Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black, Chair]: Hi, Alex. Hi. Well, first we have Alex and Addy, and Addy's gonna and Alex, they're gonna we wanted to get an update. They were running a little late today. We wanted to get an update on the exchange because I know that's something that we're kind of watching every single month. And I really just wanted to get a read on what's happening with enrollments on the exchange. No, not at all.

[Alex McCracken, Director of Communications and Legislative Affairs, Veeva]: Absolutely. Thank you, Madam Chair and members of the committee. It's wonderful to see all of you again. My name is Alex McCracken. She, her pronouns, Director of Communications and Legislative Affairs for Veeva, and I'm going to immediately pass it off to Addy because she does have a prior obligation that she's rushing to meet, so wanna make sure that she can give you all the details that she can. And if there are follow-up questions or additional discussions, I'm happy to answer what I can and take back follow ups as well.

[Rep. Alyssa Black, Chair]: Great, thank you. Thanks, Abby.

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Great. Hi everyone, Addison Stremolo, she, her pronouns. I'm the deputy commissioner at the Department of Vermont Health Access. It's nice to see you all. Yeah, I'm happy to kind of keep this informal and brief if that's okay. We did send the coverage map, which is what we publish quarterly, which has a large amount of detail about our enrollment levels on the exchange. So I think I spoke to you all toward the end of open enrollment and gave you the big picture readout, which is that our enrollment did decrease over the course of open enrollment expected and largely due to the expiration of the enhanced subsidies. I think we can say that with some certainty because the high level of terminations that we were seeing was mostly at the over 400% of FPL level in terms of income, and that's the population that is no longer eligible for subsidies under federal law. So the big trend is this decrease, and then consequently, our subsidized percentage of overall enrollment has also decreased. It used to be up in the 90s. It's now around 80%. And this is all kind of clear on that coverage map that we posted. We will post the next one later this month when we have all the data from the issuers. The trend is continuing. Again, I would say as expected, people have a grace period during the first quarter of the plan year to pay their premium. So I think those who are facing that kind of rate shock may have made a decision, you know, not to pay and not to see it through. I think our total enrollment number is going to come in around 29,000, which is another decrease of about a thousand enrollees as of April 1. And we're seeing the same trend in terms of disenrollment levels by income. Interestingly, most of the disenrollments are customer driven, so they track in our system as quote unquote voluntary terminations, but I think as opposed to non payment terminations, but I'm sure that the premium amounts are kind of driving those decisions that customers are making. So we will get that analysis posted again later this month. There's a lot of detail that we would be happy to go through with you all if you would find it helpful, but those are the overall trends. I think that's probably the shortest version of what I can share today, but happy to take questions.

[Rep. Alyssa Black, Chair]: I'm just going by memory and if we continue to be wrong, so please correct me if I am wrong, but under the ACA, wasn't it that you ninety days before you could be disenrolled for non payment. So we passed that. Do we know numbers on just people who were disenrolled from not paying their first ninety days?

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Yeah, so that's that, generally speaking, that's the April 1 kind of deadline, and that's where it is interesting and we're still processing this data, but we saw an overall decrease. The larger percentage of the disenrollments are, again, tracked in our system as voluntary as opposed to nonpayment. So I think people made decisions before they reached the end of their grace period to go ahead and drop. But that will all be reflected in the April data that you see later this month. So we have passed that federally mandated grace period for subsidized coverage for people who were facing their premium increase as of January.

[Rep. Alyssa Black, Chair]: Okay. And how about the shift in metal levels?

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Yeah, still seeing this general trend of people quote unquote buying down, so buying into bronze plans. As I think I spoke to you all about earlier in the session, we had a really big shift in the opposite direction last year, both during open enrollment and beyond. So showing that many more people enrolled in gold plans basically during 2025, and that the lingering effect of that shift makes the shift into bronze plans for this year a little bit less pronounced, but it's definitely clear in the data that that is what people are choosing brand plans at a higher rate than they have in the past on the exchange.

[Rep. Alyssa Black, Chair]: I know what happened last year, which again, great work getting people off of silver into gold. Nice to see it here on the graph,

[Dr. John Saroyan, Executive Director, Blueprint for Health]: a

[Rep. Alyssa Black, Chair]: really big jump in that. So do you have any updates for us? I mean, do you have any updates around what the federal government is doing around silver loading? Thanks for

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: the question. I think this maybe had just happened last time I was with you all, but they have proposed a rule that appears to be intended to limit silver loading within states and especially in the kind of way that we have done it here in Vermont, is a pretty robust rate increase on the silver plans. That rule is expected to be finalized later this month, and I think it'll take an interpretation by the Green Mountain Care Board and the rest of the stakeholders within the state to see if we feel like we can continue with the same strategy or not in light of that federal change.

[Rep. Alyssa Black, Chair]: Any questions? I feel like I'm going to need to look at the charts before I'm able to actually formulate questions. So, I hope that if I have questions later that I'll just forward them to you. Yeah, go ahead, Lori.

