Green]: having me today. Devin Green, Vermont Association of Hospitals and Health Systems. And I will just say that right off the bat, you know, it is an outline that you have going on, but there is so much packed in there that I would hope that this would not be the end of my testimony today. We'd love to even bring a few witnesses then if possible in the future. We'll speak on [Chair Ginny Lyons]: some We'll try to accommodate as much as we can. Thank you. [Devin Green]: So I'll just start off by saying we really appreciate the access and affordability problem in Vermont. We want to be a part of the nation, and we want to come to the table. For part one with the statewide health care delivery plan Mhmm. We do support a plan and ensuring that we look at affordability and access in Vermont holistically and having all the players available to come up with solutions, I think, is a great idea. I was thinking about what doctor Elliot Fisher said about coming at this from an emergency management perspective and that there is a certain framework that we could put on this that might be helpful and you could be able to take deep intention. But, you know, after an event occurs, so we just have the all payer model. Usually, after an event happens, there's something called a hot wash, which is like an after action report. And you take what you've learned and what went wrong, and you sort of carry that forward into the next thing. And I think that would be useful here so that we're not just jumping from one thing to another without it informing our future actions. Another thing is a tabletop exercise. So this is where other players get into a room. There's a facilitator. And it's a safe space to throw out all possible solutions, stress test everything, do cause analysis. And I think that should be helpful in this scenario as well. And then I really wanna stress the role of act one sixty seven in this. The capability piece of act one sixty seven is happening now. We've met with the rural health design center. They presented to our hospitals last week. The hospitals are engaging with them. And so, again, I wanna make sure that things are integrated and aligned instead of jumping from one thing to another and having a whole different thing. And then finally, we just need to understand the increase in cost to hospitals as well of all these efforts. Hospitals [Sara Teachout]: are one [Devin Green]: of the payers. Self insurers also pay for, Green Mountain Care Board work. The state pays as well. And so it'd be helpful to know what that increase might be. We do not support the Green Mountain Care Report review of hospital strategic plans. While we think that having a statewide plan in place makes a lot of sense, Going into each individual's hospital strategic plan is really gonna have a chilling effect on our volunteer boards. It's really hard enough to recruit them already, and it will significantly increase administrative burdens and cost to have a whole other structure right now. The hospital budget process is a good eight month process, six to eight month process, and takes significant resources. It'd be helpful to understand what the thinking is here, but for now, we cannot support it. Health. So that was part one. Part two, the health system evaluation support improvement and development of the statewide health care delivery plan. Again, if you are going forward with the plan, we would really like to see Avaz, Amani, as well as all the other stakeholders in that advisory committee. This is how Maryland or this is how Pennsylvania did it with their global hospital budgets and their planning. Maryland also has individuals on their rate setting board that have hospital administrative experience and also commercial insurance experience. And so I think it would be helpful in this space. R3, the vital piece and hospital or an integration of data. We support that hospitals are working on interoperability between hospitals because we think that there is an opportunity for each EHR system to talk to each other. And so we're working on that. Yay. But the most value that we can get is through, you know, hospitals having communications with their community care providers. And so we really support VITAL in that hyperbole developing network. Part four, hospital budgets and payment reform. Reference based pricing, we are, you know, we are happy to look at proposals and to think about how to do reference based pricing in a way that increases affordability, doesn't impact access. And in doing that, we would just, like, make sure that folks consider factors such as payment, like the amount of Medicare and Medicaid the hospitals are receiving when they're developing a proposals. And give hospitals the opportunity to do the calculations of what the impact will be of the reference based pricing to the hospital. It would be great if there was a thirty day payment of claims with reference based pricing so that we have continuous cash flow and we don't have to worry about that piece going forward. And then also if Medicaid grew at half the rate of inflation, that would also provide hospitals with a lot more predictability and ability to, etcetera, reference based pricing. And then just triggers and guardrails, if if this isn't working out the way we plan. We know that the other states have really just implemented this to a small amount of folks compared to their population. If this is going broad, we think that there needs to be, like, triggers of this is not working. It needs to set up. We go back to feed our service or something like that. Total cost of care, we support Value based payments. Yeah. Yeah. Our value based payment. Our global hospital budget. Total cost of care, we support it. We would like to see net patient services revenue eliminated. If we're pursuing this rigorous total cost of care, it does there is a conversation around that patient service revenue and access because it is the amount that hospitals are paid for care. Oh, I thought it's another good question. [Sara Teachout]: We're already at sixteen. Sorry. [Chair Ginny Lyons]: Wait. We're we're twelve. Is twelve. We're at sixteen. [Devin Green]: Do I put the thing on for you all? [Sara Teachout]: Put the tag out. [Chair Ginny Lyons]: Sure. Thank you. [Mike Fisher]: I love [Devin Green]: how you're in town service. [Sara Teachout]: I am. She's. [Chair Ginny Lyons]: Yeah. She's got no big voice. Excellent job. [Mike Fisher]: I count the same time you did. [Devin Green]: So total cost of care, we'd love to have a conversation about what happens within that patient services right now in that space. Global hospital budgets. Again, we support global hospital budgets. I noticed that you mentioned, Sharyn Lyons, that you would go forward regardless of the head model. We think that that is difficult. Oh, that's correct. Yeah. Because, you know, a a huge chunk of our patients are Medicare patients. And if we really wanna change services that we provide or Mhmm. Our health care delivery system, it's really difficult to change if our Medicare is gonna be on a fee for service because the fed the feds don't agree to what we're doing. They are pushing the head model, and commercial and Medicaid are something different. We'll see the buttons you can use today. [Chair Ginny Lyons]: Change pair of shoes. [Mike Fisher]: Yes. Yes. [Devin Green]: Yeah. We we just need a really substantial portion of our patient population to in order to change our behavior. GMC be GMC be