Vermont Legislature SmartTranscripts:

[Jennifer Carbee (Office of Legislative Counsel)]: Good morning everyone. It is April 1

[Alyssa Black (Chair)]: and we are continuing discussions around primary care And we've invited in several witnesses. And to start with, we have Doctor. Allen Ramsey with us on Zoom. So thank you for joining us.

[Allan Ramsay, MD]: Thank you for inviting me. For the record, my name is Allen Ramsey. I, again, thank you chair chairman Black. Thank you, vice chair, McFaun, ranking member Berbeco, who I don't know that well, but, thank you all. I have been a family physician in Vermont for forty four years. I spent thirty two years in the Department of Family Medicine at the Larner College of Medicine. And in 2011, I, became a professor emeritus when I was appointed to the Green Mountain Care Board, where I spent five years as an original member of the Green Mountain Care Board. During that time and starting in 2012, I transitioned my practice to the People's Health and Wellness Clinic in Barrie, Vermont. And the last few years, being the medical director at the People's Health and Wellness Clinic. So I am pleased to be here in support of house bill four thirty three. And I have a few reasons why I I wanna explain to you why I support this bill as a natural progression to act 48, which is still the law in in which I dedicated those five years of my life to trying to make that single payer health care system for all Vermonters work. So why do I support this? Number one, first and foremost is improve the quality of care in Vermont. Quality is processed, quality is outcomes, and quality is satisfaction. The process being when you call a doctor or can you get to the doctor? Do you get a timely appointment? If you need it, do you get a timely referral? Outcomes are, do you get appropriate screening? Do you get appropriate preventive care? Do you get appropriate case or chronic disease management? And satisfaction, are you satisfied when you leave the doctor or clinician's office of the care that you've gotten? So they're very simple. Can we achieve any of those without increasing investment in primary care mental health and community based services? No, we can't. We've got 190,000 Vermonters now who are under insured. And as a clinician who has only taken care of the uninsured or underinsured for the last thirteen years, I can tell you that number is gonna increase. We're anticipating increases in the number of people who would need it, who provide who require access at the Vermont Free and Referral Clinic network, including the People's Clinic. Primary care is six to 8% of the spend in Vermont, depending on how you measure it. That will never improve the quality of care we provide. Never ever ever. K? Reason number two is the holy grail. How do we control the growth in health care costs? We can't unless we invest more in primary care mental health and community based services? The last time I spoke before this committee, 2018, talking about the universal primary care bill, expenditures per Vermont cost per Vermont were around was around $7,000. Now in 2024, we are at 11,500. That's almost a $3,000 increase year over year. When I joined the Green Mountain Care Board, cost was an issue. How do we control the growth in health health care costs? Well, what are the drivers? Oh, the aging population. We have a poor risk pool. Oh, the increased technology. Oh, the hospital costs. And I would say, how do we we really can't control any of those, but we can control the amount of money we invest in primary care. Let's do it. And the response I would get from politicians, from policy people would be, oh, preventive care, primary care takes too long. Fifteen years ago, that's what I heard. It takes too long. Well, here we are now. We haven't done it, and the costs are totally out of control. I have firsthand knowledge of this based on my work at the People's Clinic. I see costs explode in people who have not had access to primary care services. And that and if we keep saying the drivers are hospital costs, the small aging population, more utilization, higher acuity care. If we keep saying those are the problems, but we don't address the solution, which to get more people into primary care offices and and have primary care services. The other thing that is a big cost driver, and I'm gonna talk about that next, which is provider which is provider shortages, that's the workforce. We have a workforce crisis in Vermont, not just in Central Vermont, Washington County, Orange County, but the Northeast Kingdom, Orleans County, down in Bennington, Windham, Windsor Counties. There is crisis in terms of access to health care to primary care services throughout the state. I have been involved in the education of literally thousands of medical students, hundreds of medical residents. We even did a small study at Dartmouth a few years ago asking Dartmouth medical students, what would be what what would be incent you all to maintain your interest in primary care? And three things came up. Number one, we think primary care should be treated differently. It's unique. It's special. But there's nowhere else in the health care system that we see that. That basically came down to the idea of respect. Number two is the lifestyle issues. We see our mentors dealing with administrative burdens like prior authorization, and we say, what is that what good is that for our patients? Okay. And number three naturally is the fair and equitable reimbursement, which includes ways to achieve loan repayment with without bank without, you know, sacrificing a mortgage or a college education for your kids. So those were the three

[Francis "Topper" McFaun (Vice Chair)]: things. If

[Allan Ramsay, MD]: if we don't invest more, primary care mental health and these community based services that are so important to so the social determines the health, we will not build a sustainable workforce. It just won't happen. Let so let me tell you a story about primary care. So last time I went to my primary care doctor not too long ago, I noticed on his desk, next to his computer and around his neck was a stethoscope, the usual things. And on his desk was an ultrasound probe. And he had in his office on you know, immediately available ultrasound. You can't go to a primary care or family medicine review course without having a workshop on using ultrasound in the office to diagnose pneumonia, to diagnose joint effusions. And I said to I said to him, I said, how often does that actually change what you do? And he says, most of the time, it doesn't. But once in a while, it really does. And that once in a while is where the cost savings are and where the value is. So we now have new technologies in primary care, ultrasound, artificial intelligence, telemedicine, that should attract more students into primary care, and it will. But we have to treat primary care differently. So that's what house bill four thirty three should be targeted to do. Let's increase quality. Let's use it to decrease costs. Let's not say primary care prevention, primary care screening, good disease management just takes too long to control costs. Let's do something about it. We can't control the aging population. We can't re we can't really control the new technologies. Now the big one is drugs with all the new immunologic agents and the GLP one in agonists. But we can control access to good quality, cost effective primary care, and this is the first step. So, that's all I had prepared. I on fairly short notice, but it's not something I haven't thought about. It's not something I haven't experienced at the People's Clinic. And so I wanted to leave some time for you all to question me.

[Alyssa Black (Chair)]: Thank you. And that's exactly why we wanted to have you in because your thoughts are very valuable on this. And I know that you're a thought leader in this. Any questions for Yeah, go ahead Leslie and then topper.

[Leslie Goldman (Member)]: Hi Doctor. Ramsey, thank you for all your work in primary care. I was listening to you talk about it and we're looking at three different bills, four thirty three is one of them. One of the bills came from the Senate 01/1997, which we haven't really walked through yet.

[Alyssa Black (Chair)]: But Yeah. We were at 10:00.

[Leslie Goldman (Member)]: Okay. That's good. Because I I I read it, so I'm familiar. But okay. And you listed three things. I I mean, I care a lot about workforce. It seems like that's sort of the fundamental issue of, you know, what we're facing. And you mentioned three things, but I only got two, respect and money. And what was the third, and what else did I miss in terms of building our workforce?

[Allan Ramsay, MD]: Well, I I kind of generically called it lifestyle. But what what it means is we are not emergency doctors. We don't work shifts. Number two, we're not hospital doctors. We don't work shifts in the hospital. We work until the last patient is seen and taken care of. That being that's a commitment we make to a relationship. So we expect in return that the system protects us from unnecessary administrative costs. We don't wanna spend a lot of time on prior authorization. We don't wanna spend a lot of time on claims denial and resubmissions. We don't wanna spend a lot of time on copays and deductibles and coinsurance. All those things could be taken away with universal primary care. So I kind of generally called it lifestyle, but what I mean is respect us for not being shift workers, Respect us for doing what we have to do until patients are cared for, and respect us by not burdening us with these unnecessary things.

[Alyssa Black (Chair)]: Yeah. So there is

[Leslie Goldman (Member)]: a fundamental difference in, you know, being a neurologist or dermatologist and being a family practice clinician. And the respect piece seems so fundamental in that primary care doesn't seem to have the credibility or cachet that these other specialties do. How do we make that leap?

[Allan Ramsay, MD]: Well, it it's an it's

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

[Allan Ramsay, MD]: spent thirty three years, listening to medical students transition from freshman year to their senior year And going through this and and hearing the stories that my specialty friends would would say to their students when the student says, well, I think I wanna be a family doctor. I think I wanna be an internist. Okay? But I tell you when that dermatologist or neurologist had a two year old kid with an earache and didn't know what to do about it, they wanted to be sure that there was universal primary care available to them. Okay? So I spent a long time listening to that, and and I never bought into it. I mentored students through it. I tried to model what what a continuity care relationship would be. And but you're right. I'll tell you another story. I went to my dermatologist. These are my personal stories. Okay? And we got talking, and he he was always interested in health care reform. He was interested in that 48. And so we had a lot always said, he never spent much time really examining me, but we all talk we had time to talk about primary care. I said, you know, we've had to set up a Xalazine clinic at the People's Health and Wellness. And he said, a Xalazine clinic, what the heck is that? And I said, well, that's dermatology. Xalazine a a vet drug that's laced with fentanyl and people inject it and they get these horrible ulcers and cellulitis and we have and and nobody wants to take care of them except us. He said, I'd never know how to take care of that. So we would have a Xylazine clinic a Xylazine clinic at the People's Clinic. A nurse became quite expert at seeing people for daily dressing changes, changing antibiotics around. So you don't hear those the medical students need to hear those stories those stories and learn about, really, the respect that and and but it really comes down to the money. Because some of the I had one of my one of my colleagues, Joe Haddock, who is a well known family physician in Tinna County at the Williston. And, actually, you're gonna hear somebody from somebody, I think, from the, Wilson Health Center. But we used to have the Haddock Ramsey rule. Pay office based primary care clinicians at the same level as you pay emergency room doctors, shift workers, and hospitalists, shift workers. And I I said that to John many, many times. Why can't you do that? Well, you know, all is an excuse. There is no excuse. Invest more in primary care, mental health, community based services so that we can also the community based service, always add in there because you gotta adjust social determines the health. No other part of the health care system is gonna do that, but primary care is gonna do that. They're gonna address those social determinants. Mental health, drug drug dependency, homelessness, food insecurity, all those things can be addressed through primary care into the community based services. Sorry about that long winded response.

[Leslie Goldman (Member)]: No. It's really interesting to me. I just have one more thought, if I may. What we've learned is the investment in specialty care by the federal government is enormous rather than investment in primary care. And how do we make a shift? I mean, countries of course invest in primary care big time. We don't. We invest in specialty care. I'm not sure I understand why, where that power came from, and maybe that's not relevant to these bills right now. But what I'm trying to figure out is how do we address those issues in the bills that we're looking at, at least for Vermont, to try and strengthen primary care?

[Allan Ramsay, MD]: Yes.

[Leslie Goldman (Member)]: So how do we do that in the context of a culture that is specialty focused, that invests in specialty care you know, intently and research.

[Allan Ramsay, MD]: Good question.

[Leslie Goldman (Member)]: I'm gonna throw in research. And research. Yeah.

[Allan Ramsay, MD]: Yeah. You heard the charge master?

[Leslie Goldman (Member)]: Yeah. Alright. Hospitals I mean, we all know what it is.

[Allan Ramsay, MD]: You know, hospitals have a charge master. The Green Mountain Care Board or the Green Mountain Care Advisory Board could could develop a primary care charge master. Risk adjusted, fee for service, completely not not linked to Medicare payment, not linked to Medicaid payment, but linked to the investment that the legislature legislation places in primary care, the spend rate. Just let's have a primary care charge master. I wish I would have seen that. What have we done? What have we done since we which since we canceled act 48? We've tried everything else. Oh, we're going to do payment reform. Oh, we're gonna do accountable care. Oh, we're gonna do an all payer model. Okay? How long does that list have to be before we invest where we need the money to go? Primary care and mental health. You tell

[Leslie Goldman (Member)]: me I'm gonna follow-up with one thing. One of the things in the bills that we're looking at is a per member per month payment to primary care. Do you think that would address it? No.

[Allan Ramsay, MD]: No. All this stuff about how oh, the evils of fee for service, the cost shift. Oh my gosh. The cost shift. That's why we pay so much commercial health insurance because of the cost shift. Never ever ever been proven. Let's just agree that there are some good things about fee for service. Number one, it it increases the likelihood of providing a service. And number two, most importantly, all my patients, they understand fee for service. Ask them about accountable care. Ask them about all payer model. Ask about capitation. They don't capitation. Oh my gosh. That just means that you don't wanna see me, then you'll still get paid. Okay. So there are some good things about fee for service. Let's not throw that under the bus. So I'll leave it to the I'll leave it to the economists, but I won't accept the fact that fee for service in and of itself is going is evil. It's not. There are some good things about it.

[Alyssa Black (Chair)]: Thank you. I would say we there's nothing wrong with fee for service. We just pay the wrong fees for the wrong services.

[Dr. Mayer (first name unknown), Pediatrician]: I agree.

[Jennifer Carbee (Office of Legislative Counsel)]: Tucker, question?

[Francis "Topper" McFaun (Vice Chair)]: He's great Doctor. Ranchi, thanks for coming in. I've been involved in type of thing for over twenty years now. And I've come across you several times. The biggest roadblock that I have experienced personally whenever I talk to anybody about universal primary care or universal healthcare is, okay buddy, how are you going to pay for it? Now, I don't know if you remember H304, it was a universal healthcare bill quite a while ago. And we figured out a way to pay for it. And it included fee for service. It included people being able to, based on their income, amount, there was a scale set up so that lower income people would pay lower price. And it set up a pool of money. It set up a fund that would all of the healthcare money would go into that fund and then it would be doled out. And primary care was a big deal in that because we were looking for primary care to help lower the cost. Instead of doing it in the hospital, we would do it out in the field. You just talked about money and then you said, I'm gonna leave that up to the economists to figure that one out. You've been involved in this for a long time. It's come across your mind, I'm sure. What do you think is the best way to fund this? Well,

[Allan Ramsay, MD]: there's two issues that have been worked out. Three issues that have been worked out. One is attribution. Two is the benefit package. Both of those have been worked out. They were worked out in back in 2016, 2017 by the Green Mountain by policy people at the Green Mountain Care Board. And number three is payment. How how you pay for the system. So and and number three is always where things you know, in this bill, if it moves out of your committee, it goes down the hall to the house appropriations. You know? That's when that's when the rubber meets the road. So let me, years ago when I was more involved in that part of the process, I believe there needed to be it. And I cut a primary care trust fund that kind of like you mentioned that I believe there need to be now. And whenever you say primary care trust fund and Howard Dean met this one, you know, he started years ago with Chip, but people start worrying about the tax burden. Will there be a payroll tax? Will there you know? And that's why I like the idea of four thirty two starting out on a very gradual set of benefits, looking at how to transition money out of the commercial insurance market, out of Medicaid, into a fund. And we have tools. We've got the Green Mountain Care Board. We have got DFR. We've got, you know and you will have a Green Mountain advisory board that that can can really link the money to the benefit package. And as the savings come in, that's when you expand the benefits. But I I I don't know. That's again, I I like the idea of a trust fund, like education trust fund, but I don't wanna talk about that now because that's such a difficult issue. But I I like I like that issue I like that concept eight years ago, a an actual trust fund with the tools that we have in place to manage it. And starting out slowly, you know, give everybody hearing aids the first year, but building on a benefit package as you start to see the savings come in. And, you know, you had a consultant, you had Oliver Wyman come or or the Greenville Care Board, I think you had Oliver Wyman come and said it just reduced reduction in health care costs can save $300,000,000. But look, another issue in terms of in terms of driving the increase is the the financial instability of our hospital system. I mean, I I I I watched I I I, know, watched some of the hospital budgets reviews by the Green Mountain Care Board, I see seven or eight of our hospitals in serious financial trouble. You know, that's gonna have an impact on those communities, in a big way. Anyway, that's totally off, but but that that's the best I can do, representative McFaun, about about what when I was more invested in the actual financing years ago. Right now, I'm invested in the quality. I've invested in the workforce. I'm invested in controlling the growth in health care costs and using that money appropriately.

