Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: I had oatmeal too. I can't stop me. Ate 100. Real Real life. You're alive. Hold on one second, Doctor. Merman. Let me close the thing that is, you're actually totally blocking the taking of you. The important part. Alright, so we're going back to just again, we're still talking about primary care. I asked Doctor. Merman to come in even though he is not a primary care provider, but I asked to get his thoughts on this as a physician. I think we wanted to make clear, you are on the Green Mountain Care Board, but you're representing yourself. You're not representing the Green Mountain Care Board.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Yes. So for the record, Dave Merman. I'm a physician. I'm on the Green Mountain Care Board. I work as an emergency physician at Central Vermont Medical Center. This is totally I've been invited here today to speak about primary care. And so this is totally my views informed by my perspective and my time working in these various fields. And I did not prepare slides. I prepared some thoughts to speak with you about. And I appreciate, Chair Black, throwing out the caveat that I'm not a primary care provider because sometimes I was struggling with preparing this because I have this a little bit of a feeling of impostor syndrome here that I really shouldn't be speaking too heavily about someone else's field. But I think working in emergency medicine, and now I've been in Vermont for fourteen years working in emergency medicine. I've seen We interface with patients a lot, and then we interface with the primary care system. So I think I have a perspective that I think is informed. Although I think that I really appreciate you know, that you have, some of the leaders in primary care in the state with Faye Houghton and the residency director, I think, coming up from UVM, Gordon Powers, who who I've worked with back when he was a resident and as an attending as Cal and Allen Ramsey. So all people, I think, who have really great perspectives, much more sort of on the ground and focus than than my perspective, which is on the ground, but looking looking at it from the outside. I also wanna sort of give a little caveat that I think a lot of my thinking on primary care has been influenced heavily by people you've had speak already. So Faye Houghton has been involved in the primary care advisory group for a long period of time. And I've been in a bunch of those meetings and had conversations with her. And then Lisa Rosenbaum, who does this New England Journal of Medicine essay series and podcast, I think has really done a really impressive job of coalescing a lot of the important issues around primary care and thinking about them from all these different directions, which is quite thought provoking. And I think one of the challenges of how do we work towards fixing all those things? I don't know, there's hopefully a lot of work in this committee to come on that.

[Rep. Alyssa Black (Chair)]: Full disclosure. I know I had my fangirl moment the other day, but it was Doctor. Merman who actually sent me an episode and said, I think you might enjoy this. He was right.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: It was actually my wife that said it's me because she works in medical informatics, and she was listening to the AI episode. And she's like, you should listen to this. Yeah.

[Unidentified Committee Member]: Oh, credit given.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Yeah. And someone else probably gave it to her. So she can come tell you that at some point.

[Rep. Alyssa Black (Chair)]: And Laura Lisa thinks that nobody's listening to her podcast. So