regulatory duty. We're fine with the revised timeline. Our issue with that is that, you know, for a critical access hospital, it's about a hundred and twenty one thousand dollars to change the fiscal year timeline. It's probably more for larger hospitals, so it comes out to between one million and two million dollars. We would be it would be really helpful if the state could fund that one time change for the fiscal the fiscal calendar year. And so that's what we would ask so we don't add to administrative costs. [Chair Ginny Lyons]: And there are different basic ones. Mhmm. [Devin Green]: Yes. Implementing budget orders in a manner that's consistent with the approved strategic plans. Again, we are really concerned with the Green Mountain Care Board implementing a whole new process to improve a strategic plan. We're also concerned with the idea of them tying our budget to the strategic plans. And so we would definitely we can support that at this time. The reverse BON, I think with this first of all, I need to know how it works because the backlog was going out of business and doesn't have days cash on hand. Like, what is the how does it work in that process? And then, second, I do think it's worse before we build a bold process. I do think it's worth seeing if we're going ahead with, like, being ahead model because with global optimal budgets, it gives hospitals the opportunity to provide those lower cost services more or with lower reimbursed services more predictably, like birds birthing services. You can say, I have this amount of money, and I will you know, I can get rid of orthopedics and geobirthing services, that sort of thing. Ratios to of executive and other administrative salaries to clinical and other staff salaries, we don't support this because we already report this to the Green Mountain Care Board in terms of executive and clinical leadership. The GMC, we considers the salaries and the hospital salary spread and includes a comparison of median salaries for Northern New England. We feel like this adds more administrative cost and burden, especially because it adds the right now, we have executive and clinical leaders, which is fairly well defined. If we're talking about administrative salaries, that's, you know, collecting bills. That's also a lot of hybrid folks. So there are a lot of people working in hospitals who are both clinical and administrative and how do we handle those folks. So we feel that that is already covered under current law. The uniform system of accounts, we also do not support that because the revamp care board has adaptive, which has the ability to standardize hospital financial data, And they've used this approach in the past, so it feels like another layer of administrative cost to add on to the system and the tools that they already have. And, you know, as doctor Kane pointed out, we have a lot of data. It's just a matter [Sara Teachout]: of which questions. I think she [Chair Ginny Lyons]: was talking about audits. [Devin Green]: Yeah. In audits, but we have the financial data. She pointed out that, you know, we supply the financial data. [Chair Ginny Lyons]: The the standardization would be for hospital how hospitals analyze their their do their own do audits and standardize their own finances. So out of the Oliver Lyman report, well, it wasn't an audit. It was more how every hospital does the same thing for financial analysis. Right. [Devin Green]: And the adaptive program does that. So it has specific fields that the hospitals have to enter and then ways to adjust that to make sure that it's all standardized. [Chair Ginny Lyons]: With every other hospital in the state. [Devin Green]: That's my understanding. [Chair Ginny Lyons]: The [Devin Green]: single auditor piece, we also don't support that. Again, I'm excited with doctor Dean and how we do have the audits available and the data available, and you just need to ask the right questions. The payments for clinical services, normally, I would support this. I don't support it here because we're already pursuing all the possible payment options. [Chair Ginny Lyons]: Then it supports it. Then it supports [Devin Green]: it. But just because your work. Hospitals really need like, it would be very helpful to work with you in the direction that we're going in and to have something out there that's like, we picked a direction. We're going with a head and then but wait. There's this advisory committee out here and they could throw a different payment model at you and at any time. Mhmm. It's pretty deep table, I would think, for hospitals. So [Chair Ginny Lyons]: The the only difficulty with that is if it's happening out there, there's nothing that guides it in a statutory or rulemaking process, it can change out there, and then it's different. So looking for some continuity, I guess. So if there are suggestions here, that would be helpful. [Devin Green]: Yeah. And I think I'm with you. We are looking for continuity. Okay. We are looking for continuity and predictability. [Sara Teachout]: Continuity. And [Devin Green]: then the additional fifteen remit care board staff, we understand that this is a lot of work. We think and, you know, there are no numbers attached to it yet, so I can't totally speak to them. [Chair Ginny Lyons]: Yeah. But it's all good to repeat. Oh, awesome. Okay. But we [Devin Green]: you know, One Care is going away, and they have staff that works on One Care Certification. That, we've been told, is about nine hundred and fifty plus two million dollars that is freed up that I think that they could provide, dedicate those resources to this effort. They have the four point one million from f one sixty seven that they've been using for global hospital budgets and hospital transformation. And then we really just think given where we're at with primary care, you know, resources that would be going towards regulation should be going to primary care, in this moment, this next year. [Chair Ginny Lyons]: So if there are suggestions about how to move funding to primary care, that would be helpful. And then any of the other places where there might be some language that would help us align or be have continuity, that would help be helpful. I do understand your I think we we all we understand all your comments. It it's very helpful knowing that we may not end up exactly where you are, but we do wanna move forward in a way that everyone understands, but but, yeah, I appreciate you taking the time to do this. [Devin Green]: Yeah. Thank you. And, again, we'd love to come back and give you further detail with your results. [Chair Ginny Lyons]: The coming back part is gonna be quick. Okay. Right. So and I'll talk about that a little bit later. Great. Alright. [Devin Green]: Thank you. [Chair Ginny Lyons]: Thank you. And we have Jessupar here from VMS, from Mount Memphis Society. And, Claire, I see that you're here. Did you wanna be on the agenda? Okay. Well, we'd like to have you. Thanks. It's good to see you. But she can get me a copy of whatever we're working on for [Devin Green]: that [Chair Ginny Lyons]: bill. Yes. Yeah. Yeah. That's on her investigation. I know. Yeah. I just I'm Yes. Okay. Can you get her to help you then? That'd be great. Thank you. [Sara Teachout]: Good morning. Jessa Barnard. [Jessa Barnard]: I'm the executive director of the Vermont Medical Society representing physicians and physician assistants around the state. We've been both primary care and specialty care, so focusing