Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Welcome back and also before we get started with representative Olson, happy birthday to Deb. We're really casual in house healthcare, so welcome.

[Rep. Herb Olson (Commerce Committee)]: Thanks, and I'm really glad to be here. Wonderful committee.

[Alyssa Black (Chair)]: So we're gonna do a walkthrough of a bill that you introduced. Yes. We, obviously, we're toast crossover, so not taking off your bill necessarily, but there's some really great things in it that I want people to be thinking about when we start looking at 01/1997.

[Rep. Herb Olson (Commerce Committee)]: Great, so. I'm super very happy to be here. You have great rep on the floor of the house. You have great House Healthcare Committee representation right behind me in the city. This is great. So appreciate very much representative Herb Olson. I represent the towns of Bristol, Lincoln, Moncton, and Starksville. And I am on the commerce committee, but one of my lifelong passions is healthcare policy and primary care in particular. And I'll give you maybe I'm not gonna walk through the bill, Jen will do much better job of that. But I wanna sort of give you an idea of what motivates this. You know, why why is this something that at least I feel is very important? I think a lot of other people feel is very important. The whole core purpose of the bill has to do with increasing access to primary care for patients. Right? And in the same time, lowering our total system costs. And the two really go together. They're really kind of inseparable. You need to deal, I believe, with with both at the same time. I'll give you a little background to tell you a little bit why I I talk about this stuff so passionately. I did some work in the legislative council way back in the day, in the nineties, when we were starting to develop our infrastructure for regulating health insurance companies, hospitals, the whole bit. So I got very involved in that. After that stint, which is one of the best jobs I ever had, I went over to be general counsel to what then was called Bishka, great name, whatever. And they regulated health insurance, they regulated hospitals, a whole sort of assortment of health system issues. And different agencies have had that responsibility since then. But a lot of the same regulations are still there. Later on, I became involved in oh, I went down to Rhode Island at one point and I picked up a job in a similar kind of agency, regulating again, health insurance, primary care and sort of the intermix between hospitals and health insurance and primary care, and really got involved in writing some regulations down there that had to do with systems of care and with an emphasis on primary care homes, medical center homes. And one of the features that they had down there, wrote into it a rule, different political. So you do different things in different places, but we were able to write an administrative rule that first, you know, obligated health insurance carriers to cap their their spending by contract with health insurance to a certain percentage increase year over year. So there's some sort of flavor similarities, that kind of things. The other thing we did was to establish a primary care spend target. And the key there, at the time, the primary care spend was really, really low, and primary care doctors were having a tough time and just not staying around. I have enough doctors, you're not gonna have access. It's all sorts of problems. So we increased that by regulation and that, by all reports, that worked out very well. So it's like that's a lot of stuff that I've done and what I bring to the table in terms of working with the medical society in putting together this bill. There are a number of key elements, I think, to the bill, and I would say that they are all important. Mhmm. It's it's difficult, as you know, with the health care system. You try to pull out one thing or you push in one one place, it'll pop out somewhere else. So we're trying to, in this bill, connect a lot of elements that we think work very well together, but all again for the purpose of increasing access for patients to primary care. And in the process, you know, with the ratio, I'm sure you've heard the ratio of one to 13, you know, a dollar spent on primary care is gonna eventually save the system, about $13. It's important. Now, go through the

[Alyssa Black (Chair)]: Yes, go ahead. I'm reading about Rhode Island.

[Jen Carvey (Office of Legislative Council)]: I am stuck on primary care spend. Can you just explain that to me?

[Rep. Herb Olson (Commerce Committee)]: Yeah. We did it over, Allen, and there's a penalty in this bill as well. There's some dispute about how much we actually spend on primary care right now in Vermont.

[Rep. Allen "Penny" Demar (Member)]: As a patient, that refers as a patient, the primary care spend?

