Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: And welcome back, it's afternoon, January 8. Thank you incorporating the date on the thing so I didn't have to

[Leslie Goldman (Member)]: look somewhere else. And

[Alyssa Black (Chair)]: this afternoon we're starting with Green Mountain Care Board and Emily Brown and Cher Foster to update us on what's going on. Impacts of all that big long list that Jen brought this through yesterday.

[Emily Brown (Executive Director, Green Mountain Care Board)]: So good afternoon. My name is Emily Brown. I'm the executive director Green Mountain Care Board.

[Owen Foster (Chair, Green Mountain Care Board)]: And my name is Owen Foster, and I'm the chair of Green Mountain Care Board. It's nice to see you all.

[Emily Brown (Executive Director, Green Mountain Care Board)]: So I know I've been in this committee before, but I believe there are some new members. So I thought it would be helpful in our slides to do a quick introduction to the board and who we are. Next slide. So, the Green Mountain Care Board was established in 2011. It's a five member independent board. Each board member has a six year term that are staggered. We are independent, meaning, we are not under the administration. We are an independent board with a chair, and as I said, for other members. And we are quasi judicial. Nice pictures of our other board members up here. Next slide. So we always like to circle back to our mission, which is what drives our work. So our goals are to improve access, affordability and quality of health care. So whenever we're exercising our regulatory functions, those are areas of focus on what we're concentrating on in our decision making. We regulate major areas of Vermont's healthcare system. So those include hospital budgets. We also oversee major medical rate setting. We assess in Vermont as well. And any area I'm missing there? Next slide. So this job, just as I said, what we actually regulate. So as all of you know, the health care system and health insurance system in the state is very large. The Green Mountain Care Board has specific direct regulation over a subsection of that. So as I said, rate reviews, certificate of need, hospital budgets, and the ACO oversight and certification. Next slide. So this

[Owen Foster (Chair, Green Mountain Care Board)]: is really important because I think people do often conflate what we do and what we don't do, and they think that we do all things health care. So last year, there were really high rate requests from the insurance companies, and we were able to drive it down by really leaning harder on the hospital finances, most particularly the University of Vermont Health Network. But without regulatory authority over all these other parts, there's all this other spending that happens that goes into insurance rates. If you actually look at an insurance rate, which we talk about later, so much of it has nothing to do with anything where we have a regulatory authority. So our ability to get rates down is really limited, and it's really focused particularly on hospitals, which are also financially strained. And I'll provide an overview of the landscape of where we are. First, nationally, we're seeing hospital closures really across the entire country. There's been 195 closures since 2005, and this slide is a little bit dated, so there's probably been a few more. And here in Vermont, we've had no closures yet, although we are seeing an increase in service line closures. We've seen service line changes at Copley Hospital with closing of birthing. We've seen a proposal to close inpatient pediatrics at Rutland. We saw inpatient psych, primary care, and some other services at the University of Vermont Health Network. So finances get strained, hospitals try to preserve their reserves and their margin, and they generally go low margin services first. Those are the services where they lose money providing it. Not every service makes money. Some services make tons of money. Last year, was a bill on the drug price cap. Hospitals make a ton of money, or were making a ton of money on outpatient drugs, but on inpatient psych, they tend to lose money. That's one of the fundamental failures in our and the nation's healthcare system, is we don't pay properly for the services that we actually want. So you have this really wild dynamic that's creating loss of really important services across the system. We do think that service line closures will probably accelerate in the next twelve to twenty four months. Next slide. This is one of the more troubling aspects in our health care system, and it is the affordability of health care. It was spoken about a lot last year in this committee, and it should remain a focus. On the qualified health plans, which are the only health plans that the care board regulates, Vermont has the highest cost in The United States premiums for families. And it's between $50,000 to $60,000 a year for a family of four to have platinum insurance premiums. And even for a bronze or gold plan, you're still looking $40,000 a year ish, depending on what plan you get for a family of four, which plainly very, very few Vermont families can afford. That problem is really going to hit home this year as we lose subsidies on the individual market. They have expired, it does not appear that there'll be any sort of extension, and I think 27,000 out of 30,000 Vermonters got subsidies. The subsidy stated was instead of paying $60,000, a family might be paying 20 or 25. All of that savings that they have from subsidies are now gone, which means they're gonna pay the full sticker price. That has huge ramifications for people's ability to get health care because they're not gonna have insurance anymore. And then second, it will impact their health care as they just they just don't get the health care that they need right away as they're uninsured. And it will have pretty deep ripple effects across the health system. People who don't have insurance, they're now not getting care, or they're not being able to pay for the care when they do go, hospitals, bad debt and free care goes up, and that further strains their finances. Really, what that means is if you look at the last three, four years, the amount of bad debt hospitals carry is spiking pretty significantly, and it will now spike even greater. When they lose money on services, they have to eat into the reserves. So this death spiral we've been talking about for a couple of years now will be challenged further now that these subsidies have expired.

[Alyssa Black (Chair)]: Before we go on to the next slide, just ask a philosophical question, I guess, because I'm always struck by this slide. We were doing okay. Do you think that it was anything that Vermont specifically did beginning in 2018 that did this to us? Or do you think we're kind of the canaries in the coal mine and it just hit us faster and quicker? I'm just trying to figure out what the heck happened in 2018.

[Owen Foster (Chair, Green Mountain Care Board)]: So there's a couple of different things. One, I do think that we are a little bit of a canary in the coal mine. We look at last year's health insurance premiums. Vermont, we should actually be very proud of it, we had the second lowest premium increases in the country last year. Really, we're fiftieth out of 51 states in the District Of Columbia. So other states, I think national average, it's around 20% increases. So a whole lot of states were making up a lot of ground on us last year. So we were a little bit ahead of the curve. I have to speculate a little. There's not really a hard, clear study that gives you the answer on this. I do think the all pair model caused some problems. This was around when we started the all pair model. It was very expensive, it cost a lot of money and it didn't work. We never saw the savings to the commercial market that we had anticipated. We did not see the increase in preventative care that we anticipated. And I believe the care boards analysis of the all pair model showed on the ACO, I think we spent around $100,000,000 plus dollars. And in health care in Vermont, when you have Medicare and Medicaid not covering the cost of care, where does that 100,000,000 come from? The hospitals were paying the dues for the ACO. Ultimately, that money was largely coming from commercial. So that's part of the problem. Two other problems I could point to off the top of my head. The University of Vermont Health Network spending on their New York operations started increasing very, very, very significantly. We,

[Mike Fisher (Chief Health Care Advocate)]: I

[Owen Foster (Chair, Green Mountain Care Board)]: think last year, testified it was probably 125,000,000 in debt that was paid from UVM to the New York hospitals. That money, again, had to be largely out of commercial money. So there's another 125. What am I missing? I would also say that the system that we had really was not a good system for providing affordable care, because it is largely backed up in hospitals. And I think that just sort of caught up to us as well. We didn't have a lot of the preventative care, the independent practices, the primary care, and a lot of care was getting back into hospitals, and the mental health care and long term care. I would point to those. Yeah.