a bit of my attention today on primary care in relationship to the bill. We know that one of [Chair Ginny Lyons]: the big goals of the bill [Jessa Barnard]: that we support is moving Vermont forward with achieving high quality and cost effective care. And that that goal is not possible without primary care services doing the screenings, the managing chronic conditions, keeping people out of the emergency department room. We know you get it. We know you Mhmm. You talk a lot about primary care. In fact, there was a primary care a fairly depressing scorecard released yesterday by the Mille Lake Mille Lake Fund highlighting how we have the United States as a whole have not been doing the needle on primary care investment in fact going in a wrong direction. That we are simply not investing what we should be in primary care, whether it's direct payments or workforce or moving away from fee for service towards paying for volume and whole patient care. I would say, Vermont has actually done more than probably I would argue even any other state in trying to move in that direction. So, I think we have some things to be proud of, between the blueprint and One Care's programs for primary care. So one thing, it's a little bit of a a little bit of a pivot from the heart of the bill in front of you. But I just have to to highlight the the gap we are facing in this year between the end of the all payer model and what we're moving towards, with the AHEAD model in twenty twenty seven. And so I as representing primary care, I I can't talk about hope reform without talking about these one year needs that we're facing because we we've been in a place of payment reform. We are moving to a place of federal payment reform, And yet we have this year in the middle of the gap where we could really lose primary care practices in the meantime and not have the foundation we need to build upon starting in twenty twenty seven. So in our view, any plan to support primary care needs to address that really gaping funding and programmatic hold for twenty twenty six. So I just to be about forty five minutes upstairs, I will not take forty five minutes, but I'll just name some of the gaps we are facing for twenty twenty six. The details are in my testimony. But OneCare, again, with that whatever feelings you have about OneCare, one thing it has successfully done is merge Medicaid, Medicare, commercial payments, hospital payments into sort of combined payments for primary care services and really supported primary care over the past five years. Can I talk from here? Because I I [Chair Ginny Lyons]: you may be gonna talk about it, but I'll just throw it out because I think others may wanna comment on it as well. And one thing that we've heard that One Care has done is to build a a basis for quality metric analysis through payment system. So we'll just leave that right there. Yes. Yep. I can address that briefly as well. So the [Jessa Barnard]: two programs that we're we're looking at that they really use to fund primary care, there's a population health model program that's every practice that every primary care practice and non non what we might think of as traditional primary care practices also have received funding through this program. So the some from health agencies, designated agencies can also receive these payments. And that there's a base payment and a bonus payment under that program. And then there's the independent practice, prospective payment program. So a a monthly payment and it'd be, for services and then also, some truing up at the end of the year. That's the comprehensive payment reform program. Nineteen independent primary care practices currently participate in that, and it's been a lifeline to these practices. Two or [Chair Ginny Lyons]: three years to come. What's that? Four years ago. [Jessa Barnard]: Well, so so this is actually separate from Oh, this is separate. This is separate from who this is a one care one care program. The comp it's called the CPR program. Right. So, there's actually a five point five million dollar gap, that our loss for twenty twenty state fiscal year twenty twenty six until we get to ahead for these programs that has no that is not currently in the governor's proposed budget. So no no real plan to fill that that hole. There will also be, until we're in ahead, the loss of Medicare's contributions to the Blueprint for Health program. That's the community health teams, the sort of on the ground care managers, community health workers, the direct patient payments to patient centered medical homes, primary care practices, and the SAS program. That's ten point eight million dollars in lost payments and that is there is the state component of that built into the governor's recommended budget and we support keeping [Chair Ginny Lyons]: that [Jessa Barnard]: in the budget. And Medicare has said they will pick this payment back up when we are in the ahead model. So this is a big gap to where in the ahead. There's also going to be a need for primary care practices to and all practices actually that were in One Care to implement what's called MIPS. This is a Medicare quality reporting program that has some bonus payments if you do well, also quite significant penalties if you don't meet their, benchmarks. And practices in Vermont have been exempt from this program because of participating if they have participated in One Care. With One Care going away, that exemption goes away. There are conversations with CMS about whether there would be continued exemptions when we're back in ahead, but we know for sure that it's gone for twenty twenty six. So that is gonna be a big lift for practices. The blueprint and AHS have indicated that they are will be working to help practices learn what it means to comply. It is very costly and burdensome. And I think, Senator Lyons, this is what you were, part of relates to what you were commenting on with quality measures, that there has been a lot of work to align, what the ACO requires, what the blueprint requires, sort of what quality measures, primary care practices have to report. We hope MIPS somewhat aligns with that, but we report. We hope MIPS somewhat aligns with that, but we really have not done that analysis yet. It will require specifically, electronically reporting quality data out of electronic health record. That's gonna so so those components will all have to be set up for practices if they aren't already. You've heard, I think, from AHS how they are working with the rural health redesign center to help move transformation efforts forward. There is a hospital component they are supporting. There is also a primary care component they are supporting. So we are really and we're actually meeting with them soon. And one of our big asks will be can they help practices come into compliance with this? So then there is also the loss of the pilot expansion program that you heard a great presentation from doctor John Soran in the last week maybe or the week before about what how the expansion has been working. We think it's been successful in increasing screenings and increasing community health team workers, staff on the ground to help support primary care. The governor recommended budget allows carryover funding for the pilot for a third year but no new funding. And it is unclear to us at this point if there actually is any carryover funding available. That's invested over ten million dollars in state and federal funds per year to support that