[Rep. Herb Olson (Commerce Committee)]: Primary care, yeah. Okay. Yeah, yeah. As opposed to other sectors, just grossly, hospital sector or say specialty care, medical care, those kinds There's a bunch of other. So focusing on primary care. Because in my opinion, I think the opinion of a lot of folks, by focusing on primary care, you're gonna do a lot of good things. You're gonna increase access to the service that Vermonters really are looking for, you know, right off the bat. And in the process, you you can't ignore the cost issues. I mean, you know, you've this committee has done terrific work, I think, over the past year, and the Green Marian Care Board has has really done some good work around this. But it's still a problem. And I sort of see this as a way that you can tackle that problem and at the same time have something positive at the end of it, which is better care for patient. So I'll just run through some of the elements and I wouldn't say any is really is the core, but that's all sort of intertwined. There's a payment reform piece. I'm sure you've heard all about fee for service, some of the disincentive you know, the wrong kinds of incentives that occur when you pay folks on a fee basis. It tends to increase utilization. So the endeavor here Jen will go through the details, and it is a little complex. But the big picture idea is if you pay folks on a per capita or per member per month basis, it's just a better the the incentives are much better for that primary care provider. And I'd say at the same time, there's an overlay of administrative cost issues. One of the key things that some of the data that the medical society put together talks about primary care offices and doctors spending 50% of their time doing administrative tasks, and that includes billing. That includes the sort of back office stuff that the primary care practitioner needs in order to keep their business afloat. Right? And they get, you know, however money however many insurers or self insurers or or or agencies programs they have, each one of those payers has their own way of doing things. In terms of how they get paid, you know, how things are you know, coding, I guess, is is fairly uniform, but there there's a lot of differences in how different payers pay any sort of medical provider, including primary care. And that just adds to the complexity and reduces the time that primary care physicians can spend actually with the patient, which is what we'd like them to do. So that's a big piece. There's the primary care spend target that we talked about also. I think that's a really important element of this program. In the legislation, it's cast as 15%. Get you'll have testimony about, you know, what it is right now and what maybe it should be. But that's what was put into into the bill to start the the discussion. The key element of the way that it was structured in the bill is it's not an add on. We got heaven knows we have high enough cost as it is. This is not intended to be an add on. It's really talking about we have a system that spends a whole lot of money, and how can we allocate, reallocate those monies to do something that that would be good and reduce costs over the long run? So that's the spend. It's important to get all payers into the system. Some of the reasons I talked about, it's good to get these folks aligned. It makes a lot of sense for the primary care office and practitioner. If everybody's in line, all the payers are in alignment about things like payment and in terms of things like administrative costs. What are the measures that each one of these payers is asking the office to comply with, whether they're quality measures, whether they're reporting records measures, there's a lot of different ways to do that. And I think it's really helpful to think about all the payers getting on board there. It'll just make the system much more functional. And I would not I would not set aside the self insured folks. We understand, you know, what the federal law limitations are around that. I would say that some of the big self insured companies who have administrators or whatever helping them with their employee health benefits, they're not stupid. And if they I think if they see a way to actually help with their health care costs on a voluntary basis, I mean, you gotta prove it. You gotta show them that you're gonna save some money. But I think it's well worth some discussions with some of the bigger employers and their self insured plans to see if they would come on board with something like this. Another key element, I just mentioned this kind of in context of all payers, trying to get a payment pool so that the primary care practice doesn't have to go to a dozen or so insurers to do business, and they'll receive the the ideal is if they can receive this per member per month payment as a single funding stream. It would just help them out a lot, I think. With some adjustments, Jen will go through some of the details of the bill. There's gonna have to be some exceptions to that, and it might need some fee for service kind of stuff in there, worked in there. But the core idea is core to have this pool, have people, the funding stream coming from the pool, all payers to the primary care practice. Mentioned administrative costs. Really, this is really I mean, this is a huge amount of time. And I think there have been reports. I think the medical assistant No, maybe it was the Green Mountain Care Board. Did a study a few years ago around what are the real sore points, what are the things that really take a lot of time for a primary care practice in terms of complying with records kinds of issues, quality measures, access measures, a whole bunch of different things. Each payer has their own. So if some work can be done of that, I think it would I think it would really help. And and again, this isn't all this isn't to make primary care practitioners happy. The public purpose the public person purpose isn't to make folks happy. It's the public person purpose is to increase access and to lower costs. And these are the tools or the elements that I think working together will help to do that. Universal access Oh, I'm sorry.

