Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Hi, welcome back after our extended break, and we are just moving on to some committee education. As we've mentioned many times in the past, we do know that we'll be getting a bill around primary care. It was one of the things that we prioritized in our own discussions at the beginning of the session. And we'll be getting lots of education and discussions in the next ensuing weeks. So I thought we would start with our very first witness, Faye Coleman, and a member of the primary care steering committee that for those of you from last year will remember an S126 and don't ask me the act. 68. So thank you, Doctor. Houghton for coming in.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Thank you. I'm very happy to be here. And I'm still learning the acronym too, and I'm actually the chair of the committee and I still have trouble with the acronym, but it is the Vermont Steering Committee for Comprehensive Primary Health Care.

[Rep. Alyssa Black (Chair)]: Does it sound something fancy when you did? We, I specifically remember, this is not relevant to any of this, but I remember when developing this, we went round and round about names. And one of the things that I forgot to think about was there would be a cool sounding acronym. And I'm sorry, I failed.

[Unidentified Committee Member]: There is

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: no cool sounding acronym. It's all a bunch of Cs and Ps and one V and I can't think of a good acronym for it.

[Rep. Alyssa Black (Chair)]: We can change legislation, so maybe we can come up with a cool one and then we'll amend the name of the steering committee.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: We're just calling it steering committee because we all know that it's all about primary care. Okay. So I'm willing to do this in any manner that works for you all. I have about a five minute statement that I have modified and used in the Senate and also used in a op ed that will be coming up in digger soon. Can just read that if you'd like. I included that in the attachments for your committee. And there's also a list of characteristics of what we're looking for, for a high functioning primary care system that we've worked on in the steering committee. And I could, that's included too, and I can refer to that, read that to you or have that open for discussion too. Unless you, go ahead. Let's start with reading what you have

[Rep. Alyssa Black (Chair)]: prepared already.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Okay, great, thank you. So I'm a family physician at Little Rivers Healthcare. That's a federally qualified health center in a very rural Vermont town of 400 people in Wells River on the Eastern Side of the state. And I've been here for thirty two years. And so what I'd like to share is that after I have been involved with advocacy for primary care through Vermont Academy of Family Physicians, the primary care advisory group to Green Mountain Care Board and now this steering committee. So it goes back a few years. After decades of federal and state health care reform efforts, each with its own catchphrase, acronyms and political perspective, there's one area of profound agreement. If we want to increase quality and decrease cost, we must provide more primary care. Data shows that patients with a primary care provider have better health and lower healthcare costs. That's even more true when patients can work with a healthcare team, get care close to home and get appointments when they need them. As a family physician in rural Vermont for thirty two years, I know this is true, but it's not just my opinion. There's research to back it up. One study shows that for every dollar spent in primary care, 13 is saved in overall healthcare spending. If we want to decrease the cost of healthcare, a critical part of this strategy has to be shifting more of our care, more of our spending into primary care. But changing how much we spend in primary care needs to be accompanied by a change in the way we pay for it. Our current system with a fee charged for each service which is practices to keep every slot full in their schedules just to keep the doors open. As a result, most primary care providers in Vermont have productivity expectations from their employers, and need to move patients quickly in and out of their offices. That leaves no time to see the patients when they need care promptly. And it leads to an increase in emergency room visits and referrals to specialists. A bill in the senate floor this week at s 1 97, but that's the house bill. Do I have that wrong? Is 680 is the house? I might have my number.

[Rep. Alyssa Black (Chair)]: Something like that, but that's okay because we haven't even gotten it yet. So we haven't committed it to memory either.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Okay, I think it's S197.