[Alyssa Black (Chair)]: I was struck recently at a hospital meeting that somebody said the abundance theory. They were talking about the abundance theory. And I'm just wondering, we inject too much money into our system?

[Owen Foster (Chair, Green Mountain Care Board)]: I guess everyone's reading as refined right now.

[Alyssa Black (Chair)]: I mean, my initial reaction was, let's not add the word abundance into in any realm, but

[Owen Foster (Chair, Green Mountain Care Board)]: So it's hard to say. I know that if we hadn't injected that money, the system would look different. To me, the question is, where did we inject it and where was it being used? And again, going back to what I first said of how we're allocating the money to where we want the support services, the essential priority services, we did not do that as a state. Whether it's ultimately too much or too little, I don't know. It would look different if we had not put that on.

[Alyssa Black (Chair)]: Brian, you had a- Well,

[Brian Cina (Member)]: we trying to save questions for the end or are you taking them as we go? Do you have a preference?

[Owen Foster (Chair, Green Mountain Care Board)]: Whatever the chair's preference is, it's fine with us.

[Alyssa Black (Chair)]: Is it related to this slide?

[Brian Cina (Member)]: It is. It's my favorite slide. It is. How about I ask the question that's very related to this slide and then I'll look at the presentation before I ask any more and see if anything is going to be answered coming up? Because I didn't do that yet. In case this is coming up, sorry. I'm just curious, you just talked about hospital closures, and now you're talking about premiums nationally versus locally. How do premium rates nationally compare to hospital closures nationally? Is part of why our rates going up that we're shoring up hospitals or you know what I mean? Are the states that are having lower rates having more hospital closures? And then the other question related to that is, why does UVM have such huge reserves when all the other hospitals in the state are struggling? And you can get to this later if you were.

[Owen Foster (Chair, Green Mountain Care Board)]: Sure, I don't have a good analysis of comparing insurance rates versus hospital closures. But to your point, I do think that we have subsidized our current hospital infrastructure system with really large rate increases. If you look at what the care board's rate increases were in '21, '22, '23, they're very, very steep. And if they hadn't been steep, we would have seen some of what's happening now happen earlier. The care board has dialed it back and its regulatory authorities to a lower level of increase, and there is a consequence to that, and that is that services and the system needs to change. So yes, I do think we propped up that status quo of the hospital system with very large commercial rate increases. Keep in mind, the insurance rate increases have a lot more in them again than hospitals. There's a lot more in there, it's not just the hospitals. Was there another party question?

[Brian Cina (Member)]: The second question, well, it was related. It was like, why does one hospital system in Vermont have such a like a billion dollar reserves or something? And then all the others are all these other components, not even the hospitals, but our designated agencies, our specialized service agencies, are operating on a day by, cash for only a few days.

[Owen Foster (Chair, Green Mountain Care Board)]: Right, great question. So the University of Montana Health Network, I don't have their current data. The last number I had was about a year ago. I think it's 1.3 ish billion dollars in reserves. Keep in mind though, their operations are really vast, really expensive. The metrics we generally look at is the number of days cash on hand. And what you look for there is you really want one hundred and twenty five to one hundred and sixty five days ish. UVM was generally in that range, even though the raw number is enormous. The latter part of your point, I think, is really valid, though. You look at the FQHCs and the mental health providers and you look at Howard Center, their days cash on hand can be one, two, six, seven days cash on hand. So one part of the system, even the struggling hospitals have seventy, eighty days, whereas I think Howard Center, I heard maybe a year ago had six days cash. So it's not quite exactly even. Part of that is that the hospitals have, UVM has a very good payer mix. What that means is that more commercial payers, that's where you make money, that's where you put into the bank. If you're only relying on Medicaid, you're going to have a harder time cashing money into the bank on your operations. And Howard Center has very few commercial payers. So that's, I think, part of it.

[Karen Lueders (Member)]: Karen Lueders, I'm the new Murray Chorus. You don't regulate every category, but from what we know from the Oliver Wyman report, the most expensive category is hospital, so that is what you do regulate. Proportionately, can you say how much of that system may be, percentage, or whatever? Can you just sort of delineate what, you know, the extent of the categories that you do right now? Okay, I should have

[Leslie Goldman (Member)]: had your

[Brian Cina (Member)]: disclaimer. Is anyone getting blinded by like I was trying to set up?

[Alyssa Black (Chair)]: Sorry, feel

[Brian Cina (Member)]: I

[Alyssa Black (Chair)]: just try not to interrupt, but I can see. I'm sitting in people's eyes. It's three. Okay.

[Owen Foster (Chair, Green Mountain Care Board)]: Thank We you. Might not see it again for two months.

[Brian Cina (Member)]: It's still coming in. It's just going up now.

[Owen Foster (Chair, Green Mountain Care Board)]: That's the

[Alyssa Black (Chair)]: thing. It's nice. Ambien versus blinding. Okay, so anyway, here we go.

[Owen Foster (Chair, Green Mountain Care Board)]: Good question. Question was how much spending in Vermont health care dollars is on hospitals versus non hospitals. This slide, the data is dated, that's how we get the data. And this slide shows nearing 50% as of 2022. I believe it's actually over 50% of our health care dollars that Vermonter now spends on hospital spending. And here's a point that I wanted to make back to what happened in 2018 that the chair asked. So in 2018, when we're doing the all pair model, a lot of the theory of health care reform was the same theory we have now. Preventative care, long term care, mental health care, let's do that. That's what we said back when we did the all pair model, and it's what we're saying today. But if you look at what happened during the all payer model, 2018 to 2022, if we had more recent data, this would be even a greater disparity. We actually increased hospital spending in that time, and we actually decreased some of the other spending that we would want on home healthcare, nursing's about the same, other primary care, those are all physicians, clinical, outpatient. Those all went down. We actually did the opposite during the all payer model as opposed to what we were trying to achieve. So as we look at the Rural Health Transformation Program that you've heard about, I believe, yesterday, and we start embarking on that, we need to really think about, in five years from now, is this gonna look like this again? Are we gonna make the same mistake that we did last time? And what are we doing now to make sure that we don't?

[Alyssa Black (Chair)]: FYI, physicians spelled wrong. Oh, thank you. It's

[Emily Brown (Executive Director, Green Mountain Care Board)]: been in there for a while.

[Alyssa Black (Chair)]: I didn't even think about it, I actually didn't even think about anything else.

[Brian Cina (Member)]: Maybe they meant Seeking.

[Mike Fisher (Chief Health Care Advocate)]: Not a

[Brian Cina (Member)]: very expensive component.

[Alyssa Black (Chair)]: So the very things that we thought we were investing in, it flipped.

[Owen Foster (Chair, Green Mountain Care Board)]: Yes, went the wrong way.