[Rep. Lori Houghton, Member]: And I apologize. I, again, meant to be on time. And so if you talked about this, that's fine. But I'm just curious how things are now with all that is going on, how morale is, how everyone at Diva is functioning. Just kinda like I know things that we keep saying every year is gonna get easier, it never gets easier for for your group.

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Thank you, representative. I think that we weathered the storm of open enrollment, which we knew was gonna be really, really challenging and was, and there were kind of aftereffects definitely. We are almost completely now focused on the Medicaid changes in our department, so working really hard on getting all of those federal changes to Medicaid eligibility put in place, which have to go live this fall and for January 2027. So I think everyone's just got their heads down and is doing the work. It's a huge amount of work. It's different work than we expected to be doing this year. But I think that's kind of, you know, the overall theme is just we're getting a lot thrown at us. Vermonters are getting a lot thrown at them, and we're, you know, just trying to react and implement in a way that is gonna have the best outcome for our state. So that's that's where we're focused.

[Rep. Lori Houghton, Member]: Thank you for that.

[Rep. Alyssa Black, Chair]: Daisy has a question, but really quickly, can you remind us when the automatic enrollment in the individual in the exchange ends where people have to actually reenroll?

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Yeah, the pre enrollment verification requirement,

[Rep. Beth (full name not identified)]: which

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: is what they're calling it from HR1 goes into effect for plan year 2028. So we're working on that next year for open enrollment that takes place in the 2027.

[Rep. Alyssa Black, Chair]: Great. Another storm for you to look forward to.

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: And Madam Chair, I wanted to just say that we gave you more information than you asked for with this coverage map. I just thought it might be helpful to remind you all that we do this on a quarterly basis and try to make sure it's available to see kind of the overall landscape of enrollment in the state and very happy to take any follow-up questions you have on it.

[Rep. Alyssa Black, Chair]: Great. Daisy,

[Rep. Lori Houghton, Member]: Lori's question prompted me to wonder about your staff and how staffed up are you to do this work right now? I'm curious if the return to commuting has had any impact on your team.

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Well, I think we've said I'm not sure I can speak to the causal connection, but we definitely have a higher vacancy rate than usual. We but we also know that the work itself is increasing because of these federal changes. And so we are we did a whole kind of projection about what additional staff we think we need in addition to having, you know, the full slate of our current staff filled. And so that I know you all have considered as part of the governor's recommended budget, but we are asking for additional positions to supplement our eligibility workforce and get this work done. So that's definitely an area of focus also.

[Rep. Alyssa Black, Chair]: Right. Thank you. Thanks for joining us. Appreciate the updates.

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: Thank you very much. Bye bye.

[Rep. Alyssa Black, Chair]: Thank you. Alright. Switching back to S197 Doctor. Sorayaan, Doctor. Jones in with us. A little bit more around specifically the blueprint as it pertains to S197. Did obviously have you with Doctor. Soren last week and just sort of a general overview of the blueprint.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Good morning. Good morning. This is Gruffaun from Peppark, Vermont in Windsor. I live in Norwich, and daily presence there. Good to see you all. Good morning. Good morning. Oh, I'll sign in Is

[Rep. Alyssa Black, Chair]: Ara joining us, by the way?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Unfortunately, need to. So yes, talked, was updated with agenda. Thank you for asking. You want to introduce yourself, because some of them may not

[Addison (Addy) Stremolo, Deputy Commissioner, Department of Vermont Health Access]: know you.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: I'm just getting my slides together.

[Rep. Alyssa Black, Chair]: I'm not sure you've been in person in our room.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: No, it's been a long time, well not for many years. Many years. So I'm Craig Jones, I'm a contractor helping DHS with their healthcare routine work including care transformation and Blueprint primary care transformation and at one point I was the executive director of the blueprint from 2007 through 2016 and from then till now have been working on national primary care models supporting centers of Medicare and Medicaid Innovation. So it's good to be back actually.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: It's great.

[Rep. Alyssa Black, Chair]: 2007, the program began

[Dr. John Saroyan, Executive Director, Blueprint for Health]: in It actually started

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: a couple of years earlier. Governor Douglas started, I think February was the first. Then they had some real, really good legislation outlined exceptional vision. And that's honestly what recruited me here to Vermont. So in 2007 is when we really started working on the advanced primary care, their community health team model, launched some pilots and in 2010 we were able to get the White House to get Medicare to join and that's when we went state by. Thank you.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Good morning, I introduced myself last time. I'm John Storan, the executive director for the Blueprint for Health. Happy to have Doctor. Jones with us, both pediatricians, both from California, long story. So S197, an act relating to payment reform for primary care. Slides. So how does S197 strengthen the blueprint's ability to strengthen primary care? It reduces administrative burden on providers. It increases payments to providers. It opens the door for quality standards other than the National Committee for Quality Assurance, which we spoke about last week. It concretizes the necessity of achieving payment contribution parity across payers, and it establishes a target amount for per person per month spending for primary care services and requires a transitional schedule for that to increase over time. It raises the per member per month payments. Per member per month payments find essential activities, including care coordination, chronic disease management, proactive patient outreach, improved access that could include in the future using eConsults with specialists, and many activities that occur outside of the office visit that the provider provides to provide that whole level of team based and holistic care. We have heard from Blue Cross Blue Shield, and I'm meeting with them for the third time at 1PM this afternoon. Have the strongest alignment in terms of directionality and adherence to the same principles around finding common ground for payment, measurement, and care delivery to strengthen primary care while maintaining affordability. And we agree with national recommendations that have come down from a number of different organizations stating that per member, per month payments must be meaningful to sustain the model. I know Chair Lyons was up here. I know that you all have heard about other presentations with the per member per month really being in the $18 to $22 range in terms of a per member per month that's robust and meaningful.