right here. There's a sunset for a medical student incentive scholarship program that we'll be hitting in twenty twenty seven. That's also been a really important program to get primary care providers back in the state and staying in the state for this. And there's a family medicine residency program getting off the ground to train, family medicine trainees. So the so the point of bringing up all these gaps is to say there's a lot happening. There's a lot that needs to happen in primary care in terms of big transformation efforts. If we can't get to twenty twenty seven, we're not gonna be able to do big transformation. We're we're losing our foundation before we even get to the what would we like to do better. Mhmm. So I I really implore the committee to find you know, to to help us, get our our base strong, and then and then look at what can we do. We we are optimistic, if we move to a head, that includes a seventeen dollar per Medicare beneficiary per month payment to primary care practices. Setting PDFs aside, which will largely not benefit from that program, and there may be other ways to strengthen that program, that at least would help stabilize some of these payments as well as continuing our blueprint payments. So we hope some of these, again, base supports could be built into any bill looking at payment reform or health reform because without primary care, we can't do that work. Specific to the bill, moving beyond twenty twenty six, we do support thoughtful, creative, forward thinking planning. We really you know, we know it's important to highlight the and I just did this, highlight the challenges facing our health care system in Vermont. I also hope we can sort of recognize and build off of our history of innovative approaches and and frame this with some positivity. And then I I'm really worried about our workforce and that the the continuing emphasis on sort of being in crisis. We're actually hearing already of physicians turning down jobs in Vermont, thinking that their worksite is not gonna exist in another year or two. And I think we're moving we're we're sort of putting ourselves in an even worse position by sort of only focusing on what's not going well and not having some optimism that we can make our health care system a great place to be a patient and a clinician. We think there is a lot of good work going on. The Act one hundred and sixty seven report has led to some really important transformation work already underway with hospitals, primary care, and community being led now by ATS and the Rural Health Redesign Center. We think that could you know, they're really I think we'll be hopeful on the ground listening to what could help hospitals and primary care be stronger. We wanna support that work. We wanna align that work with any future, sort of directions. And as far as every we are no, we are on the path towards ahead in twenty twenty seven and we want to make sure those efforts are coordinated and aligned with anything proposed in the bill. So some specific feedback related to the outline. Week Part one would be the planning. We do support one integrated vision for the future of Vermont's healthcare system being informed both by AHS and the Green Mountain Care Board. We do think AHS's involvement is critical given their broad role with much of the healthcare system outside of hospitals. And we would like some additional clarity regarding how that planning would differ or build on feasibility planning already led by AHS's Office of Healthcare Reform to evaluate around the patients and then I'll rewind and report and align with transformation we're already moving forward. Part two of the stakeholder group, we we strongly support input from the healthcare community, especially practicing healthcare professionals regarding the future of our healthcare system. That is one thing, you know, we we try to help be that voice of the practicing healthcare professionals, but they have so much knowledge and offer could bring so much opportunity to the table of ways to be more efficient to improve our practices. They want to be part of the solution. And so we would strongly support including some Vermont practicing clinicians in any future work and aligning with a transformation advisory group already being formed by the Office of Healthcare at Vermont. Some questions on part four. We are there was a reference to feasibility implementing reference based pricing for non hospital services. We were not entirely clear if [Chair Ginny Lyons]: this was for outpatient [Jessa Barnard]: hospital services or services happening completely outside of a hospital and what range of services that can include. Are we talking about independent medical practices like primary care and specialty care practices? Does it go as broad as dental, dental health services? And how would that information be gathered regarding their existing rates? What benchmark would we set it to? We just had a lot of, sort of, unknowns about that section and whether that could help or or, availability of services. We do strongly support a primary care spend target that is in the bill. That is also a part of the MHED model. It is required under the MHED model. We've testified in more length, regarding our support for that, last year on on s one fifty one. So I won't repeat all the reasons, but we do think having an an investment target for how we start shifting dollars to primary care is important. [Mike Fisher]: Mhmm. [Jessa Barnard]: We would actually love to see the the target be even more aggressive under the AHEAD model, Medicare's agreement in our in our agreement with the with CMMI is actually quite modest and that we we would love to see in further direction. Under the the reference to payment for clinical services, we were just I guess we'll echo Vaz's testimony. We were a little unclear what other options there was even in mind beyond reference based pricing, global budgets, total cost of care already in reference. So, it left sort of some concern about, what that might mean. And then I will say we we also share our concern about investing significantly in additional policy and regulatory staffing when direct services are struggling so much day to day. We have practices consolidating locations, leading rural communities in Vermont. You know, the most reason being Memorial Health Partners in Stowe, leaving that community, really unserved at the moment. And so we really ask the legislature to first to first direct any available funding to care delivery rather than any additional regulatory infrastructure and then look to redeploying staff and funding that's already being used to oversee the all payer model. As, you know, I just I I really feel like from on behalf of my members, I have to say they are they are under such stress. They are trying to be so efficient to do more with less every single day. And I think it's fair to ask the same of our regulatory bodies. So So thank you for listening for our feedback and forward to working on [Chair Ginny Lyons]: Thank you. This this is really very helpful. Well, thank you very much. Thank you. So we're gonna just keep going to Fed. I I feel, you know, sometimes you feel the weight of that clock on your shoulders. Mhmm. Those days. Yep. So, Sarah, go to the mouth. Thank you. And I will send you written testimony now. [Sara Teachout]: Okay. From my notes. Okay. Pull it all together. So I just wanna start out. Sarah Teachout with Blue Cross and Blue Shield of Vermont. I really