[Rep. Alyssa Black (Chair)]: We'll know it when we see it.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Proposes to change how we pay for primary care. This system would expand on our existing Blueprint for Health program to provide a fixed monthly amount patient to primary care practices. This type of per member per month payment allows flexibility in scheduling and gives primary care providers time to see our sickest patients when they need it. This will decrease emergency room visits and lessen the delays that patients currently face in accessing specialty care. Monthly payments can be designed to support the things that matter most to our patients. A broad scope of primary care available close to home from a provider who knows them. It can give providers the breathing room for more effective communication with specialists, home health and mental health agencies. A per member per month payment could allow for initiatives that bring care to patients in diverse settings, such as school clinics or mobile vans for a substance use treatment and home visits. The proposed system would also allow practices to invest in healthcare teams to support complex patient care. A healthcare team can have many facets such as on-site counseling, dental care, regular contact with nurses to reinforce self care at home, and care coordinators who connect patients with insurance coverage and other services, such as fuel assistance or transportation. Primary care providers spend 50% of their time on administrative tasks. This is shocking, sad and unfortunately accurate. This decreases access for patients and causes burnout for physicians. The payment system proposed in this legislation would simplify billing, coding and other administrative tasks, allowing primary care providers to spend more of their time caring for their patients instead of their computers. A few weeks ago, I saw a patient who rarely comes in for care. He was booked in a short appointment for a diabetes check, But he also has heart disease, hypertension and depression. I would normally see a patient like him every three months, but he has difficulty getting into the office because he doesn't drive. And he struggles with motivation due to depression and anxiety. It was easy enough to add the hypertension visit on top of the diabetes visit. But we also discovered that he had not returned to his cardiologist after his heart attack last year, and was still taking medication which should have been discontinued. We spent time talking about his depression, and how it makes it difficult for him to prioritize self care. He agreed to see a counselor who works in our office. That felt like a big win. It had been many years since he had been willing to do that. As the visit was winding down, he mentioned several new problems which we had not known about. He brought up balance problems, dizziness, falls, abdominal pain, nausea and vomiting. So we had to do a quick pivot for brief neurologic and gastroenterologic workups to determine how serious the problems were and decide on next steps. Finally, as I had my hand on the doorknob, he asked, Does anyone have time to cut my toenails today? I can't see them and I can't reach them and I can't get a ride to the podiatrist. So we did that too. That is primary care at its best. In that appointment, we did endocrinology, cardiology, psychology, neurology, gastroenterology, and podiatry. That's the kind of care that we are trained to do and that we love to do. But there's nothing our current payment system which makes that possible in a usual office day. That's what makes S197 so important and so deserving of support. Thank you.

[Rep. Alyssa Black (Chair)]: Thank you, Faye. Lots of things I'm thinking about. I'm going to ask if anyone has any questions. I really wanted this sort of more to be discussion. All right, well then I will, oh, topic.

[Rep. Francis McFaun (Vice Chair)]: I have one question. It's about coordination. There's another group of people that have been around for quite a while. I mean, close to twenty two years. The leader is Ellen Oxford and there was a Doctor. Richter that was involved and others. Do you know of that group?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I do, I do. I think that is perhaps Healthcare for All. I can't remember exactly the name, but they've been very active. I think they were very active maybe a decade ago when we were trying to do universal healthcare self in Vermont and then universal primary care also, yes.

[Rep. Francis McFaun (Vice Chair)]: Yeah. Do you have any contact or anything with them?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: So we overlap a bit a lot in in many of the things that we are shooting for and believing in, and we attend each other's meetings and read each other's stuff quite a bit. So, yes, we do have some contact with them.

[Rep. Alyssa Black (Chair)]: I think we have some more general philosophical questions. Okay, so full disclosure, I've been obsessed for the last month with a podcast from the New England Journal of Medicine. Know what not otherwise specified. I have now listened to it twice.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Amazing. She was actually a speaker at

[Rep. Francis McFaun (Vice Chair)]: Vermont. Was with

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: her last call, she's mind blowing.

[Rep. Alyssa Black (Chair)]: You reached out to her to see if she would but I have so many swirling thoughts. So, some of the things that you said and kind of melding together with the premises is that what is primary care and it's the expert generalist who has a longitudinal relationship with a patient, Which is actually really what patients want. You ask patients, what are you looking for in a physician? They're looking for a relationship with a physician that they trust, that they know cares about them. And you talk about this visit that you've got a visit scheduled with the diabetic follow-up on their diabetes, but they also have all these other co occurring because that's what the generalist is. Generalist is able to put the entire body together with all those specialties. And I worry a little bit, we're just coming out of what I'm so rambling, I'm so sorry. You know, we're coming out of one care, which was sort of based on this notion of all payer and value based care. And I'm not sure we ever really defined what value means. And that if we just sort of threw money at the problem that maybe it would solve itself. But I think one of the unintended consequences of what we did was we made primary care responsible for essentially public health. Do you think we dunged down the specialty of primary care? Do you think we do that with prevention? That we put such an emphasis on prevention that you're not able to see people, you're not able to see your patients when they're sickest and need you the most? Because that's my rambling philosophical question.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I heard echoes of that in one of Lisa Rosenbaum's podcasts too, there was definitely a physician there who felt that way. I will answer that this way. I think that there is a clear role for prevention. And I use prevention in my office as a way to just have a touch point with a patient, even if they're completely healthy, don't really need to see me. I like to see them once a year. I call it a physical. It may not be anything that we would all recognize as a physical. I don't even always do a physical exam, but I want them to know me and I wanna know them. And even if that's once a year, when they do get sick, they're gonna know who they're talking to and I'm gonna know who I'm talking to, which is even more important. So for me personally, I don't think the focus on preventive care is getting in the way of taking care of our sick, complicated patients per se. What's getting in the way of taking care of our sick, complicated patients is that we scrape by even with the support that we have in a federally qualified health center, we scrape by financially. And our schedules are jammed full at the beginning of every day, we're supposed to have same day acute appointments available, they're always filled a day or two beforehand by things that seem really acute. And so when someone like this guy shows or someone calls with something that sounds like it's gonna be complicated, The default is we can't handle that today, to the emergency room. So I don't think it's the preventive care that's getting in the way. I think it's the need to flip a certain number of burgers per day to keep the finances working in our practices.