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

[Alyssa Black (Chair)]: Kind of furthering on that questions, Topper's question, essentially how are you going to pay for it? I'm thinking of this as a reallocation of resources. I mean, we already spend way too much. So how do you reallocate resources to move more to primary care?

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

[Alyssa Black (Chair)]: And then of course, you just mentioned the hospitals. And Who's going to take a cut if primary care is going to get more?

[Leslie Goldman (Member)]: Right. Who

[Alyssa Black (Chair)]: takes the cut? Because every single time that we try to even slightly cut some area, people clamor about you can't do that.

[Allan Ramsay, MD]: Yeah.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah.

[Allan Ramsay, MD]: I I I I, during the five years on the board, I I went around to every hospital, met with every medical staff, talked to a lot of the specialty organizations, radiologists, pathologists, anesthesiologists. And the first thing I had to reassure them, I had to reassure reassure them, they're not there are not going to be big winners and big losers. There will be some winners and some little losers, but that's the reality of change and making us a whole system work better. Because that was the huge fear among, you know, the more higher paid hospital based people and administrators. So, you know, I guess they I'm not sure they believe me, but I I tried to make that point. You're right. There are going to be winners and losers, but they don't have to be big. And in the final analysis, the quality and work you do and how you feel about the work you do when you go home at night is gonna improve. I mean, people are suffering. Oh my goodness. Do I see people suffering? And and if we can reduce that and if not eliminate it, that's a winner. Oh. So it's a quite great question, chairman Black. I, I don't have a great answer other than other than reality. You know, are we gonna say, it's too hard a problem to fix, and let's just wait another five years? I probably won't be the person sitting here then. I'm almost sure I won't. Or are we going to try again?

[Alyssa Black (Chair)]: I wanted to ask you about workforce, you know, particularly with your lengthy career and the places where you have been, I've been thinking a lot about sort of our medical education, our medical system, the system of health care and how hierarchical it has become, where specialists are respected and primary care is not. Been thinking about the role of RBRVS system and how that just adds to it. From the standpoint of a physician in the state of Vermont who has been in the Department of Family Medicine, how do you think our only medical college, how do you think they invest in the training and concentration that they put on primary care within just our College of Medicine?

[Allan Ramsay, MD]: Well, that's a good question. You might ask, the dean when he is there, later either, I think, next week, maybe tomorrow. And, you know, and, again, I've been out of academics for several years and things all change very quickly. So that that's a good question for him. But and then I I hope you can have Gordon Powers come in, the residency director. And, you know, and I know you've invited him and talk about, you know, how he feels about residency training in Vermont. And I hope for dear sake that you can find some the legislature can find some money to invest in, Maple Mountain residency program. But but in that being said, the last time the family medicine residency program, which is six residents per year at the medical center, was increased from four year to six year was 1995. I was the interim, chair of the department, and part of my negotiation with the dean to take on that short term role was you have to support increasing the size of the family medicine residency at the medical center. Oh, and it got he was, you know, was John and, you know, he's an orthopedist. Grumble, grumble, grumble, but we did it. Now since then, since that increase occurred in 1995, anesthesia, radiology, pathology, cardiology have all increased dramatically in terms of training programs at the medical center. So you might ask the dean that question. I'm too far out of it right now other than to give you a historical perspective.

[Alyssa Black (Chair)]: Well, thank you for your thoughts on that. And we will. We've invited both both of them to come testify. Allen, did you have

[Francis "Topper" McFaun (Vice Chair)]: a question? Yes. Thank you, sir. If you talk about winners and losers, could you give us an example of maybe, you know, without going into in-depth of some of the winners and some of the losers that might happen here?

[Allan Ramsay, MD]: Oh, I I'm sorry. I didn't I didn't get that question.

[Francis "Topper" McFaun (Vice Chair)]: Yeah. You talked about winners and losers.

[Allan Ramsay, MD]: Oh, yeah. Right. Okay.

[Francis "Topper" McFaun (Vice Chair)]: Yeah. Could you give us an example that went into too far in-depth of maybe some of the losers that we'd be concerned about and maybe some of the winners?

[Allan Ramsay, MD]: Yeah. Well

[Francis "Topper" McFaun (Vice Chair)]: I know I'm putting you on the spot here a little bit.

[Allan Ramsay, MD]: Yeah. No. Oh, you you I I hope you recognize my frankness in this testimony. Yeah. I I don't I don't hold back. And that because that doesn't do you guys you any good in your decisional process. So winners and losers. Well, you know, the winners have to be those that provide primary care services. So those clinicians who invested their lives in office based primary care medicine, family medicine, pediatrics. Okay? Those that have have the desire to both practice in a hospital setting, an FQHC setting, or an independent practice setting. We've got to have all three models supported. Okay? Right now, we don't really support I don't think we adequately support those that wanna run their own show, those that wanna be in independent practice. So those are the winners. They you know? And when you start out at six to 8%, if you wanna get to 12 or 14%, which is the very minimum that most integrated health care systems like Kaiser do, that's not a big win. But for a family physician or a practice, that it could be a big win. Okay. I let the since a lot of the what I consider to be potential losers would be the hospital through the hospital budgeting process, and that would you know, and I was part of that when I was on the Green Mountain Care Board, and and and we would look at that, you know, carefully. What again, what are your what's your margin? What's your revenue stream? And what are your costs, and and look where things are totally out of balance. If they're totally out of balance in the endoscopy suite where the cost of the service you're providing has dropped dramatically, but your charges haven't, there's something wrong there. And that's what's happened over the last ten years. Now the endoscopy suite is so is so efficient that the costs have decreased but has has the revenue stream. So little things like that. But I'd I'd like to talk about winners, and I want the winners to be those people who come here and make a commitment to family medicine, internal medicine, and and pediatrics, and get the option of joining a hospital based practice, joining an FQAC, or joining a private practice. That's what I like. Those are the winners.

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

[Alyssa Black (Chair)]: Now.

[Jennifer Carbee (Office of Legislative Counsel)]: Hi, Allen. Leading from the endoscopy,

[Karen Lueders (Member)]: the pricing that didn't change that you just mentioned. Did I say that correctly?

[Allan Ramsay, MD]: Yeah. I don't know. I don't know. That's what would need see, the Green Mountain Caribou never want to get down in the weeds of those decisions when it would approve or modify a hospital budget. But there could be a there should be a way to force the hospital administration to address that because other hospital administrations have address addressed the fact that if your cost decrease, then you shouldn't be charging the same amount for the service.

[Karen Lueders (Member)]: Is that their revenue? Sorry to interrupt you. Is that how the hospital stays afloat and stays balanced?

[Allan Ramsay, MD]: Yeah. Yeah. Because they have talk about winners and losers. Neonatology is always gonna be a loser. So they have to I'm not saying they're wrong, but they have to generate the revenues somewhere else. And in if they generate those revenues through cardiology, through endoscopy, that's okay, but it there's gotta be a balance. There's there's got to be some sort of balance in that effect. Again, you're getting you're asking me to answer questions about hospital budgeting and hospital revenue streams that but I I'm just saying I got the question about what's you know, who are winners and who are losers. They're you know, hospitals don't have to be big losers. They may have to change their what they're doing a little bit. They're you know? But I'll leave that to to Green Mountain Care Board. And they've already taken that on. It's a pretty big challenge.

[Alyssa Black (Chair)]: Thank you. Thank you. Thank you so much, doctor Ramsey. Really appreciate all your thoughts on this. Doctor. Mayer, would you mind if we went to the next person? Because I think they have a time limit and they're on Zoom. Is that okay? Okay. And then we'll do you after that. And so Doctor. Niedecker, which I'm probably butchering your last name.

[Jennifer Carbee (Office of Legislative Counsel)]: Hi.

[Reese Neidecker, MD (UVM Family Medicine Resident)]: I'm doing well. How are you?

[Alyssa Black (Chair)]: Can I say your name anywhere remotely close to how it's been?

[Reese Neidecker, MD (UVM Family Medicine Resident)]: It was really, really close. To be fair, I call myself Nydecker, so you are 90% there.

[Alyssa Black (Chair)]: I would have gone Nydecker if it was B I, but not E I E.

[Reese Neidecker, MD (UVM Family Medicine Resident)]: And please just call me Reese. That's what I ask everyone to do.

[Alyssa Black (Chair)]: Well, thank you. Thank you for joining us today.

[Reese Neidecker, MD (UVM Family Medicine Resident)]: Yeah. No. And thank you. Thank you, Chair Black and, all of the other members of the committee for having me here today to talk. Once again, my name is Reese Neidecker. I'm a Vermonter. I'm a family medicine resident here at UVM, and I'm one of the elected delegates and members of leadership for our committee of interns and residents or union here called CIR. We represent about three sixty, three seventy five residents and fellows training at UVM. And I'm here today as their representative because me and a number of my fellow resident physicians wanted to share our concerns around the state of primary care here in Vermont. As individuals who are, you know, intimately involved in providing care in the state on a daily basis, we just wanted to offer our perspective for consideration as this conversation moves forward on a number of bills. In our opinion, the foundation of any healthcare system is a functional, responsive, and most importantly, accessible primary care network. Our PCPs act as the main touch point with the medical system. They're the people who we reach out to with medical questions and concerns. They're the individuals who should know us the best and therefore be able to provide us with the most personalized health care. However, I don't really think it would come as much of a or be much of a surprise to anyone here today that primary care in the state is really struggling. It's widely known in the community that it can take weeks, if not months, to get an appointment with your primary care provider. And that's only if you're one of the lucky few people that already has established somewhere in the state because a lot of people are not accepting new patients. This really is only compounded by the fact that about a third of Vermonters under the age 65 are underinsured. And many of those who are fully insured still struggle to afford the co pays and out of pockets associated with health care. Many Vermonters are unable to engage in primary care in any meaningful way, and we as providers see the downstream effects of that every single day. Just to give you an example, I'm currently spending time with the palliative care service here at the UVM hospital. And just yesterday, I met with a patient and his family up in the ICU. The patient is in his mid 40s and had a massive stroke last week, likely driven by his diabetes and high cholesterol. And now he's completely paralyzed on the right side of his body with a lifelong dependence on a ventilator for breathing support. The thing is this patient prior to his stroke didn't even know he had diabetes or high cholesterol, as he had not seen anyone in primary care since he was 17 years old. And when I was asking the family, you know, why was that the case? They said, well, actually, tried multiple times in the last ten years to get in with someone, he would call a couple offices, he would be told, sorry, we're not taking anyone, or we can see you in a year. He got frustrated with the process and just threw his hands up and didn't do anything. And after those, and after all of that, you know, he never ended up having a doctor never ended up seeing anyone or getting treatments or even basic screenings that would have let us know he was at a high risk for, this event. His stroke was likely entirely avoidable, if he had those regular screenings or just medications or just education around things he could do to mitigate his risk. And now he's going to spend the rest of his life in a long term care facility on a ventilator. My colleagues and I see similar things every single day here in the hospital or in the emergency department or out in our personal clinics. And what these scenarios often boil down to is a fundamental flaw in how American healthcare systems just function as a whole, right? Insurance reimbursement rewards intervention over prevention. Healthcare systems are incentivized to shunt resources to the higher reimbursement procedural subspecialty care. And in the same vein, recent generations of medical providers are encouraged to pursue these specialties for a number of reasons. Because they're going to be employees for these healthcare systems going forward. Vermont in particular struggles to recruit for riders to the state. I am finishing up my second year here and currently talking to a number of recruiters around the state for what jobs look like. And I can tell you that people are really worried about what provider, access is gonna look like five to ten years down the road as they're not able to bring in anyone now. For instance, I was talking to head recruiter for a multi site FQHC up in Franklin County who told me that she has been unable to recruit any MDs over the last five years, even though they try every single year to any of their locations in Franklin County. This, she shared with me, is probably or primarily because of the pay they're able to offer, which is around half of what many other rural states are offering the same physicians for comparable work. I've heard similar worries from practices across the state that struggle to bring in physicians to the areas that don't already have previous ties to their communities. And I can personally attest that I get messages daily from recruiters across the country, many of which offering me at least 50 more than I can make anywhere here in Vermont. Residency acts as our strongest recruitment tool for physicians in the state, and I feel like all of us residents strongly believe this. More than half the people who train in primary care specialties at UVM end up staying in Vermont after they finish their training. I can share that five of the six family medicine residents graduating this year have jobs lined up in Vermont. And this trend does extend to my internal medicine, pediatrics and emergency medicine colleagues. People come from around the country to train at UVM, and they end up falling in love with Vermont and choose to make their careers here. This is why I think that it's so important to make sure that our residency program, which is provided through UVMMC, remains an attractive and competitive mechanism for bringing physicians to Vermont and remains one of our strongest recruitment tools. Further, investment in primary care, I believe, is one of the best ways to manage health care costs in the long term. And I'm sure you've had many people bring this up before, right? That patient on the ventilator who I mentioned earlier, his short term cost in the ICU and the procedures associated with that likely ranges in the tens to hundreds of thousands of dollars. And he'll likely require millions of dollars over the course of his lifetime for continued health care because of the condition that he's in. You know, when you compare that to the cost of annual checkups and out of pocket, you know, generic prescriptions and a little bit of education, it's not even a comparison. The exact impact of primary care is so hard to quantify because the fruit of the investment often takes decades, decades to be fully appreciated. Right? But investment in primary care is an investment in our community. Investing in primary care keeps Vermonters out of the hospital, keeps Vermonters out of the emergency department. It keeps them at home, living independently with true quality of life, which is the goal for any health care system. And it is our best chance at long term viability from a financial perspective. Myself and the other resident members of CAR are personally invested in these ongoing primary care and universal health care discussions. We do not see these discussions as being mutually exclusive at all. In fact, we think funding primary care to increase access to providers, to mental health services, to social work, to case management, just to education for patients is one of the first steps that you need to take when moving towards making healthcare universal right. We are grateful for the opportunity to be here today, share our perspective, and look forward to continuing to engage in the future as we work to elucidate more ways to increase primary care funding with the ultimate goal of reaching publicly funded health care for everyone. Thank you all for having me.

