Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good afternoon. It is Tuesday, March 31, and we are continuing I'm trying to think are we continuing or are we starting doing a little bit deeper, continuing a little deeper dive into primary care. We do have SB 97, which came over last week, and that's the bill from the Senate regarding primary care. So I'm intending to take testimony. I'm going to lay this out here just for everybody from the beginning. We're going to do walkthroughs of all the bills that we have on our wall that pertain to primary care. I want to be very clear that obviously it is post crossover, so it's not like we're taking up any of those bills, but we're using the walkthroughs as committee kind of education, things we want to be thinking about as we look at S197. And prominently featured in S197 is the blueprint for health. So Doctor.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Soraya is in with us today. Thank you, Madam Chair. You. May I? This year? I haven't, so I would Oh, yeah. We could start with some of the new folks, though many of you are familiar.

[Alyssa Black (Chair)]: So do an introduction or a wrap. Likewise. Leslie, do you want to start? My noble. Yeah, Leslie Goldman representing Rockingham, Westminster, and Brooklyn.

[Karen Lueders (Member)]: Karen Lueders representing Lincoln, Stuxborough, Bristol, and Mountains. Addison four. Debbie Powers, I represent Waterford, Barnett,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: and Michael. Barnett, is that what you said?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: And Tasha, you wanna introduce yourself? I'm Tasha Cloudera, I'm the committee assistant.

[Allen "Penny" Demar (Member)]: And I'm Tasha Clouderaun, and I represent Barry Teller of Potawattingstown.

[Alyssa Black (Chair)]: And I'm Alyssa Black, I represent the part of the town of Essex. Wendy Critchlow, I'm the Bayside Of Colchester. Val Taylor, Route 111, so I have Killington, Pittsfield, Mendon, and one other one, Chittenden. I

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: was gonna say that this is a good idea. I should, it's actually on here now.

[Alyssa Black (Chair)]: It's a little upside down.

[Allen "Penny" Demar (Member)]: Allen Demar, I represent Enisburg and Montgomery. You're the Canadian board.

[Alyssa Black (Chair)]: Oh, online? Daisy and Brian?

[Daisy Berbeco (Ranking Member)]: Hi, John. It's Daisy Berbeco representing Winooski. Sorry to not be there in real life. I'm home with sick kids.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Understood. Thank you, Daisy.

[Brian Cina (Member)]: And this is Brian Cina representing Chittenden 15 in Burlington, and that's the East District and part of the Old North End.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Hi, Brian. Black, I'll introduce myself, and I think I'll have you introduce yourself, Doctor. Armstrong, maybe when you forget to use slides, it'll be great. I'm John Saroyan. I'm the executive director for the Blueprint for Health at the Agency of Human Services. I'll try not to talk quite that fast the whole time, but for the introduction, I think it's okay. I began this role in January 2022. Prior to that, I was a hospice physician in Vermont and New Hampshire and a regional director for hospice from 2013 in Vermont when I arrived from New York City, where I was a faculty member at Columbia University, and my areas of specialty training beyond my pediatric boards was palliative care and pain management and end of life care for children. So I have worked my way from the very grave ends, I guess one could say, of serious illness through adult work, which I did as a hospice physician in many, many homes and many of the towns that you all were seeing, seeing people in person, and now working for the state in this role of the Blueprint for Health executive director. And it's a real honor and privilege to return to House Health Care for an overview of our program. I will stay on track as best I can so that there's time for questions. Please do interrupt me, and Doctor. Armstrong will be presenting some of the outcome data from Blueprint for Health in the last few slides of our presentation. So thank you, everyone. Move this bar here. Okay. Twenty years, The blueprint for health was codified into Vermont statute. 2006, first pilot site was in St. Johnsbury Health Service area. I still keep in touch with some of those early individuals who helped bring community health teams and patient centered medical home to the foray, and I'll talk more about all those terms for those of you for whom they're new. In 2010, Vermont was included among one of eight states selected for a multi payer advanced primary care practice demonstration. I'll talk some more about what that means to be multi payer as opposed to single payer. In 2011, ACT 128 shifted the blueprint from a pilot to a statewide program, so we're fifteen years past that. And in 2013, a term that has become familiar around country, really, not just for opioid use treatment, but for other conditions, including Alzheimer and other dementias, the hub and spoke model came to be where opioid treatment, frequently the most intensive day to day work of clinicians, was strengthened by the ability to receive opioid treatment in clinics, practices, primary care, and I'll go into more of that too. Our formerly known Women's Health Initiative, which is now called the Pregnancy Intention Initiative, and it's more inclusive of a term, was started in 2017. 2022, so that was my first year. Act 167 required a recommendation on the amount to increase commercial and Medicaid contributions to our community health teams. And in 2023 to 2026, the legislature approved funding for a two year mental health integration into primary care pilot, which we were able to continue into state fiscal year 2026 with that funding that was allotted, and I'll speak more about that program and all of those programs and their outcomes. Just recently, in the first half of our current biennium, the Vermont Steering Committee for Comprehensive Primary Health Care was created, And as statute dictated, I convened that roof before 09/01/2025, and it has been meeting monthly. And I know you all have heard from Doctor. Houghton at least once, maybe a couple of times. And she's been speaking in the Senate Health and Welfare too. So Doctor. Houghton chairs that committee. Also, in just 2025 at the end, Blueprint released its 2026 to 2031 strategic plan, including our mission, vision, and values. That's not something I'll be going into today, but that as well as our annual report are valuable documents to pursue in more depth for the details of our programs, our payments, and health service areas where you all represent Vermonters like me. So the Blueprint structure is focused and surrounded and centered upon that individual Vermonters. And Vermonters residents here engage in Blueprint through their primary care, their primary care practice, and sometimes, firstly, through a member of our community health teams, both of which ideas, these medical homes, the standard of care and community health teams that I'll go to in more depth. Our practices receive support not only in dollars that I'll talk about with our payment models, but also from individuals, program managers, leaders in their area, their region of the state, in overseeing the many community partners that are brought together around practices. And they're also supported by our quality improvement facilitators who are trained professionals in quality improvement activities specific to health care. And the aspect of Blueprint that I think people, not just in Vermont but around the country, identify mostly with us in the Blueprint is our community health teams, which I'll speak about as well. The Blueprint assigns practices to a health service area where that administrative entity helps funding for the community health teams and other supports, and I'm going to show a map in just a sec about what those are. So currently yes, Leslie.

