Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Hi, welcome. We are continuing some work around S197 and we have in Elena Berbe from Fremont Care Board, who's going to talk to us about a report that we I don't know, is it commissioned? Was it reordered, we mandated, statutorily required some report? And you're going to talk us

[Leslie Goldman (Member)]: through it a little bit.

[Elena (Director of Policy, Green Mountain Care Board)]: Thank you. I'm Nina Berbe, Director of Policy at Dream and Care Board. Thanks for having me. So this report was part of Act 17 of 2019. It was a joint report between the Green Mountain Care Board and DIVA. And we did this work as part of a broader set of states that were getting together to define and measure primary care spend as a proportion of our total health care spending. And the report focused on a Vermont specific definition of primary care, which I'll get to in a moment. But there was a stakeholder group that was created and convened. This Vermont definition of primary care was created, and then we calculated the measure based on twenty eighteen claims and non claims data using the all payer claims database that we have at the Green Mountain Care Board. And that report found that between 5.910.2% of health care spending is on primary care. That report, the 5.9% is if you just use claims, And the 10.2% includes non claims data, such as Blueprint for health payments and other population health payments that fall into that bucket of work. What's important and I sent around a one pager that summarizes some of these key statistics. So the report is quite dense, but tried to pull out some of the main things for you. So I think it's important to understand what's in that 10.2%, that big number. So in the Vermont definition that was convening a stakeholder group, primary care in terms of providers, services, and settings. So you have family medicine, internal medicine, general practice, pediatrics, nurse practitioners, physician's assistants, naturopaths, OBGYNs, and osteopaths. So those are all of the providers that were included in the definition. And it was across a range of services, which included office visits, preventative care, care management, mental health, substance use disorder services. So you can often get similar primary care services from a specialist. Like if you have a rheumatoid, other kinds of specialty care, you could go get those kinds of things there. You could get it in a acute hospital setting. But here, this is really focused on primary care and related clinicians.

[Alyssa Black (Chair)]: Can I interrupt? Yes. Okay. So we took family medicine, which is a specialty, internal medicine, which is a specialty, general practice. I don't know what general practice is. So this is

[Elena (Director of Policy, Green Mountain Care Board)]: just kind of another set. So we're taking kind

[Alyssa Black (Chair)]: of some of those Medicare, those claims based definitions. We have a claim. There's different ways to categorize who delivered that service. And so we've checked all the boxes that could possibly fit. Yes. So when you get to things like nurse practitioners and physician assistants, they aren't technically a specialty. So how did we extrapolate out the ones like, you know, you're a physician assistant working in the emergency department or in orthopedics. You're immediately

[Elena (Director of Policy, Green Mountain Care Board)]: testing my knowledge. But, you know, so there are different ways to do it. I just have to go back and look at how we did it. But some of the newer methods, because we don't classify those, all practitioners as primary care and non primary care, you can kind of look at their claims and look at what they're doing and allocate them that way. Or you can kind of see where they work and if they work with primary care physicians. But you're right, there isn't a great way to identify those kinds of clinicians in terms of their staff. I can look up exactly how

[Alyssa Black (Chair)]: we did that here. I

[Daisy Berbeco (Ranking Member)]: think that's the same question as I have around the mental health services. I'm assuming you didn't focus on designated agency clinicians. This, I'm assuming, includes all of them and it's more diagnosis code based. Yes, Very broad definition. So you looked at private provider claims as well?

[Elena (Director of Policy, Green Mountain Care Board)]: No. So I think we I have to go back and look at mental health. So this was part of, I think, the non claims portion was more challenging. There were actually some non claims data that we were not able to allocate many years ago. So there are some claims that are nonclaims that are excluded. So we know that there are some spending that's happening that's not reflected here. Yeah. Is this data from 2020? 2018. Because claims takes a

[Alyssa Black (Chair)]: long time, that was the latest available data we had at the time.

[Elena (Director of Policy, Green Mountain Care Board)]: Can I Yeah? Keep going?

[Leslie Goldman (Member)]: Yeah, okay.

[Alyssa Black (Chair)]: You keep going.