[Rep. Alyssa Black (Chair)]: Know, moving away from fee for service into more of a payment, just a set payment. I still call it capitated, but I don't know what it's being called now. What is it called now? What are we calling it?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Well, capitated can be risk adjusted. So risk adjusted capitated might be one way of putting it. But we did a whole meeting, we did an entire meeting just talking about the terms and how they sometimes overlap and sometimes mean a little bit different things to different people. So you use any term you want, and I'll know what you're talking about.

[Rep. Alyssa Black (Chair)]: Well, I worry about first of all, that we will set a rate and then we will never go back and adjust the rate. So that's my first concern because haven't we seen that a thousand times over and over?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: And that's what's with the Blueprint, which is a little bit different system, but Blueprint payments haven't changed in however many years it's been.

[Rep. Alyssa Black (Chair)]: And the also the the thing that I also concerned about with with having a model payment like that is that, you know, that

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: the

[Rep. Alyssa Black (Chair)]: incentive rather than in a fee for service world, the incentive is to perform as many visits, procedures, things as possible because that's where you're getting paid per procedure.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: And

[Rep. Alyssa Black (Chair)]: which to me in primary care is a good thing. Like that you should be seeing your patients. So it's almost like we And doing small procedures sort of doing all I worry about going Because with the the incentive in the other direction is that you then need more and more patients to keep the lights on and that your panels become too full. In your opinion and in the steering Has the steering committee talked at all about what is the ideal for a full time provider? What is the ideal panel size? If you have equal It's sort of a relative population with, obviously some people have higher needs and some lower, like imbalance. What's a good panel size?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: That is something that is debated a lot, I would say in a broad scope family medicine practice, the number is settling somewhere around 1,200, 1,000. If you have that typical array of ages and complexities. What I think we're really looking at with most of the capitated payment systems are these corrective factors. If you correct for complexity, for age, for socioeconomics, if you have a multiplier on that capitated payment for complexity, then I think panel size could be a lot smaller than that or a lot bigger than that. So if you are in strongly strong socioeconomic area where people don't tend to smoke and they do tend to get exercise, you don't need as big a multiplier on those patients. So there's a number of models for that, for how to build the capitation so that it reflects that. What I really think this just sort of turning it on the head is we really want, with a straight up capitated system, physicians are going to be, providers are gonna be incentivized to take the healthiest patients, right? You still get the money whether they see them or not. That's where it could go off the rails. If you have the right correction factors, what we really want is to have the most complicated patients be the ones that everyone would like to have in their practice, that would stabilize the practice's finances. And there's a really interesting bill in the Massachusetts House. I don't know if you all know about it. It's called PC for you or Primary Care for you. And it's got a lot of different corrections and multipliers for their capitation in there that have really been thought through about, we want to incentivize a broad scope of primary practices. So you get a little multiplier, a little additional if you do office procedures, if you provide substance use treatment, if you provide behavioral health in the office, that kind of thing. It's a it's a really interesting bill worth knowing about. If if it hasn't come across your desks, I have some contacts for that too. But you're right.

[Rep. Alyssa Black (Chair)]: Any payment system and payment systems

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: in different I was just gonna say that it is true that any change in a payment system, you have to look at what you're incentivizing and what you're not incentivizing. And and I think I know that fee for service isn't right for our patients and isn't right for providing good care. I can see that there could be some pitfalls with a capitated system, but I think if it's built right with the correct risk adjustment in it, I think it could be immensely beneficial. Daisy has a question.