[Leslie Goldman (Member)]: Thank you, Jill. The quality improvement facilitators, are you going to

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: go into more I am. Okay. Yeah, absolutely. And if I don't, please remind me. But that's this next slide, actually. I'm going just take a sip of water, excuse me. So a patient centered medical home is a model of primary care delivery that seeks to provide accessible, comprehensive, whole person centered care in a coordinated and team based fashion. The components of that combine prevention, acute care, chronic disease management, and other services in a single setting, patient centered medical homes. So this isn't actually a building, it's a concept, it's a philosophy of delivering care that's been codified by the National Committee on Quality Assurance, which began in 1990, the national nonprofit organization that sets standards in primary care and also in other aspects of health care. There's a term we have for you all our glossary, which we continued year to year. I encourage you to open it up. I still reference it. And it codifies measures that we use, outcomes measures too, as well outside of primary care. Studies, many studies, indicate, demonstrate that attaining National Committee for Quality Assurance standards year over year improved clinical outcomes, increase patient engagement in follow-up and treatment, and decrease utilization of the emergency department. To Leslie's question about quality improvement facilitators, they're trained professionals who not only help practices in the application of recognition by National Committee on Quality Assurance, they also work with individual clinicians and leaders in practices to meet the many other quality pursuits that practices and individuals pursue, whether that's from another insurance, an ACO, or NCQA itself. So Leslie, just to get back to your question, that's a resource available to the practice. But go ahead with your question about quality improvement facilitators. Two questions.

[Leslie Goldman (Member)]: One is, how many practices does the quality improvement facilitator work with? And how are the measures determined?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. So the number of practices that a quality improvement facilitator works at, I'll have to come back to you with the actual number. I can give you the range in my head, but I can follow-up with you all in terms of the number of practices. There is a ratio. It's just a little outside of my specter right now. And then your second question, please? What are they measuring? Oh, sure. I'm going to answer that. Yes. So our health service areas are based upon the Department of Health's hospital service areas and are shown on the map on your treatment that you all can see. The names of the health service areas are paired with the administrative entity throughout. So Windsor, Springfield, Brattleboro, Bennington, Rutland, the administrative entity has to have the ability to receive multiple payments from multiple insurers and distribute those out to community health teams in a variety of arrangements. And they have to be a CMS, that's Center for Medicare and Medicaid Services eligible provider. To be an administrative entity is a lift. It's an administrative lift that they provide to that service for the health service area they're in.

[Alyssa Black (Chair)]: So every single health service area is administered, I correct? Every single service area, the administration is done by the hospital in that area. Except for Springfield. Except for Springfield. And North Star? Is an FQHC. They're the administrators of that.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. The community health team, who they may include: nurse and social work care coordinators, licensed mental health counselors and alcohol and drug counselors, licensed clinical social workers, community health workers, nutritionists and dietitians and health educators. Services are provided at no cost to patients or providers and are not billed to insurers. They support individuals by identifying root causes of health problems, addressing and identifying mental health needs, screening for social determinants of health, needs around housing, food, transportation, finance, and providing team based care when it's indicated so that people really get wraparound services that are in addition to that medical care that I was trained in, in medical school. They serve, care for, and connect patients through providing brief interventions. Brief interventions are structured, evidence based, usually time limited interactions that focus on identifying, motivating, and bridging and giving a warm handoff to services that might be needed in a more sustained way. Supporting management of chronic conditions, coordinating care, and supporting improvements in well-being through team based care. So this is a quote from a patient working with a Blueprint nurse on the community health team. I wouldn't be a successful productive member of society if it weren't for her believing in me when I didn't believe in myself, caring for me more than I cared for myself and guiding me through the darkest of times. And each year, our annual report contains multiple quotes from patients, community health team members, providers by health service area, and we drew this quote from the annual report.

[Leslie Goldman (Member)]: Go ahead, Debra.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Oh, thank you, sorry, yeah. Where is the doctor committee? Sure. The provider is typically the appointment that is scheduled. So a person might have an annual wellness visit, a person may have a need, an illness, A person may have a chronic condition like diabetes that they need to see their provider for. So they would check-in at the and I go to patient seven medical homes. I'm Okay talking about it. I check-in to or a person can check-in, they see their provider. And if need suggests, either through a questionnaire or something that comes up in that appointment, that a number of this team may be beneficial, helpful, and the person's accepting of it, they would then include a community health team. The provider is still the leader of their care and still their point person. That may change over time, but the provider is definitely always involved and briefed by any work that the community health team does. This is additive. So, hubs and spokes. The opioid treatment programs for more intensive treatment around opioid use disorder can dispense a variety of drugs beyond buprenorphine. Vivitrol and methadone are two of them, and they have a higher amount of staffing intensity and ability to follow individuals who need that individual treatment for their opioid use disorder. And the Division of Substance Use Programs in the Department of Health oversee our hubs. The term is opioid treatment program in Vermont, we call them hubs. And I think there's the map. Spokes exist not only in our patient centered medical homes, our primary care sites, our practice sites, but also in specialty. So our spokes have grown both in terms of the numbers at patient centered medical homes and in practices that specifically work in addiction. The term more nationally for them is OBOT or office based opioid treatment, but in Vermont, we call them spokes. The funding that Blueprint is able to direct is for a full time nurse and licensed addiction mental health counselor per number of Medicaid members serve. And the community health team administrative entity moves that money to those folks sites to pay for those individuals. So Topper, to get back to your question, the individual still sees their provider for their treatment of their opioid use disorder. They receive a prescription, they receive treatment, and there's a nurse and a counselor who's available to help them with other things that might be going on, work applications, anxiety, panic attacks, seeing that cardiologist because they just got discharged from the hospital for a heart condition. So the provider's still right there, Blueprint, through the mechanisms that we've developed and that I'll elucidate in greater detail, is paying for other individuals to be part of their care team. Patients may go between the opioid treatment program and the office based opioid treatment. Like I was just saying in answer to your question, they do that work in conjunction with the primary care provider. Also in Vermont, we have rapid access to medication assisted treatment in which our emergency departments serve as places to start opioid use disorder treatment. That's also overseen by our Department of Health, and then help individuals get longer term care within specialty or a practice based setting that's not the emergency department. I know there's a lot on that map, but to me, it's to communicate to you all just the number of sites that are available. There's the close-up of Burlington. There's the close-up of Rutland, and you can see how they're distributed across our state. The plus signs with the background, this sort of rosy pink, are the hubs, and the yellow dots are spokes. And when there's a number in the middle of it, that means there's multiple practices right in that area, but we didn't show you all the dots. So that's the Hub and Spoke program, established in 2013. The Pregnancy Intention Initiative is comprehensive family planning counseling that's offered in addition to the medical care that the provider in a primary care practice or in a specialty practice will And the screening that goes on there includes the one quick question, which is, do you want to get pregnant in the coming year? With enhanced screening around mental health as well, I'm sorry, Lori. I got Which also can include brief intervention and referral to services. Present in that program also are increased access to contraceptive counseling, which has been shown to be effective in reducing the rate of unintended pregnancies, same day access to long acting reversible contraceptives, and or moderate to most effective contraception. This program, like the spokes, is also funded only by Medicaid. It's available, like spokes, to all individuals of all different insurers for no insurance, but expended by Medicaid. And I have a graph that I'll show or a grid that I'll show that shows our payers more clearly than this. Participating practice yeah,