[Elena (Director of Policy, Green Mountain Care Board)]: Okay, so there's the definition. What did this report, kind of what were the insights? I think the Vermont definition, the report that focused on the Vermont found that overall 8.9% of all payer total cost of care was attributable to primary care. That's without, it's just the claims. Then a 10.2 includes the Blueprint CHT payments, etcetera. Medicaid had the highest share of primary care spend, and that also included mental health spending and SUD, or substance use disorder spending. And then Medicare was on the lower side, point 5% to 6.5% of Medicare total cost of care spending. Then, as I mentioned before, there's this NEESCO primary care report. So this was a group of New England states. The link to this report is on your website as well. And this report compared Vermont spending to other New England states using a broad and a narrow definition, which was a little bit more tailored than our Vermont definition, but kind of gives you a sense with and without some of the OB GYN, for example. But their report has a breakdown of exactly what's in and out of those definitions. And that found that Vermont had the lowest commercial spend on primary care across New England states. So 4.9% versus Massachusetts, which had the highest at 8% using the narrow definition. But this was consistent when they used the broad definition. We had 7.4% primary care spend versus 11% spend in Massachusetts using the broad definition. And then Vermont had kind of average to higher spend if you look at government payers across New England states, so Medicaid and Medicare.

[Alyssa Black (Chair)]: They look at the disparity between Medicare, Medicaid is a really big number. Did they look at that and identify?

[Elena (Director of Policy, Green Mountain Care Board)]: I mean, why would Medicaid be 25%? Right. And I think this is where you get to how we look at dual eligible spending, for example. I'm not exactly sure how they factored that into here, but I think having the mental health and STD treatment available to Medicaid may have something to do with that. I don't know. I have to go back and look and see how and if that would be included in the Medicare spending in the same way, or if there's overlap in these populations. That would be maybe one reason.

[Alyssa Black (Chair)]: Would that account for the difference between Medicaid and commercial? I don't think that would be the same. It could have something to do with it. Okay. I'm just trying to figure out, are we comparing apples to apples or apples to oranges? We are likely comparing apples to oranges a little bit. Yes. All right. Thank you. You're welcome.

[Elena (Director of Policy, Green Mountain Care Board)]: That's really all I had. I mean, I'm happy to answer more questions, but those are kind of the big It's a lot of data analysis for a couple of statistics.

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

[Elena (Director of Policy, Green Mountain Care Board)]: It just seems like such a small number for primary care. I guess you did the New England. Is there a national average? That's a really good I mean, I think part of what this NESCO report wanted to do was to build a standard way of looking at it, to the apples to oranges question. There isn't a national all payer claims database, so it makes that kind of analysis really difficult. But there are We can compare using all Medicare claims, like how states may differ in terms of their primary care spend to get a general sense. So we could look for some data on that. And then I'm wondering if it'll go down even more now that people are not covered, their deductibles are to their primary care. Right, yeah, absolutely.

[Alyssa Black (Chair)]: So we used V Cares data. So other than percentages, what are we talking in real dollars here? Keeping in mind this was 2018. Yes. So what was the projected total spend on healthcare in Vermont by all payers?

[Elena (Director of Policy, Green Mountain Care Board)]: So this report at the time used this total cost of care measure, which is kind of a subset of the total health care spending. So if you compare it to our expenditure analysis, it's a little bit different, but that's a 2,630,000,000 figure. So if you take 10% of that or 6% of that, that's the primary care dollar you're talking about. And then we're talking about there's different ways of measuring who actually got that care. There are a lot of people who didn't get care at all. Are we allocating those dollars to those residents? Or are we talking about dollars spent on people who actually access care? So what's really important to know, depending on what you're trying to figure out, how you're allocating those dollars is really important.

[Alyssa Black (Chair)]: Do we have any I'm just thinking about the Green Mountain Care Board and their role around hospital budgets. Additionally, the role you play with rate review. When you do Blue Cross Blue Shield and MVP, do they break down for you how much is spent in primary care? We do.

[Elena (Director of Policy, Green Mountain Care Board)]: We look at primary care. We can look at primary care, hospital care, drug spending. We look at those drivers and you can kind of see the major drivers as being traditionally hospital home spending growth and drug spending.

[Alyssa Black (Chair)]: We know that since 2018 that spending has increased. We can all agree.

[Leslie Goldman (Member)]: We

[Alyssa Black (Chair)]: know that the drivers have been, we've seen, because I know we've seen the little charts that go along and then there's, so we know drug spending, hospital spending has, it would seem to me that that percentage to private care would be going down, I'm assuming. I would guess that

[Elena (Director of Policy, Green Mountain Care Board)]: it would go down, but I would need to bring that back to you as a relative sense. If our hospital spending has grown over time, then it has to come from somewhere proportion.