[Rep. Alyssa Black, Chair]: You had in 2025, I believe, in your Blueprint annual report, we had tasked the Blueprint with looking at the per member per month, the direct payment, not for the CHT, but for the provider payment. And you had recommended that commercial payers come up to the same per member per month that Medicaid uses. I'm actually not clear on does the blueprint or AHS have the ability within the blueprint to mandate what commercial payers are going to pay or can you just make recommendations?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Great question. Thank you, Chair Black. The way I've read the statute and the way others have read the statute at AHS is that the authority is there, but it could be strengthened.

[Rep. Alyssa Black, Chair]: Okay. So you chose to make a recommendation rather than just say you will pay. That's correct.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: That was also, well, this is just, if I can confirm, this is the blueprint for report on payments to patients in our medical in accordance with act 21, 2023. We released it January 2024. So at that time, yes, those are the recommendations we made. Did they do that? The commercial insurers? So no. What's new, I think, since then is that the all payer model has ended. The CPR payments from the ACO have ended. And there's new leadership with new willingness to really engage in very meaningful ways right now to align better for the good of Vermonters, for the good of providers, and to look at our similarities rather than our differences.

[Rep. Alyssa Black, Chair]: Thanks. Oh, I'm sorry. Go ahead, Beth.

[Rep. Beth (full name not identified)]: Just a quick this is what you want to do in the future? Up at the top, right now, you do not cover e consults or the outside activities?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: So the e consults are future state, word or the verbiage before that is current state, and it needs to be raised. The support for those activities needs to be increased. We do it. It's become less financially potent than it was. It needs to be increased. But we do do it. It just needs to be supported to a more meaningful level.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Those principles, it's a really, really important question. Those principles have always been part of the blueprint structure. It's why you have a combination of community health teams with payments to practices that was purposely invested into support these kinds of operations. Now, when things like e consoles, the technologies changed and there are RHTT, rural fund initiatives that can help bring that to scale even for smaller practices if they choose to use it. But the payments haven't kept up with what it takes to really fully operate with an advanced as an So advanced primary care it's intriguing, we use the concept of PMPM here throughout. Everybody talks about a per person per month payment. As John said, has to be meaningful, meaning substantive enough that I can go hire the people I need to run an advanced primary care practice, but it isn't just one payment, the national approach to structuring these payments is a per person per month, they call it a capacity payment. So you actually have the capacity to offer to do these things and do them well. There are other components in these hybrid payment models. There's components around a little bit of an encounter payment too, so that you have an incentive to continue to keep your volume at a good level. And then there's a performance component where you tie it to the measures. And so there's a hybrid payment structure. Blue Cross Blue Shield is highly aligned on this. And so for at least the first time I remember, we're probably as close as can be in structuring a really rational primary care payment, they'll honestly bring this back up to the national leader again, which is critical. So it's a good question. It's yes, they pay for it, but not adequately.

[Rep. Alyssa Black, Chair]: I didn't, but again, you read my I didn't raise my hand, but I absolutely had a question. I need to make an appointment with an optometrist. I've never had peripheral vision lately.

[Rep. Lori Houghton, Member]: I'm having I just have yesterday, we heard from the state auditor, deputy state auditor maybe, about the 2025 audit of Blueprint. And I'm a bit distracted by reflecting on that and trying to focus on this. I wonder if you could take a moment to speak to whether you've reviewed that report and Sure. Your thoughts

[Dr. John Saroyan, Executive Director, Blueprint for Health]: on Thank you. Thank you, absolutely. Sure. We worked very closely with the state auditor office from their initial questions in December 2023 to their report being released in February 2025. We were very engaged with their auditors and very appreciative of the really critical and detailed look that they gave over our annual reports, over other publications that we produced. They really helped us to be stronger. We spent pretty much all well, not quite all the calendar year, but two thirds of the calendar year last year developing our strategic plan, mission, vision, values, which has been wonderful. It was very engaging with our executive committee, which represented Houghton is on. We got the steering committee, but just kind of at the tail end of that. They helped us with some of our communications too, to really what is a nonscientific, nonphysician sort of audience. This might not be read the way you're intending it to. You need to put guardrails on how you're communicating in your Blueprint annual report of what this meaning is. And I could go through that specifically with you all or send examples. Think they mentioned just the strength of the annual report in 2025 when we get to some of the graphs at the end, what this is, what this doesn't mean, what we're aiming for, what next steps we're gonna take to improve it. They were instrumental in in really helping us do that. And they they just looked at our communications very carefully. Any changes that I could make immediately, I absolutely made immediately as well. So I think we benefited greatly from the state auditor's report and are stronger for it. It was an excellent opportunity. Absolutely, we were all very, very engaged during that whole time. Now I did get back to them with our one year report in terms of progress, and I am waiting to hear their kind of official sort of assessment back to me, and I'm happy to share that with you all if you'd like to see it, if you wanna follow along, however, but we very much benefited from their input.