[Alyssa Black (Chair)]: Thank you. Any questions? I have one question. I have two. You want go

[Francis "Topper" McFaun (Vice Chair)]: ahead? No, go

[Leslie Goldman (Member)]: ahead. Thank you, Doctor. Nidecker. I hope you do choose to stay in Vermont. I'm thinking about what's realistic for primary care, and I know that you just gave really good accolades for primary care, But I think we understand that medicine only really can affect twenty percent of a person's health, the other 80% being all those other things, which I know you know about. So if a primary care clinician sees someone two hours a year, which would be thirty minutes four times a year, which would be good, how does one really have an impact on a person's health without looking beyond the medical system?

[Reese Neidecker, MD (UVM Family Medicine Resident)]: Yeah, I think that's a really good question, right? And it kind of gets into the role of what primary care should be for. In my mind, a lot of it is about preventative care, and making sure the patients have the education or the tools they need to keep themselves healthy, as opposed to just being given medications or screening tests or things along those lines. As you said, the majority of healthcare is living a healthy lifestyle, right? You know, eating well, sleeping well, exercising, making sure you have a good supportive environment, being like emotionally supported. And we are significantly limited in the time we're able to help patients navigate all of those. I think that primary care is a piece of the puzzle, and that by catching things early before they become bigger problems with screenings, with discussions with patients, with just getting to know people in the community, if we're able to catch things before they become big problems and prevent them into in becoming from becoming like life altering events, we would be able to save lots of lots of money, heartache, and time for patients going forward. So as you said, it's always going to be a limitation. Think the biggest thing is to try to help support our patients in living that healthy lifestyle when we're talking about kind of long term effects. And that's what primary care focuses on more than most of the other specialties who see a problem, fix the problem, but they don't necessarily try to prevent the problem that might come down the road ten years.

[Leslie Goldman (Member)]: Yeah, I'm thinking about primary care as a team sport way beyond just the clinician, that interaction which you're talking about, and that's what I'm thinking about is how to surround primary care with what's needed in order to deal with. Because otherwise I think we're asking primary care in fact to do too much. And that's what I'm worried about.

[Reese Neidecker, MD (UVM Family Medicine Resident)]: That's fair. And I really rely heavily on my social work case management and mental health service colleagues for kind of being those support systems for patients outside of the doctor's offices. And I fully support, you know, increasing funding to those groups because they are also integral to lowering overall long term costs of health care in the state.

[Alyssa Black (Chair)]: Thank you. So I'm on UBM's website and you are getting ready to finish in 2027. I like that you make unnecessarily complex meals. That's what I'm having. Well. So this is just sort of a you said you you have recruiters calling you all the time.

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

[Alyssa Black (Chair)]: In your and this is just you personally, not representing everybody. What do you in your dream world, where would you practice or what type of community would you practice in and what would a practice look like to you that you would find satisfactory over a long term career?

[Reese Neidecker, MD (UVM Family Medicine Resident)]: Yeah, I have always envisioned myself and I always, know, as an adult, as a rural PCP, right? I'm from Vermont, I want to stay in Vermont, and I fully intend to do so. And I think ultimately as I continue to gain, you know, the skills, the acumen, the experience required to practice more and more independently, I would like to be that primary care touch point that does a little bit of everything in the community in which I live. I'm from Arlington, Vermont, small town, Southern Vermont. There's, you know, 2,000 people, one stoplight, you know, one gas station, that's it. And I would be completely happy living and working in a community like that. The issues with all of that is, you know, access to additional resources. You know, right now, as a resident training at UVM, I have all of these subspecialists, all of these caseworkers, and mental health services, and all of these support pieces around me that really allow me to, like, connect my patients with the services they need outside of primary care, which is great. And I would love to have a more integrated, you know, statewide system that would make that easier as well. I think that a lot of times when I talk to the federally qualified health care or FQHC groups, they have difficulty sometimes with sharing information between like the big hospital and what they have or the resources they have in terms of like imaging and diagnostic skills when they can do laboratory tests and the amount of things they're able to provide for their patients. I think that kind of a greater integration of both of all the primary care offices with the larger institutional things that already exist here in the in the state, like the hospital and their diagnostic tools and their support systems would go a long way to improving health care. And I would like to kind of, know, work towards that in my long career here in the state, hopefully over the next few decades.

[Alyssa Black (Chair)]: Great. Thank you. Thank you so much, and thank you for joining us. I know you had a time crunch, so we're grateful that you got to spend some time with us. Thank you very much.

[Francis "Topper" McFaun (Vice Chair)]: Yeah, thank you for

[Reese Neidecker, MD (UVM Family Medicine Resident)]: having me. It was nice to meet you all.

[Jennifer Carbee (Office of Legislative Counsel)]: Good luck. Good luck in your career.

[Alyssa Black (Chair)]: Let us know where you land in Vermont.

[Reese Neidecker, MD (UVM Family Medicine Resident)]: I'll run into all of you someday. Okay.

[Alyssa Black (Chair)]: Doctor. Mayer, you want to come on up? Have a seat. Thank

[Dr. Mayer (first name unknown), Pediatrician]: you. Thank you for joining us. So I'm at the other end of Doctor. Nynaker.

[Alyssa Black (Chair)]: I opened

[Dr. Mayer (first name unknown), Pediatrician]: my first dedicated Actually, the first pediatric practice in Eastern Franklin County, Ennisburg Falls in Rickford, and that was in March 1976. I remember that. Okay. Doctor. Judd. No, you're right.

[Francis "Topper" McFaun (Vice Chair)]: And Sam Epley. Sam Epley. Yeah. Thank you.

[Alyssa Black (Chair)]: Just wanna say that is what I want in doctors.

[Dr. Mayer (first name unknown), Pediatrician]: And I also came here to Vermont because I felt I had a mission as a physician to provide care in underserved areas. So, am and it was it was rough. It was I was a solo practitioner, and it was really hard work, but very, very gratifying. I so I I wanna start with my remarks by just telling you about the saddest day of my career. My patient, let's call him Brian Lueders, had been sick for a few days and was getting worse. His dad's job at the local mill didn't provide health insurance, and the family paid out of pocket. Their financial situation was difficult. They were a proud Vermont family, always paying their bills. Brian's mom was trying to treat him at home, but finally called me with her concerns. Could I just send in a prescription to Spears Pharmacy for amoxicillin? She asked. Her description of Brian's condition alarmed me, and I convinced her to bring Brian in right away. He had meningitis. Had I seen him just one or two days earlier, I could have treated him successfully, and he'd be a normal boy. But it was late in the course of his illness, and he suffered severe brain damage. Missus Lucier, it was hard to ask this question, but I had to know. Did you wait because of the money? She nodded and took another tissue. Is that why he's behind on his shots? She nodded again. So and I'm sure every primary care physician has a story like this to tell, and this this shouldn't happen in America, particularly not to children. So today, many of the hundred and eighty seven thousand underinsured Vermonters with high annual deductibles, people like missus Lucier, don't see a doctor because they simply can't afford to pay the out of pocket fees. No family in America should have to defer medical care because they can't afford it. America is an outlier among all industrialized countries, as you, I'm sure, are aware of, in our failure to provide publicly financed universal health care as a human right. We continue to rely on a system where insurance companies, which provide no care, take almost 30% of our health care dollars and erect barriers to care. Just by way of an example, at the the Duke University Medical System hospital system, they have 932 beds, and they employ about 1,300 administrative billing clerks to administer these hospital situations hospital system. The Toronto University Hospital System, which has 1,272 beds, so 300 more beds than Duke, operating under a national health insurance, employs less than 10. This past town meeting day, I was part of a effort to pass a resolution about universal primary care. The the it was a brief I'll just read it briefly to you. Shall the voters of the town call upon the general assembly to discuss, take testimony, and vote on h four three three during the 2026 session. H four three three, an act relating to incremental implementation of Green Mountain Care, would establish publicly financed universal primary care, mental health services, and substance use treatment as a first step in phasing in universal health care for all Vermont residents. This so we we started gathering petitions rather late for this town meeting resolution. We had about two and a half weeks. We were able to get on the ballot in 10 towns. Every single one of those towns passed this resolution resoundingly, overwhelmingly. Sadly, h four three has still been languishing in committee, and I'm glad that there is now that we're now having this discussion about it. So if if passed, then primary care will no longer have to be mediated by insurance companies, and people's health care costs will decline significantly. Of the 33 industrialized countries of the world highly industrialized countries of the world, 32 of them have some form of publicly financed universal health care. We are the only outlier. All of those other countries have better health outcomes, and they have substantially lower costs than we do. So we can we can do this for Vermont and do it and this is talking about primary care as a stepping stone, as a first step toward in the process of a of a national system. And as as a model, we might look to what happened in Canada. The the the first national health insurance system in Canada started in Saskatchewan in 1947, and it started out as a a universal payer for hospital care only. It was very successful. They then expanded the program to cover all all care, and then it became a nationwide public public system. And they they have a a a well functioning publicly financed system. We in The in Vermont and in The United States continue to produce to to pursue failed models of care and financing that rely on private insurance companies. We've had the whole alphabet soup of of attempts. We've had HMOs and IPOs and accountable care organizations, and the cost of care continues to rise steeply. We're doing the same thing over and over again and expecting different results. The second highest cost for school budgets is health care. Hospital budgets, as were alluded to before by doctor Ramsey, eight or nine of Vermont's hospitals are losing money. Four of the 14 hospitals in Vermont are facing the the possibility and the danger of bankruptcy, which would truly be catastrophic. Our property taxes are heavily weighted by health care costs, business costs, as chair of Black knows all too well, trying to provide insurance for for employees and provider burnout. We have we have got to find a way to make primary care the attractive medical career that it once was, And we can do we can do that if we are able to find some way of of making a a private practice, the remuneration, equitable and fair for for all Vermont. This also is a way of addressing the the the maldistribution of primary care in small rural states like Vermont. Because if you can guarantee a an income that's based on a on a budgetary approach where you have one large pot of money that's then doled out to primary care providers, well, then you can encourage people to go to Eniesburg Falls, to go to Newport, to go to Island Pond, where where primary care is is in great demand and short short supply. I think the the the bottom line for me also, at least philosophically, is that health care is a human right. Health care is not a commodity. It's not a marketplace. It doesn't work that way. We have tried in vain to pursue that that line of financing, and it it it doesn't work. And we are now at a tipping point where where we're seeing costs going through the roof. And and I'm sure all of you have had the sticker shock of what your health insurance premiums are are going to be for this year. So I think it's time to give up the failed model of private insurance as the bedrock of a stressed health care system. I just want to end with something that Winston Churchill once famously said about us Americans. He said, and this has a lot to do with how we finance healthcare, Americans always do the right thing after they've tried everything else. So thanks for your attention.

[Alyssa Black (Chair)]: Thank you. Any questions? I have a question.

[Unidentified Committee Member]: Yeah. Then Just visualize this for me. Like, you carve out just how do you envision this? How do you carve out just primary care to be universal and have all the other insurances take on the specialties and everything? How do you visualize that?

[Dr. Mayer (first name unknown), Pediatrician]: Well, think two responses to that. One is, I think we do need to have some sort of a financing and operational plan and a committee to to look at this. This would not be a very expensive study to do. We're not talking about millions of dollars. A couple of $100,000 will will provide something like what the Oliver Wyman report provide. The other response is that we're starting with primary care because the return on our investment in primary care is incomprehensible. I mean, is just, you know, have high blood pressure and get a cheap pill to treat it, and you're good. Don't do that. Don't have primary care, and you have a stroke. What doctor Neidegger was talking about. And then you're you're in for hundreds of thousands of dollars of costs. So the I I think the the we have the ability to do this, and and and I and I know there's gonna be a lot of pushback from insurance companies because this is their business model. And we are and and a a single payer publicly financed plan is interfering with that. And I I would hope that we're able to to stand up to them and say to look. What what you have done for the last fifty, sixty, seventy years is clearly not working, and it's not it's not equitable. It's not fair. Act 48 has has also put put forward for us a a a a guide map of how to start how to start approaching this. Until we really enter the have these these studies done and look at it and I'm I'm sure that we will save much more money than it will cost, and the the cost burden will not be on who do you work for or what's your what's your what's your income, what's know? Or or no. It will be based on what's your income, but it won't be for who you work for or what's your accessibility or how far you have to drive to get primary care. It it it'll be it'll be equitable. It'll be it'll be financed. There are I mean, I I've seen many options of how to finance this, whether a a small addition to the payroll tax or and there's all kinds of ways to do it in a progressive and an and an equitable fashion. I think we just have to start with the the I think it's a question of of what's our basic premise in health care going to be. If we're going to continue to rely on private health insurance and involve the profit motive in health care delivery, then this is what we've got. If our basic premise becomes that health is a public good, like roads and clean water and schools and fire and police, then we're we're walking down another road. You know, Robert Frost talked about the roads that diverge in the woods. Well, let's take the other road because we sure haven't gotten very far on the one road.

[Alyssa Black (Chair)]: You. I do want to say, h four thirty three isn't languishing on our wall because we don't care.

[Dr. Mayer (first name unknown), Pediatrician]: We

[Alyssa Black (Chair)]: have had some incarnation of universal primary care since I've been in this committee. I actually ran for my first election on this issue. And in this case, we have an ongoing joke in this committee that if you don't believe in universal health care when you start on the committee, you will by the time you finish. But in this case, it's not even that we're thinking about the profit motive and the insurance. It's that we understand how concerned we are by the federal government to not actually allow us to operationalize something like this. I just wanted to make that statement that I think sometimes people think that we don't care and we're not listening and we are. We care and we're listening. Yeah, it's really hard, particularly hard for things that are completely outside of our control. I just want to make sure that That I say being said, we're going

[Dr. Mayer (first name unknown), Pediatrician]: to do a walkthrough of H433. So I just want to briefly respond that the question always comes up, how can our brave little state do something in the context of this federal health care system. And that's that's why I think looking at the experience of Canada is so instructive for us because they started out on the provincial level, and they started out with an incremental systems. They started out with hospital care. We're talking about starting out starting with universal primary care. So and and and it worked. We we can do that. We can demonstrate to the rest of the country that this is a viable means of financing the the the most critical aspects of of health care. And and there are wraparounds, and there are ways of dealing with federal waivers for Medicare and Medicaid. So and that's where this this committee, something like the the the Windham Committee, would be able to to tease these threads out and figure out a way for us to do it. But I'm I'm convinced that we in Vermont can can really shine a spotlight on the the the possibility and the and the success of a primary care universal. So and and I thank you for for your your I I I know that this is a a top concern of all of you, and I I thank you for your hard work, and I realize this is

[Alyssa Black (Chair)]: Well, think in this committee that we hear an awful lot about universal primary care and what something would look like. So, we did ask Jen to do a walk through at 04:33 just for educational purposes, and then we'll do a walk through of S197, which is a bill we actually do have that we got from the Senate as a follow-up from yesterday's bill that we walked through.