[Alyssa Black (Chair)]: Went the wrong way.

[Owen Foster (Chair, Green Mountain Care Board)]: Although there's some nuance, there's always nuance in any healthcare data, and There could be some hospitals increasing some of those services, and that's part of this. But really anytime a hospital is providing services, it is a more expensive way to deliver it. Hospitals are critical, but if you're doing everything there, it is going to be more expensive.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Next slide. Next slide. So I'm just going to, I think the committee wanted to hear some updates on the legislation from last session and what the Green Mountain Care Board is up to right now. So this slide, I think some of you may have seen this, is just a summary of the various acts that went into effect last session, end of last session that directly relate to the Green Mountain Care Board's work. I won't spend too much time on this, but I think it's important to point out Act 68 was a huge component of the work that we are now undertaking at the board. That included the implementation of the reference based pricing framework, which I'm gonna speak to in the next slide. And then also I wanted to point out the notice of service reduction requirement was contained in act 68. And I'm sure as many of you are aware, the board just had our first, notice of service reduction come before us, this past month. Act 55, that was another very impactful piece of legislation. That was the cap on the outpatient prescription drugs at 120% of the average sale price. That was then reflected in the hospital budget process that we had last summer and drastically decreased prices across the hospital system, as well as in the rate setting for the insurance premiums. Other relevant pieces that we are now requiring, the reporting of the 340B data, that is now on our website and is a new reporting requirement, which will hopefully add transparency to the 340B money that hospitals are receiving. And there's also other pieces I wanted to point out were in the Act 15 updates to the CON thresholds. This was a change that the legislature implemented to make it easier for some projects to occur in Vermont without having to go through the complete Green Mountain Care Board CON process. And that was again to try to encourage more healthcare offerings in the state. Next slide. So I wanted to spend a little time talking about reference based pricing. So in the legislation last year, the effective date or the expectation for implementation of reference based pricing was FY '27. So that would mean that next year hospitals would be implementing reference based pricing. The current status of that work is that we are integrating reference based pricing into our hospital budget guidance, which we are developing currently. But we expect to have a rule in place for FY 'twenty eight. So hospitals implementing reference based pricing for not this coming summer, but the next one. But we are in the development phase. We're developing the policy. We're working on rulemaking right now, engaging with stakeholders to try to make sure that this is going to be a very impactful change for hospitals. So it will be a phased in approach to make sure that not only our hospitals, but also our insurers are able to adjust and adapt and implement this. Any questions on that before I move along? Daisy, do we

[Alyssa Black (Chair)]: need the legislature to change any language in that for the

[Emily Brown (Executive Director, Green Mountain Care Board)]: So I would say no, and the reason is because we are planning on having the rule be in effect FY27. So this coming summer, we are currently developing the rule and plan on filing it with LCAR next summer. So we wanna be able to have that authority as we go into that process. And I think the legislative clarity that was added last year is really important. And then also, as I mentioned, we are including some benchmarking in our hospital budget guidance that is directly correlated to a reference to Medicare. So we do think it's important to have that be effective for FY27. That gives us the backstop and the authority to start implementing this in a phased approach.

[Alyssa Black (Chair)]: You were talking about a phased approach. Have you thought about just for this one year for FY27 doing something around, I don't know, some service or something like that, sort of like what we did last year with the ASP cap? So

[Emily Brown (Executive Director, Green Mountain Care Board)]: the hospital budget guidance isn't finalized, and I'm sure as many of you know, the board needs to adopt that guidance. So I don't want to speak out of turn. Don't know if Chair Foster has any comments on that.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, so the timing of this, the guidance is developed December, January, and then it goes out to the industry and the industry works on it and gives us feedback to the health care advocate in the hospitals, and then the board has to vote on it. And where the board ends up going, we won't know until the board votes. So it's quite possible that three board members say, hey, this is what we actually want to have in our guidance. And then when you get into the budgets, there's a question of whether or not you again have three votes to do what's in the guidance. The guidance is not binding. There's two related concepts. So reference based pricing is to dial back the prices at hospitals for commercial insurance companies. The board has taken a number of steps to already do that. When we have enforcements, we talked last year about some enforcements on UVM and other hospitals that were over budget. When they're over budget, what we've done is we've taken that amount of money and required it to be a reduction in their prices for future years. So we don't take back the money for the care that they gave, but we take that amount, we equate it to a commercial percentage and we reduce their prices. So this last year, UBM's commercial prices went down 9%. I think it was 8.9% in one year. So essentially, we are reference based pricing. They're a very high priced hospital. We have data on that, and we use that to go down. The second thing you can do is in the budget guidance, typically we've given budget guidance of a 2% or 3% or 4% increase in commercial prices. If we say zero is a commercial benchmark, would essentially be reference based pricing as the rest of the nation will be going up 3%, 45%. Alternatively, the board could vote to have the commercial rate increase less than zero, which would be a faster cadence to referencing price.

[Alyssa Black (Chair)]: Price, though, mean, I'm just saying, so you order the hospital to reduce their price. It's already an inflated price. And as we know, in most cases, not always, but in most cases, the price isn't a meaningless number anyways. It's more the reimbursement that they receive. So if you order them down 9% on their price, that doesn't change their contracts with insurers.

[Owen Foster (Chair, Green Mountain Care Board)]: It does.

[Alyssa Black (Chair)]: It does.

[Owen Foster (Chair, Green Mountain Care Board)]: So the way our board orders are written, it's not just the charge master, it's the effective price that they receive from

[Alyssa Black (Chair)]: the commercial insurance companies.

[Owen Foster (Chair, Green Mountain Care Board)]: So they actually do get paid less by the insurance companies. Related to your point though, if they increase utilization dramatically, the insurance company and the people still have to pay more money regardless of what you did with the price, is that raw dollar amount that really matters to the people and the insurance companies. So the guidance would also have a number of commercial NPR, that's the total revenue they bring in from patient care. We anticipate having a commercial revenue cap. And if the cap for the price increase is zero or negative, we would translate that to what that means for the commercial cap. And last year in the budgets, had a commercial cap in every hospital's budget so that we don't have the problem that we had in prior years where utilization went up and Blue Cross had financial difficulty.

[Francis "Topper" McFaun (Vice Chair)]: As we reorganize how primary care is gonna be delivered and that will mean a difference in cost, How is that coordinated with setting the maximum price for a hospital or service provider?

[Owen Foster (Chair, Green Mountain Care Board)]: Sorry, missed part of the question.

[Francis "Topper" McFaun (Vice Chair)]: As we reorganize how primary care is going to be delivered and how much it's gonna cost, how does that relate to setting a maximum price for hospital services if they still had some primary care being delivered there? Right, I

[Owen Foster (Chair, Green Mountain Care Board)]: think when you say reorganize, do you mean moving primary care providers out of hospitals? No. So we would have no regulatory authority over the prices that the non hospital primary care providers receive from the insurance companies. We don't regulate those prices. I'm getting a look. A not very subtle one.

