Vermont Legislature SmartTranscripts:

[Alyssa Black]: Good morning. Still? Good morning. It is I'm sorry. It is March 3. April 3. April 3. And quickly we're going to do a walkthrough of S-one 154, which is a bill we just received from Senate.

[Jennifer (Jen) Carbee]: Whatever want. Former Jane Carvey from the Office of Legislative Counsel. I'll put the language up on the screen. This is an act relating to health insurance coverage for biomarker testing. And this asks for a some studies and a report. So it starts out with definitions, and I will take a step back and say the bill has introduced in the senate. It would have required health insurance coverage for biomarker biomarker testing. This is taking a step back from that and looking at the cost implications first. Strike all perhaps? Is it strike? Yes. But it uses a lot of the same language. All of the definitions are the same, for example. So as used in the section, biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene drug interactions or medications being considered for use or already being administered. And biomarkers include gene mutations, characteristics of genes, and protein expression. Biomarker testing means analyzing a patient's tissue, blood, or other biospecimen for the presence of a biomarker. And the testing includes single analyte tests, multiplex panel tests, protein expression analysis, and whole exome, whole genome, and whole transcriptome sequencing. Oh, wait. What? Yeah. And I'm gonna let other people tell you what all those mean.

[Alyssa Black]: Yeah. Consensus statements.

[Jennifer (Jen) Carbee]: I won't go into the details of that right now, but these are census statements by kind of bodies of experts. Nationally recognized clinical practice guidelines, again, has a definition that we don't need to go through, I think, in detail at the moment. You can get it from the name, but it's important to the language of the bill. This directs the Department of Financial Regulation and the Agency of Human Services to analyze the costs associated with requiring health insurance coverage and Medicaid coverage, respectively, for biomarker testing for the purposes of diagnosis, treatment, appropriate management, and ongoing monitoring of a patient's disease or condition when the test is supported by medical and scientific evidence, including labeled indications for a test approved or cleared by the FDA, indicated tests for an FDA approved drug, warnings and precautions on FDA approved drug labels, CMS National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations, or nationally recognized clinical practice guidelines and consensus statement. So that's why those definitions are in there. On or before 01/15/2027, DFR would report to this committee and the Senate Committee's jurisdiction on the estimated amount that health insurance premiums would increase if Vermont were to enact legislation requiring health insurance coverage of biomarker testing, including the amounts of the state's financial obligations for defraile, the state defraile concept of premium increases for qualified health benefit plans as required under federal law and for premium increases in the state employees health benefit plan. So figure out what the likely premium increases would be if biomarker testing was covered. You'll hear, I think, from other folks about why they think biomarker testing should be covered and what value it may bring. Also by 01/15/2027, the Agency of Human Services would report to this committee and Senate Health and Lawfare on the approvals that would be needed from CMS in order for Vermont Medicaid to cover biomarker testing and the costs to the Medicaid program if Vermont were to enact legislation requiring NASH coverage. And it would take effect on tests. So this is there was a lot of interest in pursuing coverage downstairs, a lot of interest in pursuing coverage for biomarker testing. I think they heard a lot of compelling witness testimony, but there were also concerns about what the financial implications would be for the state. And so wanted to have some analysis done first.

[Alyssa Black]: We've done this multiple times around changing our benchmark plan. We'd be looking at changing our benchmark plan.

[Jennifer (Jen) Carbee]: This would be looking at

[Alyssa Black]: much of it cost?

[Jennifer (Jen) Carbee]: How what the state the frail obligation would be because the state has to pick up any premium increase attributable to a new insurance mandate for qualified health plans. Also, what the cost would be to the state employee's health plan and then what the Medicaid cost would be and whether we would get CMS approval.

[Unidentified Committee Member]: Okay.

[Jennifer (Jen) Carbee]: So, yes. And I think some of the testimony that they heard downstairs looks at at potentially avoided costs down the road, from having appropriate from having testing and appropriate diagnosis earlier, but there financial trade offs in the shorter and longer term for that too.

[Alyssa Black]: I honestly have no idea. I know that the Senate oftentimes will strip out an appropriation until the budget comes to them. Was there ever an appropriation in this bill? There was not

[Jennifer (Jen) Carbee]: an appropriation in this bill because it was just doing an right. And I would have to look.

[Leslie Goldman]: I believe there is

[Jennifer (Jen) Carbee]: a fiscal note on this. There were a few different things that were being asked for, and I don't recall as far as actuarial analysis which ones were and were not included. See, I'm looking at Nolan's fiscal note. So, yeah, so DFR did not specifically request an appropriation, but it may be necessary. I think AHS had testified, although you can hear from them, but that they could do the work under their current actuarial plan design contract. But DFR may. Okay.

