Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome back. We're pivoting away from five eighty three to five eighty five, and we have Doctor. Will Epprich in, and he wanted specifically to speak on, I believe, one of the sections or a couple of the sections, maybe, that are in the bill. So happy to have you in, and thank you so much for joining us. You can go ahead.

[Dr. Will Everett]: Good morning to the chair and committee. Thank you so much for having me. Again, if your schedule at all accommodated mine, I do very much appreciate that for this opportunity. I just mentioned, I'm Doctor. Will Everett. I am a family physician and hospitalist at Grace Cottage Family Health and Hospital, which is the rural health clinic and critical access hospital down in Townsend, Vermont. I currently serve as the medical director here, as well as the medical staff president, and I'm the president-elect for the Vermont chapter of the Academy of Family Physicians. To my understanding, as you just mentioned, yes, specifically, I've been asked and or directing my testimony towards section 11 of H five eighty five to provide further context about prior authorizations and the possible impact of the suggested verbiage of the bill. And this is something, unfortunately, that pretty much all primary care providers have too much experience with. The definition of a prior authorization is really pretty straightforward. It's the idea that an insurance company states that before they will approve or commit to paying for a service, that they need further evidence that the service is warranted. Given the ubiquity of this, it's become standard practice for really any healthcare entity that they will ensure this step, meaning the prior authorization, is completed before actually offering the service to a patient in order to avoid passing the cost to the patient, and then running into a much greater risk of it not being reimbursed. While in principle, this relatively straightforward process or practice does make some amount of sense, the numerous services that prior authorizations are applied to, and the administrative burden sorry, make an enormous administrative burden, and the design of the system consistently leads to delays in care. For perspective, and again, I apologize, my testimony is not written ahead of time. I will get it to you all. A recent KFF poll showed that forty seven percent of insured adults had a delay in or denial of medication service or treatment within the past two years, and that sixty nine percent of insured adults find that prior authorization for at least some amount burdensome, which was greater than any other aspect or possible burden that they felt related to their health care. This legislation specifically is talking about prior authorizations related to procedures or imaging studies, so I'll focus focus there. Recently, I had an opportunity to see a woman in her fifties. Just a few days before the appointment, she found herself on the ground seemingly having cast out. She has no history of heart or metabolic or neurologic disease, that this would be common for her, we would expect it. She found it to be a very odd experience, but she felt completely normal when she got up, and so she didn't feel like she needed to be evaluated emergently. She saw me a couple days later, and we reviewed the experience, what she was feeling, what was going on. There was no signs of any active disease. There was no evidence of any recurrence or, you know, further preceding symptoms, which was quite reassuring, but it is still generally concerning when a fairly darn healthy human suddenly collapsed without an explanation. My concern, or one of my concerns at the time, is that she was experiencing a heart arrhythmia, which is an abnormal rhythm of the heart that can come and go, but when it is there, and sometimes that's without symptoms or trigger, it can cause her to pass out. The tool that I have immediately in the office is an EKG, which is ten seconds of heart monitoring, and very unsurprisingly, it was normal. She wasn't having any symptoms at the time and was feeling just fine. What would have what would be very helpful in that situation, what is very helpful in that situation is something called the Zayo patch. This is a sticker that goes on someone's chest, and it sits there for fourteen days. And during that fourteen days, it constantly monitors someone's heart rhythm, so it provides much more context about what someone's heart is actually doing over a period of time. We have a number of these, meaning the Ziopatches sitting right down the hall from my office. The patient was in full agreement with the plan given the concern about the episode as well as some family history of heart disease, but the test required a prior authorization based on her insurance. So instead of me simply walking down the hall, putting the sticker on, and then getting results, you know, basically sixteen days later, we sent the order to the insurance company and waited for the response. Depending on the insurance company, this can take quite some time, days to get back to us. This was a patient who recently collapsed, has a decent risk for recurrent symptoms or a more concerning situation, and I couldn't initiate the test to sort of to help figure out what was going on while she was literally sitting in front of me in the office. Unfortunately, like many folks, this is a human who is working, and her paychecks are very important to her livelihood on a week to week and month to month basis. And she has to take off work to come to the office, which creates