do appreciate the chair sharing her ideas in alpine form. From my perspective, this is an easier way to respond. But the details matter. And so Right. You know, these are our comments on your concepts and the big picture. I'd also like to say that this is an ambitious plan. You weren't you weren't holding back, so we know it. Our health care dollars are a precious resource, and we really need to balance our investment in planning and health care reform efforts and the money that goes to direct patient care. So I think I am echoing a little bit of what I've heard from our provider community. We are a small rural state that by definition is inefficient at scale. Because of this, we must ruthlessly prioritize our investments. We also need to focus on what can be done quickly to make a real difference. So I'm gonna talk really quickly about your delivery plan and evaluation of the delivery plan. And I guess I wasn't gonna get into all the details, but is this the most streamlined approach while also meeting our goals of timely, transparent transparent evaluation and being open to feedback. So it just it's pretty exhausted. [Chair Ginny Lyons]: So if we can get the exhaustion on our web page, that would help. And if you can give us some bullets. Okay. [Sara Teachout]: The way others should have, that would be great. Okay. So I'm gonna jump really to the the database integration piece because this is something we've spoken about a number of times, And we have very strong opinions on combining vCures specifically with the vital database. I appreciate the efforts to create a uniform HIE so that providers have the information they make they need to make clinical decisions. But integrating vCures is a separate project that's more for research and evaluation. And we feel like there are too many flaws in that database for it [Chair Ginny Lyons]: to be [Sara Teachout]: useful and worth the investment that it will require. So just to jump at a few of the issues, and I have quite a bit here. So the this would require the significant investment of dollars to create a database for research purposes alone when there are so many other dire needs related to health care the delivery of health care services. And there are so many limitations in the data. So you heard from others, the Medicare data cannot be combined with any other data. So that's about a third of our population whose data can't be included. The commercial data, it's pretty lacking as well. We've seen a decline in the number of commercial payers who won't be included in the database. And so there's that. There's also some legal and governance issues with the data. I've just taken the high level ones, and I'll include more of this in the other stuff. But the two databases treat mental health and substance abuse data differently. There's also, data on abortion and gender affirming care that is sensitive and inconsistent in its treatment, in the different databases. There's a lot of human and financial resources that it takes to maintain, these types of databases. And we really think we again, that's when I say ruthlessly prioritize. Is this our top priority for how to spend our health care dollars? And then we always come back to privacy issues. This is a pretty significant database, and it would be a target for, you know, actors who want to compromise data in the health care space. It's something we're all worried about across the system. So those are the really high level concerns on on that part of the database. So I think you could do pieces of what you're suggesting here, but we really think that the Medicurus data is not as useful. I'll just conclude it by saying that all the projects that we've been involved in doing research for, say, the the head model, we've had to separately provide data to the to the researchers doing it because that vCures database is not useful. So I'll return to the next thing we have here, which is reference [Chair Ginny Lyons]: based pricing. So clinical clinical database clinical information is clinical information regardless of its source, payer source. So why not have it available for making decisions about patient care overall? Yeah. I mean, really, that's the goal. [Sara Teachout]: Yeah. I understand your goal. Totally audible. There's not much in a claim that gives you clinical information. It really depend it's a lot of coding, and it doesn't you know, even when we wanna research what actually happened in an appointment with a patient, we need to go to the medical record. The claim doesn't tell us enough about what happened. And I did did hear the concern that you don't know if a patient took a medication, but that's one thing that the Yeah. That's correct. The vCares database could add. All it tells you, though, is that they went and purchased it. It still doesn't tell you whether they actually Yeah. Adhered to their, you know, medication schedule. So the other thing is that Always try. Really full. We've tried. We've tried. We've tried. I appreciate you trying. And as someone who loves to do research and use great databases, like, I completely understand the goals here. So reference based pricing, we [Chair Ginny Lyons]: Blue Cross [Sara Teachout]: and Blue Shield of Vermont supports the effort to to do reference based pricing with some conditions. We really do I think you have it in here, but we really do believe it needs to apply to all commercial payers and can't favor some employer groups for Vermonters over others. We need to allow one entity, and I think you have the Green Mountain Care Board here doing it, design the reference based pricing system. We think that's really important. I did listen to the testimony from Montana, and we really don't want employers designing their own systems. I think that would create more confusion in our health care system and rather than simplification. And we also really believe that it should be phased in. It's a pretty big project, and we should start. This is a pretty the way that it's in here, if you have it applied to pretty much everything right away, probably the recommendation even with all of our Wyman was to not start even with all hospitals, but start with some. We would also recommend starting with some services, things that really should be equal across systems and are a little bit slower to evaluate. So recommending things like lab work, imaging, drug prices, you know, stuff work. The drug you buy or the MRI you get should really be the same in any facility. So I'm moving quickly. I'm trying. [Chair Ginny Lyons]: When can I move? Go ahead. Can I yeah? It's helpful. [Sara Teachout]: So in the hospital budget section and we're supporting total cost of care. But then when I get into the global hospital budgets, we really need the incentives within the hospital to align with our health care reform incentives. And so we have concerns about payers paying providers in a way that incentives them for additional revenue generation and a fee for service model. We really need to align the incentives within the hospital to the incentives we are trying to do as a health care system. And then one piece I'm gonna call out in your I think I'll jump into oh, we really need hospitals to manage their annual budget manage to their annual budget, and we can't have significant overages in parallel our system. If hospitals are generating more revenue because they are truly increasing access, then they have to have then they have the opportunity to gain efficiencies and