[Unidentified Committee Member]: Well, first time I've seen this, okay? Haven't read

[Jennifer (Jen) Carbee]: a call. Everybody.

[Unidentified Committee Member]: Okay. So I just

[Jennifer (Jen) Carbee]: I was

[Unidentified Committee Member]: just thinking we're talking about dealing with health insurance, Medicaid and Medicare.

[Jennifer (Jen) Carbee]: Not Medicare, just health insurance.

[Unidentified Committee Member]: Not Medicare, would not be required.

[Jennifer (Jen) Carbee]: No, because we can't tell Medicare what to cover.

[Unidentified Committee Member]: So, okay. So this is a kind of like a study to get the cost of Exactly what this would

[Jennifer (Jen) Carbee]: what it is. Yes, there was interest They report to the legislature

[Alyssa Black]: K.

[Jennifer (Jen) Carbee]: In January.

[Unidentified Committee Member]: And then we determine

[Jennifer (Jen) Carbee]: And then you decide if you want

[Unidentified Committee Member]: to pursue that.

[Jennifer (Jen) Carbee]: Right. If you want to Okay. Pursue a right. If you wanna pursue legislation requiring coverage.

[Unidentified Committee Member]: K.

[Alyssa Black]: Can I have a question? Sure. Let's be cognizant then I have to Yeah, you may need to.

[Leslie Goldman]: And this covers our time. I just want to understand a little more about State to Frail and what that means. When it says that we pay for costs beyond our standard benefits. And I just don't really understand that. And that might be

[Jennifer (Jen) Carbee]: Yes. For another I'm happy to come in and talk a bit more about state to frail. One thing I cannot necessarily answer in any given situation is would the state have to pay for this under state defraudism? That is

[Alyssa Black]: would require further amounts. We can With the law of conflict. With the frail. That's behind it. Okay. I will be back. Shortest walk through ever.

[Leslie Goldman]: Just to get your next time. Into it.

[Alyssa Black]: Oh, I left the goodness. Thank you. That does not work. Okay. Are, when Jen gets out, we are going to move on to Jessica. Jessica is testifying on 01/1997, and I am turning this over to Daisy for all of about two minutes. Will be right here. Good

[Leslie Goldman]: Morning. Gears.

[Jessa Barnard]: Yes. I'll give you a minute. I have to take a Yes. I also have to take a minute and get my slides up. You should have my slides already on your website. And I will also show them.

[Alyssa Black]: Can you switch that? We can move around. Look at that.

[Jennifer (Jen) Carbee]: Oh, no. We have a we have space to set.

[Alyssa Black]: Okay.