[Rep. Lori Houghton, Member]: Excellent. I'm so glad to hear that.

[Rep. Alyssa Black, Chair]: Sure. Yeah. And they did tell us they were working on that and it should be

[Dr. John Saroyan, Executive Director, Blueprint for Health]: out soon. Okay. Yeah, there was some reference that was made to sort of an acronym I didn't know or some oversight that I wasn't familiar with.

[Rep. Alyssa Black, Chair]: Awesome. I'm wondering if Okay, so this one slide that you have here, you're talking about improved access to eConsults and coordination with specialists. So is your PMPM payment to primary care, to incentivize primary care, to improve access to those things?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Or is

[Rep. Alyssa Black, Chair]: your PMPM to e consult consultants and specialists to incentivize them to

[Dr. John Saroyan, Executive Director, Blueprint for Health]: work with primary care? Great question, We're thank in the design phase right now. I just called three meetings at the April and we'll be leading meetings that speak to our clinical aspects of these new innovations for us, very similar to groups that I convened when we received the appropriation for mental health integration. So this is all very much in the design phase. Did you want to add some? Sure. Just to kind of match up to national standards?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Yeah, it's a good question. So the PMPM that goes to a practice, that is really intended, as I mentioned, to give them the chance to hire the people they need to operate this way. So who are the dedicated people to pull up the panel reports to do care management every day? Can you hire the people and have the capacity? The e consult, the payment is envisioned and what's being talked about right now is actually tiering that fee on PM based on the degree that the scope of services that you're offering. So those that have formal agreements with specialists to do e consults for an example, may actually enter into a higher tier of service than those that don't. You build in the PMPM tiering based on the fullness and the capabilities and the services they offer, so that you always have an incentive to do that. And then lastly, there's financial obstacles to just sometimes getting the technology in place, even if you can hire people. And that's where the advantage of the short term rural health funding comes in, because it allows you to maybe add the module and the capability to your EHR, so you can have eConsult interaction with whether it's Dartmouth or UVM or whoever the tertiary provider may be. And so now you have a payment structure which makes it possible and gives you an incentive to do it. And then you have the initial upfront investment in the technology so that you can bring those two things together and operate the practice in a different way. That's really, there's a systemness to it. It really means thinking about all the different changes and levers that are underway right now.

[Rep. Alyssa Black, Chair]: I'm gonna just ask a follow-up and then I see Val has a question. You said that the PMPM payment allows providers to hire, have people to do these things that are, you know, like chronic disease management or care coordination. Has there been, I guess, I don't know, surveys or has there been data collected directly from practices on the costs associated and whether or not the PMPM or whatever mechanism is covering those. So

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: as John said, it's a great question. As John said, we're really in the design phase of this with Blue Cross. There are national benchmarks about the level of investment that needs to finally honestly be made in primary care in order to allow them to operate the way it's envisioned. I don't think we've sampled directly, but that's part of the discovery work you do with people. Well, a lot

[Rep. Alyssa Black, Chair]: of these are requirements now.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: They are, they're underfunded. Got it. Sure, go ahead. No, it's okay. I'll prioritize your question. Sorry, just, I had a story to that's okay. I could tell a story wrong.

[Rep. Lori Houghton, Member]: Go ahead, Steph. Well, I'm sorry,

[Rep. Beth (full name not identified)]: I apologize if you already answered this. I'm just curious, So I don't go to the doctor a lot.

[Rep. Lori Houghton, Member]: I'm thankful that I'm healthy at

[Rep. Beth (full name not identified)]: the moment. So I might go every couple of years. Is there a window that you, when you're looking at the panel, that you actually count? That's great question. Like who is on the panel?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: For our attribution, which Blueprint's methodology is used by Blue Cross Blue Shield also, that's a very formal term for figuring out how many per member per month, how many members there are in the per member per month. That attribution is a look back of two years. Now, a practice, to my knowledge, would make their own decisions about how far they would look back before they'd seen someone in terms of their practice. And I can follow-up with you to find out if there's standards for that. Does that help get it to some of your question a little? Okay.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: And a piece to that, too, there is the look back period. And so you want to fairly count the people who are getting their care into practice, even if they haven't needed any in a recent period of time. That's one thing. And that attribution, as John says, that drives the payment to the practice. But on the other side, there's also the incentive to get people in for what's called recommended and preventive care. So there you can, and that's part of this care management where you proactively, if it's an annual wellness visit that a certain age group is supposed to have, what's recommended for people in terms of screenings, assessments to be done either annually or within a certain period of time. That's part of the incentive structure in that PMPM. How well do you do on measures of recommended and preventive care in your practice? So there's both a look back to make sure that you give sufficient capacity in payment. Then there's also a performance component of what we're saying out of your thousand patients, how

[Dr. John Saroyan, Executive Director, Blueprint for Health]: many of them have recommended preventative care? And there are for age groups, absolutely recommendations. I'm a very literal person. I was actually thinking of you specifically, but for age groups, in infancy and adolescence, there's very specific. Ahead.