a lot of logistical and financial stress. She ended up having to come back four days later, again, missing part of a day of work to get the patch placed because that's that is how long it took to get the prior authorization for the test. I will share another example. It is also quite common that patients arrive to my office with some version of abdominal pain. This can be quite variable, but about a month ago, I saw Mike, who's a patient I've been seeing for a while. He came in with his wife, and for two days, he was getting quite a bit more lower abdominal pain to the point that he wasn't really hungry anymore. He didn't have a fever. He wasn't sick in some way. He has no history of abdominal surgeries. His vitals were lovely. The only things that were abnormal is he looked pretty darn uncomfortable, and then when I pressed my hand to the right lower part of his abdomen and let go abruptly, he exclaimed in quite a bit of pain. By definition, this was called rebound tenderness, and it made me quite concerned that there was an active infection in his belly. There certainly are much less concerning things that could be causing that, but I can't rule those out without further testing, and the testing that's really important there is a CT As I mentioned in my introduction, I work at Grace Cottage, and what I love working at a small hospital based practice is up a single flight of stairs or elevator ride. There is what many of us consider quite basic medical tools, including a CT scanner. If I was working somewhere else for a more isolated practice that I couldn't coordinate this in a timely manner, I would have to send him to the emergency room because realistically, that would be the only option in terms of getting a timely CT scan. Instead, I walked right down the hall to our patient coordinator's office. I reviewed the situation. They opened up the online portal for our patient's insurance, and within minutes of inputting the appropriate information, we had a prior authorization that said that we could proceed with that. We gave him a ride upstairs, and I got a call from a radiologist thirty minutes later that he had appendicitis. I called the local surgeon in Battleboro, and we successfully coordinated his care in a timely manner without a prolonged ED stay. If he had gone to the emergency room at Grace Cottage, we do not have a surgeon on-site, so he would have required an ambulance transfer to any other facility that had a surgeon to then have another ED visit and potential intervention at that time. To me, especially the Mike example, emphasizes the role of prior authorizations really as simple administrative burdens. In his example, as was, I think, clear, there was no thorough review of the medical record on the other end. There was no suggestion of other treatment or evaluation options. We literally ensured that the correct box was checked for, quote, abdominal pain, and then we were allowed to proceed. It, in that case, happened really fast. In other cases, it doesn't. I feel that Mike's example also illustrates the financial burden on health care entities to engage in the prior authorization process. Very few providers that I'm aware of actually engage in this process themselves, meaning the processing of the paperwork or the clicking the buttons, unless sort of the final stage of it is a verbal appeal with a quote unquote medical specialist with an insurance company. Who actually does this are hired administrative staff. So for perspective, in our small institution, we have less than 10 full time equivalent clinical providers. We have one full time administrative staff just to cover the medication prior auths, and then we have two full time patient coordinators that handle all of our referrals and then the prior authorizations for procedures and imaging studies. And as I was reviewing this bill and sort of thinking about healthcare costs in general, this is something I come back to a lot, imagining if we scaled this model as it is to bigger clinics and bigger hospitals and the amount of administrative burden and cost that goes along with processing leads. I really do appreciate the verbiage in H585 limiting prior authorization exemptions to independent practices with what I would hope would be the goal of minimizing all administrative burdens to smaller and perhaps less resourced practices. In my opinion, it is missing an opportunity to allow all Vermonters to access timely testing and treatment no matter where they happen to access care. Grey's Cottage is a hospital based practice, and we are quite literally in the middle of nowhere. We are the resource in the area. And with numerous barriers to transportation in our state, many Vermonters don't have the opportunity or ability to shop around for healthcare based on price or any other factor, even if it was more readily available. And in many cases, they wouldn't want to. The notion of a medical home and cognitive care is really important to many in our communities, and they often feel strongly about keeping their care local. Reducing the prior authorization burden for all practices, including hospital based practices, only reduces the administrative burden and costs for a clinic or hospital and increases the efficiency of appropriate medical care. There are multiple avenues being explored in our state to minimize the administrative costs of healthcare and to improve access, accessibility, and the timeliness of care. I really do feel that minimizing prior authorizations are a clear opportunity to further all of these goals. Thank you all for your time today.