[Rep. Daisy Berbeco (Ranking Member)]: I'm curious to hear your thoughts on the process of really operationalizing all of this, the shift to a more value based system, I know that our agency of human services has been doing it over the last, I don't know, eight or ten years with some healthcare providers. It is a slow moving train. And at a time when not all providers have sophisticated technologies to really help them move toward a more measurement based system, as well as all of the federal changes happening so rapidly. How do we align things like the AHEAD model with what we know about this kind of change and trying to afford our providers to make it and what we've charged you with in existing legislation. I'm very curious what the committee sees in terms of direction for the next five years.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yes, operationalizing it is, many of us on the committee, not all are practicing clinicians and we're out there seeing patients every day, and we don't have PhDs in health policy, and we don't work for AHS, many. Some do have those credentials. I don't know that I can answer that question in a comprehensive way and speak for people on our committee. We do talk about implementation. In a sense, AHS has been doing some of these capitated payments to primary care for some years now through Blueprint, although it's a completely different model. It's not all payment for primary care. It's these additional layered on payments for the patient centered medical homes, but they do have some experience in doing that. In the presentations we've had about the AHEAD model, I think there's just still so much uncertainty about what's gonna happen federally that I don't know that anyone would feel confident in answering that question. I'm gonna think about that question a little bit. It feels a bit out of my area of expertise, but I might be able to think of some folks who would do a better job at answering it than me.

[Rep. Alyssa Black (Chair)]: I'm wondering if you have thoughts and I don't want you to any of your colleagues in your claim specialty, wondering if you have thoughts around primary care located within a hospital system versus community based, independent? If you had thoughts around that.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I mean, I think we need all the primary care we can figure out how to get our hands on in this state in any manner whatsoever. So we have folks on our steering committee that are in private practice. We have folks who are in federally qualified health centers and some who work for the university system. And whatever we do should make it possible to do that for everyone. I think the concern might be about a university owned or UVMMC owned one. I think the concern might be that if they were getting these risk adjusted capitated payments, would those payments really be being used in primary care? Everyone else, their reason for being is primary care and so the payments would support that. I think with the medical center, there would wanna be some way to assure that those additional payments were truly used to expand primary care. And that's just a little different when you have a much bigger system overseeing it, but I don't think it's impossible to build into payment system.

[Rep. Alyssa Black (Chair)]: I mean, I worry about that with the blueprint currently. Receiving money from the blueprint, is that going to where it's supposed to be going or incentivizing what it's supposed to be incentivizing? Daisy, you had another question?

[Rep. Daisy Berbeco (Ranking Member)]: Yeah. You mentioned Blueprint and FQHCs. I'm curious what the committee is thinking with regard to integration of mental health and substance use services. I know there are a lot of different models. And I'm just curious if you can talk a bit about what models you might be contemplating right now or at least exploring.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yeah, we talk a lot about healthcare teams and that that team including, based care really includes mental health, substance use treatment, even our relationships with home health, with our specialists, all of those things. It really does take coordination amongst the entire group to give good care. The system that's suggested in the Senate bill would be providing incentives for behavioral or mental health within the practice. And that, I believe that's how it's interpreted. I think that could be written and interpreted in different ways. How does that work with our connection with the designated agencies? And how does that work for independent practices who may not have someone within their walls doing mental health? I think my answer to that is somewhat that I do keep going back to this Massachusetts bill because they seem to have really spent a lot of time thinking about what do we most want to incentivize and how do we work that into a payment system? And I think that my answer to that is the more that that's built into the payment system, the more likely it is to be either cohoused with primary care or easily accessible to that primary care office.

[Rep. Daisy Berbeco (Ranking Member)]: I'm glad to hear that it sounds like thinking of aligning the payment changes and system with where care is delivered and how care is delivered. Because a lot of times it feels like we talk so much about the payment and service delivery reform is in a separate conversation or room. So I'm really happy to hear you mention that.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yeah, thank you. We have some very a lot of folks who are thinking along those terms on our committee.

[Rep. Alyssa Black (Chair)]: You have on the principles that the committee has discussed. Number four, quality measures and other metrics are aligned to limit administrative burden.

[Rep. Francis McFaun (Vice Chair)]: Hallelujah.