[Rep. Alyssa Black, Chair]: Can I follow-up on that? Sure. Not a doctor, like to pretend I am one sometimes. I've always thought, or I've always been taught two in your twenties, three in your thirties, four in your forties, it's crapshoot once you get to fifties. But if we look at, I'm wondering if there is, and I know that this is one of the quality measures that practices are evaluated on is whether or not someone has had an annual screening. But if I'm wondering if there are clinical recommendations for health outcomes on 20 year olds being seen for a preventative visit when they have nothing happening, or a 30 year old being seen every Is there clinical data on health outcomes for seeing someone as frequently as the quality measure that a provider is being judged on? And, oh, by the way, not only are they being

[Dr. John Saroyan, Executive Director, Blueprint for Health]: judged on

[Rep. Alyssa Black, Chair]: the quality measure, but they're actually forcing their patients to come in more frequently than clinically appropriate because they're trying to keep that attribution.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: I'd have to research the questions nationally, Chair Black, to find out what that is. I wanna just make sure I'm really getting to the core of your question though. So that's the first part of my answer, to take that back and look at it more carefully. And I don't know the answer to it. I think that the clinician's judgment with the families and with patients as a person enters young adulthood is paramount. I hear where you're getting at. I hear where you're getting at. That's as far as I can go as as an answer right now, but I hear where you're going with your question, I think. Yeah, me

[Rep. Alyssa Black, Chair]: too. Then you have a perfect example is that used to be back in the day, if you were a female and you were on birth control pills, you were essentially forced to come in and have a Pap smear every single year to get your refill of your birth control pills. And then ACOG came out and said, Well, that's silly. You don't need a Pap smear every year. And they have completely changed the recommendations because there was no evidence based. I'm What I'm getting at, are we doing that with our attribution and our quality measures? Are we encouraging providers to provide low value care at the expense of trying to maintain the member per month. I think,

[Dr. John Saroyan, Executive Director, Blueprint for Health]: was this question asked to Rick too when he was presenting? I think I remember hearing his answer. So I could also follow-up with him too, because I remember a similar question there. I could be I remember because I remember hearing his voice. Remember hearing his voice and and his voice thinking. Unfortunately, Leslie's Leslie's Leslie's very much so. I may be asked this question.

[Rep. Alyssa Black, Chair]: Of Okay. Of this two year. I'd like to know evidence based.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: I just offer a perspective on this, necessarily what's in the program right now. So for the nationally standardized measures, usually, in fact, they are based on guidance and recommendations in order for CMS or ARC or anybody to incorporate them. So you really wanna stick to measures when you're designing an incentive system like this that do have the evidence behind them. That's level one and the standard ones do, but those change. And sometimes the measures are slow to keep up with advancements in care delivery and care guidelines, like from the National Heart, Oil and Blood Institute, they take time, they lag. So there's a really important step in here, and I think it's one of the strengths in Vermont because of network and the learning system and the committees that you have working together. And that's to select measures where there's agreement that these are meaningful measures and they're not gonna drive, as you say, or low value care. So you have in place a learning network in this state, people working together in these committees where you can sound that out. You have an insurer that's willing to work with you. They don't wanna drive low value care either. So part of it's the selection of the measures and making sure that you have the right input. They will have evidence behind them, but that changes. And then I'll give you an example of your example for gynecologic care, preventive care is totally right on, but where we see a trend right now in younger age groups, it's turning out, there's a need for hypertension treatment that is growing in 20 and 30 year olds. They're supposed to be screened because it's going up and it's becoming a problem. So there's changing guidelines around when to measure blood pressure in young people. Another one, is really critical is the change in colon cancer in young age groups. And so the guidelines on those are shifting. So what you have to do is keep up with the shifts in the real science, as you said, and then form alignment and consensus in these work groups around which measures are meaningful. But there has to be a process to it to avoid the point that you're making. And then lastly, would say there's a whole series of low value care measures. And there's discussion about whether we should bring the measures of low value care in as part of the evaluation and performance component too. So there's a series of ways in which to balance considerations that you're bringing. Wait, I just want to be clear on what you just said.