[Francis "Topper" McFaun (Vice Chair)]: In

[Alyssa Black (Chair)]: 'sixty eight? 01/1926, S-one hundred twenty six. There was a section in there that gave the board the authority at any time, not just in twenty twenty seven, twenty eight, but just that the board could set a floor for community based providers. So you do have that authority. We gave you that authority.

[Owen Foster (Chair, Green Mountain Care Board)]: Sorry, you're skipping my mind.

[Emily Brown (Executive Director, Green Mountain Care Board)]: But I'm also I wasn't here.

[Alyssa Black (Chair)]: Is that in there, Jess? Counsel is I

[Emily Brown (Executive Director, Green Mountain Care Board)]: guess what I'll say to that point is right now we are focused on implementation of the reference based pricing because there was that date certain of when we needed to effectuate it. We have not been focusing on that other aspect. It said it was a May. May set the floor. So that is currently not something that we are actively working on. And I am aware that there are potential legislative proposals coming this session. So if that is something that is of interest and you want to discuss with us about how that authority can tie in with any potential legislation coming, we'd be happy to have those discussions. But right now we are definitely focusing on reference based pricing. We have an RFP currently out. We've been hiring staff to do this work. It's a new area and a new piece of work, so it is very labor intensive. So that's really where we're focusing our resources right now on the reference based tracing work.

[Francis "Topper" McFaun (Vice Chair)]: What we want to make sure is as this transition takes place, like you were saying, want to get it right this time. We're gonna have to be careful because reference based pricing is gonna affect the whole system. Right, correct.

[Owen Foster (Chair, Green Mountain Care Board)]: I don't know that we know that primary care providers will be leaving the hospital. I don't know if we know that reorganization is going to be effectuated or happen. I think I would support it, but I don't know that there's immediate plan that any hospitals to divest of their primary care.

[Francis "Topper" McFaun (Vice Chair)]: They're starting to do it now. They know we're coming. It's starting to happen now. I think it'll be a positive. Especially in Central Vermont. Yeah,

[Alyssa Black (Chair)]: I think there is a section in H585 that was just introduced.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Yes, I saw about the site neutrality. We discussed that with DFR, we're aware of it, so happy to again come in and talk about that. I

[Brian Cina (Member)]: know you have a lot ahead, so I'm going to ask you a question in hopes that maybe we can talk about it another time, but I want to ask it now before we get caught up in more stuff, which is, what is the potential for using technology like artificial intelligence to help with controlling costs? Because as I think about controlling the cost and what Tapa was saying about how it's interconnected and complex and you adjust one lever here and it affects something here, is it possible to use AI to look at or track all of the costs in the healthcare system and then give us some recommendations, not to be in control of it, but to help us analyze such a complex system.

[Emily Brown (Executive Director, Green Mountain Care Board)]: So I don't wanna get ahead and I know that there was a request for us to come and discuss our piece, our small piece of the Rural Health Transformation Fund. We have a project, a data infrastructure project that we've been working with AHS on and had proposed. So to try to answer your question, it's using better technology and having a better data infrastructure to try to track the overall system costs to see, Okay, if we implement reference based pricing over here, what effect is that having on the system as a whole? So that's definitely something I think that's very top of mind. I know staff at the Green Mount Care Board are deeply invested in understanding that. So that's something we are focused on in the project that I mentioned is a five year implementation. So we're hoping to be able to increase our data infrastructure, again, part of it AI, to be able to really, in more of a real time fashion, get data from the system and actually use that as a way to then make decisions or at least hold ourselves accountable to the decisions we're making.

[Brian Cina (Member)]: Yes, I know that. And so we'll hopefully bring you in to talk about this if this topic comes up in greater depth, but I know that there are applications where you can adjust things and then the model, you can create a model and so we could, not we like us, but we, Vermont and the experts in charge of this piece like you could adjust numbers and see what it can do in a quick, rapid way in real time that we can't do otherwise.

[Emily Brown (Executive Director, Green Mountain Care Board)]: And I think that's why just going back to reference based pricing, why a phased in implementation is really important because you don't want to in one year flip a switch and then have all the unintended consequences like that was mentioned about the primary care access. We want to be able to actively monitor the decisions we're making and making sure we're going in the right direction with prices. Because as we've discussed, when you lower something here, it puts pressure on different services. And I think we will start seeing that as we start putting downward pressure with reference based pricing, with our hospital budget process. There are then ramifications throughout the system. And we need to be able to make sure that we're accounting for that and being thoughtful. We need

[Leslie Goldman (Member)]: to move along a

[Alyssa Black (Chair)]: little bit because I know we've got a lot to go.

[Emily Brown (Executive Director, Green Mountain Care Board)]: So we can move on from reference based pricing. The next slide just again highlights some projects that we have right now. As I mentioned, the notice of service reduction, we have an interim policy for those who are interested in reading that. We've started rulemaking for our ACO, moving that to a certification model. You will be shortly hearing a report on prescription drug affordability that is due January 15. I believe we'll have it to you on Monday. Have the 340B reporting document, which I've cited here. And then the Act 55 outpatient drug cap, we implemented through the hospital budget review process, as well as the rate review process.

[Alyssa Black (Chair)]: I think I just personally apologize because on the notice of service reduction, that was probably not one of the best laid out things and I totally appreciate that you all had some very, very difficult things in front of you that you were trying to make decisions on without having out of foot information. And I just wanted to say, I'm sorry.

[Emily Brown (Executive Director, Green Mountain Care Board)]: I will pass that along to I our

[Alyssa Black (Chair)]: am sorry. I know that these were very hard decisions. And I watched all of your meetings and discussions around it, and I know that you had some difficult things, and I think you handled it wonderfully. And again, I apologize.

[Owen Foster (Chair, Green Mountain Care Board)]: Thank you. The bright news is we didn't make any decisions.

[Alyssa Black (Chair)]: I know what the intention was behind that, but it probably should have been a little bit fuller fleshed out.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Next slide. And so I won't I already mentioned these two things, so I won't spend any more time. But just, again, other things that we're actively working on and engaging in right now.