reduce prices without impacting patient care. Here. So huge profits are unacceptable in a largely not for profit health care system. And I'm I'm down here under budgets, regulatory duties. I'm a little off topic. [Chair Ginny Lyons]: So if you have specific comments, yeah, that would be good or maybe Okay. [Devin Green]: Well, we think that this [Sara Teachout]: could be included in the Green Mountain Care Board regulatory duties. What we've seen a lot is hospitals asking for increases so that they can maintain very high bond ratings. And we don't think that Wall Street bond ratings should be dictating the choices here in Vermont about a hospital expenditure. How much are we charging in premiums to achieve honest interest in bond savings? [Chair Ginny Lyons]: Six a bond rating here, destroy a bond rating there. [Sara Teachout]: Oh, there and I'll I'll attach in in my written comments. There's some articles about this issue by Hoffman Paul. They have insights in an article, ratings matter, talking about credit credit ratings driving financial decisions in not for profit hospitals. [Chair Ginny Lyons]: Go ahead. Send it. Please. I'll put it up. Okay. I'm glad you read it. [Sara Teachout]: So that's great. So we just think some of our health care systems priorities are out of sync with the state's goals of affordable accessible care, which is what you're trying to do here. And that's why I'm bringing it up. [Devin Green]: On the global hospital budget, so I'll [Sara Teachout]: jump ahead to that one. Without Medicare participation and CMMI financial support, we're not sure that the AHEAD model still makes sense for Vermont. I think exploring what we can do with global hospital budgets, but maybe in a much more simplified form than the sort of grand vision behind the AHEAD model. Or maybe making this in your prioritization list of things to do, lower priority amongst all the efforts you wanna make here. You know, all of these things require significant investments. The CMMI was gonna provide some offsets on the provider side. So on the payer side, it's just premiums increase to make all of these changes in our systems. And and so we just really, really do need to think about how we're investing our resources into it. Right. I'm still on Green Mountain Care Board regulatory duties, I guess. The one piece that I would call out is you have a a line that says, deep in hospital services result in decreased health insurance premiums. So I think we would all love that, but this is very limited in prescriptive view and doesn't allow the Green Mountain Care Board any flexibility in decision making. It also only assumes that you know, reducing service lines will actually reduce costs. I would say that the Green Mountain Care Board tries within its regulatory process to link hospital budgets to health insurance rates as tightly as possible. You know, as you know right now, pay insured they improve the rates first and then try and line the budgets up, and that's not optimal, which is one of the things you have here. This tightly regulating only works if hospitals stick to the approved budgets. And practice when the hospitals have gone over the budgets, they've the additional claims of drained member reserves of Blue Cross and Blue Shield are not impacting self funded plans like BEI. So if you add language like this, you need reverse language so that if it goes the other way, you can also make And and you'll give us some [Chair Ginny Lyons]: of your recommendations for that. Sure. [Sara Teachout]: You know, some other examples of things that the Green Mountain Care Board has urged us to do if there's any room between the hospital budget and the premium is to make investments in primary care, which is one thing we've done. So that would preclude that as a choice. So I I think it's too I guess I'll say, I can offer suggestions, but we think it's actually too restrictive and it doesn't allow the Green Mountain Care Board to make the decisions, you know, the latitude in making decisions across the whole system, which would be ensure solvency, investments in primary care, you know, and and the ability to adjust when things aren't going the direction they think they go in. As well as quick comment on the reverse CON and the hospital service lines. To date, we haven't offered any comments on the certificate of need process, but it doesn't capture some of the major investments hospitals make in new service lines because it's so focused on equipment. It's equipment heavy. And so one of the most important decisions is how much the care is going to cost patients, not only the investment in the service. And then are we providing this care in the most efficient manner possible? So I think those would be the questions not only on the reverse COM, but on the things that you're adding. Two recent examples are the tear surgery I read about in today's news. [Chair Ginny Lyons]: I haven't read it yet. Well, I'm thinking about the time. [Sara Teachout]: Okay. I'm almost done. Do you [Chair Ginny Lyons]: have the tearjerker in your testimony? No. Look at it in the news. [Sara Teachout]: Okay. Look at it in the news. Tear surgery and CAR T are two things that are incredible developments for just a handful of patients, and the costs are extraordinary. So we really do need to think holistically about what we're adding to service lines. And then one thing I'm gonna recommend is that you elevate health insurer solvency in the DFR in the Green Mountain Care Board regulatory duties. So I'll make a recommendation there for that. And then the last thing on audits, I listened attentively to your the the testimony on audits. What is recommended here goes beyond, I believe, what Oliver Wyman and the experts recommended. I think they do recommend aligning the type of audits and the type of data reported to the Green Mountain Care Board. We can make just as much sense for consistency, but this seems to add a whole another layer of audits that Yeah. [Devin Green]: Seems to be [Chair Ginny Lyons]: We heard that, and we heard that from the experts. Experts. [Sara Teachout]: Great. Yeah. So I made it to the end, and I appreciate you listening. [Chair Ginny Lyons]: This is great. And but we do need your [Sara Teachout]: I will write it down. I have it written down [Chair Ginny Lyons]: for you. And I'll go ahead and ask you to ask that anyone who has testimony for this get on our web page by the middle of the end of the day before before four o'clock. Okay. [Devin Green]: Thank you. Press. [Chair Ginny Lyons]: Okay. Welcome. [Mike Fisher]: Welcome. I know. Mike Fisher have part benefits, and you guys are getting a raft of stuff. I mean, interesting stuff. I just wanna Keep going. Okay. Take some breath. [Chair Ginny Lyons]: You're not being deserted. I am. Sorry. [Mike Fisher]: So my fish will pop. So I I think I can kinda be so apparently, Well, I'm so sorry. So so from the health care advocates perspective, it's one thing you do on this list is reference based pricing. And the the board already has a provider rate setting authority and giving them a directive to plan and do it and do it well and implement it, we think, makes sense. Like others have said, take plans that require a good federal partner off the list. We don't think it's hard for me to fathom a world in which a plan a a payment reform plan that has the word equity in its title is going to live in, going forward? [Chair Ginny Lyons]: I think people don't realize that the e in the