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: any questions, just feel free to interrupt. Had some general thoughts that I've been thinking for a while. Care, when I first came to Vermont, I was amazed at the ability of my patients follow-up with primary care. It was not like where I had worked before. It was amazing what we did not admit here and could get really good follow-up care, and I think we're really successful with that, 2013, 2014, 2015. As we were coming into COVID, it started to feel like we were a little bit more at risk. And I think, really, in COVID, it dawned on me that we were like, we're not past the tipping point. We've tipped and are are colliding down the other side. And what I mean by that is, at least in my community, there were a lot of people that retired. And various reasons, there was personal reasons, there were health reasons, there were other reasons people retired. But once you kind of get that critical mass retiring, then the rest of the primary care infrastructure can sprain. And then the turnover, which just seems like we've had turnover after turnover. And so and so and and when I and my, again, my experience with this is mostly through talking with patients that I'm seeing. So patients are continually frustrated because they feel like they can't make appointments, and it's really the urgent visits. They can schedule out an appointment two months, three months, four months, not a problem. They can have their annual follow-up for their blood pressure check scheduled. But if they have something urgently wrong, they can't get in and they call. And again, overgeneralizing, I'm sure, but this is my perspective. See the ones that come to me. But a lot of people say, oh, I just called them and they said, just go to the ER urgent care or express care. And I think that the patients really want that connection with the primary care provider. They're calling them because they've well, one, I think they feel like it's the right thing to do. Two, they're probably financially incentivized to through co pays. But three, I think a lot of them know, at least they used to have connections and maybe they still have connections with these individuals. And so there's trust there. I do hear stories of patients, and my personal experience too, and family, is that sometimes when we go to the primary care providers, it feels like they're burdened with all these check boxes to try to justify us being there. My dad went to his Medicare screening exam six years ago and he said he's never going back because it was the most useless hour of his life. Now Medicare screening exams, I'm finding out can be done just with a phone call, which is probably good, but it's not a primary care appointment where you're connecting with somebody, developing trust, developing a treatment plan together. And then I think people feel feel rushed often through their these very short appointments, which I'm sure you've heard about and all have felt. One more thing that I think that I see, which I don't see it that commonly, but I don't know how much of it I'm seeing like, what the part of the iceberg is is that in order to patients come into the emergency department for a medication refill. And that refill is the reason why they need that refill is that the primary care provider is trying to get them in every three months to have a visit to prescribe the med. And I've seen this on antidepressants and I've seen this on insulin, where they missed the appointment because they had the flu. They got scheduled out six weeks, now they don't have the antidepressant prescription. So I think these all speak to some of these problems with how are we this is the payment issue. If we're paying in a fee for service structure, we're incentivizing schedules to be full as far out as possible so that you have a steady revenue stream. You're scheduling people to come in at as frequent intervals as you can in order to make that revenue that you need. You don't leave places in your schedule for urgent visits because what if they don't fill? You don't make the revenue. Maybe the provider's being judged on their their RVU production or their relative basically, their revenue production or the potential revenue production. So if there's no appointment, they get dinged there. So there's so much incentive to keep the schedule full. Easy way to keep schedule full, schedule it out. So I think all of those kind of speak to some of the issues that we have with payment issues. There's one more anecdote I wanna give on this of of my own, which is I would say, like, I don't know, back in the good old days of ten years ago, when I asked a patient who their primary care provider was, they could tell me who their primary care provider was. And I feel like now when I ask a patient who their primary care provider is, a lot of a huge majority I mean, not majority. A large proportion of the time they would say, I don't know. Or, well, I had this person and then they retired. And then I had this person, they left. And now I had this this nurse practitioner, and she was great, but she left. And then I have this new person that they I don't know who it is. So so clearly, this whole thing I think Lisa was talking about last week, which I think is really important of having a trusted relationship with the primary care provider is provider is really is is maybe that's the tip that happened is it's it's it's less frequent than it used to be. And for those of you who have them, and I think I've spoken with people who have strong relationships with their primary care providers. You're lucky and hold on to it because once you lose that, it's really hard to get that again. So that was my general thoughts on some of the challenges that I see for patients in primary care. I think those all relate to this concept that have been talked about that could be related to a a payment structure fix, I think, could could deal with a lot of those.

[Rep. Alyssa Black (Chair)]: Like what?

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Well, I think, like, what Sorry. Oh, I think, like, what Faye and

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

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Yeah. I think what Faye and Lisa, you know, and others have talked about is, can you pay primary care in a way that's not based in a fee for a service, you know, a a revenue generation based upon individual transactions? Can you, you know, sort of the direct primary care model where people are paying a subscription, can you do that outside of a cash based world and pay a capitated payment? I think that therein lies the challenge. Just how do you get how do you how do you build the system to do that and how do you make it happen? But I think that's I think there's a lot of people who believe and would argue, and there have been some pilots of these over the years. There was I talked with somebody who worked, in Washington in the nineties, and Medicaid had a three year pilot where they were in a capitated system like this, and they felt very freed to practice primary care, have nonphysician team members working in concert to deliver services for people. But, yeah, I think that's generally thought of as sort of the way to do that.

[Rep. Leslie Goldman (Member)]: And that has to be

[Rep. Alyssa Black (Chair)]: done by statute? How does that like, I

[Rep. Leslie Goldman (Member)]: mean, it's a culture. I

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: mean, an insurance company could create a capitated payment model for their

[Rep. Alyssa Black (Chair)]: for their people.