[Owen Foster (Chair, Green Mountain Care Board)]: And I'll go quickly through the hospital budget process from last year and the rate review process. Hospital budget review process, March 31, our guidance goes out, and that again sets the target of how much money we'd like the hospitals to have in their budgets, how much their commercial prices go up or down, their commercial revenue, and their total revenue from all payers. By July 1, the hospitals give us their budgets and their proposals. Last year, the hospitals did a pretty good job almost across the state coming in right around our guidance levels, And the budget process was pretty smooth. By September 15, we vote on where we want their budgets to land, and then we issue opinions by October 1. Next slide. This is the current status of the hospital's finances. This is the highest level picture of how their solvency looks. The first measure that I want to talk about is that day's cash on hand, which is the measure of how long they can operate if they were to have no more money come in. How much cash is in the bank and how long can they go without any income? Under one hundred and ten days, cash on hand is considered vulnerable, and less than 80 is considered highly vulnerable. From this slide, you can see that a number of Vermont hospitals are in the vulnerable stage vis a vis their 26 budgets. So Brattleboro Memorial Hospital is 72, CVMC is 80, Copley 65, Gifford 90, Grace Cottage 81, Northeastern 82, Springfield 33. SVMC has some money at its parent company, so that forty five days is misleading. Copley actually has a parent company with a little bit more money at it as well, and then UVMMC has money at a parent company as well. So the ones that I would be particularly concerned about this time would be Brattleboro Hospital, I'm concerned about Gifford, concerned about Northeastern, and I'm definitely concerned, again, about Springfield. The second metric on here is the operating margin. That's how much money they're losing from their operations. So it's like you go to work and you do your job, but every day you go to work, it costs you more money to drive there and eat lunch than you bring in from doing the job. That's essentially what operating margin is. You need to be neutral best, and that means you won't eat into your reserves since your cash reserves, your bank account go down. We'd like to see hospitals one to maybe 3% positive so they can invest in their infrastructure and have adequate reserves. A negative operating margin is deeply troubling. So for 2026 budget, Brattleboro Hospital is budgeting a minus 12% operating margin. That's an enormous loss that they're budgeting. Dollars 14,000,000 for a hospital that size is a very big loss, and that's going to eat into the day's cash on hand. That number has been dropping a lot faster than we'd like. The other ones, Northwestern, Rutland, SVMC, they're also negative. A couple of these have positives that we're concerned they may not hit. They might not have the patient volume, or they might not have the expense control that they had hoped for to have a positive margin. We'll see where they come in, but over the last several years, the operating margin system wide has been inadequate. It's not adequate to operate the way they have been.

[Francis "Topper" McFaun (Vice Chair)]: Next slide.

[Alyssa Black (Chair)]: Thanks, Helen. Oh, please. I was going ask one too. Ahead. Well, I was going to ask you specifically about Brattleboro,

[Leslie Goldman (Member)]: Well, so am I. And

[Alyssa Black (Chair)]: I know that because they have now How many resubmissions have they put in? They're on their

[Owen Foster (Chair, Green Mountain Care Board)]: I think they'll be on their third.

[Leslie Goldman (Member)]: On their third.

[Alyssa Black (Chair)]: And I know that they had cited the price cap as one of their contributing factors. Part of that bill specifically said if the price cap negatively affects your ability to provide essential services, you may ask the board to be able to increase rates in those essential services. Have they done that?

[Owen Foster (Chair, Green Mountain Care Board)]: They have not.

[Alyssa Black (Chair)]: Do you want to add

[Leslie Goldman (Member)]: something? If I may. So I'm from Northern Windham County, I've got Springfield here and I've got Rattledore there. Worrisome, clearly. And I'm wondering about the approach. What happens as time unfolds? And what do we have? What levers are there? And you may not want to answer that. I don't want to put you on the spot, but that's my concern.

[Owen Foster (Chair, Green Mountain Care Board)]: Right. So I think it's a good question and it's a good concern. Going Going back to Brattleboro, there was a lot of discrepancy with their data. Their data was not accurate, which is why we're on, I think going on to the third submission. They made some changes in the team that works on that. They brought in some outside resources. I believe it was this committee, gave the board last year authority to appoint an outside observer or a monitor kind of role for hospitals that are in a situation like that. I didn't really want to personally use that authority at that time. We did work with them and say, you need to get this straight, you need to get it straight fast. Their board stepped in and took some actions and got some assistance that they need. It turned out the numbers they'd been giving us weren't as bad as they actually were. Now they're worse and see where they land. In terms of what becomes of this, what happens, there's a couple of things. One, you hope their management and their boards make changes that allow them to provide necessary services in their community and maintain solvency. And that's their job. And if that means that they need to renegotiate with the insurance companies to change rates so that they can provide those essential services, then they need to go and call those insurance companies and try and readjust their rates so they can prioritize what's needed with their communities. I'd say that's number one. Number two, I see the agency of human services here, they're working on transformation of the healthcare system. They've received the grants, are receiving, I think pretty soon transformation plans from a number of hospitals. So this would be something that AHS and Brattleboro and Springfield are sure working on and would work on in the future.

[Leslie Goldman (Member)]: Something you can imagine. Maybe is there a three?

[Owen Foster (Chair, Green Mountain Care Board)]: I don't like to hear a I'm

[Leslie Goldman (Member)]: being contacted by constituents. They're frightened that the hospital's going to close, and I'm trying to figure out what to say. So any help about how we're supporting these very much on the edge hospitals in our region would be most helpful.

[Owen Foster (Chair, Green Mountain Care Board)]: I don't think that we're at an immediate risk of closure. Springfield's numbers that they've been giving us, to my understanding, have been accurate. So thirty three days is very, very low and something needs to change, but I wouldn't view it as an immediate closure risk. Brattleboro is seventy two days cash on hand. Even if they had a negative year, they're not going to close. More likely, you'll see that I think they have some runway to make some pretty significant changes pretty quickly. Will those hospitals need to look different in three to five years or two years? Yes. I mean, we've been saying that for years now. The whole healthcare system and hospital system needs to look differently. There's not money unless the committee and the legislature and the governor want to increase Medicaid rates significantly. There's no money to really solve this problem.

[Leslie Goldman (Member)]: So my saying to them, there's no immediate risk of closure, which is what I've been saying, is accurate.

[Owen Foster (Chair, Green Mountain Care Board)]: I believe so. I thought

[Leslie Goldman (Member)]: it would be accurate to

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, mean, from my position, yes, I don't think Brattleboro is going to be

[Alyssa Black (Chair)]: closure, like a whole hospital closing. That's what people are pregnant.

[Owen Foster (Chair, Green Mountain Care Board)]: I do not see that as something that's on the rise in the next twelve months. Now, if the numbers that we've been given are still wrong, I can't promise you anything. Don't know for sure what their number, I have an audit of them. And Springfield, if things go bad, if they lose a number of providers, if they don't get the patient flow, if more people start going to Dartmouth, it could be, you just can't predict what will happen. But things have operated over the last two or three years, I don't see the next twelve months having a hospital closure.

[Alyssa Black (Chair)]: Thank you.

[Owen Foster (Chair, Green Mountain Care Board)]: We also have a transformation work in a good way with AHS that is intended to address these issues.

[Alyssa Black (Chair)]: Hopper and then Val.

[Francis "Topper" McFaun (Vice Chair)]: As we all know, these hospitals are all supposed to be nonprofit. Are any other hospitals owned by a private equity firm other than Springfield? Or is Springfield still owned by one?