[Alyssa Black (Chair)]: And I think the other question I have is if this information is coming out of vCures, there had to have been a sort of total claims looked at, what percentage of claims were actually identified as a primary care claim to the whole? I mean, was it just 10% of all claims were primary care or I'm trying to get a sense of how much we allocate financial wise versus how much care is being delivered. Think we've heard earlier this year, somebody's I remember some testimony that we've had that, you know, it's less than 10% we spend on primary care and yet they make up over 40% of all encounters or something? I'm looking over to Jess because I can't remember who said it, but I feel like somebody did. And I'm wondering if we actually have data around that.

[Elena (Director of Policy, Green Mountain Care Board)]: We should have data on that. I think we do have some reports we've been looking at recently related to our all peer model reporting that we can probably look at and see if we can get some of those numbers to you.

[Alyssa Black (Chair)]: Go ahead.

[Daisy Berbeco (Ranking Member)]: I'm just looking at the reports on page 19, the analysis of anticipated impact and increasing primary care spend and forward facing recommendations is the phrase that caught my attention. Can you say a couple of things about next steps? How does this report or the data that it finds sleep in with the things that we're working on with payment reform for primary care? I know that it's captured a point in time, but I've also just, in my glancing at the report, seen that it says, when you're going to do future work, measure this all again.

[Elena (Director of Policy, Green Mountain Care Board)]: Yes, that's a great question. And I'll give you my take on it related from our board perspective, but certainly speaking with the agency of Human Services and Blueprint is important. But this report became I think a lot of states have been looking at primary care spend and how do we increase primary care spend. And it was a major component of the first AHEAD model negotiation. And so we were actually in the process of updating this analysis and negotiating a definition with the federal government. That model has changed, and so there's still a primary care spend component. But I would look to AHS for the latest available information on that. So what should we do with it? I think that's a question. I think some states do primary care spend targets in their rate review process. Some states are working on an ahead negotiation and have a primary care spend target as part of that model. I think it depends on the state's approach to primary care reform.

[Alyssa Black (Chair)]: In the budget process with Green Mountain Care Board Hospital budget review, do hospitals who actually have primary care, do they break down that service line as far as costs and revenue?

[Elena (Director of Policy, Green Mountain Care Board)]: We have seen primary care revenues. We get a breakdown by department, but we have not made it an explicit focus or made any orders related to primary care, to my knowledge.

[Alyssa Black (Chair)]: My last question is in 01/1997, it appears as though we've tasked the blueprint to advise the agency of human services around coming up with sort of targeted methodologies in order to find sort of a per member per month amount. Considering that the Green Mountain Chair Board has done this work previously, does it make sense to then ask the Agency of Human Services to start over again? I think that's a

[Elena (Director of Policy, Green Mountain Care Board)]: good question. I think we have a lot of infrastructure to build the spend measurement. I think if it's about designing a payment model for primary care, maybe they'd be better positioned to do that, though there's overlap in some of that work. So I think that's a question.

[Alyssa Black (Chair)]: Any question? I guess I'm just thinking about the fact that we already have given the Green Mountain Care Board rate setting authority, and I'm not sure how this is different, why we would cast somebody else with setting a rate when you already have when I say you, I mean the board. The board, yes. And the board already has rate setting authority.

[Elena (Director of Policy, Green Mountain Care Board)]: We could do it with the authority we have.

[Alyssa Black (Chair)]: Any other questions for Elena? On rates of the authority, it across the board, or is it more limited?

[Elena (Director of Policy, Green Mountain Care Board)]: I think it's pretty open. I would like to have our general counsel weigh in on exactly how far that goes. But I think we have explicit direction to establish hospital reference based prices, right? But there was an allowance to set a floor for primary care or other types of businesses in '68 as part of that work.

[Alyssa Black (Chair)]: So there's yep. Mhmm. Think one of these days, we'll have Jen Carpe go through and read the Green Mountain Care Board section. I don't know what is it. Chapter or is it Shake. She's she's

[Daisy Berbeco (Ranking Member)]: I

[Alyssa Black (Chair)]: think sometimes we're really confused over the years of, like, what we've put in there.

[Daisy Berbeco (Ranking Member)]: Go ahead, Daisy. The report says the board currently does have the authority to set provider rates. However, the authority has never been staffed or funded. In FY 2016, the board staff estimated the cost of implementing an FFS rate setting program could range up to $2,300,000 depending on complexity and structures.