[Unidentified Committee Member]: Value based care is not a new idea when you're like, this is the challenge or the concept. I mean,

[Rep. Alyssa Black (Chair)]: maybe Right. Is that value based care? I think that's The definition of value based care.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Yeah. I think that's something that kinda came up the other day too with who was it that was talking about this? I can't remember someone in here or maybe it's in the other conversations I'm having. The sort of differentiation between Capitated payments are commonly part of value based care, but in the value based care equation, you have all these measures of which you need to value based care is kinda like pay for performance. And so you're trying to measure the performance. And I think that a lot of the performance measures and and I think, you know, Tom Morris talked about this, but I think others have talked about Lisa and Faye have talked about this is maybe some of those performance measures we're having aren't really that valuable to the to what we're trying to get to. If we're trying to get, you know? So so I think of capitation and value based care is interrelated but different. And capitation in its sort of purest form, I think, would be like a direct primary care. You're just paying cash to have access. You know? And, like, where value based care is, you know, is, I think, is really that pay per performance. You know? You're you're you're doing well in this metric. You get a little bit more money. Do it well in this metric. You get a little bit more money.

[Unidentified Committee Member]: You think cash for access fee for service?

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Well, cash for so fee for service is cash per transaction where, like Oh, you're direct well, I'm saying in direct primary care, you know, they're just paying us it's a subscription fee as opposed to you know, instead of, yeah, you buy your Netflix subscription as opposed to paying remember we used to pay per movie?

[Rep. Alyssa Black (Chair)]: Mail in the DVD.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Mail in the DVD. Go to Blockbuster. So it's a I think of those as sort of different but sorry. Captation and value based care is similar they're similar elements, but different beasts. So, like yeah.

[Rep. Alyssa Black (Chair)]: Can I expand and ask a question on that? That's a question I did not ask Doctor. Page this morning. Value based care is essentially a capitated. However, the capitated payment is based upon measures that we have that we think of as value. Like the ACO model was actually, it was set so that there was a target spend. And if you increased quality so that they did not spend as much. And we've had, I know Doctor. Loeffler has actually come in here and talked about this before. Basically, like you get a return on, you get to share in those savings.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Yes, yes.

[Rep. Alyssa Black (Chair)]: You can show savings for the system You as a get a share of those savings based upon this value judgment of the care you provided with a capitated payment. So, would we consider that sort of model to be something that is calculated on what the return on investment would be? Can we say that that's actually making a judgment on the return of investment?

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I'm not I'm not quite sure if I can answer it exactly. I guess the way I I think of that system is I don't know. Eighteen years ago or something, I was working in an emergency department and some of the primary care providers were in a they said they were in a capitated payment, but I think they were on the hook for the total cost of care of the patient. So whenever the patient would come to the ER, you know, we'd wanna admit them and they'd be like, no. Don't admit them because they're like gonna totally blow their total cost of care contract, you know, because, you know, you're talking primary care visit primary care visit, you know, couple $100 a piece admission, you know, $20,000. You know? So one admission totally blows that, which seemed unfair to me. When we put it into something where, like, you have a whole health system, you know, that's where you have enough enough distribution of of all those variables. Right? That, like, you know, you have a big enough pie. I think that's how I think of, like, the the Medicare shared savings program. So within Medicare, if a hospital if that health system could reduce their spending, in Medicare, they could take part of that shared savings. But when I think about capitated payments for primary care, I guess what I've been thinking about is, especially for independent primary care, FPHCs that don't they're not part of a hospital, so they can't participate in that shared savings as much, think, to not maybe hold them so on the hook for the total cost of care of the patient, but just encourage them to do the primary care that they've been doing. And I guess there's a little bit of a leap of faith that's gonna work because the measurements get the attribution and the whose fault is it that their care went more expensive? It just gets so complicated.

[Rep. Alyssa Black (Chair)]: I think what I was thinking about and what I have been thinking about is that we keep making primary care responsible for the cost of care to the system as a whole, which I think of as are we getting a return on our investment in primary care? But I wonder, does anyone ask what's the return of investment on CAR T cell therapy? Was a question I didn't ask Doctor. Page.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Think what was the

[Rep. Alyssa Black (Chair)]: ROI of CAR T? How many patients? And people I did not ask the question because I felt like people would be horrified with me asking the question. But why don't we ask the question? Why is it horrifying to ask the question what the return on investment is of the most expensive care that we deliver? And yet at the same time, we ask what the return on investment is in primary care.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I think we think of, like with primary care, always ask how much more money could we save? And I don't think we think of that something in like CAR T. CAR T is an access to a very sophisticated treatment.