[Jessa Barnard]: So yes, dollars 197, primary care. My goal for a little time this morning, and thank you very much for giving me time on a, I know you've heard a lot this week. It's been a long week. I am hoping to do is pull together a little bit of, make the link between some of the testimony you've heard from the amazing primary care practitioners you heard from this week with what's in 197. Why does 197 help move the ball and help make things better for primary care? Why is my organization excited about it and the members we've spoken to who are primary care practitioners excited about it? So that's what I hope to accomplish. Stop me at any time. And again, thank you for your time on a Friday. So the goals of one hundred ninety seven, I would argue, are to increase sustainability of primary care and access to primary care. And there are three main levers the bill uses, a primary care investment target, primary care payment reform, and strengthening the primary care workforce. I am excited that the bill both moves the needle on investing more in primary care and paying differently, but we're using Vermont's existing infrastructure. And I think that's why the bill maybe flies a little bit under the radar, or you may have people saying it's not doing enough, because it's not something new and big and shiny, but it is using trusted, proven tools we have to, I think, actually make really significant progress to strengthen primary care in our state. So I'll first talk about payment reform. And the first step I think of the bill as kind of doing things in steps. What the bill, I think, first does in payment paying differently for primary care is strengthening what we have. So you heard from John Saroyan, you heard from the Blueprint about these kind of what I call an add on payment for practices that meet this patient centered medical home. You've heard about the NCQA designation. When they do that, they get this extra monthly payment for each of their patients from the different payers. What the bill does in section two, it expands the definition of insurers that are contributing to that. It requires all insurers to contribute equally to Medicaid, which is currently $4.65 per person per month. And it also strengthens the role of the Blueprint executive director to adjust those contributions annually. So what does that do? Why is that in the bill? What would it actually do? There was a report, the Act 51 report from 2023, that recommended bringing all payers in to support the Blueprint. There are the payers, especially the larger employers, the third party administrator plans, the ERISA plans, who do not contribute anything to the Blueprint. I believe that this is a mechanism, the way we're defining insurers to include those plans, that we could expand which payers are contributing. There is an interesting analysis out of Massachusetts, which is looking at a similar primary care expansion program of how their program interacts with ERISA, federal law that governs those plans, and saying basically an assessment on ERISA plans is allowed. You can't tell them what to do about their benefits, but they can to they can be assessed payments. And so if the determination is that this is the assessment we need of all payers to support this program, we're not telling them what they have to do for their plan design, their benefit design, we're simply saying every insurer is assessed the same amount in our state, that we could likely do that. This means that we could increase support for primary care without increasing how much we're asking of our existing payers. So we know who Cross Blue Shield and MVP don't have money lying around. We can't necessarily ask them at this moment in time to do much more to support primary care, but could we get everyone in who's currently not contributing? So that alone could significantly increase the support primary care practices are getting. We also know that of those existing commercial payers that are contributing, and hopefully more of them, that their contributions are lower than Medicaid and is not keeping up with the cost for a practice to meet this patient centered medical home requirements. That takes a lot of You've heard the staff that requires, the time that requires to collect those measures. So our organization believes that should be more adequately supported, and this would be a way to do it. So that's step one, expanding or growing our existing patient centered medical home, what I think of as an add on payment. Remember, they're all still billing fee for service for all of the other services they're providing. Step two is, can we actually reimagine that scope? Can we go from an add on payment on top of fee for service to actually replacing what we're paying for the core primary care services? And get that to what you've heard of as a capitated payment or a per member per month that isn't just in addition to the core medical services, but actually paying for those core medical services. It would require in the bill a report by January 2027. Importantly, in my view, with input from primary care practitioners on the Comprehensive Primary Care Steering Committee and the Blueprint Executive Committee, how do we transition from this add on PMPM to actually covering what's typically a billable primary care service. We think we actually want that more input. We want time to design that correctly, but it also asks for an operational plan to implement these changes no later than 01/01/2028. We want to move the needle. We want to move towards this as quickly as possible, but we want to get it right. So again, why take this approach? Why build a fee for service replacement or a comprehensive payment off of the Blueprint model? The Blueprint already has, with the end of the ACO, really our only multi payer primary care program in Vermont. They do that. They have a methodology for how do we attribute patients, which payer are you attributed to, how do we get the money out to you? They have relationships with our primary care practices in the state. So we think it makes sense to build off rather than making something new. That was a concern we heard in the Senate with S197 as introduced is what the bill would the way the bill sounded like what it was asking for was asking for a whole new primary care payment program. Who would do that? How would we pay for it? How would we staff it? We actually have a primary care program in Vermont. We build off of that. Do think sometime makes sense to get it right. So, it's actually not as simple as just making a monthly payment. We have to decide what are those core primary care services. Does that look the same for every practice? What if this practice does x rays, dental services, lab work, but another practice doesn't? Are we paying them the same? Which things actually go in a capitated payment? Which things do we maybe want to keep fee for service? We've heard from some of our members, maybe vaccines should always stay fee for service because we actually want more of them. One thing fee for service does is it can incentivize actually doing more of something. So the things we do want to see more of and that maybe are a little more procedure based, maybe those need to stay fee for service. Or if we want to incentivize primary care to do, say, a mole removal, so they're not being sent to dermatology where it's more expensive, maybe some things we actually don't want to build into a fixed monthly payment, we want to actually give you an incentive to do more of. So I do think we need couldn't start this new program tomorrow because we don't know exactly how to do it right that will work for primary care

[Alyssa Black]: practices. Was going to say, if you'd like to a question.

[Leslie Goldman]: Okay. Thank you. I'm sorry. No, I did look like that.

[Jessa Barnard]: And why not I heard some testimony this week about rate setting. Why not just go through a rate setting approach? I think you've heard testimony that there is sort of two things primary care needs. They do need more investment and a bigger proportion of the spending, but they also want to get paid differently and be paid more globally. And a rate setting methodology is really, in my mind, still a fee for service methodology. It's just saying pay more for those fee for service items. It's not saying, how do we turn this into a capitated payment or program? And also a difference or distinction from some other proposals on the table is that it doesn't require creating a new sort of insurance type infrastructure or insurance type system. We're saying your existing insurer, whichever that may be, you may be on Medicare, Medicaid, commercial, you pay your premiums to them, you still stay covered by them. They would just be making a payment to the blueprint that would then go to a proportion of your primary care services.

[Unidentified Committee Member]: Do they up your premiums with that? I pay a monthly payment or whatever, and if they start paying this fee or whatever, will they increase my premium cost or will it come out of what I pay?

[Jessa Barnard]: So again, this is why we need some time, I think, to develop this correctly. But the goal would be this would not be just additive, that the insurer could take the proportion of the premium dollars that are already going to primary care and then submit it to this blueprint program, and that would cover those primary care services. It wouldn't be sort of double. It wouldn't be like they would be charging you to do a fee for service, and they'd be paying this amount to the Blueprint. The vision would be that they're directing the payments they would be making directly to the providers to go this other funnel. Openly.