[Owen Foster (Chair, Green Mountain Care Board)]: To my knowledge, not a single hospital in Vermont is owned by a private equity firm, including Springfield. I think the question might be alluding to a couple of the Vermont hospitals have

[Alyssa Black (Chair)]: a

[Owen Foster (Chair, Green Mountain Care Board)]: private equity firm that owns a consulting company that they work with. So Springfield, to my knowledge, used, and I believe still does use, a company called Ovation, which is owned by, I believe it's called Grant Avenue Partners, a New York City private equity fund. That private equity fund owned consulting company provides them consulting services and management services, but they do not own the hospital. Exactly what role they have and how

[Francis "Topper" McFaun (Vice Chair)]: The FQHC owns the hospital, don't they? Sorry? Wasn't the FQHC own it?

[Owen Foster (Chair, Green Mountain Care Board)]: No. Who does? FQHC. The FQHC, I think, owns Gifford, but does not own Springfield.

[Leslie Goldman (Member)]: No, they're separate. North Star and Springfield, separate.

[Owen Foster (Chair, Green Mountain Care Board)]: No one owns the hospitals in Roth. There's no shareholders, there's no private equity firm owners, there's no hedge fund owners. They're just nonprofit hospitals. I believe that Ovation, the private equity firm owned management consulting company, also does work or did do work with Northwestern and Brattleboro.

[Francis "Topper" McFaun (Vice Chair)]: Thank you. So,

[Alyssa Black (Chair)]: any of these hospitals that are negative at this time, what does the primary care look like outside of that? Is that also in a poor place? What does that look like?

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, good question. I don't have perfect insights into each community's primary care. We regulate anything outside of the hospitals on the provider side. I do know statewide and systemwide that a lot of the primary care in Vermont is provided by our FQHCs, our federally qualified health care centers. Their reserves and margins are very, very strained as well, by and large. So community health centers in Burlington, it's our largest in the state. They have had steep declines in their reserves and operating losses for the life of their units. Little Rivers down in Wells, same story, I think even single digit days cash on hand. Lemoyal Health Services, Morrisville, were near insolvent as well. So a lot of the primary care is extremely strained. For the independent practices, haven't seen their data. I I would be very surprised if they're flush with cash.

[Alyssa Black (Chair)]: Can we move on just because it's what I'm saying? Okay. It doesn't even necessarily need an answer, but I'm assuming that the provider tax has been integrated or calculated into, like when you reduce the hospital bottom line and therefore reduce the provider tax, do you put it, you're considering that in your calculations?

[Owen Foster (Chair, Green Mountain Care Board)]: Yes, the provider tax is included in the overall budget numbers that we see and that we report. So last year, the insurance rates were exceedingly high. It was really problematic to us from a policy standpoint to have insurance rates that were so high, given that we were already the highest in the country. At Blue Cross, I think, proposed a 23% rate increase on the top highest cost in the country. That was going be very, very detrimental to families, to demographics, to economic growth, to equity. It was very problematic. We worked really, really hard to try and find paths to get that number a lot lower. There are really two main drivers. We were able to drive those rates significantly down. I believe the rates were, there's four of them, I think they're right, 1% to 3%, another was 4.5%, and one plan was 9%. But overall, they're all under 10% increases. Like I said earlier, Vermont had the second lowest insurance increases on the QHPs in the country. So we've really made some strides in getting back towards the rest of the country, and we did not disrupt the health system too significantly as we did that. I think we, as a state, threaded the needle quite well. We didn't see any closures. There's some service lines that are always gonna be up there that's too dramatic. How that was done is really largely depicted here. First and foremost, was Act 55 that the legislature passed. That was one of the biggest drivers in allowing Vermonters to have lower commercial insurance increases. That was a $104,000,000 change in the commercial revenue and cost to the insurance companies. And then the second was the care board's hospital budget orders, which was $94,000,000 and then our hospital budget enforcement, which saved $31,000,000 So all pulled between the legislative action and the board's regulatory decisions, it was $230,000,000 that was saved. When we saved that $230,000,000 that really reduced those rates to where I described it earlier. This is however really a one time decision and one time effect. It's true, the hospitals will not have those higher prices that they had before, but when we get the insurance rates this year, there will not be another $104,000,000 you can knock off because of the drug prices. That's gone, that's done. And as we saw the hospitals being more strained, there's fewer pockets that we can go to. I do liken this what the governor or legislature does with the property taxes, the one time buy downs. We really leaned on the hospital budget orders and enforcement. It was largely UBM. We looked at their budgets, we looked at their numbers, and almost all that money was out of the UBM reserves. Does UBM have another 110,000,120 million dollars in its reserves that we can use to help the rest of the health care system if we want to increase primary care rates somewhere else? Where are we going get the money? If Blue Cross continues to have financial trouble, where are we going to get the money? UVM is not a piggy bank. It's an important hospital that we need strong and we'll look everywhere we can to make the best decisions, but it will not be as easy this year when we see again, I anticipate high rate increases. I've alluded to this a couple of times, the insurance rate review.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Next slide, Kristen.

[Owen Foster (Chair, Green Mountain Care Board)]: This one's fine here, Kristen. So Blue Cross Blue Shield came in with a request of 23.5% for an increase on the individual plans. We approved 9.6%, so a 14 decrease from what was requested in single digits, which is an achievement. You have to remember that Blue Cross's financials were really, really strained. There's no reserves we could wiggle with there. And their increases have increases for those primary care providers that are outside hospitals that we do want to see. They have increases for FQHCs that we do want to see or we're going to lose those services. And they had a large amount of money in their requests for their reserves because they were so low. The bright note is the last data I heard is that Blue Cross' fiscal year 'twenty five was actually quite positive, and so they'll have a better reserve starting 2026 than they had in 2025. MVP proposed 6%. We approved, I forgot the number, maybe 2%. Oh, sorry, 1%. Next slide. And then on the small group plans, Blue Cross requested 13.5%. We approved 4.4%. Quite reasonable, not low enough, but again, you have to consider all the other issues. And then MVP was 7.5 and we approved 2.5. I will note two things in this process that jumped out that I think are relevant to your session this year. One of the things we found in our budget order was that Blue Cross was losing a lot of money on a lot of different services, and there were larger increases being requested on the individual plans and the small group plans, the QHP plans, almost cross subsidizing some of the other book that was losing a lot of money. Blue Cross lost a lot of money on its Medicare Advantage plan, which is a sense exited. When they lost all that money on Medicare Advantage, that depleted their reserves as well. But now they don't have that book to make up the money, so they need to make up the money elsewhere. And that was a problem that the Care Board had. Another was there were large executive compensation increases. In the two prior years, if memory serves, was a leap of about a 40% increase in the top level of compensation at a time when rates were the highest in the country and the company was losing significant reserves. We did call that out in our order. We identified it as something that was problematic from our perspectives.