[Rep. Alyssa Black (Chair)]: Okay, good. So first of all, when in you your opinion or in the steering committee's opinion, you've discussed, like, what actually is quality? And how do you measure it and should you be measuring it as a function of the payment system?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yeah, it's a really complicated topic. And we did at our meeting earlier this week, we did these little breakout sessions and talked about exactly these things. And I hope to what we're trying to put together is a little more, some specific bullet points for each of the nine charges that we have in steering committee. We're working on that now. So I hope I have a really well defined answer for all of this coming up. But what I would say is what's happened with quality measures in the last decade or so, is that every different insurer or every different program has different quality measures. At one point at my FQHC, we were collecting 164 different data points for various people's definition of quality. We know that's insane. We have entire employees who do nothing but comb through the chart trying to find the data. And we as providers spend a lot of time ticking boxes in order to make it look like we're doing a good job. There was no crisis of terrible primary care prior to us having computers and quality measures and all of this. So I think we a few really basic quality measures. Have you seen your patient in the last year? Like that seems like a pretty good one to me. I used to sort of sarcastically say but it's I'm not that sarcastic about it, I would say that the only quality measure you need is does every Vermonter have a primary care provider and have they seen them in the last year? I think if we did that, quality would go up, and cost would go down. Anything, anything we do in primary care costs less than the same thing being done in a hospital based system. So the first thing would just be everyone is attached to a primary care provider. In terms of other quality measures, I think they could be very basic. They could be, has the patient been in the door? Some really simple ones about screenings for mammograms and colonoscopies and things that we ought to all be keeping up with on our patients, I think are fine. But we're tying ourselves in knots with quality measures that don't make any sense at all. An example would be some places you get quality measure points if you have patients whose diabetes tests or control tests are called a hemoglobin A1C if it's under a certain number. We all know we have patients whose diabetes tests are never gonna be under that number. They have extraordinary challenges and difficulty addressing their own needs. Those patients, we shouldn't be avoiding them or not taking care of them because they're going make our numbers look worse. We should be throwing the doors wide open to them. So those ones that are sort of based on are you controlling the problem well enough, I think are really poor quality measures. I think access and face to face are the most important ones to me.

[Rep. Alyssa Black (Chair)]: Thank you for saying that. Why do we make primary care providers responsible for population health? And I was actually at my own physical, and it's been ten years since I've had a colonoscopy. And my primary care is the one doing a referral to the exact same gastroenterologist that I saw ten years ago. And the onus is upon her to make the referral and schedule it. Why is that gastroenterologist not reaching out to me to get me scheduled?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: It's a great question. An awful lot of administrative things have flowed down to memory care. It's a great question. Yep.

[Rep. Alyssa Black (Chair)]: Great.

[Rep. Daisy Berbeco (Ranking Member)]: Hi, Anna. Yeah. A lot

[Unidentified Committee Member]: of I haven't read the entire book. I'm trying to, like, read through it right now. As somebody who's never had to utilize the healthcare system prior to my aging right now, I find it so interesting. I go to my primary care doctor. Had like probably too much information here, but I've had a lot of symptoms that ended up being a diagnosis after five years. But during that time, he felt obliged to send me to a dermatologist because I had some skin issues and a gastroenterologist for my stomach issues. And nothing was ever found in any of those things. But they keep calling me to go back. And I'm like, when does a primary care physician feel like the caregiver instead of the referral conductor that's trying to just send you out. I would have preferred after nothing was found for my own primary care to follow-up. I don't need to go back to the same person to say that nothing. Do you understand what I'm saying? I just don't understand why don't go Absolutely,