[Leslie Goldman (Member)]: go ahead, Leslie. You may be getting to this, so I'm sorry. What outcomes are you measuring in this space?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. Let me get to that when we get more to outcomes. Thank you, though, for asking. So outcomes is a really important thing for us to come back to. Great. And then we have funding for staffing and specialty practices. So there's the community health teams that are primary care practices would serve them. If it was an OBGYN practice, they would actually get additional funding for that. The mental health integration into primary care pilot that I mentioned in the line that I gave you at the beginning around our history was a $16,000,000 appropriation allocated for a pilot to increase community health team services by embedding mental health providers in primary care. So with this money, we augmented, made more specific, and were more prescriptive about what community health team composition was. When we looked at community health team composition and we stepped back, we saw and we heard that more expertise in mental health was needed. So that's what we did in addition to the community health team dollars and teams that were already there. We were able to add more support for mental health, substance use, and social drivers of health. We were able to embed, in many, many cases, those individuals within primary care practices. They still kept their physician. They still kept other providers. And this was additive. We also had a variety of education opportunities that we offered with that appropriation and really worked hard to improve the screening that goes on in practice as well through our quality improvement facilitation. And we will have some outcomes on this too as well, I think, coming.

[Alyssa Black (Chair)]: People indicated at the beginning that this was a two year pilot through fiscal year twenty six?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: We were able to identify unspent funds to extend it a third year without additional appropriation.

[Alyssa Black (Chair)]: Okay, so what happens after next year?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: One of our initiatives through rural health transformation is identified that's closely linked to this, and we're working very hard to continue the program with those federal dollars.

[Leslie Goldman (Member)]: Can I ask a quick question? You said in one of your earlier slides, slide five, one hundred and twenty four patient centered medical homes the state. Do you

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: know the denominator? Sure. So it varies in terms of the time of year and who's opening and who's closing. I believe our latest count, which we rely on our program managers for and also phone calling and googling, I believe the denominator is 168. And I can follow-up with you. Can follow-up with Two thirds of

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: the 5%. It usually hovers between two thirds and 75%. Okay, that's helpful.

[Alyssa Black (Chair)]: I'm sorry, I just wanted to go back to the funding for a second. Oh, sure. You said that you were able to identify unspent funds. Okay. So I'm assuming of the 16,000,000 over two years, you did not spend all 16,000,000.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And that paired with legislative language that extended the pilot was able, that was how we, yes, I believe that was how we were able to do it, that's correct.

[Alyssa Black (Chair)]: Okay, how much has been spent on it so far?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: We can give you that exact number, Chair Black. Maybe we could follow-up with the exact number, though I know you could probably do it off your It'll be spent down to zero by June 30.

[Leslie Goldman (Member)]: Well, that's my question.

[Alyssa Black (Chair)]: At June 30 or twenty seventh?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: No. Twenty sixth. Yeah.

[Leslie Goldman (Member)]: Okay. So there's not gonna be any money left on the table.

[Alyssa Black (Chair)]: Where'd you find the money to extend it for another year then?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: We are working with the Rural Health Transformation Initiatives to fund it. Okay. Going forward July I'm sorry, I'm just

[Alyssa Black (Chair)]: a That's okay. Little You indicated that there was unspent funds that you were able to expand it for another year, a third year. Yes. This would be FY '27.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Oh. It started in FY '24. It started in July January 2020. That makes more sense. Thank you. '25, we had the appropriation. '26 was unspent funds. Now we're out of cash.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. That helps. So what

[Leslie Goldman (Member)]: didn't get funded if it was unspent?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sorry, sorry, what?

[Leslie Goldman (Member)]: What didn't get funded if

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: it Positions was unspent were hard to fill. There was a runway.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Yeah, was the runway. It wasn't actually that it wasn't filled eventually. It's that for the first six months, the physician is saying it's that by the six months on the other.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That's Doctor. Addison Armstrong.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: I'm Doctor. Addison Armstrong. I'm the health services researcher with Blueprints, for the record.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So a few more quotes before we go on to details of payments. So a Blueprint program manager, we're not just improving systems, we're building a stronger, more connected future that addresses social drivers of health. Through Blueprint supported initiatives, we are shaping a responsive, collaborative system that rises to challenges and delivers on the promise of a healthier community, A community health team member, Blueprint's community health teams connect people to resources that address the full spectrum of health needs from housing and food insecurity. Because we're local to the area, we understand the unique challenges Vermonters face in each community and can tailor our approach to support them effectively. And finally, a clinician. A family going through a major transition shared how grateful they were to have access to support during the process, not after. Without Blueprint's integrated care model, they likely wouldn't have received help at all. Being able to connect with a clinician in the moment within their trusted medical home made a meaningful difference. It allowed them to navigate the emotional challenges of change with guidance and reassurance rather than waiting until things reached a breaking point. So I'm going go over some definitions of value based and capitated payment programs and then Oh, sure.

[Leslie Goldman (Member)]: I'm pleased to know Sorry, please. Go ahead, Leslie.

[Alyssa Black (Chair)]: Do you

[Leslie Goldman (Member)]: think there's a difference in turnover in practices that are involved in the blueprint as opposed to not? I don't think we

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: tracked that. So you're asking a difference in turnover of which patients, staff? Staff. I can speak anecdotally to it, but I can't speak from a data perspective on staff turnover. Are they saying? When I do my visits, it's very common for me to meet community health team members who've been there from the beginning of the program, because they tell me it's the best job they've ever had.

[Alyssa Black (Chair)]: Are there community health team members that leave community health teams and become just embedded billable providers within practices?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: To what degree that happens, I don't know, but that does happen to a degree. The other thing that I've heard, just to build on my answer to your question, Leslie, is that providers also tell me that they wouldn't be able to operate, survive, continue doing this work, these supports through community health teams help them not to retire, keeps them longer. I've also heard, and again, this is all anecdote from traveling to state, talking to people, going to lots of practices, is it helps us to recruit because applicants are wise to the supports that they get in practices. They're wise to quality standards and what that means. And so it's also not only just a retention tool and strength, it's also effective in recruitment.

[Alyssa Black (Chair)]: Is that anecdotal or did Yeah, you have

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: for sure. I mean, again, I try to bring to you all everything that I have, the data, the anecdote, etcetera, the quotes. Brian?

[Brian Cina (Member)]: Yeah, have a question. It goes back to something earlier, but I didn't want to interrupt over Zoom. And now that people are asking questions, I'm asking. But before I ask it, I have a first question would be, are the community health team members placed in practices? Are they paid for by the state, not the practice? Who's their employer and where's the money coming? I know the money's coming from Medicaid ultimately, right?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: No, it's more than Medicaid. That's actually my next couple of slides is to show you all the payers.