[Lori Houghton (Member)]: Lori? And this is just a comment for the committee. I think the struggle this is all fantastic. And yet, the struggle when we talk to Vermonters is they're not going to notice that because if they're buying on the QHP and they had a subsidy and that subsidy is gone, they're seeing a huge increase. So they don't see the weeds of this. But I do think it's important for us to recognize the work that was done by everyone.

[Alyssa Black (Chair)]: Yeah, a couple of questions, because we're going to give Mike ten, fifteen minutes. I've got Just a minute. So I'm just wondering what the impact is going to be if a lot of people without these subsidies leave the marketplace and they're, I hate to say this, stuck with very sick people. What is this going to What do you think is going

[Emily Brown (Executive Director, Green Mountain Care Board)]: to happen? I'm worried. So when the insurance companies filed their rates this past year, they actually put into that rate the assumption that the subsidies were going to go away. So these rates reflect that impact of the subsidies. So you're exactly right. There will be less people. Probably the people who aren't as sick will choose not to purchase health insurance. But the insurance companies did estimate when they filed these premiums, the assumption that the subsidies would not come back.

[Owen Foster (Chair, Green Mountain Care Board)]: At the same time, there will be other impacts.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Right, correct.

[Alyssa Black (Chair)]: System. To the people who are

[Owen Foster (Chair, Green Mountain Care Board)]: not getting health care because they don't insurance or they're paying out of pocket. And then also, of course, as I said earlier, to the providers who have tens of thousands, whatever the number is, insured people.

[Alyssa Black (Chair)]: I've got Topper, and then Karen, just said, like a sentence.

[Francis "Topper" McFaun (Vice Chair)]: Does any other insurance company have an impact on any of this? Like Cigna, do they have any impact at all?

[Owen Foster (Chair, Green Mountain Care Board)]: Cigna is not in the qualified health plan space, they provide self insured insurance to some people in Vermont, maybe other products, but that's not anything within our, Cigna is outside of our regulatory purview.

[Emily Brown (Executive Director, Green Mountain Care Board)]: They do have some large group rates that I believe we review, but very small.

[Alyssa Black (Chair)]: Did somebody over here I just wanted

[Leslie Goldman (Member)]: to thank you because I'm noticing on our front porch forum that you're posting your rule changes, and I think that's really cool. So thank you. I

[Alyssa Black (Chair)]: think I want to make one last comment, and then we're going to move to Mike. And it's sort of in reaction to something you said. You're talking about you liken it to a one time buy down of property taxes. I think one of the things that struck me as I was watching all 14 hospital budget reviews, I was amazed at how in almost all cases, they did. And they did it in ways that I almost, as I was going through listening, I'm like, you never look at it. You know, I mean, I almost feel like having the challenge of meeting these expectations allowed a lot of these hospitals to probably look at some efficiencies and things that they hadn't looked at in many, many years. And so I would push back a little bit on, you know, you liken the the ASP cap to a one time buy down and that you're not sure that they have the capacity. But, you know, when we're talking about reference based pricing, I almost feel like we should do something like that again. I liken it to dipping a toe in the water. Do you feel as though if they did have to reduce again, that maybe they would be able to transform.

[Owen Foster (Chair, Green Mountain Care Board)]: It's a really good

[Alyssa Black (Chair)]: point. Transformation.

[Owen Foster (Chair, Green Mountain Care Board)]: It's a really good point. Necessity is a great

[Alyssa Black (Chair)]: Yeah. In

[Owen Foster (Chair, Green Mountain Care Board)]: prior years in '22 and '23, we gave really large rate increases and even then the sky was falling because they weren't large enough. Well then now in '26, for '26, we ratcheted down in '25 and '26 and lo and behold, the system was able to respond and be very productive, to their credit they did a good job. As a regulator, finding that line of how much is reasonable for them to take out that doesn't upset the system is very, very difficult exactly where they are. We do know the system needs to transform, and I think this really relates to the Rural Health Transformation Fund. We're now getting $200,000,000 a year for five years. How are we going to translate that to lower premiums in a more affordable system? And if we're trying to use that money to bolster all those things we've all been talking about for, I think, about a decade, doesn't that mean those hospital numbers have to go down? We're trying to increase mental health care, and we're trying to use primary care and everything else. So are we going to flip that? I mean, we now have $200,000,000 to do it. So I think that the ability to put on more pressure more limitations, our flexibility and has probably increased because we have $200,000,000 a year for five years.

[Brian Cina (Member)]: Of course,

[Alyssa Black (Chair)]: we saw what happened with the all payer model. Our intentions were the exact same thing.

[Owen Foster (Chair, Green Mountain Care Board)]: The only difference I would cite just is that that was a policy theory on how we're going to repay for This is actually cash coming into the state to bolster other things. It's more direct. It's literally straight cash that we get to inject into other parts of the system. And that's an important distinction.

[Alyssa Black (Chair)]: I'm just gonna give Daisy one It's okay. Okay, thank you.

[Owen Foster (Chair, Green Mountain Care Board)]: Thank you. Thanks

[Mike Fisher (Chief Health Care Advocate)]: very much. Thank

[Alyssa Black (Chair)]: I'm sorry, it's Mr. Fisher.

[Mike Fisher (Chief Health Care Advocate)]: I'm gonna significantly Mike Fisher, healthcare advocate. Is this my first time here this year? How many months have we been at it this year?

[Francis "Topper" McFaun (Vice Chair)]: No. That's my work. Blood.

[Mike Fisher (Chief Health Care Advocate)]: I must have left it there earlier for for this. Mike Fisher, health care advocate. Yes. I was gonna come in and spend a little time trying to ground all this stuff back in people's lives, much like I did in the fiscal briefing, and maybe tell those stories another step or two into the year. But I'm not gonna do that because I don't have the time. But part of the outcome of that discussion is a refocusing on the urgency of this moment and just how devastating our prices and our health insurance premium costs are for various populations of Vermonters. Yes. Federal policy is devastating as well, and there's populations that we're particularly worried about. Maybe I'll talk about that another day, but I I think I wanted to just spend this moment saying, hey. It's a really good thing that the board was able to do the small rate increases this past year. They did that in large part because of, yes, UVM monies and the actions that this committee took to reduce outpatient administered drugs. And so as I look at the landscape going forward and sort of the real tangible, like, I sort of think in terms of the calendar. What's coming at us in this next year's rate rate review process? What are we gonna give are we gonna give hospitals medical inflation growth? I don't personally think we can. We can't afford it. We're tell them that they're gonna be level funded? Are we gonna tell them they're gonna be lower than level funded? I think in those terms and the impacts of that on insurance rates in people's lives. And so I've sort of left with this, you know, I have this sort of question in my head. How, you know, how fast can we put downward pressure on hospital spending and not kill them? We don't wanna kill them. And how fast do we have to do it to not kill Vermonters? Sorry. I didn't really mean to say it that way, but not to to destroy people's portability or continue to to give people access. And so I guess I'm, you know, sort of more being responsive to the testimony we just heard than anything else. You guys set a great path forward on price setting, on reference based price pricing. And I think your language was right to take all available steps for '27. Do I have that year right? '27. Recognizing this thing is complicated and has to be done right. And I absolutely agree with something that Emily Brown just said. We have to feather this in. We can't do it all in one big step. To me, feathering this in is taking another meaningful step this year. And like you did last year on outpatient administered drugs, that we focus on a particular line or two. I don't know whether it's imaging. I don't know whether it's labs or professional services or something like that, and say, okay. Board is working on getting this right. We wanna give the board time to get it right. We're not overstepping, but we're going to but in recognition of the crisis we're in, we're gonna set a reference for a set of services across the hospital system to continue to move the bar in the range.

