Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: I'll figure

[Dr. Elliott (Elliott) Fisher]: it out once we get going.

[Rep. Alyssa Black (Chair)]: Okay. Good morning. It is House Healthcare, April 23, and we are going back to S197, which is the primary care payment reform program bill that we're working on, and we're just taking additional testimony. We haven't done any markup on this bill. Frankly, we haven't even had committee discussion around it. But we have Doctor. Elliot Fisher in. Elliot, I'm sorry, you're a doctor, right?

[Dr. Elliott (Elliott) Fisher]: Yeah.

[Rep. Alyssa Black (Chair)]: Oh, okay. Sorry. It's not on my agenda that I'm looking at. I'm like, What

[Rep. Brian Cina (Member)]: kind of doctor?

[Dr. Elliott (Elliott) Fisher]: I'm a primary care physician.

[Rep. Alyssa Black (Chair)]: Nice. Well,

[Dr. Elliott (Elliott) Fisher]: was. I stopped practice twenty five years ago when the research got too busy and the policy stuff got me engaged, but at heart, a primary care physician.

[Rep. Alyssa Black (Chair)]: Well, welcome and thanks for joining us. And I know you have slides, so if you want to put them up, you're welcome. And

[Dr. Elliott (Elliott) Fisher]: for your audience, would you like me to say a bit about who I am before I start? A word

[Rep. Alyssa Black (Chair)]: Introduce for yourself to us.

[Dr. Elliott (Elliott) Fisher]: Great. Let me see if I can get my screen up.

[Rep. Alyssa Black (Chair)]: We have new committee members as well from

[Dr. Elliott (Elliott) Fisher]: Great. I'd love to have an introduction if that worked at some point. Do you want

[Rep. Alyssa Black (Chair)]: to Let's go around. We'll introduce ourselves to you again. You know a lot of us, but we've got three new members. Cool. Leslie, you want to start? Hi, Elliot.

[Dr. Elliott (Elliott) Fisher]: Nice to see you, Leslie.

[Rep. Karen Lueders (Member)]: Yep. We know each other. Good morning, Elliot, Karen Lueders, new member from Addison four.

[Dr. Elliott (Elliott) Fisher]: Oh, great. Good morning, Doctor. David Sousse representing Barrytown in Washington, Orange County.

[Rep. Alyssa Black (Chair)]: We also have Tasha. You know Tasha. Morning, Doctor.

[Dr. Elliott (Elliott) Fisher]: Oh, yes. She's been so helpful. Thank you, Tasha.

[Rep. Alyssa Black (Chair)]: And I'm representative Alyssa Black.

[Dr. Elliott (Elliott) Fisher]: Yep.

[Rep. Brian Cina (Member)]: I'm Brian Cina from Burlington.

[Rep. Wendy Critchlow (Member)]: Wendy Critchlow from Colchester. Debbie Powers, Caledonia One.

[Dr. Elliott (Elliott) Fisher]: Allen Demar, I represent Ennisburg and Montgomery. Is that everyone, I think?

[Rep. Alyssa Black (Chair)]: That's everyone. That's everyone. Great.

[Dr. Elliott (Elliott) Fisher]: Can you all see the screen?

[Rep. Alyssa Black (Chair)]: We can.

[Dr. Elliott (Elliott) Fisher]: Oh, but maybe I should figure out how to play it rather than show the Doom.

[Rep. Alyssa Black (Chair)]: Yeah. And if you want to introduce yourself and Yeah.

[Dr. Elliott (Elliott) Fisher]: Me see if I can get

[Rep. Alyssa Black (Chair)]: this loaded.

[Dr. Elliott (Elliott) Fisher]: No. Don't. I do not want to go to full screen. Alright. I won't see you guys while I talk. I that seems to have disappeared for me. Just wanna see if I can damn. Lay out. Let's see if we can do this. Can you get that?

[Rep. Leslie Goldman (Member)]: Looks good for us,

[Rep. Alyssa Black (Chair)]: and we can see you.