[Alyssa Black (Chair)]: Yeah, go ahead. So

[Rep. Allen "Penny" Demar (Member)]: do you see any revenue services be pulled from the hospital that may, if people were to take advantage of this and use their primary care for services that maybe the hospital would be making money off of at that time?

[Rep. Herb Olson (Commerce Committee)]: Well, there's definitely the inverse or I think about a total system kind of. So if you can are able to see a primary care practitioner in a reasonable period of time. Right now, I think the average is about two days and so high as one hundred and eighty days before you can see a primary care doctor. So if you're able to get in there, that means that that individual doesn't delay their care that could get worse, and then they go to an emergency room. Were you talking about something else?

[Rep. Allen "Penny" Demar (Member)]: Well, I didn't know if the hospitals see a loss. Oh, yeah,

[Rep. Herb Olson (Commerce Committee)]: so let's totally acknowledge that point. I sort of mentioned it before. This bill talks about a reallocation of total cost of care in the state. The poor hospitals, I think, are feeling a little beleaguered. I understand that because a lot of pressure is being put on them to reduce their costs. From the Green Mountain Care Board and some other things we're doing, good things we're doing in the legislature. So, I'm not minimizing that. I would still say there's a lot of money in the healthcare system. And to my mind anyway, it's about reallocating that money rather than increasing, you know, what you call the single health insurance. Increase it, you know, your health insurance rate is gonna if you pass the money usage in some way, you know, that's gonna put some downward pressure on that. Universal care, I think, is really an important element of this. The same reason why you wanna get someone who's insured into the primary care doctor sooner rather than later. You also want to try to get the folks who are not covered in to see a primary care doctor. Because, again, the multiplier is one to 13. The numbers might not work out the same way with the uninsured, but there's still a net benefit, I believe, to the system as a whole. So that's why universal access, whether you're insured or not, I think is a really important element of this. Finally, there's some pieces around reinvigorating or continuing some of the workforce issues, and I think there's identified a loan program, there's a scholarship program, there's a residency program. I think you folks are familiar with those issues. They're a tough challenge, I know, in any budget year, but certainly in this budget year. I would, without giving the hospitals more angst, I would wonder whether that would be an avenue to think about in terms of funding these some of these initiatives, which again are directed at workforce, increasing the workforce for primary care and saving some improving access and saving some money. I've been following the bill in the Senate. I I, you know, I I totally respect the work that they've done. I've worked with Senate Alliance long time, and I really appreciate her work. What struck me, I wasn't so I wasn't in the in the committee room, but I I, you know, I read stuff and go online, use them, and stuff like that. What struck me was that a lot of the stakeholders that came in I mean, it's like mom and apple pie. Everybody loves primary care. Right? And we like primary care, but, you know, jeez, that might be a little too soon or that that might that might affect me in a way that I'd rather not. And my I could be wrong, but my sense was there wasn't really a champion. There wasn't a champion for someone to to make a real difference in terms of primary care. And I'm hoping and urging you guys to be that champion. I think you can do it. I very much admire what you guys have done over the past year for sure, but and previously as well. I I think that the bill needs a champion. You're the champions. I hope that the stakeholders will come together and help you to achieve that. I think it's terrifically important, like I said, it's passionate with me. Again, good access to primary care means better care and and lower costs. So Thank

[Alyssa Black (Chair)]: you, Graham. I'm checking out really quickly. I just did you work with any any stakeholders' advocacy on this bill at all? Or was I

[Rep. Herb Olson (Commerce Committee)]: tried I I maybe I didn't say that more clear clearly enough. The folks at the medical society have been terrific. I've been talking with them since last summer, and they've been wonderful to work with. And when I say no champion, I should the medical society is there. I'm looking at some of the other stakeholders and hoping that they will get on board with something that the medical society has championed. I certainly am champion, and I hope you folks will too.

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

[Rep. Herb Olson (Commerce Committee)]: fun this afternoon.

[Alyssa Black (Chair)]: Back to commerce. Jen's just going come up and give us a quick walkthrough. Again, this walkthrough is just, you know, things in here, you can see things,

[Rep. Allen "Penny" Demar (Member)]: are not

[Alyssa Black (Chair)]: concepts against. Some of them are elsewhere, right? Guess what I'm saying is, let's not get caught up in the language. What I want to know is what's elsewhere so we don't even have to think about it.