[Jennifer Carbee (Office of Legislative Counsel)]: Good morning. Jane Carby from the Office of Legislative Council. And we are looking at h four thirty three. It's sponsored by several members of this committee and others. And it is entitled an act relating to incremental implementation of Green Mountain Care and has been introduced, I think, for some times over the last few bienniums, and this is the most recent version, although this was introduced in 2025. So any dates in here, you know, could build it and restore it if you want. Starts out with a purpose section saying that the purpose is to initiate the incremental implementation of Green Mountain Care by starting to provide comprehensive, affordable, high quality, publicly financed health care for all Vermonters in accordance with the principles established in twenty eleven's Act 48.

[Alyssa Black (Chair)]: And the

[Jennifer Carbee (Office of Legislative Counsel)]: Act gradually expands the benefits available for Green Mountain Care over ten years, beginning with publicly financed primary care in the first year, adding preventive dental and vision care in the second year, and adding the remaining health care services according to the schedule recommended by the Green Care Board's Universal Health Care Advisory Group that is established in the field. And it expresses legislative intent that by the tenth year, the Green Mountain Care benefit package should be at least as comprehensive as the benefit package contemplated for the program back in Act 48. Section two amends the subchapter and statute on Green Mountain Care. So although Green Mountain Care as enacted in twenty eleven's Act 48 has not been implemented, and you'll see there are certain triggers for implementation that have not been met, the language does still exist in the statute and could be implemented through achievement of the triggers or in this case modifying the triggers. So on the implementation provisions in the existing statute, it says that Green Mountain Care shall be implemented ninety days following the last to occur. And there, I think it's helpful to look both at what's crossed out and what remains. So I believe what remains is receipt of a waiver under Section thirteen thirty two of the Affordable Care Act. You may remember, we talked a little bit about section thirteen thirty two of the Affordable Care Act when we did your budget memo this year, because that would be and looked at H five eighty five as introduced, that would be the authority for getting a reinsurance waiver from the federal government. So same section of the Affordable Care Act provides for waivers with pass through funding from the federal government. So under existing law, Green Mountain Care would be implemented ninety days following the last to occur of getting the waiver under section thirteen thirty two. And then this would cross out, but in the existing law, enactment of a law establishing the financing for Green Mountain Care, and approval for by the Green Mountain Care Board of the initial Green Mountain Care benefit package as set up in their statutory duties. And then this would retain enactment of the appropriations for, and so that say the first year of Green Mountain Care based on the first year benefits set forth and what we're gonna look at. And so under so and under the bill, not to be confusing, under the bill, the Green Mountain Care would be implemented ninety days following the last to occur of getting that federal thirteen thirty two waiver and enactment of the appropriations for the first year of the benefits. Under current law, under existing law, Remote Care is implemented ninety days following the last to occur of getting the thirteen thirty two waiver, enactment of a law establishing the financing for Green Mountain Care, approval by the Green Mountain Care Board of the initial benefit package, enactment of appropriations for the initial benefit package, and a determination by the Green Mountain Care Board as a result of a detailed and transparent analysis that a list of conditions would be met. In this language, it's struck that there's just certain triggers. So these are all part of the act 48 triggers. If ever hear people mention those, that's what these are. I'll go through all of them. And then under the bill, the secretary of human services would seek a waiver under section thirteen thirty two of the Affordable Care Act. When act 48 was enacted, that wasn't an option yet. That's why it says as soon as allowed under federal law. So this would direct the Secretary of Human Services to seek a thirteen thirty two waiver to allow the state to, and then as changed by the bill, modify the benefit package for qualified health plans offered through the Vermont Health Benefit Exchange as appropriate to reflect the expansion of coverage through Green Mountain Care, and enable Vermont to receive the appropriate federal fund contribution, this is the pass through funding, to the extent that reductions in premiums and out of pocket costs are attributable to the availability of coverage for certain healthcare services through Green Mountain Care. And then it continues to allow the Secretary to seek waivers from other provisions of the Affordable Care Act as needed. It strikes language about the Green Mountain Care Board's analysis about all the things they had to find for Green Mountain Care to take effect. And then we get into the health benefits provision. So under current law, the way Green Mountain Care was contemplated, it would include primary care, preventive care, chronic care, acute episodic care, and hospital services, and have at least the same covered services as were included in the benefit package for the lowest cost CADAMATH health plans. So for those of you who are involved in health care at that time, harkens back to an earlier time offered on 01/01/2011. So this strikes out the language about, and talk about actuarial value. And this would instead say, and here's where we get to the incremental implementation, in the first year of its implementation, the Green Mountain Care Benefit package would consist of all primary care services, including outpatient mental health services and services for treatment of substance use disorder, all testing necessary for the diagnosis of communicable diseases, and all vaccines recommended by the Centers for Disease Control and Prevention. Though if you were to take this up, you may want to modify that based on the language you passed earlier this year. Specifies that there shall be no co payment, coinsurance, deductible, or other cost sharing requirement for those services at any time. And then in the second year of its implementation, the benefit package would have everything that was in for the first year, and as well as all prophylactic dental services, including two cleaning visits and dental exams per year, fluoride treatment as prescribed by a dentist and annual dental x rays, one vision exam per year, as well as screening for glaucoma and macular disease if indicated, and hearing aids when medically necessary and prescribed, fitted, and dispensed by a hearing care professional. So all this preventive services from the first year and then expanding to include certain dental, vision, and hearing aid services. Again, no co payment, co insurance deductible, or other cost sharing for those services at any time. And then the Agreement and Care Board benefit package for years three through 10 would include all of those services in subsections A and B, with additional services to be added by the General Assembly based on recommendations from the Green Mountain Care Board's Universal Healthcare Advisory Group, which shall prioritize the addition of the following: all prenatal and maternal care, all neonatal care, all standard diagnostic screenings at recommended intervals, including mammography, colonoscopy, blood glucose, blood cholesterol, bone density, and hearing testing, all medically necessary dental services, including dentures all emergency services, including ambulance and emergency medical technician services all physical therapy services prescribed by a healthcare professional all durable medical equipment and prostheses prescribed by healthcare professional, specialty care and outpatient treatment, including outpatient surgery and oncology services, home health and hospice care prescribed by healthcare professional and hospital inpatient care. So those are the priorities that they're directed to look at. And it also has the Universal Healthcare Advisory Group recommend to the general assembly whether and to what extent the benefit package should include prescription drugs, rehabilitation services in a skilled nursing facility, and long term care in a skilled nursing facility. It allows the, Universal Health Care Advisory to consider recommending to the General Assembly reasonable co payment, but not coinsurance or deductible, requirements for services included in the benefit package for years three through 10. So everything in the years one and two was no out of pocket at any time. This is allowing the advisory group to consider recommending reasonable co pays, but again, not coinsurance or deductibles for the services included in years three through 10. And then it expresses legislative intent that by the tenth year, the Green Mountain Care benefit package would be at least as comprehensive as the benefit package contemplated for the program in Act 48. Keeps language saying Green Mountain Care shall not limit coverage of preexisting conditions. It requires the Green Mountain Care Board to approve the benefit package annually based on the provisions of subsections A through C and presented to the general assembly as part of the board's recommendations for the Green Mountain Care budget. And then it has some language around individuals eligible for Medicare or CHIP. And that says the benefits for each year would include all benefits included in Green Mountain Care benefit package for that year to the extent that those benefits exceed the benefits available to the individual through Medicaid or CHIP. And if the agency successfully obtains Medicaid and CHIP waivers, the benefit package would include the benefits required by federal law, as well as any additional benefits as part of the Agreement in Care Benefit package.

[Unidentified Committee Member]: Okay, can you go over that part again?

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, basically this is looking at for an individual who's eligible for Medicaid or CHIP, The benefits is basically wraparound what they would be they would receive under Medicaid and CHIP. So they would sort of have enrollment in both. But if we were to get Medicaid and CHIP waivers, then it could include all of the benefits required by federal law as well as the Green Mountain Care. Instead of wraparound would be comprehensive. No? And it strikes the separate language and existing law around Medicaid or CHIP. Specifies that for children eligible for benefits paid for with Medicaid funds, the benefit package provided following receipt of Medicaid and CHIP waivers would include early and periodic screening, diagnosis, and treatment services as defined under federal law. So again, this is just part of if we are able to fold in Medicaid and CHIP, then the services provided by the state program would have to include the requirements of the federal program. For individuals eligible for Medicare, the benefits would include all benefits included in the Green Mountain Care benefit package for that year to, again, to the extent those benefits exceed what is available to the individual through Medicare. And if the state successfully obtains Medicare waiver, then the benefit package would be comprehensive for those folks under the Green Act Care Benefit Package. For an individual eligible for health care coverage through other federal programs, so through The US Department Of Veterans Affairs, TRICARE, or the Federal Employee Program, the benefit package would include all of the benefits in the Green Mountain Care Benefit Package that exceed the benefits available through the applicable federal program. So providing the WRAP, a state WRAP, for anything that exceeds what the person would be eligible for under these applicable programs. Basically, nobody who has coverage under Medicaid, CHIP, Medicare, or another federal program would be worse off than Vermont or if you didn't have that coverage, you could cover the existence of this program. So it would provide any additional benefits. And the Green Mountain Care benefits for individuals eligible for Medicaid, CHIP, Medicare, and those federal programs would include coverage of any co payment, coinsurance, and deductible amounts attributable to services that would have been covered without cost sharing under Green Mountain Care. And if the services would have included a cost sharing requirement under Green Mountain Care, then Green Mountain Care would cover any applicable amount that exceeds the cost sharing amount for those services under Green Mountain Care. Again, trying to make those people whole and in parity with the rest of the month.

[Alyssa Black (Chair)]: Do you have questions now or later? Ask them now. I actually have a question about that little section too, but

[Lori Houghton (Member)]: No. I'm just curious. So in an earlier section, it said Green Mountain Care wouldn't, maybe I misinterpreted, wouldn't include things like mammograms and colonoscopies. Or that was in the list of what would come.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, that's in the list of what to be prioritized for addition in years through treatment.

[Lori Houghton (Member)]: But for people today, like that is covered 100% depending on their insurance. So does this section we just went over make those people whole to get their mammograms and colonoscopies? Is that what that means?

[Jennifer Carbee (Office of Legislative Counsel)]: This is just because they're already covered under a plan we don't have control over, will control we will the state would would provide them coverage for anything that their coverage didn't provide that that their plan didn't provide coverage for. So it's making them

[Lori Houghton (Member)]: So as an individual, would would I and this might not be the time for this, just tell me that, or you tell me that. So I guess I'm worried about those people who, like I said, get preventative care today. Like I get a mammogram, colonoscopy, right? So now we have Green Mountain Care and that's not included. So do I still have another insurance?

[Jennifer Carbee (Office of Legislative Counsel)]: You still have, yeah, I think that That would be up a plan. To But yes, you would maintain your, or you would have the option to maintain your insurance that provided coverage outside of Green Mountain Care unless and until that you were satisfied of the services you were getting covered through Green Mountain Care replaced your insurance. Okay.

[Alyssa Black (Chair)]: So essentially, if you have other coverage, that is the payer first resort and then Green Mountain coverage would come in as a wraparound for anything not. I would

[Jennifer Carbee (Office of Legislative Counsel)]: say that yes, for these federal programs For private insurance, I think my expectation would be private insurance would evolve to cover less. And that's part of getting the thirteen thirty two waiver is to allow insurance to cover fewer services because they are being provided through Green Mountain Care.

[Lori Houghton (Member)]: So if someone buys on the exchange today, I could keep that and still have this wraparound? I would say it's not wraparound in that sense because it's, I mean,

[Jennifer Carbee (Office of Legislative Counsel)]: in my description of wraparound is really For the federal stuff. For the federal stuff.

[Lori Houghton (Member)]: Or like a self employed.

[Alyssa Black (Chair)]: We could create a plan on exchange that would just like Presumably, insurance would

[Jennifer Carbee (Office of Legislative Counsel)]: not be providing coverage for services that people could receive through what they're paying for. I mean, this would be a well, we'll see if it's funded later. But generally, products evolve to reflect what is and is not available through other sources.

[Unidentified Committee Member]: Thanks. Yeah. So just to follow-up logically, it would hopefully reduce premiums on the exchange because they don't have to cover as much.

[Jennifer Carbee (Office of Legislative Counsel)]: The scope of the services covered would be less. So you would expect a commensurate reduction in premiums. But an increase on however the I mean, people would still be paying through some mechanisms for these services to be provided so that the health care professional could be receiving payment for their services. Is that a question?

[Leslie Goldman (Member)]: Yeah. That

[Unidentified Committee Member]: can't be right, though. So I understand that you're talking about, like, tailoring the finance on the extreme world more, but they still have to include all the, and you'd still have to have all the minimal essential coverage. It wouldn't have to still, I guess I'm not understanding, I don't understand this a lot. Like, this will be a separate plan, but you'd still need insurance coverage to get I guess I don't understand how this is transitioning. Can someone explain that for me?

[Alyssa Black (Chair)]: I think it's theoretical, sort of. It's how it's

[Jennifer Carbee (Office of Legislative Counsel)]: worked. Right. Mean, yeah, if you remember, you know, and maybe we should have started with what act 48 was provided, in the act 48, the act 48 concept was a kind of a full benefit package that would be provided through the state. You know, this is the universal unified health care system that people refer to as single payer, although might not have been literally a single payer. And so the idea for that was a comprehensive benefit package. This proposal is looking at getting to a comprehensive benefit package over time. And until we get to the time at which so in year one, the package is just primary care and certain tests. That's it. That's all that's in it. So for year one, people would likely want to continue to have coverage for everything that wasn't primary care. Okay. Because that benefit package through the insurance that was everything but primary care wouldn't be covering primary care. Presumably, the premium would be somewhat reduced for that non primary care health insurance package because people were getting, but people would still be getting primary care that they would be getting through Green Mountain Care.

[Unidentified Committee Member]: Okay. So would there be an extra cost associated with- With Green Mountain Care? Yeah.

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. We'll get to the ways of paying for it and yes. And yes, so it is these big pieces of it. Right. Okay. But, you know, bottom line is healthcare is never going to be free. No, People are always going to need to be paid for providing the services. So you're sort of moving around who's paying for what, where, and and there may be some efficiencies built on you know, built in that and and increased access. And the idea, I think you heard from some of your previous witnesses, was that having primary care covered early on might have some preventive effects that would prevent other more costly care being needed later on down the road, which I believe is why this starts with primary care.

[Alyssa Black (Chair)]: Alright. Get the funding.