[Unidentified Committee Member]: Yes. And

[Jessa Barnard]: that's a little bit up to the insurer too. So let me go back to the ERISA example, the large employment employer plans. We can't tell them to not offer primary care services. They design their own plan benefits. However, if they are being charged a sufficient assessment to cover primary care services, why would they also continue their fee for service program? They could make that choice, but it may not make financial sense for them to do that. Again, with the whole goal, and I think insurers really do believe, at least the ones we've been speaking to, that primary care is good for their members. They want their members getting primary care services. It saves everyone in the long run money and gets better care. So then the step three is, this we're talking about the payment that the payers are making for the primary care services going to the practices, could that cover or include patient cost sharing? So could there be a way that this model could be expanded to say patients don't have to pay out of pocket for primary care services? There are differing views of whether this is a good thing or not a good thing. I will remind folks that everybody on a state regulated plan gets three primary care visits with no cost sharing. But do we want to expand that? Do we

[Alyssa Black]: want to

[Jessa Barnard]: say primary care is a good, everybody should have access to and not pay out of pocket? We would argue that's a good thing, we don't want out of pocket costs disincentivizing people seeking primary care. It's already, in a way, embedded in the blueprint model that all patients get access to all the Blueprint programs of that practice, regardless of insurance status. They don't have co pays when they see the community health team worker. So can we envision that as the whole Blueprint payment includes that? You look like you have a question, but I

[Alyssa Black]: can keep going or stop. I don't want to go. Okay, so first of all, Eli, I got the report from Jessa, so no need for that anymore. Right before you came in,

[Leslie Goldman]: I'm like,

[Alyssa Black]: can you find me the Act 51

[Jessa Barnard]: Yes, linked to it. Yes. Linked to it. So what was the outcomes of that report? It came to this body and it is one of those reports that was delivered and is sitting. I should say, actually, what were the recommendations of the Recommendations. So I'll go back. The recommendations were to bring everybody, all payers up to the level of Medicaid? And could we explore this concept of, is there a way to bring the existing payers who contribute, so that's really MVP and Blue Cross, up to Medicaid's level. And can we, or we should look at ways to then get all commercial, including the self insured to contribute? So one of the other things

[Alyssa Black]: that we asked in the Act 51 report was should be per member per month? Or actually, we didn't ask if it should be increased, we asked what should it be increased to. And the report came back with essentially commercial payers should increase up to Medicaid, but it actually indicate that the per member per month should go up. And the reason I'm thinking about this is on your step one, two, three, I absolutely, I mean, the infrastructure that we have already with the Blueprint, the relationship with the Blueprint, with providers, absolutely blueprint. I am fully on board with blueprint being like the pass through. That's not where I'm struggling. I'm struggling with the blueprint and AHS designing the amounts, the methodology of how the amounts are arrived at. Because it, I mean, it seems to me that the very program and Medicaid would participate in this as well, the very program that actually has a financial stake in what those payments are, perhaps the financial requirements and methodologies should be developed by a different party so that they're not influenced. Does that make sense?

[Jessa Barnard]: It absolutely makes sense. I have a couple of ways of responding. One, body is actually the body that appropriates the Medicaid budget. So is certainly an element of the whole appropriations process and the politics and policies involved with setting the Medicaid budget that comes into play in terms of Medicaid's contributions to the program. I think that is so there is some language proposed in 01/1997 that requires an assessment of are those PMPMs adequate to support practices each year. I would not be opposed to strengthening that language. And there's a whole new layer now about state directed payments. So even if your body strengthened the language in terms of requiring increased contributions, that is more challenging now. I think the reality is even if it were another entity developing the methodology, you'd run into those same challenges of, well, is Medicaid then you run into the reality of what can Medicaid contribute and state directed payments. I also think the other that the blueprint has probably a better window into more of the operations and realities of primary care practices than at least currently the Green Mountain Care Board, which doesn't regulate the budgets or see the financial information or budgets or oversee FQHC's independent practices. Maybe they have some insight into hospital based primary care practices, but that's certainly not currently what they're looking at at any granular level. So it would take a whole new process infrastructure that's not something that body is doing.

[Alyssa Black]: But if we think about incorporating pieces of six, I can't remember which one. Six eighty. Six eighty and an investment, not just creating a methodology, but actually increasing the percentage of healthcare spending that we're putting towards, then doesn't it seem like the entity that does rate review, wouldn't they have more insight in the commercial space over what it would take to increase to certain levels of percentage?