[Brian Cina (Member)]: Okay, so then let's hold on that question. And let me ask you the last one, which is, we learned that 57% of our opioid treatment programs are operated or involved with private equity firms. The hubs? Yeah, or the spokes, maybe, I don't know, because 57% of the system is just the hubs, I don't know, actually. But we lend that 57%.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Are we using government money to place workers in for profit private equity firm backed facilities? I think that's the question. I hear your question, and I'd be happy to bring back an answer on the number of spokes, and I just don't know off the top of my head the number of spokes. I probably just need you I wanna make sure I got the question right. So I can bring that back to you for sure. I don't see a problem. Might take a few days to figure out, but

[Brian Cina (Member)]: And I can give you the information that we got on the record about the numbers, so maybe that'll help you.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's familiar to me. I just want to make sure I answer your question really specifically. I don't think that'll be a problem. All right, so value based payments. So there's fee for service. There's the provider, the claim that's generated that typically goes to the insurer, the patient that's responsible. That's fee for service. That exists. That is what I'm talking to you all about is in addition to value based payments. Value based payments are a payment system that pays for quality of the program that's meeting standards and achieving outcomes. So we, through these directed payments from multiple payers, pay to meet the standards, pay for that quality of service, and there's also payments tied to achieving outcomes. We do both. And most Blueprint initiatives are funded through a per member, per month payment system that's made by Medicaid, our three commercial insurers, and up till the end of last year, Medicare as well. The amount varies in terms of the payment based on the program. The quality measures for a given practice, I'll touch on that as much as I can, but may run short on time to going

[Alyssa Black (Chair)]: ask later because I don't

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: have that question. Yes. Type of payment is called a capitated payment. So capitated payments really are synonymous with that per member per month. And they're typically associated with value based payments.

[Alyssa Black (Chair)]: I think Daisy might have had a I saw a hand up.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Daisy, you took the hand down. I did, but

[Daisy Berbeco (Ranking Member)]: I took my hand down because I think we're getting at it, but just so you know, my interest is around provider payments and rates and the variation between blueprint practices and Absolutely. Other

[Leslie Goldman (Member)]: So could you also maybe talk about how one becomes a Lutheran practice. Sure, sure. This might not be the time, but I am curious

[Alyssa Black (Chair)]: because you

[Leslie Goldman (Member)]: said 124 out of

[Alyssa Black (Chair)]: 150.

[Leslie Goldman (Member)]: Absolutely, absolutely. Why choose to, why not?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure, yeah. And the standards that are published change from year to year by the National Committee for Quality Assurance. That first year recognition is definitely a lift to document the policies, the procedures, the standards, the access, the case management. And all of that is work that is done through an attestation system. About 6% of our practices are actually audited by the NCQA each year. So that means they receive additional questions. But the standard practice of yearly recognition is through submission of multiple forms of documentation. It has to be work that's done throughout the year, Leslie, not just during that one. They document have what all the different things that they were doing throughout was to show continuous quality improvement and that commitment.

[Leslie Goldman (Member)]: Is it valuable, that process?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's a heavy lift and it is valuable.

[Leslie Goldman (Member)]: Can heavy It's I ask, was it valuable to?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, sure. Our patients, our quality standards, our payers, and nationally, the evidence backs up NCQA recognition as the slides that I showed you early on in terms of quality of care and reducing emergency department visits and curbing the cost curve.

[Alyssa Black (Chair)]: How much you called it a heavy lift.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. What are

[Alyssa Black (Chair)]: I mean, what goes like, how many things do they need to submit to?

[Leslie Goldman (Member)]: Sure. Who's listening to?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. I can bring all of that to you all in great detail for you. Absolutely.

[Alyssa Black (Chair)]: I mean, I was earlier today trying to look up what the NCQA quality standards were, and you can't even find that online.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Find a firewall.

[Alyssa Black (Chair)]: Purchase. That's correct. For $460 by the way. And then they will tell you what that is. Do practices have to incur that cost? Practices do have to incur that cost. Yes. So to become NCQA certified, you have to go through a certification process.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Recognition process, yes.

[Alyssa Black (Chair)]: And each year, you have to continue to

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: meet those standards. They change based on evidence.

[Alyssa Black (Chair)]: Tucker, did you have a question?

[Allen "Penny" Demar (Member)]: Yes, I do.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And Allen, did I see your comments? No, I'm okay. On page seven. Oh, okay, of slides? Okay.

[Allen "Penny" Demar (Member)]: It says services are provided at no cost to patients or providers and are not billed to insurance. And then now we're getting into, and maybe I don't understand- That's okay, yeah. We're getting into how payments are made and so on.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I'll show you. To get to payments, the number of members a payer makes is determined by the payer's attribution. So getting the payments, getting to the dollar amounts, this is an important step to understand, and I'll explain it as best I can. There's a standard algorithm the Blueprint uses to define attribution for a practice. What does it involve? It involves looking back over the past two years of insurance claims. This is done by an analytic vendor. We're not actually looking at the claims ourselves. They're de identified, it's done by a vendor. So there's a look back at two years of insurance claim. There's counts of the numbers of patients with at least one of a list of very specific visit codes at a Blueprint provider, which are published in our Blueprint manual and updated. And then there's a rubric, an algorithm, that assigns that attribution to a particular practice. So if an individual is seen in two different places in an equal amount of time, it's the most recent visit to the practice they're attributed. Why do we go through all this? Because for decapitated payments, for this value based payment, we don't want to double dip. We don't want to charge that payer twice. So there's a rigorous approach to it. So the total 332,606 thousand 500 patients had claims at Blueprint affiliated practices in 2024. However, two hundred and ninety three thousand eight hundred and forty seven through this algorithm were attributed to blueprint practices. Then the practices receive a payment, and I'm gonna go through those dollar amounts and cents amounts next, for each attributed member.

[Allen "Penny" Demar (Member)]: This is a this is

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: an important step to understand about the mechanisms by which value based payments occur. So there's a dependency on the claims, but there's also an independence from the claims in terms of the payments are coming because you're proving that you give quality care, you give quality care. There's also other ties there. What happened to

[Alyssa Black (Chair)]: the patients?

[Allen "Penny" Demar (Member)]: I'm sorry, Alyssa, what?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: What happened to

[Alyssa Black (Chair)]: the other 40,000 patients?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure, so some of them were seen at a practice that was in two places, and we had to choose which practice to assign them to. Okay, got it. Sorry. So, we don't want to double dip. We need to make that decision to assign to one versus the other based on the quantity of visits they've had, the most recent visit they had. Leslie has a question.

[Alyssa Black (Chair)]: I bet you I know what it's gonna be. Go ahead. No. I want you to ask it. So

[Leslie Goldman (Member)]: what about Yeah. It seems skewed towards the sicker people because they're being seen. Like, people in their thirties don't necessarily need to be seen every year or may not come into a practice in a two year period. So I'm wondering about that. Is it skewed towards sicker people? What about spreading risk across the population?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Our practices are made very aware by quality improvement facilitators and the NCQA standards of the importance of an annual visit for their patient population.

[Leslie Goldman (Member)]: Even in their 30s, even people in their 30s?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That's what we communicate to them. It's important. That's part of our standards.