[Rep. Leslie Goldman (Member)]: Or the trade off of nine years of neurosurgery training versus three years of primary care training. What's the return on investment of both of those?

[Unidentified Committee Member]: What do you think we're not looking at

[Rep. Alyssa Black (Chair)]: the ROI on that? I think I'm putting the question

[Unidentified Committee Member]: out there, do we? Well, we measure everything, right? Mean, guaranteed they're reporting to what's the

[Rep. Alyssa Black (Chair)]: NCQA? Are the we cost of systems as a whole? Are we measuring the value of I was at an NCSL thing this past year, it oh, National Council of State Legislators, NCSL conference, and it was on prescription drugs. And it was around the pricing and how prescription drugs are priced in The US. That's a whole another thing. Other But countries actually do calculations based upon what is the value of this particular They make coverage determinations. Are we going to cover this? Based upon doing a full analytical return on investment to how will this increase someone's health? What is the return on that person's health being increased? Does it extend life? I mean, these are questions we never have in this country. Does it give you an extra three months of life? And what is the quality and what is the value of those three months? I mean,

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: are pretty

[Rep. Alyssa Black (Chair)]: hard questions that we completely, but it's not just prescription drugs. We do this for everything. And Leslie's point, what is the return investment on training someone for nine years versus three years? And what are we getting for that additional six years as a society, as a whole, as a system, as a healthcare system?

[Rep. Leslie Goldman (Member)]: But I think you answered that because you started talking

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: about I don't know how to answer this. Well,

[Rep. Leslie Goldman (Member)]: why we're in the situation we are, why we have the neurosurgery versus primary care because of trade organizations owned by private equity. Perhaps, maybe not. Okay, I'm not going worry about private equity, but the very powerful trade organizations in Congress that are running the system and investing lots of our tax dollars into training specialists. We heard about that on Lisa's podcast.

[Rep. Alyssa Black (Chair)]: Doctor. Page talked about the majority of their federal grants come from research. That's right.

[Unidentified Committee Member]: I'm sorry. Go ahead. I'm just thinking we haven't mentioned governance. And I think that's I don't know, Leslie, with your point and circling back to Doctor. Merman's. Think last year was it 01/2026 when we looked at I don't know where I'm going with that. But I think we have limited spaces that we can regulate governance and good governance of health care entities. And it feels like that's where this conversation is going back to.

[Unidentified Committee Member]: I think it's important.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I don't know. I also think that when we're talking about primary care, there can be some pretty small practices out there that aren't dealing with these governance things that are struggling to try to figure out how to stay financially viable in the systems that we're in that are trying to do really good work. I mean, I guess when I I guess my mind is still sort of thinking a little bit about the measurement thing. And I think at some point, Alyssa chair Black brought this up recently, I think, to one of your one of your meetings. I don't know if I was here or if it was one I was listening to asynchronously that, you know, if you think about the time frame of when of there was a time chart up there. And I think there was some I think it was your testimony yesterday, Jessa, where you're talking about declining slightly where we started having sort of decreasing numbers of primary care physicians and physicians in Vermont, and it was sort of that implementation of the EHR. And I've been thinking about that, which is now that's when we started really measuring all this stuff and everybody's involved in reporting and documenting to get credit for the work you do. I think when And I talk with patients and I think when I think about what I want out of primary care, it's back to where we actually had someone who can integrate the information, who's a trusted advisor, who most of the time, hopefully in my health status, I don't need them, but at some points I do. And to have that touch point there. And I think that, I don't know, I guess I just think that sometimes we need to trust that the people who dedicate their lives to this work, you know, I mean, primary care medical students in medical school can look at all the different fields they're going into, and they can see the salaries. And they choose to go to primary care knowing they could make multiple times in a different field. I mean, it's not you're not, you know, sure that they could do other fields that would pay a lot more. And and some of them are the tops of their classes. Right? And they choose to do this because they really care about the work that primary care is. And so I guess, I know we set up these rubrics of measurements value based judgments. But sometimes I think if we just let the people do the job that they are dedicated and passionate about and and and, you know, left higher paying careers and careers that have more, clout within the house of medicine to do this work. I think that we should let we should facilitate them to do their work and then have some measurements. I'm not saying go without measurement, but have some measurements that are easy well, easy to obtain measurements are sometimes challenging because they're not really the ones you want. But be really, really thoughtful that we're measuring things that we really want, because whatever you measure, that's what people are gonna do. That's what they're gonna be managed to. So we just need to be super thoughtful about that. And maybe a little more hands off.