[Jessa Barnard]: Would ask Yeah, I understand your question. I would ask that of the Green Mountain Care Board and AHS. I will say we've been trying, as I think I mentioned from the sideline the other day, we have been working to get language and statute for several years about setting a primary care spend target, and have often felt caught in the middle of who should be on first or who's willing to do that work. So I would just say we, as an organization, think it absolutely needs to happen. And by somebody willing to do the work, AHS and Calm talking about 01/1997 seems willing to do that work with us. We just want it to happen and think it is really important. I can get to that, that is in 01/1997 as well.

[Alyssa Black]: Allen, did you have a question? And then we'll let Jessica continue.

[Jessa Barnard]: So that is the next piece I was going to get to. How does this relate to a primary care investment target? So Section two charges the agency of human services, as came out of the Senate, with establishing a target for the amount and I'll say a little more about this of per person per month spending that should be used for primary care services. So set what the target should be and a schedule to increase that investment over time, and says those increases should be actually directed to the PMPM that we just talked about getting established. So why take this approach? You've already heard some of this background, but there was a question about where this data came from, so I wanted to link to it. This is a National Academy of Science and Engineering study on primary care, found thirty five percent of visits are to primary care, but only 5% of expenditures. I link also to the report you just heard from, because I just said yesterday, I think, about where we are in Vermont right now, about 10.2% overall. We believe we agree with the direction you were going. We should move beyond the baseline measure to actually setting a target of where we want that spend to go and reaching that target. There haven't I just want to be really clear what that target is. It's sort of an average target for what insurers are spending on primary care. It is not individual to you. So I think there were some questions like, does this mean I have to spend more on primary care? My insurer will be spending more on me for primary care? This is sort of on an aggregate level. What is that insurer? How much of their spend is going to primary care services versus other services? Other states have done this and achieved them. For example, Rhode Island and Oregon have both achieved a goal of over 12%. A slight difference from previous methodologies that this bill is recommending is actually going to a per member per month target rather than a percent of spending. And I will say why, because I think you heard a little bit, are we really comparing apples to apples in the way we've measured it in the past? A percent of overall spending is very influenced by how much that ensures their total spending. So it's a percent of the pie. And if that pie is bigger, the percent may look smaller. So if Medicare is spending a lot in our state, their percent may look lower compared So it's a little bit harder to compare plan insurer to insurer, how much is really going to primary care. So this is actually saying per person, how much do they spend? So it's a little more normalized across payers. That was a recommendation from a recent report by Maryland's healthcare commission on how they are going to start measuring primary care. They recommend starting to measure primary care investment in their state. So we also believe that it's important to have some sort of guardrails of where that investment goes, that making sure it's really ending up supporting primary care, rather than if you leave it completely open ended. Some states at least have started out that way with their targets. It's completely up to the insurer how they accomplish that or where it goes. That's a little harder to know, is this really ending up supporting what we want it to do? Whereas if we say this is going to this payment program we are establishing, we know it's getting in the hands of primary care to deliver primary care services. So then there's some other reports that I just want to link back to what we're saying. There's a section saying that the report should use it gives some guidance on what definition to use. You heard the healthcare advocate say, I have a little different view. Thought that was a very painful process. There were a lot of meetings, I will admit that, of how should Vermont define primary care. So rather than rehashing definitions, there's been work done both regionally and nationally on this issue of primary care spend target. Let's pick a definition so we can compare to other states or nationally what definition it is. If we are doing the AHEAD model, they already have some guidance around how to establish that, that in fact, require states to set and meet the primary care investment targets.

[Leslie Goldman]: This is just a timing question. We keep referring to if we do AHEAD. So do we know when we'll know if we are doing ahead? Because I feel a little unstable about it.

[Jessa Barnard]: I am right there with you. I do not have an answer.

[Leslie Goldman]: Don't know. Okay, we keep saying if, but maybe we should

[Jessa Barnard]: We should know. Well, I mean

[Leslie Goldman]: Or no or something.

[Jessa Barnard]: Don't Right. And it would be to start by 2028. So I assume those conversations would need to be going mean, I I know there have been conversations. I don't know the latest on where they are or how optimistic they are feeling.

[Leslie Goldman]: I just feel frustrated by the idea of we're gonna do all this work dependent on maybe we're gonna do ahead and then we don't, and then it's all been for not.

[Jessa Barnard]: I agree. That is why our organization is not willing to just wait to see what primary care payment looks like if we're in a head or not. I think we have consciously tried to craft 197 where it could work with a head, but it is not dependent on it.

[Leslie Goldman]: That would be what I'd like to understand, how it separates. What's dependent on a HEAD? What would go standalone, I guess?

[Jessa Barnard]: The only thing dependent on a HEAD would be would Medicare participate with us. Medicaid, the commercial, all that work, the blueprint would all still exist. Medicare, CMS had said they're willing to keep funding their contributions for their Medicare folks if we are in AHEAD. I don't know what happens if we're not in AHEAD. Would CMS still be willing to make a contribution for Medicare covered?