[Alyssa Black (Chair)]: Thank you. Thank you. Chappra has a question, but I have a question first.

[Francis "Topper" McFaun (Vice Chair)]: Chappra, I don't know.

[Dr. Will Everett]: I'll do my best.

[Alyssa Black (Chair)]: First of all, I appreciate your testimony. I so strongly agree with you that a year ago, we did act one eleven, which starting 01/01/2025, if you are a primary care physician, you no longer have to do prior authorizations except for medications, I think. Cover meds. So I'm sorry, I can't do anything about those. However, I'm wondering why you did prior authorizations on either of these two people because both Zio patch and CT scan would have exempted you from having to do that unless, of course, their insurance is one that we don't. So I'm wondering if

[Dr. Will Everett]: Certainly. The very appropriate question is the question that I had myself and have continued over the last year. I know I've not testified before. I'm newer to this process. But I was aware of that bill through the Academy of Family Physicians and in full support of it. When talking to our patient care coordinators preparing for this, I you know, they're the ones who process I asked that same question. The simple answer is it it did not all magically go away, and that's gonna be a very unsatisfying answer because I am clear what the bill showed. But prior authorizations still are, you know, still are at play in a numb in a number of scenarios. For these specific pieces, it could be related to the insurance that they certainly it would be related to the insurance that they had, but I still think that they emphasize, even if I perhaps misplaced the insurance that these specifications were on, it emphasizes the clear burden of the prior authorization process, and as a hospital based practice, this is exactly what it would go back to, if not persist as, if if the verbiage in the bill remains the same.

[Alyssa Black (Chair)]: Yep. Great. Thank you. Topper, did you? Yep.

[Francis "Topper" McFaun (Vice Chair)]: Let's say you have 10 tests that you wanna perform. Okay. And all of them and and just use the experience you've had in this last year. How many of those prior authorization requests have been approved?

[Dr. Will Everett]: Thanks for that question. I specifically I I had about four days heads up for this. I specifically wanted to try and get internal data for us regarding that. I apologize. I don't have an exact number. I'll try and provide it in my written testimony. What is my impression of that, again, having reviewed specifically with our patient care coordinators in the last couple of days, is it can be quite variable. What is my answer yesterday and today to that is my prior, my patient care coordinators are saying it's about fiftyfifty right now. Really? Yeah.

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

[Dr. Will Everett]: And I know this is not in reference to medications. I'm not trying to make it about that. Just for context though, that number is, know, the number of denials and or delay is dramatically higher. My initial comment that this is something that is ingrained in us from the moment we start down our primary care path is very true.

[Alyssa Black (Chair)]: Thank you. Leslie.

[Dr. Will Everett]: Thank you for the question.

[Leslie Goldman (Member)]: Thank you for your testimony very much. I am from your area, so I'm very familiar with Grace Cottage.

[Dr. Will Everett]: Great.

[Leslie Goldman (Member)]: One of the other previous witnesses said there was a concern that specialists were going to run prior auths who work in a hospital system through their primary care colleagues rather than do it themselves. That was one of the reasons why they wanted to carve out this independent practice to reduce, well, to stop that practice, I guess. Now, I don't imagine you have a lot of experience with specialists in that way. But I was just wondering through your experience at work, is that something that is a worry to you? Do you see that as a realistic concern?

[Dr. Will Everett]: Thank you for the question. And I appreciate the disclaimer that I may not have full context there. We do not have any specific specialists on on staff at Grace Cottage. I will lean on I am three years out of residency training. I did my training at UVM, so a much different system than Grace Cottage. My experience there or in reviewing with colleagues is I mean, to be fair, where my mind goes is it's not the providers who are doing this process, it's administrative staff. So whether it's administrative staff via, you know, their title is under a primary care office versus under a hospital specialist group, it is the idea of administrative staff are being hired to then do this work. It's already part of the practice, not infrequently, that specialists will defer, and I don't mean that in terms of delay, I mean defer things back to primary care providers. For example, here we have a small pharmacy, you semi associated with us. If I prescribe for certain insurances, if I prescribe medications for patients, it ends up being cheaper at the pharmacy than if a specialist prescribes the exact same medication to a patient. Again, not trying to emphasize the medication pieces, but just to clarify that in our complex system, there are numerous examples where things sort of fall back on primary care. To me, the emphasis is really on the need for the administrative administrative staff and therefore the associated cost and burden that goes along with it, whether it's housed in a specialist group or an independent practice. If I'm understanding the question correctly, that further, you know, makes sense to carve out independent practices if they don't have the bandwidth for further administrative staff, so more tasks are being put, you know, put on them. I think we could potentially stick with the verbiage from last year to say, is this process actually really necessary for quality care for Vermonters?