[Rep. Alyssa Black (Chair)]: I asked two pediatricians yesterday, if they were not being measured, did you counsel, and I'm assuming we're talking about teenagers here, if you did not have a checkbox that said that you counseled on tobacco cessation, you stop trying to get your teenagers to quit smoking? I mean, I obviously knew what the answer was going to be, but I can't get around this concept of the people who have dedicated their lives, years and years of training to become doctors.

[Unidentified Committee Member]: And

[Rep. Alyssa Black (Chair)]: do we think they're not going to practice to the best of their ability?

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: And I also expand that. I know there's been a lot of discussion about APPs. And the role of APPs in primary care is longstanding. And well, just be careful.

[Rep. Alyssa Black (Chair)]: I already know that.

[Rep. Leslie Goldman (Member)]: 1982, I started.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: And broad. And maybe the financial argument of people go into primary care as APPAs and MPs and APPs because the financial difference between there and neurosurgery or whatever may not be as substantial, but I also think it's hard work. And so I think there's a a dedication and a passion to go into it. So I think that, you know, it's it's it's beyond, you know, just it's the whole primary care workforce, I guess, I would say. I'm not again, I think it's important to monitor things and to keep keep an eye on things and not just not have any measurements. But, like, let's let's not have measurements that interfere with what what we're trying to get them to do. So

[Rep. Alyssa Black (Chair)]: So who's like I'm sorry. The conversation I feel

[Unidentified Committee Member]: like we're talking a lot about, should we or shouldn't we be measuring stuff? Is that really our decision or is it the decision of Medicare, Medicaid, all the payers? I don't feel like we get to

[Rep. Alyssa Black (Chair)]: make that decision at That's exactly where I was going. Who's in charge? Well, me ask another question and then that might inform better whether or not we have any role whatsoever in it. So, we are struggling in the state, as is every state, we're not alone. It's not like, oh, what's happening to primary care in Vermont? Everywhere is struggling with primary care. So, other than setting up a system where everybody just gets capitated payment, is do you see any roles? Because we know that there are structural issues and we know that there are challenges that are in place that have led us where we are. Is there anything that you think that legislature or regulators or agencies or is there anything that as a state we should be doing to try to mitigate some of the issues that we're having. And then maybe that will get more into the question of do we even have a role in measuring? Does that work?

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I guess I combine the two because I think that if you all are thinking about reforms within primary care,

[Rep. Alyssa Black (Chair)]: that

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: In our last reform of primary care and the ACO model, we chose a model that had a lot of There's a lot of specifications to go with the model and then the implementation of the model, which probably drove a lot of what we're talking about now. But if you're thinking about a way to try to deliver primary care in the sort of capitated way that's multi payer or maybe within the commercial sector, which is a pretty large percentage of the population, where you where you probably have a little bit easier time defining those measurements. I guess I would ask to think about one where you can be as you you can let it be and understand it for for what it is. I don't have any specific I mean, there's a lot of ways to think about doing this. And I think that the I think the senate was thinking about some ways. There's a lot of different ways to think about trying to do capitated payments. And there's gonna probably be a lot of work to try to figure out which ones of those are are viable.