head is equity. [Mike Fisher]: The e in the head is is equity. That was exactly what I was gonna say. Where are you? I I just, so keep a little bit. Imagine that that has any viability, and I don't think global hospital budgets works without like others have said, with the community Federal. Without without without being truly global. And without Medicare, it is not global. And and we agree, focus on creating a master plan. There are a lot of plans out there, a draft, the the state health improvement improvement plan, the community health needs assessment, the act one sixty sixty seven process. All of these are good and important in their own ways. But creating a master plan that has real teeth, measurable outcomes with a clear method of evaluation with enforcement if goals have not met makes sense. So that's just the high level takeaway. I'll go into a little bit more detail. Like Blue Cross just expressed, we have real concern about the prospect of using claims data in a clinical setting. Clinical data needs to be accurate and current. Claims data is neither of those things. And so and and I, you know, I recognize that oh, I missed a section to that. I recognize that that there is an effort right now in AHS to measure, to test out whether Medicaid claims data could be useful in a clinical setting. And Yeah. Curious to see how whether that tests out with any usefulness. So I like others have said, I I lost some real information. But I wanna remind us that even if that proves to be useful in a Medicaid setting [Chair Ginny Lyons]: It may not be useful enough. [Mike Fisher]: Medicaid is complete. The dataset is complete. Commercial is anything but complete. And so even that test isn't gonna inform completely whether it makes sense. As I said earlier, reference based pricing, we think, is is an important step forward system wide. Like others have said, it's done carefully and and and that sort of in a in a careful fashion. We can't break things here. [Chair Ginny Lyons]: Mhmm. [Mike Fisher]: We have to do it right. My biggest fear at this moment is not just that we can't afford the system, the the cost of the care that we're providing right now. My My concern right now is that we're not paying for the care that we're giving right now, leading to insolvency everywhere we look. [Speaker 5 ]: So [Chair Ginny Lyons]: That's ultimately what the crisis is. Is it [Mike Fisher]: Yes. [Chair Ginny Lyons]: Why we're doing [Mike Fisher]: And so and so and and the subset of that, we support primary care spend targeting like others have said. I wanna talk for a minute about the timing of rate review and hospital budgets. Every year at about three quarters or of the way through rate review, hospitals submit their budgets. And and the carrier said, wow. That's is proposed to go up more than we expected, and so we need to increase our rates. And so it it's not ideal the way we're doing it, but I wanna recognize that there's arguments on both sides. As long as the board lives up to its commitment about how much of the hospital budget requests they're going to grant. If if they don't do that, and they have done that the last couple of years, but if they don't do that, then they have just approved insufficient rates. As long as the hospital lives up to that, the rate review process is like what happens in the finance committee. Here's how much we can raise. And then the hospital budget process is like what happens in the Appropriations Committee. Here's where those precious dollars are gonna go in the hospital system. And so I know probably, I know that in this building, there's often a discussion of, you know, know, should the appropriation committee go first or should the finance [Chair Ginny Lyons]: Right. [Mike Fisher]: Committee go first. Ultimately, they do have to go together. And so there is a certain as much as it's baffling and confusing to people, there's a certain sense to me that's deciding, you know what? Here's what we think consumers can afford in rate increases. I have to pause on that because I think we all recognize that consumers can't afford. But there is some sense to that. It's it's not a slam dunk for these things, what I need to say. And then really briefly, we support the giving the board the authority to approve reductions to services. I know that's been framed as a reverse CLN. That makes sense to me much more as a hospital budget exercise than a CLN exercise, but we support the concept. I wanna reference s sixty three on your wall has a a provision in that that we think it's vitally important that the board has the authority to enforce hospital budgets? [Chair Ginny Lyons]: You're talking about a sixty three. [Mike Fisher]: A sixty three? Yeah. [Chair Ginny Lyons]: We're we're gonna try and do something with that. [Mike Fisher]: We think that's important. Yeah. And then I know there's been a lot of discussion about audits. I think one thing that hasn't been discussed much here is the concept of a claims audit. What exactly is going on with the increase in claims at certain hospitals? Tracking utilization? Well, it is it this is what we need to measure. Is it utilize is it more equal data care? Is it them being actually sicker, or are hospitals doing a better job of generating claims for the exact same care? I don't know how to answer that question without an audit, and that's something that I think is is missing. And then I can't resist. I I I was gonna say the HCA supports elevating affordability in the rate perfume process in response to Blue Cross. Currently, the board has this, you know, very difficult task of balancing in a basic way affordability and solvency. And they are, in our minds, equal footing. And I know that's tough. I know that's hard on the carriers. I know that's hard on the board, but I don't support moving solvency. We need solvent. You've heard me, and I've been public. We need solid insurance companies, and we need affordable plans. The two, in my mind, are equally important. Lastly, I think it's important. I appreciate your efforts to make sure the Green Mountain Care Coordination has many sources to do the work we're asking you to do. Good. [Chair Ginny Lyons]: Thank you for saying that. Yeah. Thank you. And we'll get your written text. Yes. Terrific. Perfect. Okay. So I know we have I we've added both Susan Risen and Mary Kate Morman. Came in and said, can we speak to this? And we put them on, and I haven't seen the door open yet for the recovery folks. So is Susan Risen on the screen? There she goes. There you are. So, Susan and what I'm gonna ask both you and Mary Kate to do is to speak very shortly, but submit your written testimony, and then we will also try to find time to get you back in so we have so we can hear you say what you wanna say. But let's see. [Mike Fisher]: Let's see [Chair Ginny Lyons]: how we can do. [Susan Ritzen]: Okay. Thank you, madam chair. For the record, my name is Susan Ritson. I'm the executive director of Vermont Health First. We're an independent practice association that represents sixty two specialty care and primary care practices across the state. And I just wanna say I appreciate that the committee is considering the many important concepts in this outline as we all work to improve Vermont's serious issues. Many of my comments align very closely with Jessa Barnard's. And I'll just say first out, I agree wholeheartedly with her statement about we really need to make sure the foundation of primary care is properly