[Alyssa Black (Chair)]: If I could. Yeah, of course.

[Leslie Goldman (Member)]: What I'm hearing, and I'm sorry if my question's a bit inarticulate, but

[Dr. Will Everett]: It's okay.

[Leslie Goldman (Member)]: Can you imagine that if a primary care, specialty, physician wanted a PA and wanted to run it through primary care that they might not actually have the primary care clinician touch that PA and it go all through administrative land? Or would a primary care person have to be involved?

[Dr. Will Everett]: Let me try and talk through what I potentially think would happen with that. So I am not aware of a mechanism where, and I'll speak to being here in in Townsend, where an outside provider, knock on staff at Grace Cottage, a specialist, would send an order that then our administrative staff would have to do the prior auth for, you know, that. I do not think there's a mechanism for that piece of it. I suppose so how would that process work? I could be contacted either via a medical note or a message from an outside provider, a specialist, that they would recommend that I order X, Y, or Z testing, and if I am the one that orders it, I and my staff are responsible for whatever paperwork and or approval are associated along those lines. We, I think in general, in primary care and in medicine as a whole, really do work to be collaborative. I think I would say there's many steps between the standard of care and sort of who handles what, and then sort of like me being told what to order by other providers. You know, at the very least is I would be the one getting the results, and if I'm not the one that should be interpreting results, the specialist should be it just creates a delay in care about what's going on. They're the ones evaluating the the patients and the concern. Does that attempt to address your question?

[Leslie Goldman (Member)]: Yeah. I mean, I think I'm understanding it better. I don't wanna belabor it, but it is an issue about picking out the section. And that's the and I think that's what you're asking, right, for us to remove that new language.

[Dr. Will Everett]: That's what would make sense to me is to remove the language. Yes. I think to answer your question from being inside the system, I don't see how the authorization process would change or otherwise, whether it's specialists or primary care. That would be a big shift in the standard of care and the appropriate ordering of tests based on the providers actually assessing the patient and determining what testing is appropriate. I would also further, to be totally fair, I have somewhat emphasized that I don't find the prior authorization really in any way to improve a patient's care. I find that it delays, it limits treatment options a fair amount of the time. So whether it's a specialist that's running the prior authorization or a primary care that's running the prior authorization, if we are aiming to provide high quality care in a timely manner, prior authorizations get in the way of that.

[Alyssa Black (Chair)]: Thank you. That actually leads me sort of to my question, which you have answered. So Act 111 has been in effect since 01/01/2025. The prior authorization piece has for physicians practicing just primary care physicians. Doesn't matter if they practice in the community, in the FQHC, within a hospital. It applies to everyone. This bill is contemplating that we exempt hospital employed primary care providers from the exemption. And I'm wondering, we don't have a report due until next year. So we don't have any data on this. But anecdotally, since this has been in effect for one year, do you feel as though you've changed your practice of medicine and you're ordering a lot more tests than you used to?

[Dr. Will Everett]: Not in any way whatsoever.

[Leslie Goldman (Member)]: Thank you. Let's keep that on the record. Any

[Alyssa Black (Chair)]: other questions for Doctor. Everett? Okay, thank you. Thank you so much for sharing your perspective on this.

[Dr. Will Everett]: Thank you very much for your time. Do appreciate it.

[Alyssa Black (Chair)]: Thank you. Time for the morning. We can go off of live.

[Francis "Topper" McFaun (Vice Chair)]: We'll

[Alyssa Black (Chair)]: be back at 01:00.