[Jennifer Carbee (Office of Legislative Counsel)]: Get funding is Get the money. Find where we were. Sorry. Okay. Went too far. Yes. Okay. Administration and enrollment. So this doesn't change language allowing the I think this was the Agency of Human Services to solicit bids and award contracts to public or private entities to administer certain elements of Green Men Care, like claims administration and provider relations with some caveats in there, protections for consumers. So here's what we were talking about. Nothing in this sub chapter shall require an individual, and this is existing law with health coverage other than Green Mountain Care, to terminate that coverage. So again, people could even with full implementation, there may still be additional services that people that are not part of the never become part of the package that people want to retain health coverage for. They would have that option. They could have supplemental health insurance if they chose. And then this says except for cost sharing, and then this would add as permitted by the general assembly for services that are included in the benefit package for years three through ten. Vermonters would not be billed any additional amount for health services covered by Green Mountain Care. So that goes one with the no out of pocket, no co sharing. There would be an electronic benefit card that enables the person, the sort of administrative staff, to receive services covered by Green Mountain Care, and that the database of covered services would be updated to align with the expansion. Green Mountain Care would be the payer of last resort. So this was the chair's point about the other coverage being first payer. So Green Mountain Care would be payer of last resort with respect to any service that is covered in whole or in part by any other plan, including federal plans, private plans, etcetera. Can look for get an let seek an eleven fifteen waiver to include Medicaid and and CHIPs in Green Mountain Care. May also seek a waiver to include Medicare and Green Mountain Care, and, again, repeating the secondary payer or payer of last resort. Great. And then it talks about some claim submission aspects and some I don't know how much you wanna look at the administrative pieces. But to the extent that health care professionals are reimbursed on a fee for service basis, directs the agency to establish a single standard reimbursement rate for each covered service, regardless of the type of healthcare professional delivering the care. And that rate would be based on a percentage of the Medicare rate for the service applicable. And the board may recommend to the general assembly payment mechanisms other than fee for service for services covered by Green Mountain Care and give some, keep some additional language provisions as well. We have the Green Mountain Care Health, the Universal Healthcare Advisory Group is next, before we get to the money stuff. So this establishes this advisory group to advise the Green Mountain Care Board and General Assembly on implementation and financing. The advisory group would be composed of the chair of the board or designee, commissioner of taxes or designee, the chief Let's skip over

[Alyssa Black (Chair)]: to the top boards.

[Jennifer Carbee (Office of Legislative Counsel)]: Hours and duties. They would report annually to the General Assembly with their recommendations for sequencing the publicly funded health care services to be added to the package in years three through 10, recommendations about including prescription drugs, rehabilitation services, long term care, recommendations about co payments, recommendations for financing for years three through 20 and beyond, and then more about its continued existence. Meeting language, we'll go go past that. Compensation and reimbursement language. Alright. Financing and intent. So this says, It is the intent of the General Assembly that Green Mountain Care may be financed as follows: by a payroll tax levied on all employers and a tax on self employment income by an income tax surcharge and as may be determined by the general assembly following receipt of recommendations from the advisory group. So intent that there would be payroll tax, income tax surcharge, and as otherwise may be recommended, and intent that revenues would be deposited into the Green Mountain Care Fund.

[Alyssa Black (Chair)]: So it doesn't really tell you how to finance it. It says, go figure out how

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: to finance it. Pretty much.

[Jennifer Carbee (Office of Legislative Counsel)]: And then there's some some forming changes around filing and approval of plans and premiums. So for health insurance plans, and if you were to move forward with this, it would need to be recodified based on the recodification in in this chapter last year. But that and one of the things that Green Mountain Care Board would be looking at in approving rates is ensuring that rates do not reflect duplication of the coverage provided by Green Mountain Care. Same thing for DFR. And then it expressed again remembering that this was introduced in 2025. It expressed legislative intent that the first year of Green Mountain Cards implementation would begin on 01/01/2027. So if you were looking at this this year, that would say 2028. And this act would have taken effect.

[Alyssa Black (Chair)]: Can I ask a question just sort of statutorily what would be required? Let's say, hypothetically, we wanted to implement, say, just like a system of primary care, which is universal to every promoter. Don't want to get into the financing of it. What would actually be required as far as so we would need to seek a thirteen thirty two waiver for and that's for to be able to change our qualified health plans. Eleven fifteen waiver, what do we do with Medicare people? What do we do with self insured people? What are the mechanisms to get everybody into it that you

[Jennifer Carbee (Office of Legislative Counsel)]: would have to do operationalize? Right. So you would need a thirteen thirty two waiver to take primary care out of what is required to be covered in qualified health plans and to be able to get federal pass through funding or to seek federal pass through funding. If you're wanting to include people who are on Medicaid and you would be looking for the same Medicaid and CHIP waiver addressing the bill, and you'd be looking for Medicare waiver. Otherwise, I don't know that you I mean, I don't know that you need to affirmatively do I I think for for the self funded sector that the state cannot regulate, I don't know that you need to do anything. You make the the, you know, the the primary care available to all Vermont residents and you let those employers make their own decisions about what they're going to continue to offer in the way of benefits that cover primary care or don't cover primary care. That

[Dr. Mayer (first name unknown), Pediatrician]: was it.

[Leslie Goldman (Member)]: Wanting to know all

[Jennifer Carbee (Office of Legislative Counsel)]: the little machinations that would- Yeah, I'm sure there would be other provisions we need to think through if that's what you're looking to move forward with. We may wanna, yeah, I there, we, you know, I don't wanna say, and that's it, because I need to think about it some more and you'd wanna hear from others. But that's what comes to my mind. And I know that's what had been talked about with Green Mountain Care as well, is that for aspects we can't control, they get to make their own choices about the extent to which they participate.

[Alyssa Black (Chair)]: I have Lori and then Brian, and then I think we're going move on to one May eighty seven.

[Lori Houghton (Member)]: Do you know if any other states have applied for a 1332 waiver to do this?

[Jennifer Carbee (Office of Legislative Counsel)]: Specifically to do universal primary care, I do not know. I know certainly states have applied for and received thirteen thirty two But waivers for other I don't know. Don't know if others around the room know. I have not heard that anybody has. I'm not aware of any urgent primary care programs elsewhere in there.

[Brian Cina (Member)]: So the waiver is needed, what is the waiver needed exactly to do and what is it not needed to do at that?

[Jennifer Carbee (Office of Legislative Counsel)]: I don't think I can answer that right now. Would need to do some research on that Because to

[Brian Cina (Member)]: I'm curious, I don't expect you

[Unidentified Committee Member]: to answer these now.

[Brian Cina (Member)]: I'm going to put them out there, Jen, just so then you're prepared in the future. Do we need the waiver because we're using Medicaid money or Medicare money? Do we need the waiver if we only make a deal with private insurance companies to contribute to it and don't use Medicaid money? Do we know what I mean? I'm wondering, what do we need the waiver for? Because it could be possible that without a waiver, we create some system where private insurance companies are voluntarily giving money into a fund to establish this good, and then we figure I guess what I'm getting at is what is the waiver needed for federally?

[Jennifer Carbee (Office of Legislative Counsel)]: I think it depends on the I mean, there are several different waivers depending on who you're looking to put in. I think the main piece is you could not move forward without a thirteen thirty two waiver. I don't think you could move forward with taking primary care out of the required benefits for qualified health plans.

[Brian Cina (Member)]: So that's helpful to know.

[Jennifer Carbee (Office of Legislative Counsel)]: The rest of it is really money and who you're offering the benefits to. I think the idea of having health insurers voluntarily contribute and have their beneficiaries receive primary care services is sort of what you looked at yesterday in age six eighty and what we're a version of what we're gonna look at in S197.

[Brian Cina (Member)]: So what I'm wondering ultimately is how far can we go with S197 towards establishing primary care as a public good without needing a waiver? And we can figure that out as we look at 01/1997, but I'm just curious because if there's a way to collectively pool money into a fund and then provide payments through the blueprint and other mechanisms to our primary care providers, such that they can provide primary care to everyone and the system's functioning essentially as universal primary care. If we could do that without a waiver, that would be easier. And then the waiver could always be used later to take the benefits out. I'm not suggesting we take the benefit out of your health plan. It's more like we just establish that it's a good, and then however it's paid for, it's paid for behind the scenes, but for now. And maybe the waiver comes down the road as we look to fulfill the promise of Act 48.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, I think it's an interesting- Yeah, first. I think it's an interesting question about whether we could move forward with the ideas that were kind of in June and 01/1997 as introduced without taking without changing the benefit package for qualified health plans. And really, what does that look like from a practical standpoint if there is, to have that benefit available. And I think you'd wanna hear from the insurers about the effect of having kind of coverage available outside of the benefit and coverage available with the benefit and how they would reconcile

[Brian Cina (Member)]: I'm the guessing you just would have to not, you couldn't double bill. So if you're being paid through the, for primary care, then you don't bill the insurance for the stuff that's covered by that, it would only be the extra stuff. So I do think we need to hear from them though. I'm just, I think I'm

[Jennifer Carbee (Office of Legislative Counsel)]: on And the I think probably from the providers on the administrative complexity of how do they implement that based on the type of coverage.

[Alyssa Black (Chair)]: Us to save our questions about this, and I'd like to move on to 197 and be thinking of those questions in terms of 197. So if you want to do that. And I did Google, but other states have attempted universal primary care. Bad news, everybody. The only state is Vermont. That's not bad. So we don't have anyone else to look to.

[Jennifer Carbee (Office of Legislative Counsel)]: Take the lead. I

[Lori Houghton (Member)]: need to go back to my notes. But I was on a call with someone from another state that said they put a waiver request in, and they've been waiting five years. So I'll dig through my notes and find myself who I was talking to.

[Alyssa Black (Chair)]: Oregon has been moving down. They have a plan due in September for universal access. We actually did that, which was in 2015, which was the report we got back on sort of studying the costs of what universities And

[Lori Houghton (Member)]: I think Oregon put in a request. I'll I'll go back to my source and find out. I'm just curious.

[Alyssa Black (Chair)]: Oregon does the time now. They're doing fun stuff. We should take a field trip to Oregon, everybody, for their legislature.

[Dr. Mayer (first name unknown), Pediatrician]: Who's gonna pay for it?

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

[Jennifer Carbee (Office of Legislative Counsel)]: So we're now looking at s $1.97 as passed by the Senate, and it is available I've updated the link. So it is the as passed by senate that was only just recently posted. Before that, it was just the senate open law firm version. So take a moment here because we are moving on to something that is moving that has come over from the Senate. This is S197. This is an act relating to payment reform for primary care. S197 is the bill that started out in the Senate quite similar to H six eighty that we talked that you talked about with representative Olson yesterday, and then we walked through. But it has changed based on stakeholder input. So it starts off with a legislative yes. You wanna just add primary care on line five? Yeah. I noticed that

[Alyssa Black (Chair)]: when I was reading the bill.

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. Yep. It's typo and

[Alyssa Black (Chair)]: it didn't. Yeah. Yep. I just the fact that we'll have to get it set.

[Jennifer Carbee (Office of Legislative Counsel)]: I've already got it in my notes, but yes. Sometimes this is crossover. Many things happen. Alright. So it starts out with sector one legislative intent. It expresses that it is the intent of the general assembly to invest in, it should say, primary care through streamlined primary care payments that build on the Blueprint for Health and will promote the public good by increasing access to primary care in order to improve the health of Vermonters and reduce health care system costs. It then amends the subchapter in Title 18 on the Blueprint for Health. It starts out with the definitions section and says that a health insurance plan means a it's basically the same thing. Just clean this up. It means a major medical insurance plan as defined in the health insurance statutes. Instead of just cross referencing it, it includes the definition of health insurer. I believe it is the same as 9402, easier to find. So health insurer means any person that offers issues, renews, or administers a health insurance plan or other health benefit plan in the state and includes to the extent permitted under federal law, third party administrators that administer a health benefit plan offering coverage in the state or that provide administrative services only for a health benefit plan offering coverage in this state. Administrative services only piece may be broader than what's in 9402. Go ahead, Leslie.

[Leslie Goldman (Member)]: Just a definitions question. Do you think we need a definition of medical home as that's referred to later and later?

[Jennifer Carbee (Office of Legislative Counsel)]: I think it was a toxin. So let's go through the bill and I also have to look at what's included in the existing statutes. This is only showing a portion of the definitions. So under existing Section twenty eighteen Excess seven zero six under Health Insurer Participation, this is also adding new language on payments to practices. So under current law as set forth in Title VIII, health insurance plans shall be consistent with the Blueprint for Health as determined by the Commissioner of DFR. And it requires, this is still existing law, health insurers to participate in the Blueprint as a condition of doing business in this state. Then we have new language saying, In order to facilitate development of the sustainable payment models necessary for the Blueprint's success, health insurers shall submit to the Agency of Human Services at least quarterly or more frequently if the agency so requests all information that the Director of the Blueprint deems necessary to perform a comprehensive fiscal analysis of the total cost of care within Dremont and to implement one or more payment models that address healthcare capacity, volume, quality, and clinical outcomes. Modifies language around the Blueprint payment reform methodologies. Under current law, they include per person per month payments to medical home practices. This would say to participating practices, including medical homes and primary care providers, by each health insurer and Medicaid for their attributed patients and for contributions to the shared costs of operating Blueprint initiatives, including the community health teams. And it specifies that per person per month payments to practices shall be, and then we have a little bit more of a list. The first, based on the official National Committee for Quality Assurance, NCQAs, and just updating the name to reflect the changes in the NCQA language, Patient Centered Medical Home Score. So based on the official NCQA Patient Centered Medical Home Score, and this would add, or another quality standard identified by the director of the Blueprint in consultation with the Blueprint payment implementation work group to the extent practicable. Also provided in addition to, and I just changed the language to seem a little bit more appropriate, in addition to a practice's typical fee for service or other payments and new language from health insurers, in amounts at least equal to Medicaid payments beginning in 2027. So again, this is what the person per month payments to practices must be. And as I understand it now, Medicaid has the highest pays the highest amount. So this would require from health insurers that the amounts they pay are at least equal to Medicaid payments beginning in 2027. There are some changes in here to reflect that the Blueprint is now housed in the Agency of Human Services, not specifically in the Department of Vermont Health Access. So under current law, it says, Consistent with recommendations of the Blueprint Executive Committee, the directors of the Blueprint may recommend, and this would now say to the Secretary of Human Services, changes to the payment amounts or to the payment reform methodology as described in subdivision one, including by providing for enhanced payment to health care professional practices. And again, not specifically those that operate as a medical home, but including medical homes and primary care practices. So for all primary care practices. Payment also payment toward the shared costs for community health teams or other payment methodologies required by CMS for participation by Medicaid or Medicare. And this adds language saying that in formulating recommendations, the director shall strive to achieve or maintain parity across payers and payment methodologies and to adjust payment methodologies as needed, annually as needed to adequately support practices in maintaining NCQA primary care medical home status or meeting other requirements for participation in Blueprint programs. It does not make any changes to the existing language requiring insurers to modify payment methodologies and amounts to health care professionals and providers as required for the establishment of the model described in section seven zero three seven zero five, which I think is the primary care medical home model.