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: we're singing the same song. This is something that's really happened is that, and I think that this bill could potentially address as we are overwhelmed in primary care, it's easy to say, Oh, yeah, have the dermatologist check that mole. Even though most of us are trained to do mole biopsies and can easily do them in our office, but there's an incentive to kind of simplify things and get it off your own schedule. Once you're in derm, you're often getting called back for a yearly skin exam. And honestly, unless you've had a skin cancer, you do not need a yearly skin exam, but the specialties and this happens in all specialty, I'm not picking on dermatology, but we have people going to cardiology for blood pressure management or for well controlled atrial fibrillation, like things that we do every day in primary care. Once they're in the door with a specialist, the system kind of propagates itself they get come back for a yearly check or as every six month check. That is not the case in a lot of other countries. And what we're doing here is we have tons of primary care level work being specialists. That is wildly expensive and it also makes it hard for people to get in specialists when they really need them. And I know we've all heard about the delays to getting specialty care. It's extraordinary in my area right now. Most of our specialty care is through Dartmouth, but there are just extraordinary delays and their schedules are full of people that really are having basically primary care level care. Why does that happen? It happens partly because of the way healthcare is built and paid for that those offices are incentivized to keep seeing those patients back. And our offices to some degree are incentivized to say, sure, you guys take care of this. So I think one of the tenets that we have to think about is let specialists be specialists. That's what we should be aiming for. I think a specialty visit should end with some sort of a box to tick that says this patient is stable to return to primary care, or I am available should they need anything, further care, here's the plan for primary care. That's what's done in a lot of countries. It's purely consultative. You go for a consultation and then you go back to primary care. And somehow in The US, we're no longer just consultative, it becomes an ongoing relationship and it's an expensive ongoing relationship. So we on strength committee have lots of ideas for improving all of our interactions with specialty care so that more of it comes back to us and more of it comes back to us with a clear plan. And I'm I hear you a 100% on that. And you yeah.

[Unidentified Committee Member]: Thank you. Yeah.

[Rep. Alyssa Black (Chair)]: Can I expand on that a little bit? Sure. Speaking of this podcast, of course, one of the things is the person who actually developed like CPT coding and things like that indicated that Great Britain was the only country that he had seen successfully do this and it was a accident of pre World War II where specialists were all hospital based and primary physicians, the generalists were community based and they made them the gatekeeper, like, it was the specialist who actually relied upon getting the referral from the, the independent generalist that has kind of put their system in a little bit better position today than lot of other countries are, particularly The United States. And I'm not advocating in any way, shape or form of going back to a system of HMOs. I never want to fill out another referral again in my life. But do you think that there's a role in which maybe we should go back a little bit to making certain that if people have access to primary care, that primary care becomes the gatekeeper. Then I'm going talk about consultations.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Okay. I've always hated the term gatekeeper because it sounds like a not very intelligent job and that all I'm doing is, I've always cringed at that because I sure don't feel like a gatekeeper in my day to day work. But your point that someone should have a primary care provider who functions to synthesize the information that's coming in and coming in and going out from specialists, I think is a really good one. The system, for some reason, I've talked to someone recently about New Zealand and the system in New Zealand, it is truly consultative. You go to the specialist, they answer your question, they tell you what's gonna continue on in primary care and they come back to you and they don't see the specialist again. I think we would benefit from that here. And again, it's for two reasons, partly it's just that you're paying specialist level for primary care, but also because we can't really get people in with specialists when we need to. And if I were a specialist, I would want it to go that way because you have extra training in your expertise. I don't know why you would necessarily want to be taking care of blood pressure, for instance, if you had done extra years of training in cardiology. That actually sort of leads to my add on question,

[Rep. Alyssa Black (Chair)]: and I know Daisy has one, but I'm thinking, and you have been in primary care for a very, very long time, and there was a time, and I'm wondering if you've seen it progressively become worse, There was a time when there used to be coding for consultations and specialists were able to bill consultation codes which were much higher reimbursed and then those were eliminated. So now they're relying on the same E and M's of lower reimbursements. And I'm wondering about I personally am wondering about the correlation between the fact that they are now sort of competing for the same visits at the same level. And that might be a reason why we're increasing seeing specialty care, taking care of things like, you should come back in a year for your skin check, or I can help you with your hypertension.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I don't know about that change with the consultation coding and whether that's the driver of it. I can say that despite the fact that we're using the same E and M codes, you know it's way, way, way more. If you just look at your bills, you know you've spent a lot more being seen by a specialist than you have in primary care. And so I guess I'm not sure what the driver of that is. But I think, so I guess you're wondering maybe if we should have consultation codes back again and maybe, it's an interesting idea. Then there's a whole system that's built up around that so that many of the times when I send people to ortho or to cardiology, rheumatology, all of these specialists, they're seeing nurse practitioners who are specializing in that area, but it is a different level of training than someone who's been to a cardiology residency. So sometimes that's curious to me too, that they're leaving primary care for, again, for a level of care that I think is more analogous to what we're doing in primary care.

[Rep. Alyssa Black (Chair)]: I'm just thinking back twenty years and it was you referred to the specialist and then you received a written consultation report back from the specialist with recommendations, their expert opinion on this, and the patient went back to you to then Daisy with has a question.