[Alyssa Black (Chair)]: Yeah, I would agree.

[Elena (Director of Policy, Green Mountain Care Board)]: Would agree. But that's a

[Alyssa Black (Chair)]: For service setting.

[Elena (Director of Policy, Green Mountain Care Board)]: So I think what we're doing right now, right? We have deal if

[Alyssa Black (Chair)]: we just set one capitated rate. Yeah.

[Elena (Director of Policy, Green Mountain Care Board)]: The simpler it it is, the better The

[Leslie Goldman (Member)]: plus three.

[Daisy Berbeco (Ranking Member)]: But I guess the point is that it's not

[Alyssa Black (Chair)]: just enough to give them the authority. We need to give them the money to do it. Or the directive. And the resources.

[Leslie Goldman (Member)]: The resources. Okay.

[Alyssa Black (Chair)]: Any other questions? Well, have

[Leslie Goldman (Member)]: a question, but you're not going know this answer. But it came up this morning when we got anecdotal testimony about what pediatricians would want in order to have a per member per month viable practice. Don't have my notebook. Well, do. A $100 per member per month, which is way I think if I understood it right, so maybe you can help me make sure I got it, that currently Well, the ACO is doing 63 and then another 5, so it was 68. So they were getting 68, so they're asking now maybe 100.

[Elena (Director of Policy, Green Mountain Care Board)]: Yeah, and I think it depends too, like what's a per member per month versus what are the other ways these providers are getting paid. Like I think to the point made earlier, apples and oranges. Yeah, that was because there's

[Alyssa Black (Chair)]: a fee service. Doctor.

[Leslie Goldman (Member)]: Lindsay said he'd rather have fee for service, which was a little hard to interpret.

[Elena (Director of Policy, Green Mountain Care Board)]: That doesn't have to be all or nothing. There are hybrid models where you have per member per month for some services and carve out certain fee for service for others.

[Leslie Goldman (Member)]: Does that make it more complex? I mean, that sounds

[Elena (Director of Policy, Green Mountain Care Board)]: I mean, just sometimes it's it's easier depending on what the service is, but that's where you have these stakeholder groups weigh in on how would the payment best support the best care.

[Leslie Goldman (Member)]: This is supposed to be effective on passage, but there's a lot of reports. Seems like a lot of it is. So what's the time frame could you imagine? The Green Mountain Care Board meeting to do its work once it gets funded for whatever million?

[Elena (Director of Policy, Green Mountain Care Board)]: Oh, so I think the reports in here are a little different than what we talked about. I think some of so I think there was one report in the January version of this, I think, if I recall, that required focus groups and a lot of touch points with communities and providers. And I think that took we had a dedicated FTE for maybe a year to get that report done. So we could probably think of other ways of doing it, but that level of detail did require quite significant effort.

[Leslie Goldman (Member)]: So what is the level of detail required to work through it?

[Alyssa Black (Chair)]: I think once we get into the bill and start rushing into it. But just to summarize a

[Leslie Goldman (Member)]: little bit this

[Unidentified committee member]: morning, there's this increase in vaccine counseling, and there's no

[Elena (Director of Policy, Green Mountain Care Board)]: way to get compensated for that, but

[Alyssa Black (Chair)]: they have to provide it. We spent

[Unidentified committee member]: a lot of time and education doing that. They were basically saying a lot of care does not get paid for in the food for service model, and that pediatric specific needs need to be taken into account because you can't quote your services that would be provided. So there's a lot

[Elena (Director of Policy, Green Mountain Care Board)]: of those nuances to really provide the level of care that's going to make a difference than the comprehensive primary care. Would it be a blending? I imagine that they're exactly. I think it's not going to be just a very simple formula.

[Alyssa Black (Chair)]: And maybe I'm editorializing here. I keep asking people what would be And we keep getting numbers or ideas of how to just sort of sustain the system we have right now and just changing the methodology of how we do it to keep it at a sustainable level. I just keep asking, are we trying to sustain it or are we trying to elevate it?

[Leslie Goldman (Member)]: Well, means that it doesn't crash,

[Alyssa Black (Chair)]: which is a worry. Or are we trying to make it thrive?

[Leslie Goldman (Member)]: We'd like to make it thrive, but we don't want it to crash either. Sure. Yeah.