[Jen Carvey (Office of Legislative Council)]: Great. Good afternoon. Jen Carvey from the Office of Legislative Council. Let me put the language up on the screen. This is H680 and activating to a primary care access reform program. It starts out with findings. I don't know if you want me to go through the findings or if you kind of got a

[Alyssa Black (Chair)]: sense for the findings. Yeah, we have a pretty good idea.

[Jen Carvey (Office of Legislative Council)]: Talks about the importance of access to primary care, barriers to achieving primary care, elements of reform. So, think I'll stop at number six here for a second just because it does come up later. And I think there was a question about the sort of primary care spend and what that means. So in 2020, there's a report and I think Tasha has it and maybe he's posted it. She's posted it to your committee page. There's a 2020 report from the Green Mountain Care Board and the Department of Vermont Health Access that was required by legislation that directed them to calculate primary care as a proportion of overall healthcare spending. And so they did, they calculated both across all payers and by payer type. And it found that 10.2% of all healthcare spending was allocated to primary care, though investment varied by payer with Medicare at 6.5% of their 100% of spending, Medicaid at 24.3%, and commercial health insurance at 9.2%. So you'll see some language in here about updating that study, but that's where that comes from. And then it talks about legislative intent to invest in primary care by establishing a streamlined primary care payment system that promotes the public good by increasing access to primary care in order to improve Vermonters' health and reduce health care system costs. I would add a new section in Title 18 in the chapter on the Blueprint, but as its own different subchapter, directing the Agency of Human Services in coordination with the Green Mountain Care Board, the Blueprint and the Vermont Steering Committee for Comprehensive Primary Health Care that was established in last year's Act 68 and in consultation with others to develop and implement a primary care access reform program that will promote the public good by investing in primary care and reducing administrative burdens in order to increase access to care and reduce health system costs. It would have the program be voluntary for primary care practices, and it would be funded by allocating a portion of commercial health insurance premiums, a portion of premium equivalents from other participating payers, and to the extent permitted by federal law waivers and federal initiatives, public funds for Medicare and Medicaid. The idea is that it would collect and aggregate payments from the participating payers in order to provide a capitated per member per month payment to each participating primary care practice that will cover all of the routine primary care needs of attributed patients who are covered by participating plans without any patient cost sharing required. It puts some limitations on administrative and documentation requirements and other requirements to try to address administrative burden. So to the extent the program included any practice participation requirements, administrative or documentation requirements, or quality measurements, the agency required to establish them in a way that streamlines and reduces administrative burdens on primary care practices imposed both by the program and by public and private payers, including aligning with and incorporating necessary blueprint requirements. It would direct the program to establish not more than 12 quality measures and would limit how many they could require a primary care practice to adopt through not more than six. And it gives some criteria that the quality measures must meet. Each one must be claims derived, patient centered, appropriate for a primary care setting, and supported by peer reviewed evidence based research indicating it is actionable and that its use will lead to improvements in patient health. Requires a program to identify and reform administrative burdens and requirements imposed on primary care providers, including data collection requirements, data system coordination, Requires increased uniformity of requirements across networks and payers, and electronic health records requirements. Specifies that practice participation requirements must include reasonable access improvement standards. The goals of which are to make meaningful progress toward reducing the primary percentage of primary care practices that are not accepting new patients and toward reducing average wait times for appointments. And we have the Standards incorporate metrics for measuring progress and achieving the goals, and give some examples of initiatives that practices could implement to meet the Access Improvement Standards. They may include accepting walk in patients, increasing the number of same day appointments, adopting extended hours, and undertaking other appropriate access reform efforts. Directs the agency to adopt by rule a risk adjusted allocation model for primary care practices that are participating in the program that may be informed by previous accountable care organization payment methodologies and may blend per member per month capitated payments with fee for service payments as needed for specific primary care services. Requires the allocation to include a reimbursement model and level that accomplishes Vermont's primary care spending target, which comes up later in this section. Supports sufficient access to and sustainability of primary care services in Vermont, incorporates different methodologies as needed to address the unique needs of all practice types, including independent practices, federally qualified health centers and rural health centers, and hospital based primary care practices. Incorporates a methodology that is flexible enough to support and adjust for the different scope of services that different practices deliver. That accounts for the closure of accountable care organizations, accurately attributes patients to primary care practices, is sufficient to support practices and offering comprehensive team based primary care that includes supports for mental health and social drivers of health, and to the extent permitted under federal law, does not require individuals covered by participating health plans to pay cost sharing amounts when receiving routine primary care services from participating providers and practices. It directs the Agency of Payment Services to operate a payment pool to collect the primary care allocation of premiums, premium equivalents, and public programs funds due from each payer, and to determine the per capita payments or other payment mechanism to distribute the funds to participating practices.