[Rep. Daisy Berbeco (Ranking Member)]: I guess I wanted clarity because when Alyssa, it sounded like you were asking about care coordination and sort of suggesting that we do that. We get handed off to a specialist often and then get our tests done. And then we're left to take the lead on getting them to our primary, etcetera. But we have community health teams at QH that are in the Blueprint. We made significant investment in that. And then we have, I think Vermont has patient centered medical loans. Know we certainly do elsewhere in The US. So there are pockets of coordinated care. And do you think Vermont will ever stick with one model? Like, are we going to mandate one model of coordinated care in primary? Can you talk about that a bit?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I think the, let me think about that. There are many patient centered medical homes in Vermont and that's how you get those additional blueprint payments. I think that the tenants of what you have to achieve to become a patient center medical home are pretty good general guidelines for practices. I mean, it talks about things like that you have a care coordinator on staff, that you offer after hours coverage, or at least a phone number that you can call after hours that you offer extended hours. So the PCMH checklist is, I think has some good things to build on in it in terms of sure, every practice can achieve these things and could warrant getting those payments. Should we mandate it in terms of like, you have to do that to, I think practices probably still want their independence and their ability to say yes or no, I'm not gonna be a patient centered medical home. But I do think the things that PCMH incentivizes are good things for primary care and probably good things for decreasing costs all in all. I was thinking of one other thing I would just mention about that too much care happening in specialty care rather than primary care. Some of the change that needs to happen is really in the patient's understanding of what they can get in primary care. And I've spoken with colleagues, particularly colleagues who took care of a lot of folks who came to the state during COVID, came from more urban suburban areas, their complete understanding of medicine was that the primary care doc was there to dish out referrals. And so figuring out how to really get people to understand all the things that you can get done in primary care, and that's not worse care than what you're getting in specialty. So there's kind of a cultural, maybe even somewhat patient education shift that could really, really be beneficial.

[Rep. Alyssa Black (Chair)]: Yeah, think that was kind of to my point about we've sort of made the primary care specialty more in a preventive referral, and I don't think people quite realize just how skilled you are at doing all sorts of things. Say to friends all the time, Why don't you just go to your primary care for that? And they're like, Oh, I don't think they do that. Of course they do that. Wendy's Yeah, got a

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I think I've had patients be shocked that we took care of infants here. It's family medicine and they were like, Really? You take care of babies here? Same with going the emergency room for stitches. Like, well, I can do that in my office. I love stitching. Like that's fun right there. People really don't understand that. Sorry, go ahead with the question.

[Unidentified Committee Member]: It's really more of a comment that I think you're right. I think it's consumers that are understanding that they can make a choice here. And I don't know how to speak to that, but in a primary care office, just think there should be some sort of bill of rights that says that you don't have to go to a specialty doctor. From Portugal. Or that once they have gone and nothing has materialized from seeing a specialist, that there's some sort of handoff that just says, You don't have to come back here unless something else I think it's consumers that need to be more aware of how they consume primary care. And like I said, I haven't been a consumer until recently, and it was eye opening.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yeah, I think that you're really onto something there. And I think one way to shift the culture a little bit is to have no co pays in primary care, but have co pays if you're going to have co pays, have those in specialty care so that people do just take one beat to say, I wonder if I could do this locally or do this with my own doc. And we could work on some sort of a public education thing, maybe through the professional societies or something like that to show people what can be done in primary care. We have probably your primary care providers do to television screens in our waiting rooms. Like, let's put on that screen, did you know that you can do family planning and stitches and all this stuff? Really letting people know that I think would make a big difference. But incentivizing it from a patient perspective by no co pays and primary care, I think would be worth thinking about.

[Rep. Alyssa Black (Chair)]: Brian has a question, but I just want to, I think one of the things that has happened as a side effect of making preventative care zero cost share is that we have changed the mindset of people of I just go to my primary care for preventive care. And that's the only time I'm going to go because then I don't have to pay anything.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: That's very interesting, yeah.

[Rep. Alyssa Black (Chair)]: And I don't think that was the intended consequence, but I think God has done that. Go ahead, Brian.

[Rep. Brian Cina (Member)]: Yeah, just to you said one incentive would be to eliminate co pays for primary care visits. I haven't seen how S197 landed yet, so we'll read that soon enough. The other side of it to just make sure that you are, you meaning like the primary care providers are being funded, you're being paid to keep your doors open so that you're not relying on those co payments either, that when patients come in, there's some other, in other words, because right now I'm assuming that your business operations rely on co pays because that's part or all of the payment you're getting for some patients. I'm assuming they pay the whole thing because of their deductible, their cost sharing is. So if we eliminate patient cost sharing for primary care, I guess I'm just curious, what would we need to make sure we're doing with payment to make sure that we're supporting the primary care providers?