[Leslie Goldman (Member)]: We've been debating.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I know it's a debate for sure. No, I understand. I understand the debate. Yeah. Thank you. Okay, thanks. Some outcomes, some quality, and this is really just touching the surface of it, but you have been asking and I wanna show it. So there's a performance payment, it's a component of that capitated payment. So there's the payment for the recognition of delivering high quality, advanced primary care. And there's a performance payment that's based on the following. In 2026, the performance payments were calculated. This would be in addition to what we call the practice payment to the percentage of child and adolescents with an annual well care visit between 12 and 21 years old. That's important. Percentage of children up to three years of age who have a developmental screening, really important interventions that can be offered in those first three years if something's identified versus later. Percentage of individuals with hypertension in control, percent of individuals with diabetes not in control. In addition, there's a total resource use index, which looks at total cost of care compared to peers. So looking at a provider and a practice's ability to manage a panel of patients, what's the total cost of that compared to their regional peers. Additional measures, we've also had calculated in preparation for some updates to our payment performance measures. But this is a snapshot of the ones that impact the dollars that practices receive.

[Alyssa Black (Chair)]: I see Brian's handout clip. Has been an ongoing discussion and I'm happy that you have this as one of your I look at these and I think the payment that you're paying to a blueprint provider is based upon the percent of the individuals in that panel who have their hypertension in control or their diabetes not in control.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: A component of the pain.

[Alyssa Black (Chair)]: A component of the pain line.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And I

[Alyssa Black (Chair)]: keep going back to, would we ever over decide how much we're going to pay a cardiologist based upon their patient population and the number of patients they see that smoke? Would we ever say, yeah, more of your patients smoke, so you're going to get less money and this one who has fewer patients who smoke, they're going get more money than you. What difference does that make in the quality of care that that provider is giving? There's two things, if I

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: can just sort of step back, because your question about subspecialists is really important too, though it may draw me further away from my area of expertise during this talk. Our payments and I'm going to show them to you here. That base payment, that's for delivering high quality care. Individual patients make their own choices. And we're not going to hold practices solely responsible for the performance in those measures to get payment. And again, this is the verbiage. I really try hard not to use lingo. But it's a prospective value based payment, that base payment from the commercial or insurers. You're paying for that high quality standards to be met in those practices. In addition, depending on how performance measures go, and we're looking very carefully at how we're going to change these in the next couple of years, there is also a performance payment. We pay for both. The weighting, in my view, is more on that first column you all are seeing under PCMH payment PMPM for delivering high quality care because you've met those standards. So we do both. We pay for the value and the quality, and also there's some components of performance payment that go into it. So it's not just one or the other.

[Alyssa Black (Chair)]: Did the base rate for Medicaid go down this year, or was that a different PMPM that Medicaid had in their budget? Wasn't there a decrease that Medicaid was paying as a PMPM?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Not through the Blueprint program, but I can certainly research that for you and bring it back to you, Chair Black, because I do remember, can help root that out.

[Alyssa Black (Chair)]: Brian, I'm sorry to derail you.

[Brian Cina (Member)]: It's okay. I've learned to write things down,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: so I don't keep

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Should I derail you?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: No, it happens. It's not just you. It's the structure of

[Brian Cina (Member)]: this institution, and perhaps even our society, but I digress.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: So, I've just

[Alyssa Black (Chair)]: become the machine.

[Brian Cina (Member)]: So, for the community health team, for the example, where it says example. First question is that that 54,000 to $60,000 a year, it's like a payment just towards the general expenses of a practice. They're just given money, and then they budgeted it as they wish to keep their practice open. Because when we're doing service based billing, it's like, as a provider, I bill and I get paid for that service. But here, it's not service based billing. So is a check just going to the provider? It's like, this is to keep your doors open. Spend it as you wish as long as you're providing the service.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: The value based payments, the base payments are intended to support the effort of maintaining the practice as a patient centered medical home. That is where those are tied. If a practice loses recognition, we have a whole process for I don't mean to state this in the negative where I end up having to write a letter saying, on such and such a date, these payments will either diminish or drop off. So that is a value based payment. We care about quality. We care about advanced primary care. We want them to meet high standards to take care of that population of payments that they have. That's the payment they get. They've earned it, and it's a prospective payment. So we pay them reliably. So I hear what you're saying. It's just really very much tied to that recognition that they get as advanced primary care. If they're more than fee for service, try and support Also billing fee for service. Yes, they work in conjunction. They absolutely do. They get

[Brian Cina (Member)]: a lower rate for the services they're providing these other people covered by the blueprint, or do they get the same rate as other patients?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Same rate.

[Brian Cina (Member)]: So, they're kind of getting a bonus for seeing patients in the Blueprint if they do a good job.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: They're getting a value based payment based on the effort they've put into maintaining advanced primary care standards.

[Brian Cina (Member)]: Okay, and then, I I think that you said it in a more complicated way, but yes. Because it's like a reward. It's a reward they're getting for performing in a certain way, meeting certain guidelines, meeting certain criteria, proving through some system that they're doing this. So that leads me to the next question, which is the system itself. I've noticed in the previous slide it said something about diabetes in control. That's putting a lot in the hands of the patient and their choices. Maybe some of these other things the provider has more control over, like saying, It's time for your screening, we're going to do that today, okay? But not going to someone's house every day and making them, you're not making my aunt take her diabetes medicine every day. And so, should the doctors or the providers be penalized if the patient isn't making the right choices for their health? Could those kind of metrics encourage certain providers to find workarounds where they're not perhaps recording the patient's failure in the record. For example, they're like, oh, this patient doesn't control their diabetes. If we can't get them in control, it's going to affect our payments. Maybe we'll just have them come in less or maybe we'll test them less or maybe we'll drop them as a patient.

[Leslie Goldman (Member)]: Oh, add Yeah, a so there's all these other- The incentives, they're

[Alyssa Black (Chair)]: little perverse sometimes. Right, I guess I'm curious,

[Brian Cina (Member)]: I guess I'm just curious why we're putting elements of this reward on the patient's behavior that's outside of the provider's control. Diabetes

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: is measured with the blood test, hemoglobin A1c that fits in the standards. The number that is picked for it to be named out of control is widely accepted as diabetes out of control. It's actually higher than when I first came into this work, I would have expected. The number for what's considered hypertension in control is also higher than what yes, we're getting right in there. I think your bigger question comes back to what I really want to emphasize, which is those are components of performance those are components of payments that are based on their performance. And the weight, really, where it comes from to perform well, to perform ethically, to perform up to standards, comes from base payments. And I think that we are looking very carefully, and have been now for about the last year and a half, about what measures we can use going into the future that are going to be the best measures. We very much want to modernize our payment system that you're looking at on the screen. It's complicated, and it involves a lot of different components. We want streamline the outcome measures and come into agreement with commercial insurers in the coming, I hope, months so that it's less administrative burden for the practice. And we want to look at what outcome measures make sense to practitioners and clinicians. And the steering committee is a great place to bring it back to providers so that they can weigh in on these decisions, and they're not just being handed down by the state.