[Alyssa Black (Chair)]: Can I just clarify? So we're tasking the director to, in consultation, payment methodologies, payment making adjustments essentially. Who what Blueprint is already to this and AHS is part

[Jennifer Carbee (Office of Legislative Counsel)]: of this, but is that it? Blueprint is housed within agency payments? Well, director of the Blueprint makes recommendations changes to the Secretary of Human Services. Okay. So ultimately, it's the Secretary of Human Services that is deciding? It is through the Secretary's authority that treatments are required. Okay. There's alright. It does not change language around if Medicare is not participating, health insurers don't have to cover costs associated with Medicare beneficiaries. Also doesn't change much language that allows insurers to appeal a decision to require a particular payment methodology or amount. Two, it does say, have now the secretary or designee rather than the commissioner of DIVA. And just language around appeal processes generally to refer to the secretary or designee rather than the commissioner of CEVA. Then it adds a new Section seven ten on primary care spending targets, directing the Agency of Human Services to establish a target for the amount of per person per month spending on Vermont residents that should be for primary care services and develop a transitional schedule increasing that target over time. It allows targets to be adjusted to reflect specific differences such as age and health status, and requires the increased spending to be directed to the per person per month payments established in that Blueprint language. Section three has the Director of the Blueprint in consultation with the Blueprint Executive Committee and the Vermont Steering Committee for Comprehensive Primary Care reporting by 01/01/2027 to this committee and Senate Health and Welfare regarding changes to the payment amounts or payment reform methodologies or both that are necessary to transition the Blueprints per person per month payments to primary care practices to include payment for the routine primary care needs of attributed patients who are covered by participating health plans. So this is looking at how to leverage the Blueprint, the per person per month payments, using the Blueprint's current methodology to expand that to include payment for routine primary care needs of attributed patients covered by participating plans. The report would define which services should be considered routine primary care, address any differences in methodology for different practice types, make recommendations regarding risk adjustment and attribution methodologies, describe the ways in which the methodology will balance capacity, volume, quality, and outcomes, Include mechanisms for ensuring that health plans make accurate and appropriate payments to primary care practices in a timely manner. Make recommendations regarding participation or quality measurement requirements or both. Provide an analysis of including cost sharing amounts for individuals covered by participating health plans in the methodology, including the extent to which including cost sharing amounts would be permissible for a high deductible health without losing its eligibility to be paired with a health savings account. Provide an analysis of ways to incorporate a primary care spending allocation target into the methodology and provide an operational plan and description of any additional legislation needed in order to implement the methodology not later than 01/01/2028. So that report will be coming back in January 2027.

[Alyssa Black (Chair)]: Go ahead, Simon.

[Brian Cina (Member)]: I'm not sure if this is the right time for this question. So if it isn't, we can come back to it. But I'm seeing reports and reports and stuff, which I always appreciate a good report, but how does this tie into the reports from last year? Didn't we create two committees last year and I'm just curious how this builds on that work. We had a primary care committee and what was the other one called last year?

[Jennifer Carbee (Office of Legislative Counsel)]: Statewide strategic. Right, there's development of a statewide strategic healthcare delivery strategic plan.

[Brian Cina (Member)]: And then there was a primary care group.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, so the primary care group is part of, is consulting. So the director is consulting with the Blueprint Executive Committee and the Vermont Steering Committee for Confidence of Primary Care in preparing this.

[Brian Cina (Member)]: So they didn't create a report though yet?

[Jennifer Carbee (Office of Legislative Counsel)]: No, I don't. We

[Brian Cina (Member)]: can come back to it, but I'm just trying to make sure this all ties together. And I'm not saying it isn't tied together because they're mentioned here. I'm just curious how this report builds on any other reports or

[Jennifer Carbee (Office of Legislative Counsel)]: You had directed the primary care steering committee to make recommendation to the general assembly. I think you may have heard from that I don't remember. From someone from that group.

[Alyssa Black (Chair)]: Yes, we heard from Faye Houghton. Can I ask, so this report that Brian was referring to, it's to make recommendations on payment reform, payment methodologies, all of that? So in 2017, as I just go on from the Google, we had a report which was Green Mountain Care Board. Correct? And that's the report that you posted yesterday, I think? So that's the Green Mountain Care Board. Isn't this essentially the same thing? And now we're taking the exact same report we got ten years ago and giving it

[Jennifer Carbee (Office of Legislative Counsel)]: to AHS? I'm not clear enough on what the report was in 2017. It

[Alyssa Black (Chair)]: was essentially the universal primary care kind of spend analysis?

[Jennifer Carbee (Office of Legislative Counsel)]: Think it was based on a different charge. And this charge is looking at how to use the blueprint to establish a comprehensive payment to primary care practices to recover the routine primary care costs of attributed patients. Okay, thanks. Alright, section four. So

[Francis "Topper" McFaun (Vice Chair)]: on page five, talking about care spending targets. Starting on, does this mean that if you get older, are your health deteriorates that you are per person per month payment will increase? I

[Jennifer Carbee (Office of Legislative Counsel)]: don't believe this particular section is saying that. This is looking at primary care spending targets. But recognizing that I think that plans or the public or private plans that care for people have a different population mix in them, like Medicare has an older population in it, it may be reasonable to expect a different proportion of the total spend for an older population would be on primary care than for other types of care. So it's just recognizing that the targets may not be the same for all plans depending on their patient mix. That makes sense?

[Francis "Topper" McFaun (Vice Chair)]: Yeah, it does. Maybe I'm reading this section wrong, but it appears to me that it pay per person's monthly and if you get old or your health deteriorates, that causes an increase in the payment per person per month.

[Jennifer Carbee (Office of Legislative Counsel)]: The primary care spending target, believe is really looking at a, I mean, it's per person per month, but I think it has grown out of this concept of the allocation of health care spending that should be for primary care. But, yes, I think this is looking talking about the target per person per month spending, I think it is looking at and reflecting payer specific differences such as age and health status. It is recognizing that those target amounts may need to be different depending on the age of the population covered by a particular payer.

[Leslie Goldman (Member)]: I'm not sure that this is a question for you, but maybe you can help direct me. I'm trying to understand the change in the blueprint from current state, which we had yesterday, to this state. And maybe I don't know where that comes in, but I'm not understanding.

[Jennifer Carbee (Office of Legislative Counsel)]: So I would say the short term, in the short term, I don't think it's changing much other than trying to have, trying to bring the health, the private health insurer contributions to the same level as Medicaid. But then it's looking at, in, in the report piece here, it's looking, I think, fairly robustly at how to use the Blueprint mechanism as the backbone for getting comprehensive per member per month primary care payments to participating practices. And so the issue that came up in looking at both F197 and the same kind of concept in age six eighty was the agency of human services currently has a mechanism by which they distribute payments to practices, and that's through the Blueprint. The way those bills were originally introduced had this idea of them aggregating payments from different sources and doing a separate distribution to primary care practices. And so this is looking at how can we combine that concept of kind of more comprehensive payments for primary care to primary care practices with the existing payment mechanism that is the blueprint.

[Leslie Goldman (Member)]: Okay. So totally, they were saying they have 332,000 patients, twenty twenty four. So we're aiming for everybody. That, I mean, that's where a little, is that expanding the blueprint to what are we asking? But this may not be the right time for that conversation.

[Alyssa Black (Chair)]: Just trying to understand. I

[Jennifer Carbee (Office of Legislative Counsel)]: this is looking at potentially expanding beyond just the Blueprint practices, or just the practices that are currently participating in the Blueprint, because it's going by attributed patients to a practice. But yes, you can hear from

[Alyssa Black (Chair)]: I'd like to get to the language, we haven't been able to have a break and we're not going to get a break. We have three more witnesses that we have to get to by noon. It's like Ouch. I'm not Ouch.

[Jennifer Carbee (Office of Legislative Counsel)]: Section four has by 01/01/2027, the Agency of Human Services in consultation with the Green Mountain Care Board reporting to this committee and Senate Health and Welfare the baseline per person per month spending on primary care services for Vermont residents overall and by each health insurer third party administrator administering a health plan or providing administrative services only for health plans, Medicaid and Medicare. So Agency of Human Services and Greenland Care Board reporting on baseline on how much is spent on primary care services per member, per month for Vermont residents overall and by each payer. And the agency reviews the definition of primary care providers and services either from the AHEAD model or the definition used by the New England States Consortium Systems Organization. Section five directs the Agency of Human Services by 01/01/2028, to report to this committee and Senate Health and Law Fair the per person per month primary care spending targets developed pursuant to that section we were looking at, 18 BSA seven ten, as well as the proposed transitional schedule for increasing that target over time, any recommendations for payer specific adjustments to the targets, and any additional legislation needed to implement and enforce those targets, the targets and that section. Section six, and we looked at this yesterday, so I'll just touch on it briefly, that language we looked at in H680 directing the Green Mountain Care Board by 01/01/2027 to come back with an updated version of its 2017 Vermont Clinician Landscape Study report reflecting the current climate among practicing clinicians in Vermont and an updated version of their previous reporting around site neutral reimbursements, including any significant efforts implemented since 2017 for achieving site neutral reimbursements, which again, you included a portion of the age five eighty five as you voted it out of that. Section seven requires the agency of human services by 01/15/2027 in consultation with the Vermont Steering Committee for Comprehensive Primary Health Care, the Blueprint for Health, Vermont Association of Hospitals and Health Systems, the Vermont Medical Society, five state primary care, and others to report to this committee and Senate Health and welfare with recommendations for ways to accelerate the appropriate transition of patients from hospital care to care delivered in a community setting, including ways to reduce the extent to which primary care services are delivered to patients in an inpatient hospital setting following surgery or other acute care when care delivered by a primary care provider in the community would be as or more effective and less costly. It requires the recommendations to include opportunities to use the community health teams to the Blueprint to coordinate patients' care transitions, and it directs the agency to incorporate the recommendations into the Health Care Delivery Strategic Plan as appropriate. Section eight directs the Office of the State Treasurer in consultation with the Agency of Human Services to collaborate with other Northeastern states to explore the potential to establish a regional universal primary care program that would be available to all residents of the member states. And by 01/15/2027, the treasurer would report to this committee and Senate Health and Welfare on the office's outreach efforts, interest from other Northeastern states, any legal or regulatory obstacles identified and recommendations for next steps.

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

[Jennifer Carbee (Office of Legislative Counsel)]: Not done yet, but I think there has been efforts to explore interest in, not necessarily specifically universal primary care, but yes, in regional universal care. Thank you. I think my recollection is that we often run into legal and regulatory obstacles. Nine, you have included in other bills, including the budget. This is removing that sunset on the medical student incentive program for primary care medical students. Section 10 is a health insurance provision. This would go in the health insurance coverage for prescription drug section, and this would require not less than sixty days before removing a prescription drug from its formulary or the formulary maintained for it by a pharmacy benefit manager that a health insurer notify all individuals covered by the plan who filled a prescription for that prescription drug within the previous twelve month period that coverage for the drug will be discontinued and the date when the coverage will end. So again, this summing this one up, this says not less than sixty days before health insurance stops covering a drug, they have to let everybody who filled a prescription for that drug within the last year know that the drug is no longer going to be covered. And the act would take effect on passage.

[Alyssa Black (Chair)]: Thank you.

[Francis "Topper" McFaun (Vice Chair)]: Now, thank you, Jen. Thanks,

[Alyssa Black (Chair)]: Jen. Great, we have this was this minutes left, actually.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: We're here to see Karen. Hi, how are you?

[Alyssa Black (Chair)]: Good, how are you? Good. When Jen clears out, do you want to come on up? It's okay if

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: I crack the window slightly.

[Alyssa Black (Chair)]: If the people that are sitting there

[Jennifer Carbee (Office of Legislative Counsel)]: are okay to get there.

[Alyssa Black (Chair)]: Can just pass a

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: little bit. I feel like the air is stale. It's making me laugh harder. Wet air. And it smells weird, it's everything.

[Unidentified Committee Member]: Dog sniffing. Let's

[Alyssa Black (Chair)]: get started. Julie, thank you for coming in. And if you want me to start, you can go ahead.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: Great, great. So I want to thank the committee for allowing me to speak to you today regarding S197. My name is Rick Dooley. I am a family medicine physician assistant at Thomas Chittenden Health Center in Williston, where I've worked for the past twenty seven years. I'm also the clinical network director for Health First, which is the independent practice association that I'm sure you've heard from my colleague, Susan Ridzin, at this committee. In addition, I'm also the alternate for health course representing on the Vermont steering committee for comprehensive primary health care. I know you heard from Faye Houghton a couple of weeks ago. I've been involved in health care reform for twelve years, starting with the SIM grant back in 2013, going through the fits and starts of the organization that eventually became One Care, and then moving forward from that into AHEAD, maybe, maybe not, who knows, and now this legislative effort on comprehensive primary health care. And through it all, I've continued to provide care for my 1,500 patients at Thomas Chittenden in Williston. I do want to tell you just a little bit about our practice for those of you who don't know. So we are a large private independent group practice. There are four physicians and eight advanced practice practitioners, PAs and NPs. We provide care for patients from Chittenden, Franklin, Addison, Grand Isle, Washington and Lemoyle Counties. We have a full time diabetic educator, full time care coordinator, two counseling social workers, to psychiatric NPs to provide med management for psychiatric patients. A number of those positions are funded by the Blueprint as well. Chair Black had requested I speak to NCQA in my testimony today. Know we just heard about Blueprint and such. So just to put