supported, particularly in this gap year of twenty twenty six where there's gonna be a huge funding gap. I'm very concerned for our primary care practices for this. They've been most of our primary care practices did participate or do participate in the one care all payer model, and and it's really helped to stabilize them and support them. And I'm really worried about, them becoming destabilized and and potentially closing, like we saw before that support was available. So echo strongly echo, Jessa's words around that. I've agreed with many of the other things being said today. Just in really, generally, things that we support in this outline is just the intent to have a cohesive statewide plan. I think that makes a lot of sense. There's a lot of different information out there with act one sixty seven and, other, you know, data sources and agree that makes sense to, you know, look at it globally, across the system. Also, really strongly support the inclusion of an ongoing evaluation process that this outline speaks to. I think that's really important. As well as optimizing the use of data, and I hear what others are saying about the limitations of the data, and I think that's always going to exist. Working towards something, though, that optimizes the data available as long as we understand the limitations of it, I think, you know, is is a goal worth, aiming for. But I would caution, you know, any anything that's, involving health care providers, if it could be, you know, not adding additional administrative burden or cost, that would be important. Agree with the intention attention to controlling cost of care, especially hospital you know, assessing and looking that at that in a standardized manner. You know, the reference based pricing, I think, you know, our organization doesn't have a a firm policy statement on this. I think, you know, philosophically, we can get behind the concept to a certain degree, but the devil would be in the details and we'd you know, particularly if independent practices and facilities would be included in that, we would wanna be part of that conversation and And then also strongly support, the investment, targets, having investment targets for primary care and preventive care. Let's see. The thing that was less clear to us in this outline is just who would ultimately be leading this effort. It does seem like it's a Greenmount Care Board and AHS combo, which is sort of what we're doing now. But what would this advisory committee be doing? Would they ultimately be the leaders? And how does that align, or is it analogous to the division of planning and effectiveness that's outlined in act one sixty seven? And we just advocate for whatever that looks like that it'd be inclusive of, you know, the various stakeholders and health care providers. And just appreciate you continuing to consider the impact of any of these policies on independent practices and other nonhospital entities. It does seem like you you're doing that here. And then I know there's been some talk about this, just the alignment with ahead and just making sure that if if that model does move forward, that whatever language makes it into the bill, you know, aligns appropriately with that. And I'll leave it with that, and I can put my thoughts in writing and share that with the committee. [Chair Ginny Lyons]: Thank you. [Mike Fisher]: That was [Chair Ginny Lyons]: very helpful and greatly appreciated. So please do send in to Kiki ASAP. It it's really important to us over the next week to couple weeks with us. Thank you. [Susan Ritzen]: Okay. Thanks for the opportunity. Appreciate it. [Chair Ginny Lyons]: Alright. And I know we'll probably see you again. So I hope so. Yeah. Mary Kate, you're here, and we've got exactly six minutes. So Challenge accepted. The challenge is there. I know. And we everyone early on got more time, and so and I added you late. So, originally, it was fewer people. Here we go. Typical. Right? No. Slate of time. [Speaker 5 ]: For the record, Mary Keith Mollman, director of Vermont Public Policy at Bi State Primary Care Association. We support our members, the federally qualified health centers, Vermont Frame and Grow Clinics, and Planned Parenthood of Northern Illinois lives. Our mission as Biaseda and also with the federally qualified health centers and and our other members really is to serve as safety net providers, to those who have the greatest barriers to care. And a lot of our mission is to reduce those barriers. FQHCs are required to see anyone regardless of their ability to pay or their insurance status. Looking at this, this outline, I think we we wanna learn more about the the details in it, but just broadly, we will say that Vermont's best to build out of resources to better understand the state of our health care system. And I think, well, especially with the ending of the Vermont own payer model. And this investigation has highlighted severe financial fragility across many sectors of the health care system, including our members. Federally qualified health centers are extremely financially fragile right now. So in that, as we consider our next steps in health care reform through the act one sixty seven, this outlined, we really wanna make sure that the focus is on access to Vermonters. As safety net providers, that is that is our fundamental priority in making sure Vermonters have access to the care they need. So this would include the resources, for primary and preventive care. I would echo Susan. I think that you hear Justice, but I based on what I've heard that I'm echoing Justice comments about making sure we are investing in our primary care. I would also add that our system is so intricately interconnected and so maintaining that access to that higher acuity and specialty care is also really important without one Mhmm. Put too much stress on the other. And it goes really both ways. Right? So it's it's making sure that whatever we do going forward, we're not we're being very mindful of unintended consequences and, you know, not just playing a game of whack a mole with where we have investments and where we're spending our money. And so I think at this point, we would just we look forward to seeing more details emerging and working with our partners, and and thank you for your consideration. [Chair Ginny Lyons]: Well, thank you. And so the request is something in writing Yep. And details help. So each person who has testified today, any any details that can help inform our work will be useful. Yep. Not that we'll accept everything that we see, but knowing what the differences are is is critically important. Yep. Yeah. Because there's a lot of agreement. It's sort of the broad agreement, but That was Then the devil gets there. Yeah. Yeah. So thank you. Thank you everyone for for your work on this. We are very serious about moving forward what we can on all of the bill, but there'll be pieces that change, obviously. And some of the we've already identified some things that need to be modified, and you've identified those as well. We have the folks from the recovery centers coming in for recovery day, and senator Gulick is gonna take over. While we do that, you're going to a meeting. I need you. Yeah. So but thank you. And just to say this committee Thank you. Guys. But you know what? He'll be back. You know? Hold on. Just to say this. Here's your assignment. Hey. So let's throw up. You wanna close on the door?

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