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Yeah, interesting question. We are definitely struggling more as the cost sharing for patients has gone up and up and up recently and people are avoiding all kinds of care, preventive and otherwise, of the cost sharing. That has been a shift that's been quite acute since really since January, some when things when people started dropping off in large numbers off of the exchange. But let's see to get back to your question. I think what's in S197 is a capitated payment per member per month payment for people who are designated as our own folks, our own patients. That I think would stabilize it immensely because it wouldn't be anything they would have to write a check or hand us cash when they came in. Are already getting that through this universal, not universal, I shouldn't use that word, but through this.

[Unidentified Committee Member]: You can. So,

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: yeah, I think capitation would help with that tremendously.

[Rep. Brian Cina (Member)]: Well, what about, oh, I'm sorry. No,

[Rep. Alyssa Black (Chair)]: was just gonna say, I mean, my dream world is that every provider is direct primary care and the state pay your subscription fees.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: That's a great way to think about it. I mean, we all gnash our teeth a little bit about direct primary care and that it's just one more way for people who have resources to get healthcare and have less access for everybody else. But the of direct primary care are more time with your primary care provider and more time with your patients and less administrative garbage. We got to pay attention to those drivers. And then I was going to go back to Rep Campion's question. Nope, I got the wrong name, Cina. Is great.

[Rep. Brian Cina (Member)]: Wrong Brian.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: I know.

[Rep. Daisy Berbeco (Ranking Member)]: Retired Senator

[Rep. Alyssa Black (Chair)]: at 10PM from your Yeah,

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: you can tell when I was last there, right?

[Rep. Alyssa Black (Chair)]: This

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: universal payment system for primary care that's outlined in 01/1997, there is a big question to me about what happens to the completely uninsured. The way S197 is built is that everyone's primary care payments go into one bucket and the capitation goes out from that bucket. Patients with no insurance, I'm not sure what happens with them. Probably kind of what we're doing now, fee for service when they can afford it, when they can pay for it. So that's a little bit of a wild card, I think.

[Rep. Alyssa Black (Chair)]: Last question, because we do have to

[Rep. Brian Cina (Member)]: Yeah, it was related to that topic though, which is I think so, and we don't have to answer it today, but I think the trick is, if we could establish the capitated payments for the people who have the established relationships and the coverage, We just need something to fill in the gap for uninsured patients and for people who don't yet have a primary care provider because they've been under insured or whatever, not naming anyone specific, but like myself, who doesn't have one anymore, how do we get into the system if the system's already clogged? And maybe it is looking at how do we fund our clinics for the uninsured and free clinics, and how do we maybe coordinate care between free clinics and primary care practices better? But we can figure that out another day. It'd be good to hear your thoughts on it down the road though, of of like what might be some creative ways to fill the gap without actually just charging people, like, the full price to come in for a primary care visit. Maybe there's a way that the provider can build a state for those people, or there's some program, or I don't know.

[Rep. Alyssa Black (Chair)]: Or maybe all of our clinics could be free.

[Unidentified Committee Member]: Brilliant. And

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: that goes to another thing we talk about a great deal in steering committee, that's recruitment and retention. We don't have enough primary care providers now. That's obvious. There's a huge drop off coming because we're all my age or older. And that's really going to be a problem for this system. But I still don't think it's a reason not to do the system. Like not doing anything just doesn't make any sense at all. I feel like if we made a good system that was functioning, that that in itself would be a recruitment and retention tool, but also things like decreasing administrative burden and having really high functioning teams, I think would else actually help with recruitment. So I think it could be overcome and we have lots of thoughts on that in steering committee.

[Rep. Alyssa Black (Chair)]: Thank you, Doctor. Houghton. Really appreciate the work you're doing. I'm loving all the meetings you all are having And I'm really interested to keep the conversation going with what is coming out from that and the very important perspective you all bring.

[Dr. Faye Coleman (Chair, Vermont Steering Committee for Comprehensive Primary Health Care)]: Well, you so much. Happy to be here and I'm happy to do more or loop in other folks on our committee for anything you're interested in.

[Rep. Alyssa Black (Chair)]: Great, thank you very much.