[Rep. Alyssa Black, Chair]: Did you say that there are low value and that you're thinking of incorporating those low value things in as well as quality measure?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Like I say, we're early

[Rep. Alyssa Black, Chair]: in the Do want

[Dr. John Saroyan, Executive Director, Blueprint for Health]: add more?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: No, we're early in the planning. This is about how you monitor your system. It may not be part of the payment, but you may want to measure it. So for instance, imaging for low back pain in the first day or two is inexpensive and it hasn't turned out to lead to meaningful changes. So when we talk about low value care, when CMS puts out a low value care measure, that would be an example of one. The program, the least that I know, I don't think has brought those metrics in to measure its system or not, and maybe it's a backroom measure. And just to make sure are we seeing patterns of low value care, and that becomes a learning effort more than the payment. So there's a number of ways to do this, but you asked a really important question. And I think the key here is how we balance where the evidence is with what is meaningful for the providers across the state.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Well, great

[Rep. Beth (full name not identified)]: suggestion, but is there any systematic reliable way, either from the federal work that's being done or within all the disciplines that you can realistically keep track of. Because we want to reduce costs, we want to increase access, we want to create better care. And what you described, I mean, is there a central place we could go? I mean, in Vermont, we've already changed our vaccination schedule based on changes that the federal law-

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Oh, see what you're getting at. See what you're getting at. Go ahead. So right now, we're coming to each other. That is what we're doing. I hadn't really thought of it in that way. We're coming together. And the Blueprint has led annually a look at all the quality measures with all of its partners. And that's something we do regularly. I think what's different about this year is that we appear to have alignment with Blue Cross Blue Shield to do it with them, which could decrease burden considerably, I think, on practices. That's what's new. But yes, we are doing it within our own network of expertise and payer and provider mix, and I'll be sharing those things and looking for input. And then you have also the inputs from like the Department of Health. Yes. They keep up carefully on guidelines and parameters.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: There's a lot of inputs here that can help you get to a sensible

[Dr. John Saroyan, Executive Director, Blueprint for Health]: And the blueprint's fortunate in that positioning within the agency to mental health, Vermont Health Access. We're colleagues, we work together. They're right at our We know each other so we can work with them. I should probably go, is that okay? Sure. Okay. So building a comprehensive community health team. Community health teams are, I think, what has become probably most known and most unique about the innovation that Vermont has done really to address the whole person, the mental, the physical, and the social, to allow the provider to stay in that provider visit and keep on their day and keep involved with their patients and to supplement and create a team around them. They are designed to include, and we want to be able to standardize and more reliably have our community health teams have a composition that's similar no matter what practice a person goes to. That's something that we would like to do in the future so that there's more consistency around what that model is, what's that best model that can be around every patient. We're also looking to streamline our different initiatives that I've explained each year, the mental health integration, pregnancy intention initiative, and our office based opioid treatment, which in Vermont is called Spokes. We're also looking to unify that into one community health team payment that is less complicated, more easily explained. And we don't want to reinforce any feelings of fragmentation from care. This is care for the whole person. So let's make the payment per member per month one payment that's more holistic. And the other part of this too, which gets to us really transforming the blueprint model is things like opioid use disorder treatment, being able to get the drugs needed, buprenorphine and the pharmacologic therapy in primary care, that's not new anymore. So to have a standalone program, which was great when it started, we need to do it, but let's blend that into our community health teams. And it's very similar with the Pregnancy Intention Initiative. This is human care. This is person care. The program is going. Let's blend that in to reduce the red tape, eliminating different program initiative descriptions and then subsets of individuals. So that's what we mean when we say build a comprehensive community health team. What is that ideal community health team and how can we defragment our own payment structure? Refining standards, especially for affordability and access, and access is very much tied to affordability. So how can we play a larger role as the blueprint, as the innovator to create access at our practices beyond the access that our current standards create for established patients. That has been, I think, a well established shortcoming of the standards that we have adhered to is the questions that have come, the expectations and the current standards are what's the access for that established patient? And where we really need to grow and develop and incentivize is pay more for is to say that these are our standard expectations for new patients who don't yet have a provider in that practice. And that's where we wanna do our work together too, so that practices really can help their patient population avoid unnecessary urgent care and emergency department visits and create a better foundation for prevention and long term cost control. Now the question goes back, I think it's great. This is really helpful discussion around what about in the 20s? What about in the 30s? What is best recommendations? Is it more meaningful to have an established patient during those times? And also, our own, I was gonna say our children, I was thinking too literally, our young people and rates of anxiety, rates of mental health, perhaps there will be recommendations to be seen once every X number of years in your twenties because of the rise we've seen in young people and teenagers in anxiety and depression. So this is some place that we really want to focus and refine our standards on. So shared principles of measurement and success. I really valued the discussion we had last week in committee and really have taken a lot of the messages that I've heard. I think, Chair Black, from you and from the committee and to the discussions that we're having with Blue Cross Blue Shield, how can we better be aligned on measures of success? How can we ensure those outcomes and lessen the burden on them? How can we move some of those measures more into the background? And how can we align accountabilities as payers? So this is very much tied into reducing administrative burden on providers and moving those processes more into the background than I think we have in the past.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: This is critical because it was embedded in your question earlier. There's been so much asked of primary care all over the country and here in Vermont too about measuring and monitoring and reporting. And we're in a different place now in terms of what can be done. One of the things and this is something we talk, work on with the team a lot for next year. I got to work on the data aggregation programs for centers of Medicare, Medicaid innovation nationwide on their primary care models. And there's really no reason at this point, 2026, why most of the measurement can't be done in the background with the advancements we have in the ability to capture information. And the AHS has done a lot of work to prepare for this, this is actually in a good position. Like now I'm sure as you probably you've heard in testimony, they can combine findings and clinical data for Medicaid beneficiaries and the measurement and the monitoring can be done in the background. So the providers are not spending the time on that type of document. That's a really important thing. In fact, they can be spending more time using the information and thinking about how it can improve their practice. So this is a critical element. And again, just point to the opportunity of a short term window like RHDP to advance these technical capabilities for practices that couldn't do it. They don't have the money to invest in these things. And even with a PMPM, they're really not gonna have the money to make these advancements. Well, here's a window where we can help them make those advancements, just like with the consults. So again, you see kind of the levers coming together in Vermont in a way we haven't had before. It's a real window of opportunity for advanced and primary care. And this will be an exciting advancement for them, for primary care, if we can really make this behind the scenes.