[Alyssa Black (Chair)]: Agency that we're referring to there is a Regency Agency.

[Jen Carvey (Office of Legislative Council)]: Yep. Directs the agency to adopt rules to implement the program, including determining the scope of primary care services to be included in the capitated rate and the primary care practices that are eligible for the program. So the scope of the services and the scope of the practices. If using practice participation requirements, administrative and documentation requirements, quality measurements with the limitations in Subsection B, the risk adjusted allocation model, as described in Subsection C operation of the payment pool program parameters that address and mitigate against practices avoiding high risk patients or otherwise engaging in adverse selection while also striving to maximize practice eligibility and participation. Definitions of direct and indirect primary care spending and appropriate limits on indirect primary care spending as a percentage of health care spending, and set forth later in this section, and benchmarks for determining the program's performance. The Agency of Human Services or Green Mountain Care Board or BOAT are directed to enter negotiations with the Centers for Medicare and Medicaid Services to secure Medicare participation in the program and also to conduct outreach to self funded, non governmental employer sponsored plans regarding opportunities for their voluntary participation in the program and to discuss with interested plans the appropriate allocation of premium equivalents to be paid into the pool, which amounts should not unfairly disadvantage individuals covered by fully insured plans, self funded governmental plans, or public benefit programs. So this is looking at trying to get voluntary participation by the self funded plans and in amounts that don't sort of shift the cost to those entities we do have control over. Implementation of the Primary Care Access Reform Program shall, it says, increase the proportion of total annual healthcare spending on behalf of Delmont residents that is spent on primary care. This is looking at that primary care spend with an initial primary care spending allocation target of 15% of the total amount spent for all health care services delivered to Vermont residents both within and outside Vermont to be met not later than 01/01/2029. And it requires the agency to establish a transitional schedule to increase that proportion over time in order to achieve the primary care spending target. And it specifies that the increased spending for primary care shall not result in an increase in the overall amount of health care spending for Vermont residents' care. So this is increasing the proportion of the same or lesser amount of spend that is on primary care, not increasing spending overall while increasing spending on primary care. Directs the agency to limit indirect primary care spending as defined by rule as a percentage of total primary care spending for purposes of the target. It allows the agency to establish a new higher target after the initial target has been achieved if the agency's analysis shows that the program has met specific benchmarks established by the agency by rule in areas including access to primary care, quality of services delivered, impact on health outcomes and containment of overall healthcare costs. For definitional purposes, it says for purposes of the target, the agency shall use a definition of primary care services that aligns with the definition used in that 2020 report that determined the proportion of spending on primary care and the definition of primary care services used by the New England States Consortium Systems Organization. Requires each health insurer with at least 5,000 covered lives under a health insurance plan issued, delivered or issued for delivery in the state to comply with the requirements of the subsection G around the spending targets, including meeting or exceeding the annual primary care spending targets established pursuant to this subsection. And in meeting its annual primary care spending obligations, each insurer must ensure that the individuals covered by its fully insured plans do not bear a greater financial burden than their fair share of the expenses related to the insurer's compliance with its obligations under this subsection, with the proportional amount borne by individuals covered by non insured plans administered by the insurer, if any. And for non primary care services, they shall adjust reimbursement rates, implement utilization management tools, and take other steps as needed to avoid increasing the insurer's total healthcare spending to the extent feasible and in accordance with rules and guidance adopted by the program. And it gives the definition, ties the definition of health insurer to the one beginning of the chapter on healthcare administration in title 18. And it directs the