[Leslie Goldman]: Okay, well, that's helpful. At least it's just that one

[Jessa Barnard]: population. That's my take on it. Which

[Alyssa Black]: is like all of the state of

[Jessa Barnard]: It's a growing percentage of of We really want them in. They make a very meaningful contribution to the blueprint. And I think you've had this conversation around the budget. They're actually not contributing for 2027. Do I have my numbers right? Because we're sort of in this year where we're not actually in ahead yet. So the state has sort of filled some of that, what Medicare's contribution would have been.

[Leslie Goldman]: And does any of this have to do with transformation or nothing? There

[Jessa Barnard]: are dollars in the RHTE grant or proposal to also work on strengthening the blueprint. I think it is very well aligned, but I am not sure. But I would encourage you to get more information from AHS around that. I don't yet have a lot of clarity on exactly what that blueprint investment would look like from RHTP, but that is a bucket that is earmarked in there, which is fantastic. Okay.

[Leslie Goldman]: So it's like removing cart. Well, there's this bill, there's a head, and there's RHTP.

[Jessa Barnard]: My view, but feel free to ask others, is they all could work together. They're not contradictory or conflicting. They could complement each other.

[Alyssa Black]: You'd be curious to know how that works.

[Jessa Barnard]: And they don't rely on each other.

[Leslie Goldman]: I'd be curious.

[Brian Cina]: I don't remember if the Rural Health Transformation Grant is allowed to be used for studying things. Do remember? Does anyone remember?

[Jessa Barnard]: I don't recall an explicit prohibition on that. I don't think so. So I think there could be some opportunity.

[Brian Cina]: Think of the AHS question. And the reason I ask is because I'm just thinking, how do we use what we have while we have it? I know that that's one time money, or it's one time money over a period of time. So we can't rely on that to maintain a system, but if we could use that money to study how to restructure the system and finance it better, that would be great. While I'm talking, I wanted to just comment to that. I was listening remotely, and we talked the other day about this idea, but it's exciting to hear that we might be able to use the blueprint, build on it, to expand access to primary care. I mean, sounds like it could potentially be used to provide it as more of a basic public good based on what I'm hearing, and that's exciting that it's possible. I think I'm curious to see the rest of what you have to say, though.

[Jessa Barnard]: I I think I'm almost done. I it's one time. Yeah, actually, that was my only last slide. Nothing new to your committee. I will just say the bill also includes the striking the sunset on the medical student incentive scholarship program. A difference from six eighty is introduced here versus 197 is six eighty did include significant more investments in loan repayment and other workforce programs. You have already added money in the budget. Thank you to your committee and the House on loan repayment. We also think that's a really important component. It's not in this bill. We were being careful not to want to slow down progress by attaching a lot of appropriations to this bill. But the language strike is in the bill. So that's where I was that is my last slide. Oh, I did want to just mention there are some other studies in the bill. You may come back to them at a later date. We are fairly neutral. Those were not sort of our proposals. I think they're fine. They're studying the clinician landscape and site neutral billing, transitioning more care to community settings, regional universal primary care. Guess I would just caution, not caution. Perspective is that the other components of the bill, we really wanna see that work happen. We wanna see a lot of effort go into getting that right and moving the needle. So just when you're thinking of the number of studies and reports, our suggestion would be to really focus on the core primary care sections of the bill. But we have no problem with them in there, they're fine.

[Brian Cina]: Yeah, I'm just curious about the relevance of studying regional, the rest of primary care when we may be able to It may not be the exact vision of other bills that are out there, but we may be able to establish some kind of universal primary care through the blueprint. So I'm just wondering if, and I just have an opinion, you said you're neutral, but if it might be better to ask the treasurer to look at regional universal health care. How do we work with the surrounding states to move to not just be limited to primary care? And I don't know if that would exceed the scope of the bill too much to having I look mean, maybe it's just that we say, look at universal primary care and how to expand on that and work with other states to fulfill our state's I don't know, what is it, principles of health care reform, whatever they're called, that are in statute from Act 48? Anyway, I don't know if you have any

[Jessa Barnard]: I thoughts have about limited insights, I would say, to these sections of the bill. The Senate, I don't think I missed much testimony, did not really have much testimony on those studies or the intent behind them. I don't believe the treasurer's office testified, so I'm not really sure the motivation for that section. But again, I think we have had studies of both universal primary care and regional insurance models. They tend to run into implementation challenges. So whether that's what you wanna look at, or if you have other ideas of what might be more productive or informative for really realistic next steps.