[Alyssa Black (Chair)]: I'm going start using feathering in instead of putting toes in when you're going into the ocean and you really don't want to get up past the waist, because you know how cold it's going to be slowly walk in. But I like the feathering in.

[Mike Fisher (Chief Health Care Advocate)]: And let me also say there was a concept in last year's discussion that was about rice gouging and or or a frame of the discussion that was about price gouging when you see markups that are a 2,000 more percent. And so I think that's an just I just wanna put those concepts on the table. I know they've been discussed in certain circles, but, I wanted to say them out loud here. Vermonters need that kind of action. We have to do it carefully so that we don't so that hospitals can manage it. But I I I sort of appreciate some of what I just heard the chair say. We're gonna have to do it anyway. And either we do it with some planning to it or, you know, or it comes in the form of of rate decisions and budget orders that have a a sort of much more blunt impact.

[Alyssa Black (Chair)]: Daisy, can you talk a little bit about what we did with reducing prior authorizations? I know that's part of the balancing act with keeping our insurance companies in business, but it's also part of reducing hospital costs and building more efficiencies, and I think those operational efficiencies and reducing provider burden is a huge factor in what folks end up paying. So how do we know when to balance that and how much farther to go?

[Mike Fisher (Chief Health Care Advocate)]: Yeah. You're not going like my whole answer on prior authorizations.

[Leslie Goldman (Member)]: Remember, he never liked that, though.

[Mike Fisher (Chief Health Care Advocate)]: So prior authorizations are a huge complicator and frustration for Vermonters, people getting care for providers. I'm sure for insurance companies too who feel like they have to do it. And so simplifying, aligning, all of that stuff makes sense to me. I do wanna say that we talk about providers like they're your doc trying to give you care, and that's true. They are your doc trying to give you care. Providers are also director of revenue cycle at a large hospital that's trying to to to to get revenue. And prior authorizations are a impediment to a hospital's you know, it it's a check. It's an it's a tool that insurance companies have to put a check on chasing revenue that I think happens in our health care system. So finding the right I just wanna recognize both of those things and finding the right balance between that. I noticed the adjustment in the DFR bill Yes. Maybe. And I think it's an interesting conversation about sort of focusing it on the independent primary care. Have to be honest, I've only read the subject line of the bill, not the

[Alyssa Black (Chair)]: You're onto me. That's why I was asking you. Can I expound upon or ask a little further? So you had talked about maybe thinking about you didn't know diagnostic imaging, labs. Well, know that prior authorization, one of the largest number of prior authorizations that need to be done are around diagnostic imaging. So if the price was set for diagnostic imaging so that it wasn't, I'm going to use gouging here and I don't know if that's even the case, so I'm just, let's say it is. Know, not having a prior authorization and the physician who is also revenue cycle generating revenue. There would be less incentive for them to drive that type of care because it wouldn't be receiving the revenue. Which would almost have the same effect of a prior authorization. I mean, we noticed because when we did the prior authorization bill, Blue Cross Blue Shield specifically had decided if you go to this independent open MRI, you don't need a prior auth because they were trying to drive utilization to that facility because it was so much cheaper. And a lot of the work that we did around certificate of need last year, I know of at least two brand new diagnostic imaging independent of hospitals. So that could be a tool rather than

[Mike Fisher (Chief Health Care Advocate)]: That drives you in the same direction. Let me pull back to the stories for a second. Actually, this was, I think, the hardest open enrollment period for the healthcare advocate's office. The combination the collapse of the Medicare Part C market and QHP market mess was just particularly hard for us and for Vermonters. And, you know, we hear from person after person who said the likes of, I'm gonna go without insurance, but I'm gonna get a, you know, a bronze plan for my kids. You know? Or or I'm going Medicare bare. I'm not getting supplemental. I'm gonna skip my open my guaranteed issue open enrollment period and and just pray that things are okay. And so, you know, the costs you know, Vermonters are struggling to figure out how to make it through this. And, you know, we saw a lot of people move from bronze plant from gold plants to bronze plants. I, you know, I expect the next time we do the household health insurance survey, we're gonna see a you know, we we were making ground. We were going in the right direction. We were reducing the amount of underinsured people. You know, that is people for whom their out of pocket actual cost or exposure was a high percentage of their income. I expect that when we see those numbers again, we're gonna see more and more people who can't afford to use their insurance. They have insurance, they pay their premiums, they still can't afford to go.

[Alyssa Black (Chair)]: What's the difference between an authorization, a prior authorization and certificate of need?

[Mike Fisher (Chief Health Care Advocate)]: Prior authorization is for a particular service. You know, I I I need an MRI, and and my insurance company says, well, before you go to that, I wanna I want more information. I want you to get prior authorized authorization for it. Is that a fair description? Yeah.

[Alyssa Black (Chair)]: For your provider, I'm gonna have to

[Mike Fisher (Chief Health Care Advocate)]: send to the insurance company to get permission to order that and get approval for it before they would pay for it. And a certificate of need is a concept of before you build a facility, we want to make sure that it's warranted and that it's not going raise the

[Alyssa Black (Chair)]: Thank you.

[Mike Fisher (Chief Health Care Advocate)]: It's in our healthcare system.

[Francis "Topper" McFaun (Vice Chair)]: I have a comment. As we go forward with all of these things, think that you can see that things are pretty complicated and there's a very, very important need, immediate need right now to do something. Just remember the word quality of care as we are doing it, because that's a big deal. And we haven't talked about it. So, let's keep that in mind.

[Alyssa Black (Chair)]: Can't afford to use your insurance, is that

[Francis "Topper" McFaun (Vice Chair)]: quality care? I didn't get the care.

[Mike Fisher (Chief Health Care Advocate)]: Why not? Sorry, not care.

[Alyssa Black (Chair)]: Alright, thank you, and thanks for flexing with us. We'll have you in another time.

[Mike Fisher (Chief Health Care Advocate)]: I'm around. I

[Alyssa Black (Chair)]: do have some other questions for you, but so let's take a short break while I'm next witness.

[Mike Fisher (Chief Health Care Advocate)]: Maybe get to the 90,000,000,000.

[Alyssa Black (Chair)]: For just a minute while we get situated.