agency in consultation with the Department of Financial Regulation and agreement their board allows them to adopt rules as appropriate to carry out the purposes of that subdivision. Section three has some reporting. So it requires the Agency of Human Services to begin operating the Primary Care Access Reform Program that was established in Section two by 07/01/2027 on or before 12/15/2026, the Agency of Human Services in coordination with the Green Mountain Care Board would report to this committee, Senate on Health and Welfare and the Health Reform Oversight Committee regarding progress in establishing the Primary Care Access Reform Program and a timeline for its implementation and options for revenue sources and mechanisms, along with an operational and financial plan, for expanding the program not later than 01/01/2028 to any patient of a participating practice, regardless of type of the individual's health coverage or coverage status. They're not just participating payers, but any. Section four requires the Agreement Care Board to report by 01/01/2027 to this committee and Center of Health and Welfare with an updated version of the board's 2017 Vermont Clinician Landscape Study report that reflects the current climate among practicing clinicians in Vermont. This and this, the language of this section is in S197 without, I think, any changes. And an updated version of the board's previous reporting regarding site neutral reimbursements pursuant to a few listed acts, including the current state of reimbursement differentials based on practice setting and ownership type, along with the description of any significant efforts that have been implemented since 2017 toward achieving site neutral reimbursements, or so you have a provision in H585 that starts implementing some site neutral reimbursements. Section five has investments in the primary care workforce. This would appropriate $6,750,000 from the general fund to the Department of Health in fiscal year twenty twenty seven for investments in the primary care workforce. Would have 1,500,000.0 of that for the first year of implementation of the Maple Mountain Family Medicine Residency Program. This language some of you will recognize from, I think, last year's budget memo. And that is looking to increase the number of family medicine residents practicing in rural parts of the state and expresses legislative intent to appropriate funds in future fiscal years to allow for full implementation of program. It would appropriate of that $6,750,000.00500000 for the Medical Student Incentive Scholarship Program. I begin to review Vermont College of Medicine that is exists in statute. This is was also in your budget memo this year, and you'll see later in this bill, looking to take the sunset off of that program. $5,000,000 for the Vermont Educational Loan Repayment Program, established in statute to be used for loan repayment for physicians, naturopathic physicians, APRNs, and physician assistants who practice in primary care in order to fully fund existing demand for the program using the number of applicants and the needs demonstrated when additional funding was made available through the American Rescue Plan Act and expresses legislative intent to continue this investment annually until Vermont reaches an adequate supply of primary care clinicians relative to benchmarks. Section six is removing that sunset on the medical student incentive program that you also included in your budget memo and that I believe is included in the budget bill. Section seven is effective dates and the act would take effect on passage except section five, the appropriations for their sheets would take effect on July 1. Okay.

[Alyssa Black (Chair)]: Any questions on it? So we'll get a look at 01/1997 tomorrow. And it's my understanding, and I know they weren't exactly alike, but they sort of have the same concepts.

[Jen Carvey (Office of Legislative Council)]: Yes, they're led up somewhere the

[Alyssa Black (Chair)]: We're conceptually the same as they live on. So we get to see the end of it tomorrow.

[Jen Carvey (Office of Legislative Council)]: We get to see what came out of

[Alyssa Black (Chair)]: the Senate. We can see

[Jen Carvey (Office of Legislative Council)]: what came out of the

[Alyssa Black (Chair)]: Senate, not the end.

[Rep. Herb Olson (Commerce Committee)]: The original bill underlying S197 as it now is the exact same thing as No,

[Jen Carvey (Office of Legislative Council)]: it similar. They were developed.

[Rep. Herb Olson (Commerce Committee)]: It wasn't a companion.

[Jen Carvey (Office of Legislative Council)]: Was sort of a companion, but ended up with some differences. Think sometimes when you have members working on the same topic and sometimes on different timelines, bills can evolve prior to introduction.

[Alyssa Black (Chair)]: Thank you, Jen. I think we're done for the day, so we can go off of live.