[Alyssa Black]: Leslie, so I'm looking at

[Leslie Goldman]: this rural health transformation money thing. I'm seeing $30,000,000 if I got that right, going towards blueprint primary care practices meeting access requirements. That's one of them. I'm wondering if we should get a testimony on it or I'm just wondering, I'm just seeing this puzzle and wondering how it all fits together. We are going

[Alyssa Black]: to hear from AHS and your thoughts around that

[Leslie Goldman]: and its bill. Would the

[Alyssa Black]: concept of that bill and other bills and how they may help other. Thank you. You didn't speak to, am I conflating bills? You didn't speak to any of the sort of quality measures, the, you know, we've had discussion around this.

[Jessa Barnard]: So what the bill Sorry, not to make people dizzy here, but the bill does talk about that a bit in when we are asking for the blueprint and primary care practitioners to design this expanded or reimagined PCMH payment to also give input on what should be agreed upon quality measures be. Because I heard the testimony, I completely agree with Streamer. And I will say there are some other, I didn't really go into it. There is the section in the bill, I think Jen pointed out, that actually gives the blueprint more flexibility. Because right now, statute says you can only be a patient centered medical home if you meet NCQA requirements. I believe the way the language, and I know Jenna had to sneak out, says, or other quality measures. So I think it actually does at least allow some more flexibility.

[Alyssa Black]: Can I ask you about, I mean as I'm reading this bill and I'm thinking about, first of all, who would this affect? Medicaid, UHP market, essentially our regulated market.

[Jessa Barnard]: We hope it can go beyond that.

[Alyssa Black]: We hope it can go to ERISA, but we're not sure. It won't go to Medicare, unless we somehow incorporate it into a hedge. And I'm just thinking about this from a practical standpoint of you know, a day in the life of a provider is you have disparate insured patients throughout your panel and you've got different payment methodologies for different members. I'm wondering if you see, I mean, this is kind of the problem we have with Blueprint right now. Everybody gets services that are offered through the Blueprint. They're all free. I mean, well, they're non billable. They're not

[Leslie Goldman]: free, but they're free to the patient.

[Alyssa Black]: They're free to the patient. And it doesn't matter if your insurer is putting money into that blueprint. Those patients are getting the same services, and they're eligible for them, which means that some insurers are subsidizing other insurers. How do we make this? Because I know on the ground providers are not going to sit there and say, oh, I'm going to call in this patient's medication because I can't get here. Oh, but they have this insurance and that's fee for service. So I need to make them come in because that's not going happen. I'm worried that participation and this sort of capitated payment participation is going to start subsidizing the fee for service model, which everybody will get sort of the reimagined way a practice will work without actually paying for it? I don't have

[Jessa Barnard]: the answer to that today. I do know there are conversations going on between AHS and BFR and Blue Cross. So I would encourage your help to test out how we really can or how accomplishable it is to get the ERISA plans in. I agree with it. It's certainly an issue from the practice perspective of having a few new different types of payments are great, but if they only affect ten percent of your patient population, it actually could end up being harder. We want everybody in. I am cautiously optimistic this is actually a way to start accomplishing that. But there are others who are more expert on ERISA law than I am.

[Alyssa Black]: I see Brian and Leslie. I just wanted to I know it's And I'm thinking back to some of the testimony that we got the other day around One Care. I think it was the pediatricians that we had, And I was sort of chuckling a little bit to myself when one of them said that you never knew you just got money, but you didn't actually know what it was. And that sometimes the administration of different payment methodology I mean, to me, the beauty of this is it streamlines your payments. But if you're still having to continue all these sort of administrative billing things for half your patients, but not the other half, you're not really seeing that sort of administrative saving piece to it. Brian and then Leslie.

[Brian Cina]: So I wrote it in highlighter, it might take a second. Okay. So the first question is, are you aware of any other example of a universal fee that we're charging payers? Like, I know we have provider taxes for certain classes of providers. Are there any other universal payer fee that every single payer that operates in the state is charged?

[Jessa Barnard]: There is the claims tax.

[Brian Cina]: Medicare pays that too?

[Jessa Barnard]: I don't believe Medicare does, and actually that is something that is mentioned in the Act 51 report, is could that be a mechanism of assessing all Claims tax. Claims tax.

[Brian Cina]: And that's why I asked this, because there may be an existing mechanism, or we can create a new mechanism like that, like a primary care tax or something, I don't know what we would call it, or fee. The other thing is that whether we require I think there's a question, can we require these ERISA plans to pay a fee or not? Do we currently do that with the claims tax?

[Alyssa Black]: Yes.