[Alyssa Black (Chair)]: Don't forget radiology.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: And and radiology. We do have on-site radiology as well. On-site lab services. Yeah. We have a lot of stuff going on in one building. So as a requirement of participation in Blueprint, RACSs have to achieve the patient centered medical home that you just heard about, the PCMH certification, from the National Committee on Quality Assurance, or the NCQA. PCMH is a widely adopted evidence based model that transforms primary care into team based patient centered system. It focuses on improving quality of care, patient experience, and staff satisfaction, while reducing the overall health care costs through better coordination and increased access. While many practices before medical home or before there was PCMH, most family practices and primary care practices were essentially medical homes. Most of us were providing that comprehensive care, just we didn't have a word for it. So, while we're already functioning as that, the process to become certified as a medical home is pretty arduous. There's a lot of paperwork, there's a lot of report building. Once you become certified, you're then required to recertify annually. It used to be every three years, then it became annually. And the annual recertification process, to be frank, is a pain. It is generally a year of quality improvement, reporting, data collection, and submission at the end of the year. The end result is that you have are putting a lot of resources in the reporting part of that. So I was I'm pleased to read the legislation that they talk about something as an alternative for NCQA. I think the process of getting certified for a medical home is fantastic, because it really does force practices to kind of focus and see where their strengths and weaknesses are. The ongoing work to achieve that, I think, may be counterproductive. However, the blueprint has been beneficial for many practices, including my own. It does provide that per member per patient per month payment to practice for attributed patients, as well as a dollar amount to be used for access to the community health teams. The resources have been integral to our ability to provide care, and Blueprint's payer agnosticism is a model that should have been replicated across medicine a long time ago. The beauty and the strength of the Blueprint system is exactly that they don't care who the payer is. When we run our attribution list, we run a list of unique patients seen in the previous twenty four months. They don't say who's who, they don't charge, they say how many patients are you seeing, it doesn't matter where you're seeing them from, that's what our reimbursement is based on. As we expand the scope of what is considered comprehensive primary care, there are many necessary patient resources that simply aren't reimbursable in a fee for service system. The goal of the Blueprint Back On was to provide ancillary staff and funding to help offset those unreimbursed costs, but that funding has been inadequate to date. With the exception of a small bump, and I think it was 2019, blueprint PMPM, or per member per month payments, have essentially been unchanged since 2015. Likewise, the CHT funding allowance has been unchanged for that entire time, with the exception of the expansion pilot that I'm sure this group's aware of, for mental health in 2023. As payments have stayed flat for the last decade or more, costs have obviously increased. So the blueprint funding has become less and less relevant to practices as we're less and less able to retain clinical staff. What separates the independent practices from hospital owned or FQHC colleagues, as you all know, I'm sure, is our funding source. Funding for independent practices comes solely from reimbursements. Hospitals get higher commercial reimbursements than us for providing the same care, and also the ability to shift money around, so highly profitable centers in the hospital help offset lower profitability centers. FQHCs receive enhanced payments from Medicare and Medicaid, and get grants from federal government. Independent practices, however, are solely dependent on insurance reimbursement, with a small fraction we get from the Blueprint. We face the same pressures of small businesses across the state, the rise in health care insurance premiums, the lack of affordable housing, the shortage of workforce employees, all things that I know you folks have talked about at length. In addition, because we do have such decreased reimbursement, we're often at a financial disadvantage in recruitment for clinicians and staff as well when competing with the hospital system. It's for these reasons that we think primary care and health payment reform is crucial for our survival. Thomas Chittenden was fortunate to be part of the comprehensive payment reform, the CPR model, for One Care for the past five years, before One Care went away. This model allows us to receive a prospective per member per month fee for our Medicare and Medicaid population, with additional payment based on quality, and allowed us to focus on patient care rather than patient volume. In the One Care Capitated System, the incentive was to provide high quality care, reduce emergency room visits, and have improved primary care access. This allowed us to expand our care coordination services. And in addition, with the addition of the community health team expansion pilot from Blueprint, expand our mental health psychiatric and PEEP services. Programs were all focused on increasing primary care spending, rather than just reward the number of people walking through the front door. I do want to share a quick patient thing, I'm trying to talk fast, I need a lot of people to get to. Have innumerable experiences of patients that I could talk about positive outcomes with comprehensive primary care. What I'd like to share with you is a patient who I'll call Diana. She's an older patient of mine, has had a number of medical issues over the years. She had some heart disease and some lung disease and some other stuff, but generally in reasonably good health considering her advanced age. She lives in an assisted living facility, and that was a difficult transition, as it often is for folks. Several years ago, she started going to the emergency room frequently, first every two or three months, then every month, then every couple of weeks. She would typically get an extensive range of blood work, usually some imaging, sometimes it was chest pain, sometimes shortness of breath, sometimes a rash, sometimes rib pain. There was always something, but typically by the end of the visit, she would feel better when we discharged home. So, it quickly became apparent that there's a significant psychosocial component driving this cost. We got together, we realized she'd be a good patient for care coordination. Our care coordinator was paid at the time half by One Care and half by Blueprint, I believe. So, we identified her as a care coordination patient. I scheduled monthly visits with me, even if she was feeling well, just check ins every four weeks. The staff had noted that if she started getting anxious, just knowing she had an upcoming appointment, calmed her down. ER visits started to drop. Our care coordinator worked extensively with our housing staff to address her home situation, make it less anxiety provoking. Our counseling staff worked with her to address her underlying trauma, again, that's a CHT counselor, which resulted in anxiety and mood disorder diagnoses. In addition, we had a policy of seeing her whenever she needed to be seen. If Diana called and said, I'm not feeling well, we got her in the office that day, we kept flexibility for that. The end result was absolutely remarkable. Her ER visits went down from twice a month down to maybe once every six months, and she's not had a hospital admission in twelve months. She is happier, she is healthier, and the health care spend is substantially less. The services that we could offer for that wraparound care the care coordination, the counseling, flexible scheduling, were only there because of this enhanced payment system that was above and beyond the fee for service, and in fact, is related to the CPR from One Care. Those services, those extra services aren't well reimbursed in fee for service. There isn't a good code that covers the cost of provider care. In the long run, it saves the system money, but no one pays us to provide that care initially. The prospective per member per month payment model allows practice to build and sustain the systems, so payment get the care when they need, where they need it, in the most appropriate way. The Holy Grail that we've all been looking for is a way to find care to fully and adequately fund the system, so that every Vermonter has access to affordable and high quality primary care, improved health outcomes, and reduced hospital costs. We've been looking at this for decades. And while there have been plenty of efforts, and you read a number of reports that we've had in the past ten years, the reality is that funding has been unpredictable and adequate, the payment system is fragmented and burdensome, administrative burden is terrible, and through it all, health care costs keep going up, insurance premiums keep going up. This concept of paying prospectively, like the blueprint, is not new, and I worked with Craig Jones at the inception of the blueprint back in 2013 when we were establishing it in practices. I worked with Todd Moore at One Care when we started talking about PMPMs for think it was going to be Vermont Cares, and we talked about what an adequate PMPM would be and how you adjust for different patients. I worked with Tom Boris in One Care when we did that CPR model for Thomas Chittenden. This work has been done. The idea of what do we carve in and carve out of a per member per month, how much do we need to take care of patients, this is not new work. We have done report and report and report. The problem's not that we don't know how to do it, the problem is that we don't know how to pay for it, and that has always been the problem. We talk about these systems, we talk about saying here's what we need to do, we need to enhance funding, and then we get a budget, we say well we just need to cut this and this and this and this, and Medicaid rates can't go up and reimburse, and so we're saying we need to spend this much, but we're not willing to do it over here. So the system as it stands right now is absolutely not sustainable. I am cautiously optimistic, although I've done this now for thirty years, so not very, but cautiously optimistic. That this time around, we'll find a way for a suitable sustainable funding model to support a robust primary care system. I love the idea of using the blueprint as a mechanism for that, but it needs to be funded much, much higher to sustain it. Just saying they'll give us 3 or $4 a month per member per month, it ain't going to cover what we need to cover for comprehensive primary care.

[Alyssa Black (Chair)]: Can I ask you a question about that? Yes. You love the idea of the blueprint doing this. You just told us about the blueprint has not increased payments. I think they've done it once since their inception.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: Correct. I love the idea of the blueprint.

[Alyssa Black (Chair)]: I trust the blueprint to do this.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: I love the idea of the blueprint model of the attribution model of the one payer, one check coming that covers all payers based on your patients. That's the part that I love. The $2 or $3 per member per month, not so much. So the funding, and I think there's always been a struggle between the legislature and the blueprint for funding. Think Blueprint has asked for more money and we've asked for money from the blueprint. I think it's the same problem we always have, right? There's one pie, and you can only get so many pieces out of it. So I don't see that as fault of the blueprint. See the blueprint methodology good. I see it as a fault of the funding. I mean, when I talked to Craig Jones early on

[Alyssa Black (Chair)]: Blueprint is a great model. Right, right. Early on this was the ACO, and how is this any different than the ACO?

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: It's not. The attribution, I think I really like Blueprint's attribution of saying unique patient's seen. Attribution is always, with ACOs, that's always an issue of who signed up and who's not. But otherwise, I honestly think by the time we got to the fifth year of the CPR, one care had his growing pains, certainly, for the first couple of years, but by the time we got to that last year, the funding stream was good. It was great for Thomas Chittenden, it let us increase our services, and it let us sort of relax a little bit with having to see patients all the time, because we could provide care in different ways. It was a really good model. We were sad to see it go, but that's outside of our control.

[Alyssa Black (Chair)]: Any questions? How many oh. No.

[Unidentified Committee Member]: Just want will the site neutral take care of the the funding?

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: Site neutral would be great depending on how it's implemented. I mean, our I think Vermont always struggles because of our system, because of the pay insurers who can have different rules. I think it's always tricky in our system, but I think the fact that I get a third of what a hospital and practice may get for the same office visit is the problem. I think you need to if you wanna fund primary care across the spectrum, need to pay everyone a reasonable wage.

[Jennifer Carbee (Office of Legislative Counsel)]: And, Daisy, how do you

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: do site neutral payments with a per member per month? Is it just part of your prospective payment? I believe so. I yeah. I don't know how it's I don't know how it's done. I believe it's just part of the calculation. That's the system. I have no idea.

[Alyssa Black (Chair)]: Thank you for your testimony, though. That was wonderful. Yeah. How many patients does Thomas Chittenden have?

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: About 14,000.

[Jennifer Carbee (Office of Legislative Counsel)]: Do you have

[Alyssa Black (Chair)]: are there any dedicated staff to doing things like quality measures, NCQA, Medicare ACO stuff. Do you have any stats that are just dedicated to that?

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: We have one. His name is Rick Dooley. I wear a lot of hats. So, yeah, so I do the QI work, and I work with there's I have a cup an MP and a PA who also work with me, and then we have a number of, you know, staff committees that we sort of divide out. But, yeah, it's it's, again, QA work is not reimbursed either. And so we're trying to see all the patients and and stay afloat. There's not a lot of room to say, let's put this person on Dust UI projects. So we have something we sort of farm out across the practice.

[Alyssa Black (Chair)]: Are you utilizing AI Scribe at all?

[Jennifer Carbee (Office of Legislative Counsel)]: I love AI Scribe.

[Alyssa Black (Chair)]: Never been able to utilize it.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: Yeah. Yeah. AI Scribe is life changing. Uh-huh. Absolute life changing.

[Alyssa Black (Chair)]: Shame to figure out why Adrian is always taping when I'm there then, and she's got it.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: I A couple of our providers have not embraced it. They like they like the control of the note, and they like and that's sort of their thought process also. Yeah. I I think AI is fascinating from a health care perspective, because it's changed so much in just a year, and I think next year, it's gonna go who knows where. Know? And maybe that could solve it. There were ways to integrate in the system that could help reduce some of this administrative burden, which could help free up some more practitioner time. I mean, I think there's, you know, there's there's there's lots of ways to look at it, but the ultimate thing is we need enough money to keep the lights on. And that means we need staff, you know, money to pay for staff.

[Alyssa Black (Chair)]: Are you utilizing AI for sort of in the inbox flows?

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: We've not got we've only found a couple companies that integrate with our EHR, and it turns out that they're really, really, really expensive. It's as costly as hiring two people to do the work right now. Any other questions I can answer for you?

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: Thank you.

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: Great, well thank you so much.

[Dr. Mayer (first name unknown), Pediatrician]: I had

[Rick Dooley, PA-C (Thomas Chittenden Health Center; Health First)]: to talk fast, I hope you understood that. I'm Italian, so it comes to me naturally. Thank you so much.

[Alyssa Black (Chair)]: Actually Miller, Doctor. Miller, and are Doctor. Tyson and Doctor. Miller testifying together or separately. Separately. Hi, Doctor. Miller.

[Unidentified Committee Member]: Thank you

[Alyssa Black (Chair)]: for joining us today.

[Karen Lueders (Member)]: Thanks for having us. We really appreciate your time as well. I was able to catch a little bit of the last speaker. It was great.

[Alyssa Black (Chair)]: We tend to think of primary care in terms of adults and then we forget, wait a minute, where are the pediatricians? So I'm glad you were able to make it in today.

[Ashley Miller, MD (Pediatrician)]: Thank you. What can I start with for you? What's your most pressing question?

[Alyssa Black (Chair)]: No, I think sort of tell us maybe a little bit about any thoughts you might have around this bill that we're working on. How we've been robustly talking about reporting and things like NCQA the last couple of days, thinking about what that and alternative payment methodologies. So maybe if you could just speak to that in relation to your practice and the practice that you

[Ashley Miller, MD (Pediatrician)]: Sure, happy to. So a little bit about myself. I'm a New England native. I grew up in New Hampshire, did my med school residency there and have been in Vermont since 2014, practicing in a private practice down in South Wilton. We provide care for a fairly rural blue collared area with a smattering of, you know, law student families and some from the Hanover area. We pride ourselves on providing very individualized care. Since we are a small practice, we're not just a number. We know our patients really well. And we joined the ACO not right at the start, but probably a year or two in. Because we were a small practice, we were afraid of changing any funding sources and worried about what that would do since it affects us pretty quickly. And that funding model really allowed us to improve the individual care we were giving. As a small practice, we live paycheck to paycheck. So, the fluctuations with insurance payments really affected our ability to forecast what we were going to be able to provide in the future. And by being part of the ACO and having specific payment every month that we could count on, I was able to hire amazing staff and retain them because I knew what I could actually pay them versus what the bare minimum was I could pay them. And then we were also able to change, and I think the previous speaker spoke to this, we didn't have to bring everybody in because we didn't have to worry about, okay, each visit is a widget. That's how we're getting paid. So we were able to support families at home, keep kids in school, provide care, attending school meetings, helping with IEPs, doing phone consults for families with new babies, just a lot of care that isn't captured in the current fee for service insurance model. We also spent a lot less time worrying about billing and coding. We didn't have to play the game of what exact specific code combination did we need to get this particular service covered because it was covered. So, we really saw a huge benefit from that. We're sad to see the model go away. Currently, we do have staff that helps with NCQA. She's my care coordinator. She does a lot of the data collection and submissions for us. But even without NCQA and Patient Centered Medical Home, that's our love and our focus is to really provide that care for patients. So, she helps capture that, but that hasn't gone away. We also have noticed that patients with high deductibles, so private insurance, not Green Mountain Care, they are much less likely to utilize our services, particularly at the beginning of the year. So, when we're thinking about prevention, we're thinking about catching things early, we're thinking about overall cost to the system, we are very aware that those patients that have access get that prevention early on, and we really do make a difference. We see that both in mental health, we see that in nutrition, we see that in safety and anticipatory guidance. So, our patients on Green Mountain Care never seem to worry about calling us. They call, we can talk to them, they can come in. They're involved all year round. Our patients with private insurance, maybe they'll show back up in March or April when they've met their deductible or when things have gotten really bad, and now we're putting on Band Aids and we're backpedaling. So, having a one payer type model, I think, would really benefit all of us as well as our specific families. I think that discussion about other ways to provide care also is really interesting, and it's one that we've worked on providing care in schools, providing telehealth, providing telephone calls. We're also looking at getting our nurse lactation certified right now, which won't be necessarily paid for by insurance companies. But again, if we were getting one payment per month, easy to provide that service and not worry about where the funding is going to come for that. And again, able to keep our patients in our community, not having to send them out to the hospitals for that, which can be really beneficial, particularly in the middle of winter. Yeah, I think those are the big points I had. Specific questions or anything else I can answer for anyone?