[Rep. Alyssa Black, Chair]: Go ahead,

[Rep. Lori Houghton, Member]: Lori. I'm looking to the build. This may be in but I guess I'm curious, bringing up the payments, and we all agree that we need to make an investment in primary care. But this has been in place for a long time, and we haven't kept up with the payments. And it's state dollars. So what in this bill is going to guarantee that even we continue and make sure that each year we are looking at this and increasing it and committing state dollars to this?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Sure. I think this came up in BMS's testimony, but let me turn to the sections. I don't have a highlighter with me, but let me see if I can do this while we're working together here. So I have a printout of, this is from a few days ago. It's not in this morning. Have an S197 that was passed out of the Senate. I turn to let me just give me a moment if you would. I'm not good at doing things on the flys. The section and Jessa, you might jump to it quicker than I do. It says that the PMPMs have to be looked at annually

[Rep. Lori Houghton, Member]: But by the that executive director doesn't mean that

[Rep. Alyssa Black, Chair]: for recommendations for increase. Right. But that doesn't mean that the increase will happen.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: That doesn't mean that the increase will happen.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Are we

[Rep. Lori Houghton, Member]: just going to get us back? I mean, at some point, are we just going to be back to where we are today, that we're not investing in primary care? Everyone keeps talking about the fact that we're not investing, we're not investing. But no one is saying, these are state dollars. We are not a piece of it are state dollars we are not investing, that are tied to the general fund. So what guarantee can you give that we're going to sustain The

[Dr. John Saroyan, Executive Director, Blueprint for Health]: way I've seen it is that we are going to be able to prove better than we've ever been able to prove before that some of the that are one time resources that we have from our agency to really create this model can prove itself to payers in a way that we haven't proved before. That's how I see the lever to really get there. You're right, it's not written into that you must. I think there's some language that, as I can't remember exactly what the language that I Jennifer

[Rep. Lori Houghton, Member]: is all great. I just get really nervous

[Dr. John Saroyan, Executive Director, Blueprint for Health]: that there's going to be better.

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: One of the possible tools that the team has and the state has is that, and Blue Cross is interested and they understand we need to increase the total investment in primary care. Everybody has kind of looked at this nationally as what percentage of total cost of care goes to primary care. And there's some good benchmarks there about what states are trying to achieve and there's states that have put in place benchmarks that they're moving forward. So if you're thinking of a 12 to 15% range, which is a common range of total cost of care going to primary care, that gives you, you now have something to measure against. And as John mentioned, if you balance that against monitoring the impacts and the outcomes, you make the value case. And if without a requirement explicitly stated, the best thing is to make a value case. And at least we're in a position now to know there's national benchmarks and we can monitor against it and make the value case. And that be an engagement approach, not a requirement approach.

[Rep. Alyssa Black, Chair]: Don't know if you've been, I've been on a quality tear this year. Been here for twenty years. And I see a lot of Measurement. We see a lot of measurement. I haven't seen any outcomes. I mean, what outcomes? It says ensure clinical outcome and process measures are focused on priorities. First of all, whose priority? And is it just a matter of making up a measurement and then trying to achieve that measurement? Then you can show that, oh, look, we are doing better on that measurement. But ultimately, How is it increasing access? How is it helping affordability? How is it sustaining? To Lori's point, her question is, this bill, it seems to be saying, let's take the blueprint and let's come up with a new number that we should have been coming up with all along, and it should have been there. And then we'll just stop there and we'll call it, and then we'll wait another twenty years. Where You just did this a couple of years ago. Yeah. Where is the value? I mean, I care about access and I care about affordability. And without affordability, Vermonters don't have access because they can't even afford You can't afford to go. That is the worst quality care that you can get, is not getting the care at all. And I'm just not seeing I'm seeing this bill as this is just more of the same. How does this support a system of primary care that is not sustainable? I don't want to use the word sustainable. How does it make a system of primary care thrive? And I'm just seeing more of the same, and I'm seeing more of the same in your slides that we've been doing in the blueprint for twenty years, and no one's been able to show the outcomes. How has this helped access to primary care? How has this helped the health of Vermonters? We know from hospital costs that people are more acute, higher complexity, and in worse health. Make the case for why we need to keep doing more of the same.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Just on the point of access, I was looking in preparation for this talk at a measure that we had our largest participation from both pediatric age and adult age patients in our consumer assessment. So this is national standards for a separate body, all de identified information. We have greater participation in our consumer assessment than we'd ever had before. We presented this at executive committee. Access has been, so this is for patients who have a patient centered medical home. I acknowledge the limitations. Access is on a downward trend for the past four years going into 2024. Last year, access for that population stabilized. Now can we sustain that? I sure hope so, but that is a very concrete example to me, Chair Black, where I'd like to learn more, and I'd like to say, okay. There there was there was some stability there. Now is it gonna continue? I can't I can't guarantee that. Is that meaningful enough to the the really important questions you're asking? I don't know if it is. But to me, that was something that really shown. So please respond and- How are