[Alyssa Black (Chair)]: Leslie, very quick question.

[Leslie Goldman (Member)]: You said if a practice has 1,500 attributed patients, we've been talking about panel size. Is that one clinician's panel, 1,500, or is there a panel size name?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: We don't have a This is Addison, Blueprint Health Services Researcher for the record. We don't have a set like, You are a Blueprint provider, therefore we must see 80 patients a day. There's none of that. This practice example is like a site, a location. An office might see 1,500 patients have attributed lives to an idiot. They'll probably see more people, as we saw on the last slide, 40,000 people vanished into the ether because they saw another provider and they didn't have the right code this year or something. They didn't make the attribution algorithm, but 1,500 would be a whole site.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And Doctor. Armstrong is correct. Think a year or so ago, we chose to include this because the question that I would get Leslie is, oh, for a practice with this many attributed pages, so the question was framed at us as

[Leslie Goldman (Member)]: Those are panelists as attributed pages. Get it. Yeah. I'm just wondering, you were talking about what's optimal enterprise in primary care, which I would think you were Absolutely. The

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: other point in this slide that I want to bring up is approximately 75% of Blueprint practices, so around 100 practices, are at least this size. About 20% are at least double. So just to give you a span of the fact that Blueprint is has good good take up. I think I'm gonna turn it over to you for is that is it okay, Chair Black, and doctor Armstrong finishes? Because I know it's almost two.

[Alyssa Black (Chair)]: Yes. However, traffic update core Jessa always gets.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Are you okay coming back a different

[Alyssa Black (Chair)]: day? Okay. Are you sure? Okay. But I will try again. Because I think between you and Doctor. Merman, you have an hour and I wanted to get through this because I think this is really important information.

[Allen "Penny" Demar (Member)]: Just go and then I could go after and then we can see what we can get to.

[Alyssa Black (Chair)]: We just have a 03:00 is So I didn't want to go into the 03:00 time.

[Brian Cina (Member)]: I have a quick question. I'm sorry, Brian. It's okay. And I wouldn't ask you, but it's quick. It's for that 1,500 attributed patients, can you give us an estimated range of how many providers that think that's what Leslie was talking about panels.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Can come back with that, sure.

[Brian Cina (Member)]: I think we could. My primary care doctor at the community health center a few years ago, because I haven't been there in a few years, ironically, this is how it is. I can't afford it, especially when they don't really do anything for me.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: With that being said, she told me she had 1,000 patients,

[Brian Cina (Member)]: and that's why she couldn't call me back when I was very sick with COVID. And I understood, but she said she had 1,000 patients on her caseload. That was one doctor there. So I'm just curious, is 1,500 the ideal, like 100 per primary care provider? Is it 200, is 1,000 the normal caseload for a primary care provider in Vermont? That's the question

[Allen "Penny" Demar (Member)]: I'm asking.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, we've worked with Vermont Medical Society in the past and their membership, and I can come back with a more formulated answer for you. But the variety, when we did that just a couple of years ago, was quite wide in the state, from a number in the hundreds to a number in the thousands. That's helpful. We had difficulty coming down with a trend. That's where sometimes averages don't really tell the story. There was quite a range, and think Jessa may be coming back.

[Brian Cina (Member)]: Thank you. I appreciate the range. That's helpful to have that. The range is

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: the state, and I did not expect that answer. I do want to turn it over to Doctor. Armstrong, if that's okay, to go through our last few slides on outcomes, unless there's any other questions, Madam Chair.

[Alyssa Black (Chair)]: Yes, and I think, I mean, I have some questions, but I think maybe these might get into that. So I looked ahead on the slide.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. Yeah. I'm just gonna change this. And and what how many minutes are you shooting for? Because I don't wanna we're already over at fifteen. What would you like in terms of?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Fifteen, twenty minutes. So for those of you who are either on the screen and didn't see me behind John, I'm Doctor. Addy Armstrong. I'm a PhD in math, who turned my attention to health data in an effort to try to solve some things. I am the daughter of two very small practice optometrists, and so I grew up, quite literally in small private practice and know something about it from that perspective. So what I want to talk to you today about, the last few slides here, are really about we pay all this money. And there is a cost. It might not be directly. We don't bill the patient directly, but there is a cost to society somehow because somebody is paying this money, whether it's taxpayers, whether it's you on your insurance premiums. This money is going up. What does it do? So I'm going to see if I don't wreck something when I remove this. Success. Great.

[Alyssa Black (Chair)]: Can we get a baseline? Because I know this holds in all of your give us a baseline of who is not an attributed person. Why would someone not be attributed? You go

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: to multiple providers in a year, and we can't decide where you go. You've gone to five or six in the past year. You see specialist. So for example, women about my age I don't like to tell you my real age, but we can pretend about my age might go to an obstetrician or gynecologist instead of a patient centered medical home. And they might get most of their care there. And then they wouldn't show up even if they did go to a patient centered medical home occasionally because they have all these visits at another location. So they're not captured. Other people who aren't captured, their insurers do not submit data to the Vermont Unified Health Dataspace. That's a big gap. Some insurers do not submit for various reasons. There was a whole lawsuit that said not everybody has to submit, etcetera, etcetera, etcetera. That's a place where we can't find people.

[Alyssa Black (Chair)]: People who are uninsured or most ERISA plans, like I'm not thinking about large self funded plans like teachers or state employees or any of that, but like global foundries, would they submit? I mean, would their patients

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: submit That's to the up to the provider of the plan. Some of them do, some of them don't. Also, so Blueprint also doesn't run the Vermont Unified Health Care Alliance Reporting System. Speakers. I will refer to it as speakers from now on because it's a lot of mouthful. And so if you want to know exactly who's in, who's out, etcetera, Green Mountain Care Board, they're the people who own the contract. They have all the details about who they can make submit and who they can't. We don't have the power to crack a whip and say, you must submit because I want that information. So the data that we're going to look at represents about two and ninety four thousand to 295,000 Vermonters. That's a pretty good chunk. That's the blueprint line. The other line is usually, depending on the year, between 80,000 to 100,000 people who we know don't go to a Blueprint practice. And so we're saying we have two attributions. Either we know you do, and that's where you get most of your care, or we know you don't go to a Blueprint practice, and you definitely are not involved. And so together, that is a large percentage of the state. So we feel like these data sets, while they're not perfect, there are a lot of people we're not touching, they're a pretty good picture of what's going. So the first one I have here is just a chart that shows the total per member per year allowed amounts for Blueprint and non Blueprint attributed members. So what's an allowed amount? We should start there before we get too far into this. An allowed amount is the amount that a payer paid on HealthBed plus any amount that they deemed the patient responsibility. So a copay, a patient share, or something like that. So they add those up. We know that that's not reflective of the actual dollar value that got transferred because some patients aren't going to be paying their patient shares or some will pay extra. We're not actually going and auditing people's books and saying, how many dollars did you get in? But this lets us give an idea of approximately how much was paid out by payers and patients. So it's the sum of the amount the payer paid on the claim plus the allowed amount. And we always like this chart because it shows something that we hope we accomplish when we start dumping effort into quality measures and saying, change the way you do things for us. On average, over most years, Blueprint patients have a total allowed amount that's less. And that's a good thing. These amounts are not inflation adjusted, so yes, there's an uptrend here.