[Unidentified Committee Member]: I think about right sizing, that's the term, or reallocating the salaries that a specialist can command versus a specialist who's a primary care provider. So you have the extra six years, you're a neurosurgeon, you save a life, that's an expensive proposition all around. Meanwhile, you have a primary care physician who's prevented strokes and all sorts of very expensive down the line care. How do you truly value the contribution and accept it so that it's a little proportional.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I mean, I wish I had that ever, because you said, how do I? Mean

[Unidentified Committee Member]: That's one. That was the system.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I think it's I'm not gonna I don't know is the short. I think there's competing factors that when we think about Vermont as a state, we do live in a national marketplace to a large degree. And so I think those that sort of national thing tends to, one, make it seem hopeless and two, make it look like it's really hard to manage. I think there's probably been some debate in this room or maybe different views about whether or not primary care needs more money or whether primary care needs to be paid differently. I think primary care definitely, in my view well, I'm going to say definitely. I think primary care needs a bigger allocation of the health care ought to support what it's doing. And I think if Yes. So that I don't think you can I mean, there's not really much space in our system to add additional money to what's going into health care? So you're probably gonna do some reallocation. Is it gonna be drastic? I don't think it's gonna be drastic. And and I think, frankly, like, you if you could make the primary care provider experience better, that I think people just love the work so much that, you know, I think you'll still be able to attract a lot of people into it. Salary discrepancy is challenging. It's not It's kind of how we value medicine in The US. And the whole RVU system and how it favors proceduralists. It's a complicated web to So

[Unidentified Committee Member]: just discussed 12%, 15% being allocated to primary care, which the overall system seems like a relatively small amount to accomplish a lot. But there are folks that are, at least for my, they're getting to be a specialist,

[Rep. Alyssa Black (Chair)]: and to have, I don't know, if it's duplication that you need, but I

[Unidentified Committee Member]: don't quite know all the metrics of what you need to really stand up various specialties. I'm just I think

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: in a health care system like Vermont, we're gonna need specialists we need a good number of specialists. Those two lines that the specialists increasing the primary care declining seems alarming. I think what I'm going speak to the specialty world, but also probably applies to primary care world is what we need is to be able to have specialists and primary care providers. They're all specialists. Being able to do what they were trained to do And making sure that if you've got a high dollar specialist, that they can actually do the work that that value that you're assigning to them is that you're getting the value out of the specialist that you want, I guess, in a sense.

[Unidentified Committee Member]: Where you

[Unidentified Committee Member]: were going a minute ago was to make

[Unidentified Committee Member]: it more attractive. They already have the passion. They already want to do it. And you're saying, well, encourage it by making it better, easier. I mean, part of that I would imagine is the strength burden to be able to counsel on the contagious cessation or whatever, but also get compensated for providing good advice. Like we were hearing testimony yesterday, I can't check that box. I'm doing the work, but I can't check that box. Yeah. Administrative burden not really felt like specialist spread. I don't really know how you make it.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: I know there was an interesting article that came out recently, and I can't remember the entire details, but there was a new code that was brought out by CMS to try to basically give primary care providers an extra pump, bump in their reimbursements to do counseling and stuff. And it turns out in the implementation of the code that it's actually most heavily used by some specialists. I think derm was called out in the paper as one of the specialties was able to operationalize this code. Part of it so the paper summary was something about how the specialist practice just have so much more bandwidth to figure out how to implement a new code than a primary care practice does.

[Rep. Leslie Goldman (Member)]: It's a private equity.

[Rep. Alyssa Black (Chair)]: There is a new code. There's a new HCPCS code that primary care can put on to basically sort of be compensated for managing the whole person as opposed to the discrete diagnoses of that one visit because they got to think about 40 other diagnosis codes when they're thinking about this one thing. That might tell me, but I think what you're talking about is that a few years ago, they revalued, they redid the RVUs around EM codes, which are sort of, they call them the bread and butter. They were office visit codes, they're the bread and butter of primary care. And they revalued them and it turned out that like 10 specialties ended up uptick on those more than primary care because they did studies where it was primary care was so busy just trying to deliver primary care that they couldn't think about up coding. It was dermatology who reaped the rewards of it. Thank you.

[Dr. Dave Merman, Emergency Physician; member, Green Mountain Care Board (speaking personally)]: Thank you. That was

[Rep. Alyssa Black (Chair)]: the rock episode, by the way, my personal favorite episode. Thanks for coming in. Appreciate it.