[Rep. Alyssa Black, Chair]: we measuring access? I mean, what does that mean? Does that mean that you're seeing a 20 year old for a physical every two years? Or does that mean when somebody needs you hypnosis that you can see I them

[Dr. John Saroyan, Executive Director, Blueprint for Health]: can give you all the questions. I actually filled out the survey myself from my patient centered medical home, and I'd be happy to give you. It's a combined measure. It's two questions that are used in terms of both a question around routine visit and an urgent visit, and the person gets to rate it on a scale. That's how it's asked, literally. That's how it's asked.

[Rep. Alyssa Black, Chair]: I feel as though we have spent so, you know, it's the concept of teaching to the test. We've got these tests and these measures and it feels as though we have essentially changed primary care into just taking a test and meeting the measures. And to me, the most high value care of all is that when you really, really need care, your primary care provider is there for you, instantly.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: Agreed.

[Rep. Alyssa Black, Chair]: And are we even measuring?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Do you want to go?

[Dr. John Saroyan, Executive Director, Blueprint for Health]: To the degree we can within this, and we can certainly make it better. But yes, that is one of the questions is can you get in for an urgent visit? That is part of the composite score. The other part is that, yes, there are, I like analogies, so I heard your analogy on the teaching of the test, especially where I'm at with There are clinicians who see it that way, that that's their interpretation exactly how you said it. Also, or Anne, there are clinicians who really embrace it, I think, as making their practice better. And I've talked to both. I've talked to both ends of the spectrum in terms of the perspective you're presenting, which is absolutely correct, and clinicians and practitioners who see it as part of their continuous quality improvement for their learning health system in their small practice in their community. So I do want to respond and share those thoughts with you. Craig?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: Yeah, sure. No, first of all, completely appreciate what you're saying of what's real access.

[Dr. John Saroyan, Executive Director, Blueprint for Health]: And

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: the CAPS or the consumer survey, I'm going just tell you my own bias, it has nothing to do with the state. I did not feel that that survey really gives you an insight into access, for example. We all know it. We all have an experience here of people who can't get in to see their doctor when they need to get in to see their doctor along the wait times, we know the list. So it means it's not working. And approach that needs to be taken to your question is much bigger. There's a much larger story here about really improving access. Let me give you a concrete example in the new payment. So if you structure your payment based on the services you offer, and the secretary is completely dedicated to this, same day access, evening, morning access, the ability to call and get in, that's going to be part of the standards that move you to a higher tier in the per person from life. We're gonna give you a larger investment so you can hire the people and do that work, but you have to meet that standard. So you can drive access through standards. And that's one approach here. But it's really also important to think back over the last five years and maybe a little more, where the eye on the ball, that we have an eye on the ball problem. It wasn't focused on. We had the state of the all payer model. We had a whole series of initiatives to your point, there's been a long history here, but it's not just blueprint. There's been many other initiatives that actually move the aisle away from investing in true primary care. And that's the reason primary care payment hasn't been adjusted in the state through the blueprint for many years.

[Rep. Alyssa Black, Chair]: How is this not the next one?

[Dr. Craig Jones, Former Executive Director, Blueprint for Health (2007–2016); Contractor supporting AHS]: It's not the next one because now we have the focus and we have the alignment with the state and with Blue Cross. We have the upfront investments in the rural fund. We have a very different environment. We have changes in leadership, both at Blue Cross and at the University of Vermont Health Network, all of whom have committed. So there is four or five levers today that were not here three years ago or five years ago. And I think the fair question is, will we be able to take advantage of those levers and put them together in a system approach that does change access in a meaningful way? Because we haven't done that and now's the opportunity to do it. But Debra, we do have an eye on the ball problem for the last five or more years here in the state, it wasn't focused on achieving these things. And the other initiatives, intended, just didn't do it. But there and I'll lastly say, the community health team expansions, there is nothing like navigators to make sure you get in and and that they take there's somebody to answer the call, but to get in, they coordinate for you. Having coordinator and I've just been through this twice in the last six months with my own family. I had to be the navigator because they weren't there. We've all been through.

[Rep. Alyssa Black, Chair]: I think the community health teams are, they allow services, wraparound services so that primary care providers have access to the services that their patients need. I am unfortunately going to have to end it here because several of us had meetings that Thank you shared by you so much. Thank you. Really appreciate it.