[Alyssa Black (Chair)]: I'm sorry. I'm asking, like I have to put my hand up. Okay, we know that almost all Medicaid patients are attributed. We work very hard at attributing Medicaid. Work very hard at attributing Medicare. We have certain commercial, but wouldn't we think that that 100,000 unattributed people would either have a commercial insurance or no insurance at all, which would mean that they're not reporting to vCures. And wouldn't we expect that that green line would be much higher because chances are those people are commercial with higher allowed amounts?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Allow me to explain a little bit better. Okay. So the green line is people who are in B Cures. They have claims. Otherwise, we couldn't count this at all. If we couldn't find them, if they're uninsured, we can't count this. We don't know how they're paying for their care. And they are attributed to a non Blueprint primary care practice. So we know there are some primary care practices in the state that do not participate with the Blueprint. So the green line is people who get primary care following the same algorithm but not at a Blueprint practice. They get their primary care someplace else. So in that respect, we expect these to have similar behavior. They're both getting primary care. They both clear an attribution algorithm, one that goes to Blueprint practices, one that goes to not Blueprint practices. Green is Vermonters going to primary care practices that do not participate in the Blueprint. Blue is Vermonters going to primary care practices that participate in the Blueprint. So they're both getting primary care. They're both getting about the same amount of it. If you study our annual report, there's a more detailed section. And I'm trying to be cognizant of time here. But there's a more detailed section that details, like, we can do a risk adjustment where we adjust for approximately how much health care you've used and compare dollar values after adjustment and before adjustment. And so you can get into all of that in our annual report, where we'll say, Okay, after risk adjustment, this is what this looks like. This is

[Allen "Penny" Demar (Member)]: the

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: difference. From my perspective as a mathematician, I look at this and I say, this is actually a good sign because I do have a line it is not on this graph of people who don't get primary care at all. They have no primary care plans. They're really, really cheap. They don't spend any money because they don't interact with the health care system. They're hovering down there between 4,000 and $2,000 all the time, which is great. We expect them to be cheaper because they don't interact with the health care system. Typically, they're the healthy 30 year olds who don't go to the doctor, as we

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: know. Does that help, Alyssa?

[Alyssa Black (Chair)]: Possibly. I'm just trying to roll through in my mind, number one, who is not a Blueprint provider? Who are the patients that are going to a provider that is not a Blueprint provider? What sort of insurance did they have?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So I'm

[Alyssa Black (Chair)]: just, it seems like there's a lot of variables for

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: There are a lot of variables. Yeah, there are a

[Allen "Penny" Demar (Member)]: lot of variables. Brian?

[Brian Cina (Member)]: Just to the last thing you said about the people who aren't using it, could that mean then that, let's say my last primary care provider was the community health center and I haven't gone in four years, they could be getting $4,000 a month for me or

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: two No, thousand dollars month so even though I'm if you haven't gone in four years, you are no longer attributed to that practice.

[Brian Cina (Member)]: But if I went in the last two years, they could be getting $2,000 a year for me, even though I'm

[Alyssa Black (Chair)]: not No,

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: 2,000 a year. Remember, it's $3 a month.

[Brian Cina (Member)]: Oh, okay. I'm confused by these numbers then, I guess.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: So these are the total amount for all the health claims that a person submitted. So if I go to the ER and I have a $10,000 claim and they give me $1,000 patient share, that would add up to $11,000 And then you add on my primary care claim, and then you add on my obstetrician claim, and then you add on all these things. So this

[Alyssa Black (Chair)]: is the total amount of claims per person in the whole state for all the care they deliver. And what we're comparing is that amount for people who go to blueprint practices and people who don't. We're saying, do people who go to blueprint practices generally have a whole spend higher or lower than people who go to not blueprint practices? Would this also account for, I'm thinking of patients who actually do have health conditions where they primarily see a specialist and can go years without seeing their primary because let's say they see their cardiologist every three months, clearly that person is going to have a higher spend.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Yeah, they clear the attribution algorithm. Remember that algorithm has all those codes and they have to have a primary care provider. So to get in that green line, you have to have a primary care provider. You have to have one of the visits in the past two years. You have to meet all the same criteria at somebody who's not on our blueprint list as the people in the blue line meet for somebody who is on the blueprint. I

[Brian Cina (Member)]: don't fully understand what the slide is. Get the point, but like because usually it says allowed amounts. I just don't understand that. It's not actual spending. You know what I mean? Usually allowed amount is like, here's the most you're going to get for something.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Right. So the allowed amount, when we total these, we look at all the claims somebody had in a year. Say you had five health plans, And they'll have multiple lines. They'll have an allowed amount. They'll have a paid amount. They'll have a patient share amount. They might have a billed amount that's different than any of these. They have a lot of lines. And so what we're adding up is the for this definition of allowed amount, what we add up is the amount the insurer paid on all of those planes, plus the amount that the patient was supposed to pay, the patient's share, their co pay usually is what it's going to look at. So we add up all those things and say, Jane Smith had five planes and they were $100 each on these, so that's $500 and they were $5 each on these, that's another $25 so that she would have a total allowed amount for her whole year of $525 That's what we would be adding up, is each person how much the total amount of claims is for a year.

[Brian Cina (Member)]: I think I get it now. You're looking at the estimated amount of actual spending because the billed amount is going to be higher than the allowed amount. And we don't know exactly who paid what in the end. So it's an estimate.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Maybe James forgot to pay one of her $5 co pays and she actually only paid $520

[Brian Cina (Member)]: but This is a really high level comparison of healthcare spending and showing that a non blueprint. Right.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's a

[Brian Cina (Member)]: very high level. I see that. I'm getting it now.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Asking that initial question, is there any difference? Is it even worth wondering if there is a difference?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: You have to

[Alyssa Black (Chair)]: start with these. I And realize you don't have this with you, but I'm pretty sure, because you're the data person and I know you love data, it would be interesting to see the payer mix of the blue line versus the green line. Yes, we

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: will work on getting you that information fairly soon. Thanks. Other questions here? Because again, I am about out of time. And so we have a couple more slides, but I know that you have another talk and we have used up 12 of our fifteen minutes.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: There's some questions. Yeah, it's

[Alyssa Black (Chair)]: a good idea. How about we go through I think you'll have a couple more slides.

[Brian Cina (Member)]: Could we just not have any questions and let her go through the slides? I'm willing to do that.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: See you answer your questions, but I also want to be respectful if

[Alyssa Black (Chair)]: we're fine.