[Alyssa Black (Chair)]: Okay, thanks Elaine on that. Thanks for having me. Hi. We're actually done for the day, everyone.

[Unidentified participant]: Yes, of course. Would

[Alyssa Black (Chair)]: you like to you to announce

[Leslie Goldman (Member)]: who you are?

[Unidentified participant]: I haven't thought about it in years, it's a little bit of a post traumatic stress response. It was a ruling experience. Wow, three, all of the imaginations today. It was a tremendous

[Alyssa Black (Chair)]: So

[Leslie Goldman (Member)]: what do we take from that? Don't do it again?

[Unidentified participant]: Sometimes we need to do a little bit of matter of it's for something that we can actually do something about.

[Leslie Goldman (Member)]: Did you see anything come out of this work?

[Alyssa Black (Chair)]: From where I saw it,

[Unidentified participant]: I couldn't see anything. It's interesting to hear Elena just say, people have looked to it.

[Alyssa Black (Chair)]: I looked at the recommendations section, there was nothing in the recommendations.

[Elena (Director of Policy, Green Mountain Care Board)]: No, I think we didn't have a direct step. I think that the head model was the place where that

[Leslie Goldman (Member)]: could have happened or may yet

[Alyssa Black (Chair)]: have been, but

[Elena (Director of Policy, Green Mountain Care Board)]: I don't think there's another vehicle, to my knowledge, that is actively.

[Unidentified participant]: It's because you said something about it, I just want to repeat. You have heard me say in this committee for months, ten months, maybe longer, I know zero dates that it will ever

[Alyssa Black (Chair)]: How many decades have we been collecting data, and how much more data do we need? I don't know. Yes, Jessa, how much more data do we really need? Jessa,

[Jessa Barnard (Vermont Medical Society)]: for all medical society, I would let the committee know that there have been advocates, for example, the medical society saying we don't just need to measure this anymore, we need to set a goal and make progress each year towards that goal. And we have reached various roadblocks to accomplishing that. And that has been suggested for various legislation along a year. So it was seen as a first step. The measurement was the baseline. There was an intent by some to then move that baseline. And that is where we are today. And when I testify further on 197, I would be happy to share more about how we

[Alyssa Black (Chair)]: can see that when you

[Jessa Barnard (Vermont Medical Society)]: bring the needle, not just being a measurement, but it sits on the shelf.

[Leslie Goldman (Member)]: So could I ask the question?

[Alyssa Black (Chair)]: How many more times do we need to measure it? Go ahead, Leslie.

[Leslie Goldman (Member)]: So do you have a goal in mind?

[Jessa Barnard (Vermont Medical Society)]: I will say other states have set goals that range from 12 to 15%.

[Leslie Goldman (Member)]: So you've talked about a number of goals.

[Jessa Barnard (Vermont Medical Society)]: A goal for what percent is the correct goal for where that, what percent of total cost of care shouldn't be spending on primary care. There are a number of experts from other states and nationwide, we'd be happy to talk about that work. Massachusetts has a bill with a similar goals. Rhode Island had a goal of 12, nine zero eight has increased, met that goal and it's increased it to 15. We have members who tell us it should be 20, but it should be based on what our goal is to strengthen our priorities.

[Leslie Goldman (Member)]: So I have another question. Have you come across anything that is a goal that actually influences population health outcomes in a meaningful way?

[Jessa Barnard (Vermont Medical Society)]: That is where that number, my understanding of where the 12 or 15% comes from is looking at other countries and health systems and what they spend on preventive and primary care relative to The United States. And that is sort of what and their health comes based on more investment in primary care. And that's what's informed Why? It's not just a number, it's because we want to think there would be

[Alyssa Black (Chair)]: good outcomes to improve the health

[Jessa Barnard (Vermont Medical Society)]: of our population if we increase that investment.

[Leslie Goldman (Member)]: So if I understand, just so I clarify that in other countries, let's say 15 to 20% spend on primary care is what they're doing and therefore having better outcomes population.

[Alyssa Black (Chair)]: Oh, I know you'll probably, but I think about when we start comparing to other countries, other countries also invest in education, childcare, food security, housing, rental, which means sometimes you can spend a little bit less.

[Leslie Goldman (Member)]: Where do you put the resources?

[Alyssa Black (Chair)]: Where do you put the resources? Okay, everybody, thanks so much. See you guys. We're not back until 09:30 tomorrow.