[Alyssa Black (Chair)]: We've had an ongoing discussion around panel size. What do you I'm quizzing everybody. What is your perfect panel size?

[Ashley Miller, MD (Pediatrician)]: I love that question, actually, because this did kinda come up with the ACO and with, Blueprint because our panel size is small, but when you look at the intensity of care coordination, the needs of our patients, because I have a particular interest in mental health, probably about 40% to 50% of my day on any given day is spent in mental health visits. So, because I'm private practice, because I own my practice and I can make the decision, none of my visits are shorter than thirty minutes. And these mental health visits are often thirty minutes to an hour. So, the patients get what they need. So, when I look at panel size, I take that into consideration as well. So my current panel, if I'm thinking 50 to 60 mental health and then 40 are healthy, well kids, I feel comfortable in the 500 to 600 range, but I think you could stretch that, right? And I do have a pediatric nurse practitioner who works with me, and like I said, I've got a great support staff. So if I was trying to do this all on my own, so when we look at direct primary care, most people think that 300 to 400 is probably more reasonable if you're doing it without staff. When I worked for a large academic center early on, I was expected to carry 1,500 to 2,000 patients on my panel. I didn't know half the people that were on my panel at least. So, when we're thinking about personalized individual preventative care, those smaller panel sizes are really important.

[Alyssa Black (Chair)]: Thank you. I'm sure we're getting wildly different answers.

[Ashley Miller, MD (Pediatrician)]: I think a lot of it depends on what kind of setting you're in and what kind of intensity your panel has. One of the things we're talking about in school based health right now in attendance is we have captured many patients that didn't have a medical home at that point, but the ones we're capturing are also really complicated with intensive social determinants of health and that require a lot of care coordination. So, we're happy to take them on, but the time that goes into each of those patients is much higher than just a healthy newborn.

[Alyssa Black (Chair)]: Thank you. Any other questions? Thank you for making the time to be

[Jennifer Carbee (Office of Legislative Counsel)]: with us today. Really appreciate it.

[Ashley Miller, MD (Pediatrician)]: Appreciate you having us. Anytime Stephanie has my contact information, but I'm happy to answer any further questions too.

[Jennifer Carbee (Office of Legislative Counsel)]: You, Doctor. Thank you.

[Alyssa Black (Chair)]: Hi, Doctor. Tyson. Thank you for joining us. We're muted.

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: Thank you for having me. So many great speakers have already come before me, so I'll try to kind of just say what I can add to the conversation. I am pediatrician in a private practice but part of Primary Care Health Partners, which is a physician owned group in Vermont and New York. So we do have that extra layer of support with like a medical staff office where we can share resources as well as contracts with insurance companies. If any of you are aware, we were once part of Northwestern Medical Center and in four years ago we were let go from the hospital and had to start a private practice. So we have a really unique experience. Very opposite from Doctor. Miller, we have very large patient panels because of the way that the physicians were expected to work when they were part of the hospital system. So right now we serve 8,500 patients and we are pretty understaffed with physicians. It's hard to recruit, it's hard to pay what people are asking for when they come out of residency, it's hard to retain. And so we are running larger patient panels than we would like. But most of what we provide would not be possible without something like the ACO and Blueprint. So what we have in our office, we do have around 1,100 to 1,600 patients in a patient panel just depending on whether the person is newer and still growing, whether you have an older age population or whether you have babies. The things that we provide with this extra funding is we have a dolce, a worker who is a family support person who helps us. I'm sure you guys have heard about that. We also had funding for another family support person to offer help with social determinants of health. Because we all know the main issue that our families are facing right now is chronic illness associated with lack of resources. And so we can treat ear infections all day long, but if we're not addressing that they don't have transportation, food, safe housing, then we really have to start there. So that was extremely helpful. We have care coordination, we have two mental health counselors, we have RNs on the phone to try to decrease how often patients need to come in the clinic because we serve so many patients. We have a care coordinator who helps keep people out of the emergency room and urgent care. We have a nursing twenty four hour service that we pay for. We offer portal visits. We offer telemedicine at no charge. So there's so many things that we do to try to offer wraparound care that we cannot get compensated for if we're on a fee for service model. And we're already stretched at the number of patients that we all see per day. Different than Doctor. Miller, you know, we all have twenty minute appointments and that's even for the most complex mental health. Now, do we take longer? Yes, that just means we run behind and we're working into our lunch hour and after hours, things like that. So another thing to consider is that with the increase in vaccine hesitancy, we are now having to do a lot of vaccine counseling and they are long in-depth. They are not covered. There's not a single charge that the state of Vermont allows us to use to pay for this. So we are doing this all out of the goodness of our heart and wanting to do the right thing by patients. And so my fear, if we do not find something to continue to support primary care for things that don't get paid in a fee for service model, is that you're going to see more and more physician offices not taking families who are vaccine hesitant, which I think we can all agree is not a good thing. We need to be there for families and support them and educate. That's not going to be good for health outcomes. My unique experience is that I practiced private pediatrics in Florida for fifteen years prior to coming to Vermont. So I worked in a true fee for service model. And there were doctor's offices who saw private insurance. And if it wasn't something they could charge for, they didn't do it. So there was increased specialist visits. There were, you know, we didn't have any wraparound services. And then there were Medicaid offices that employed brand new nurse practitioners. They worked them to death. They saw way too many patients and the ERs were full of primary care. So having come from that model, and then I got to experience five years in Vermont with the ACO, like I don't want to go back to not being able to provide real comprehensive primary care because I've actually seen how much of a difference that it makes. And you you guys know the numbers because you helped give us those numbers, but for every dollar spent in primary care, it saves $13 in the long run. I think it actually could be higher because I don't think we've ever been fully funded. And if we could do more, we could decrease significant outcomes and improve, you know, we're all trying to save money. And I think what we could provide with being able to retain staff and recruit, we could do even more when it came for our community.

[Alyssa Black (Chair)]: What's your perfect panel size?

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: Oh, I've never been able to have one. I think that What's your dream panel size? I think my dream panel size would definitely be less than a thousand. I think that in my area where people don't come to the doctor every time they need something. And so I think that some parents, they just kind of handle it on their own, which that is totally fine. I think in that 600 to 1,000, depending on whether you had young families or older, the complexity, like Doctor. Miller was saying, think national averages are around that 900 to eleven hundred, depending on what kind of care you provide. But we have a pretty high, we're doing a lot, we're doing eating disorders in primary care, we're doing significant mental health. We're doing, I had to add on Accutane because there's not a dermatologist that will see patients with Medicaid except for UVM and they just don't have time. So we're doing more and more for our patients. And so that would make a smaller patient panel be even better.

[Jennifer Carbee (Office of Legislative Counsel)]: Leslie has a question.

[Leslie Goldman (Member)]: I do. Thank you. Thank you so much for your work and your caring. I was struck by the vaccine hesitancy time that you have to include, and I'm wondering what kind of payment per month, per person per month would end up covering, to allow your practice to be sustainable in this kind of model of the mental health that you're doing and the wraparound services, vaccine hesitancy, etcetera. How do we even yeah, and maybe Doctor. Miller, have something to say too.

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: Yeah. That's I mean, the exact dollar per month is so hard to say because one of the confusing parts with the ACO was that we never really knew what we were getting. We knew there were these payments that were given to us. We never knew when they were coming, how much were they were going to be, how did they calculate it? It kept us afloat, but it was so confusing that we didn't know what to count on. So we probably could have offered more services had we known exactly how much we were getting per patient. And so I would imagine you would have to get into that at least $20 per patient per month to be able to provide care like this. Mean, and Ashley saying even higher. He has a better understanding of that than I do because with a smaller practice, she can see what each one gets. Mine is so large, we would just hire and hope to goodness we had enough to pay for things. But in general, a vaccine counseling visit is in a fee for service world outside of the state of Vermont. It's $150 charge that usually is reimbursed to do vaccine counseling for twenty minutes. And I'm having to do three and four a day right It's that bad.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay. I

[Karen Lueders (Member)]: looked into this, Tracy, as you can imagine, as you said, we're so close to the margin. So, when the ACO finished, we were getting about $63 per patient, plus Blueprint, which is about $5 patient per month. So, that was about $68 When we look at what direct primary care practices are charging, It's interesting to me that they charge less for pediatrics more as people age because we know the mental health, particularly in our adolescents, is higher. But the lowest in our area for direct primary care and remember, direct primary care means they don't usually have staff, so it's just to keep the doors open and the physician employed, is anywhere between $80 and $250 a month. I think based on the model I have that the 68 is low end, the 80 is probably reasonable if you have enough of a balance between you're healthy and you're more complex. But we don't have dolce like Tracy has. And we have a co located mental health clinician, but she we actually had to let her go off our payroll as of today. She's going to try and make it more sustainable in private practice. She'll still be co located, but she'll be responsible for herself because we were losing $10,000 a year employing her, even though she was fully busy. Payment just wasn't enough. So, know, high in the sky, I would say around $100 $125 we could provide the things that Tracy and I are providing for our patients. 68 was bare minimum. We were making it happen. But again, that set monthly payment allowed us to really budget and plan. And I think what Tracy was referring to in the we didn't know exactly, there were bonus models that we could get, and you didn't really know when you were gonna hit the bonus. And some of the bonus components were adult based. So if you were managing hypertension, well, if your denominator for hypertension is zero, you're never going to make your percentage higher. So you're never going to show improvement in that. So I think as we're looking at models of payment, looking at if we're using quality improvement, pediatric specific ones that are obtainable are also important, and how we're measuring them as well. Because right now, the billing codes for tobacco cessation actually don't get paid, or if they do, it knocks out one of our other codes that pays higher. So I don't use that. Even though I'm providing tobacco cessation for somebody who is a user, I can't actually use that billing code because it screws up the money flow. So it would look like that I was not doing it if that was the only way we were capturing that information.

[Alyssa Black (Chair)]: Okay. So another theoretical dumb question. This is to both of you. First of all, do you think that you provide good medical care to your patients currently?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. Okay.

[Karen Lueders (Member)]: And like Tracy said, we do it after hours and we do it for no or little pay sometimes.

[Alyssa Black (Chair)]: If I handed you a lump sum of money at the beginning of the year and told you to go take care of some number of patients and left you alone, do you think that your quality of the medical care you provide would suffer?

[Unidentified Committee Member]: Mine would go up. Now, I will

[Karen Lueders (Member)]: say I was surprised to be on some of the ACO calls and listened to some of the older, and I will say bitter physicians, and what they were not doing because they were not getting paid. And I don't know if that's specific to pediatricians alone, that we just do it because we know it's right for the patients, or if Tracy and I are still younger and pie in the sky, and we do it because we know it's right. But it did make me worry a little bit without checks and balances, and that goes against like me not wanting to do a ton of administrative stuff, but knowing that there aren't always people that are just like Tracy and I out there, I do worry. But I think from Tracy's practice in mind, you would get the best care possible if you just gave us a lump sum and said, Go take care of patients.

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: Similar experience. I think the only thing I would add is that I have a hard time wrapping my brain around that because I think about the number of people that I employ and what I pay to a medical staff office to billing people to NCQ. Like I employ so much time and effort. There is hundreds of thousands of dollars leaving my practice just to check boxes. So right now, if I didn't change anything, no, I couldn't make it with just a set fee. I have to do a little bit of both. But if I could get rid of that administrative burden and the dollars actually go to patient care, yes, I think I could provide better patient care because it would be patient care, not paying six middle people to do work that isn't really part of patient care.

[Karen Lueders (Member)]: We figured out that our care coordinator spends 1 third to 40 percent of her time just doing data collection and submission for things like NCQA and PCMH. So, that's time that she's not providing social determinants of health care, not providing support. And that was pretty amazing. We actually thought about whether or not we should leave BCMH this year because of the amount of time it takes and costs her.

[Alyssa Black (Chair)]: Last question is, you mentioned tobacco cessation. If somebody wasn't measuring, if you're doing tobacco cessation, do you think, you're both pediatricians, do you think that you would stop counseling your patients to stop using tobacco if you weren't being measured for it?

[Tracy Tyson, MD (Pediatrician, Primary Care Health Partners)]: No, not at all. It's the opposite. The measuring sometimes takes away from the time that you're getting to do it or just doesn't capture what you're doing. And I mean, I'm having to spend minutes of my day and at least an hour a day because if my problem list, if there isn't a button that's hit every single visit, even though I update my problem list, if a certain button isn't hit, I'm not getting reimbursed. Like that alone has nothing to do with patient care and it's hours a day that somebody is sitting there monitoring if that is done. And the tobacco cessation, like we had this great program to capture everyone doing that, but our medical assistants were accidentally hitting the wrong button and it looked like we weren't doing it for anyone, so we didn't get compensated for it. And then we have families that are so tired of seeing these bills come up on their EOBs and saying, Why are you charging us for this? And it was like, We're not charging you for it. It's just that if we don't put the billing code on there, it looks like we're not doing it. So it also creates some distrust with families who think that their doctors are just trying to nickel and dime them when really we're trying to jump through hoops just to get base payments to keep the doors open.

[Karen Lueders (Member)]: Yeah, Blue Cross Blue Shield just changed their telehealth coding this year. So interestingly, way CMS, so Medicare set up the codes, you cannot build these specific telehealth codes with a mental health screener. So, my patients love doing their mental health depression, anxiety follow ups over telehealth. Shortens the time out of school, shortens the time out of work, they love it. But because we're not getting this lump payment anymore and now they won't pay for the screeners, I'm having to make that decision of do I still offer patients on Blue Cross Blue Shield telehealth for their mental health? Do I say you can do it, but now you have to pay for the screener out of pocket yourself, or you have to come in so I can get paid for what I'm doing? It's these sorts of thoughts and concerns that take up my day that I could otherwise be spending time with patients. Another example is we have not gotten paid for any of the COVID vaccines we gave to Green Mountain Care patients in the fall when we also gave them a flu vaccine, And it's because there was some silly error in Medicare, again, with what modifier we used on the billing code that didn't get fixed until the beginning of the year, and now we have to go back and rebill all of those patients. Again, it puts up those barriers that aren't barriers, like Tracy and I can give good care, we know how to do it, but if we're spending time on these other barriers to make sure we're getting paid so we can pay our staff, we're not providing the best care we can. So having that one payer, that one payment where everybody's in agreement will really simplify that time we're spending on things other than providing good medicine.

[Alyssa Black (Chair)]: Thank you. Thank you both so much for coming in. Really appreciate it.

[Unidentified Committee Member]: Thank you. We

[Alyssa Black (Chair)]: are done until

[Leslie Goldman (Member)]: after

[Jennifer Carbee (Office of Legislative Counsel)]: the