[Leslie Goldman (Member)]: So

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: this goes back to some measures that representative Goldman was talking about. And this is the same kind of, is there any differences that even worth studying comparison. This is a very specific measure. It's the HEDIS measure. They update their specs every so often. HEDIS is an organization that certifies health measures to make sure that we're all measuring the same thing across the whole United States. All of these very specific criteria come into this. Again, we're saying, of people with hypertension, what proportion of them have their blood pressure under control? And under control is a definition that is placed in there. I think right now it's 140 over 90. Pretty generous definition. Isn't it worth wondering if there's a difference? The difference is not huge, but the difference is there. Again, we look at the blueprint people. We look at the non blueprint people. Blueprint people, generally, a few more of them have their hypertension in control. That's considered a good thing. Hypertension work ill you, so we try to prevent doing that. And so this is the sort of evidence that we look for before we start much deeper dives into exactly why, exactly how. We're saying, is this a measure worth investigating? I want to point out something on this because the specifications on this measure changed a lot from 2020 measure year 'twenty three, which is the data we were presenting last year, to measure year 'twenty four, which is this data that you're seeing. So if you were to look at our annual report, you would see a very similar chart, except it's up in the 80s. And for both, both categories are up in the 80s, and both categories appear to have lost a lot. We actually didn't get worse with that for the last five years. They changed the specifications. And so over time, different rules about what does it mean to be good at controlling your blood pressure come into play. It's kind of crept down. It used to be like 100 plus your age, and now some of us get away with a lot. And then now they're like, no, you can't be so bad at that. And so as these things change, our items update. And that's really important because if you are digging into our annual reports, don't look at last year and expect 2023 for Black year to match 2023 from this year could something change? And so that's why we provide these five year trends in one place. Look at that trend. So that's one of the items I just wanted to point out there. The same items, and we have a ton of measures. I could do this all day. Again, I'm trying not to. But we really wanted to look at the legislature appropriated $16,000,000 to spend on mental health. And did we accomplish any Christmas math? And so one of the places that shows is if you're looking at individuals with mental health diagnoses and mental health and substance use needs, are they going to the ED? And so this graph is really interesting to me because I'm looking for what's called a difference in difference. And so as I'm watching trends, if things are going parallel and I apply an intervention and they continue to go parallel, they didn't really do very well. But what's important to us is, as we can see here from 2023 to 2024, while non Blueprint folks continued going up, Blueprint folks' TD visits with mental health needs went down. And so we started that mental health intervention, and they stopped using the ED as much. In all the past years, the lines have moved in the same direction all the time. So seeing them move in opposite directions tells us, ah, something changed in that.

[Leslie Goldman (Member)]: Go ahead, Melissa. I know we're not supposed to ask questions, but So it's a difference of three percent. And what's the absolute numbers? Because that could be very tiny.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: It's actually very large because this is 290,000 people. So 3% of the population

[Leslie Goldman (Member)]: is so big. Quite big.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: It's like 10,000, 20,000 people.

[Leslie Goldman (Member)]: Okay, that's helpful. That's what I mean about the absolute numbers because 3% doesn't help as much as 30,000 visits.

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: Right. Yeah, so this is actually large amounts of individuals, for sure. And the other thing on the same slide, I do have some more interesting stuff. This one's a lot closer and so harder to see. But this is people who had what is classified as high ED utilization, meaning they visited the emergency department more than four times in a year. That's considered high ED utilization by a variety of sources. And we see the same kind of thing here. You have a mental health or substance use need. This is just Medicaid, so this is a smaller total overall. But more ED visits is also going to be a smaller population again. And we see the same thing. The trends are doing the same thing. They both go up. They both go down together. They move together. They move together. And then suddenly, they're moving knots together. And we'll have to see. You need 25 data, which I should be able to get. Today's the last day of the quarter, so that gives me my claims run out, and I can start studying tomorrow. And so you'll be able to see twenty twenty five data soon on this. And hopefully, we'll see. Can you say that? Or maybe you won't. Maybe it doesn't make as much of a difference as we hope. But what we're seeing right now is very promising that between 'twenty three and 'twenty four, we applied a change. We dumped money into the system. We hired a lot of mental health counselors. We really enhanced our ability to provide mental health services in primary care instead of outside of it. And we're seeing that having something of an impact on the ways in which these codes. So we're hoping for more results. And I will leave you with one quote from a primary care provider that I think goes to that question of, where's the doctor in the room? The doctor is saying, I don't want to practice without the community health team. So we really value that. Thank you all so much for your patience and your time and your very engaging questions.

[Alyssa Black (Chair)]: Thank you. I just have one quick question. You have 124 practices that are enrolled in Blueprint. How many are not enrolled in the Blueprint?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: So that number is hard to get exactly because practice is open and shut. And so at this moment, my last known value of that, I think, is what, sixty forty eight, something like that? I think it's 168 total, so it's around 44.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That's right, yes,

[Allen "Penny" Demar (Member)]: one that's

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: 168 total, so it's around 44. 44.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, we range with 60 five-seventy 5% of our practices engaging.

[Alyssa Black (Chair)]: So you have to be NCQA certified, which you called a heavy lift. Do you think that if we got rid of the requirement that you had to be NCQA certified, that more of those 40 some practices would participate in the blueprint?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I see it from a different angle. I see giving more support, both in terms of the network of quality improvement facilitation that Leslie's talking about and looking at those amounts and looking at the complexity of our program as the answers to move forward. I'm fully supportive and we're fully supportive of the quality standards existing. And I think that if we get to come back with S197, I think you'll see some of the nuanced language that it provides perhaps for some flexibility within that to develop other ways in the future to include non NCQA practices. So I think we can do both, and I think we can do better. But the standards are quality, advanced primary care and quality.

[Leslie Goldman (Member)]: This is very quick. How many standards are being required in those practices to be measured?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. They're broken into five categories. And as Alyssa was saying, to the extent allowable, I'll come back with you all so that you can see the details of that.

[Leslie Goldman (Member)]: But is it 100 or is it 10?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's less than 100.

[Leslie Goldman (Member)]: But more than 10?

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: It's probably between ten and twenty five, depending on any Yeah, the timeline. Each practice has to choose. They get to choose like, Okay, I want to there are some core standards. Like core standard, you have to have certain ability to provide medical advice outside of your normal nine to five. Then they'll have another, one of these, and the practice can choose, I choose this to meet the rest of the standard. So there's a variety of things and they don't have to meet all of them. So when you do see that list, there might be 100 things. They don't have to do all 100 things. They have to do a selection of the things. It would be helpful

[Leslie Goldman (Member)]: to see that. Absolutely.

[Alyssa Black (Chair)]: Would be helpful to see. Also, do you survey Blueprint members on the administrative burden of NCQA?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Do we survey Blueprint providers on the end? No, we do not. I thought you were going say patients. Definitely say patients every year, but it was providers. Thank you so much for

[Dr. Addison (Addy) Armstrong (Health Services Researcher, Blueprint for Health)]: having Thank

[Alyssa Black (Chair)]: you. You. So let's take just a two to three minute break just so I can do some air traffic control. Okay.