[Brian Cina]: Okay, so we know we can do it with a claims tax, but whether we can do it or not, if we had a fee that they paid that delivered a good that was worth it, I bet there'd be companies who were like, oh, we'll pay for that fee in Vermont, because when we pay that fee in Vermont, it allows us to lower our premiums in Vermont because it's delivering so much, you know? Or maybe they don't lower their premiums, but it stabilizes their premiums over time if it was delivering enough of a public good. It sounds like we haven't decided yet how it would work, but it's possible that it could be that there's some basic services that everyone gets, and then when you go above that, there's cost sharing. There could be ways that it's structured. I guess the question I was really asking though, you answered, which was the claims tax thing, and so that's helpful to know that there's already a mechanism that is applicable to ERISA plans.

[Jessa Barnard]: I believe, yes, I think so. JFO and others are more of the expert on the claims tax.

[Alyssa Black]: That's only how stop loss one of these dates. Go ahead, Leslie.

[Leslie Goldman]: Yeah, on these ERISA, what's the mechanism or the pathway to get that to happen? And is that clearly

[Jessa Barnard]: It is authorized in this bill

[Leslie Goldman]: because the Could you point to that, Perkin?

[Jessa Barnard]: Because the agency of human services is already authorized to assess insurers for the blueprint. That is in it is the existing statute that starts on page one to so it's really the it's pages one through two. We're on page one. We're defining. This is all existing statute around setting up the blueprint, who a health insurer or what a health insurer is. And you'll see right between pages one to two is where they're expanding that to say, offering or renewing a health insurance plan. And to the extent permitted under federal law, third party administrators administer a health

[Leslie Goldman]: insurance I had a question mark there. So that's helpful. That's to

[Jessa Barnard]: try to get in. So you're the Blue Cross, that's part of the ERISA plans. Right. Those are the ones where it's like, they're maybe a local insurer administering it, but it's not their their self it's an employer who's self insured. And then you will and and so then on page two, the top of page two is where it says health insurers have to participate, basically. So health insurers shall participate as a condition of doing business in this state. And so if we are changing And

[Leslie Goldman]: what line is that?

[Jessa Barnard]: That is the 12 through 14

[Alyssa Black]: of page two. I

[Leslie Goldman]: think I might be in a different version. Oh, I'm sorry. Because I don't

[Alyssa Black]: have SBAS. Oh, I'm sorry. I'm looking at the SBAS. Yeah, that's okay.

[Leslie Goldman]: Yeah, sorry. So it's in

[Jessa Barnard]: the section on health insurer, section seven zero six of existing law, where it's saying that there's already So Blueprint's already doing this assessment. They're already getting payments from the payers that they are currently assessing. And then down at the end is where they can appeal it to the Secretary of Human Services. So there's sort of an appeal mechanism.

[Alyssa Black]: You see a time where practices will start selling subscriptions? I'm thinking about, like, what's to stop an employer right now who only has a couple employees, they can't afford to provide health insurance. So they're not mandated to because they don't. But you could essentially pay a primary care physician to the same amount just to take care of that one employee, at least with the most basic

[Brian Cina]: care. Isn't that concierge? Isn't that what that is?

[Alyssa Black]: Right, could

[Jessa Barnard]: you see an employer paying your primary care subscription fee?

[Alyssa Black]: But I'm also seeing more of a hybrid model for practices where yes, they are commercial and everything, but also at the same time, they've got more of a direct primary care feeding into it or it can be half concierge, half

[Jessa Barnard]: I think you tend to get into It's hard to be half and half, I believe, because of existing insurance contracts. So many will say, like, if you're participating in certain insurance contracts, they will say you can't take a fee above what we pay you. So you couldn't take a subscription fee above this. You know, it just is a little bit No.

[Alyssa Black]: No. I'm thinking about, like, uninsured. Yeah. I mean, I get essentially, it would be like a self pay Mhmm. Subscription.

[Brian Cina]: It could be good with health sharing.

[Alyssa Black]: Anyway, we should probably If

[Jessa Barnard]: I run well into your lunchtime, I apologize.

[Alyssa Black]: Apologize. Is good. Go ahead. I just have to just break up an analogy to make that we're building up an infrastructure of primary care here, and we do that with our roads too, and we require everybody to pay. I just don't know why Arissa, which I happen to be a part of, would not contribute to this infrastructure that we're desperately trying to save. Well, thank you. Is there a way to quantify,

[Leslie Goldman]: I don't know if there's a way to quantify how much care is being given to non blueprint patients. A practice do that? We don't want more work for them, but at least as part of our reporting, understand what's being given away.

[Jessa Barnard]: The Blueprint, yes, it's in the Blueprint annual report how many of encounters with community health team members are with which types of plans. So they are tracking that. Because the insurer, the existing insurers who pay want to know that too. Blue Cross wants to know, okay, we're contributing to the Blueprint. What are we getting for that? So that is in their report.

[Alyssa Black]: That's great.

[Jessa Barnard]: Thanks, Kathy. Thank you very

[Alyssa Black]: much.

[Jessa Barnard]: Thanks for your time and attention.