[Dr. Elliott (Elliott) Fisher]: Yeah. Well, let me try to let me try to use this and I'll I won't see your grimaces as I say something, which is always a challenge. My name is Elliot Fisher. I'm a professor here at Dartmouth, as it says on the slide. Was a practicing primary care clinician for twenty five years. And then based on research that examined variations in care and how we might make America's healthcare system more efficient, I ended up spending a lot of time in Washington, helped develop the ACO model, but my more recent research has been focused on primary care. I have two large NIH grants and it's really where my heart sits. And so I'm quite excited to be with you. I think we have a great opportunity in Vermont, and maybe I'll just dive into the slides. Please interrupt me because I can't see you at all the way these screens are showing.

[Rep. Alyssa Black (Chair)]: We will interrupt you.

[Dr. Elliott (Elliott) Fisher]: Just jump in and ask a question and I will be perfectly comfortable as I think I hope you experienced last time. I like being with you and I think this is a great opportunity for all of us to get to understand and think about how this bill in particular might really help us all in Vermont. Alrighty. Now I have to figure out how to advance the slides. There we go. So just imagine that you could get advice about a health concern at any time of day, you know, that it would be from someone who knows you and who knows what matters to you. They could help you with most of their problems and they could coordinate your care. Hello, question? Nope. Okay. But these were Barbara Starfield's fundamental four Cs about what primary care is about. She's one of the most influential researchers and people who influenced the whole field. And we should be able to do this. I'm actually confident that we can and that Vermont is well positioned to make that possible for everybody, and I'll try to walk you through why I think that. Still got to figure out how to advance. So, however, we're in a pretty lousy place right now. Access to care is getting worse, as are the capabilities and practices to coordinate care, help you make a wise choice, figure out whether you do need to go to a hospital. In practice, burnout and moral injury are pervasive, it's very hard for clinicians to not be able to deliver the care that they were trained to deliver. The primary care workforce is deeply threatened, people are leaving it, retiring early, and there's another serious challenge, is that the private sector is coming up with wonderful, in terms of what they're able to deliver direct primary care and concierge practices, and these are great for clinicians, and probably for the patients with the means to sign up for them, but they fundamentally undermine access and care for everyone else, and I think are a serious threat that we have to pay real attention to, and I know you have other legislation that's under consideration now in the legislature to address private equity, which has a major role in direct primary care and concierge practices, as you probably all know.

[Rep. Brian Cina (Member)]: Question about that.

[Rep. Alyssa Black (Chair)]: I guess you yelled

[Rep. Brian Cina (Member)]: it out because I don't know how

[Dr. Elliott (Elliott) Fisher]: it's be.

[Rep. Brian Cina (Member)]: No, that's fine. I I guess I can raise my hand and wait for No,

[Dr. Elliott (Elliott) Fisher]: I can't see you and it's All right, well

[Rep. Brian Cina (Member)]: I'll proceed. Mentioned private equity and you're based at Dartmouth, right? Yep. Yeah, but you do monitor the Vermont healthcare landscape?

[Dr. Elliott (Elliott) Fisher]: I do my best to, although I'm pretty busy teaching and doing research, but I love to come over here. I live in Vermont, I'm in Norwich, and so yes, I've been monitoring it, I saw the bill that was introduced, I read the bill as I believe you passed it.

[Rep. Brian Cina (Member)]: Yeah, and I don't know if you had a chance to see any of the testimony we took. There was professors, researchers from various other Ivy League schools like Brown and Harvard and-

[Rep. Alyssa Black (Chair)]: Like coming in St. 1 today. Oh, really? Okay. Yeah,

[Rep. Brian Cina (Member)]: they have looked at the landscape in Vermont, and I think like 57% of our opioid treatment facilities are operated by private equity now, and there was a few other numbers in there that were concerning, and I just didn't know if you had any additional info about the infiltration of private equity into the health care system in Vermont, or especially primary care.

[Dr. Elliott (Elliott) Fisher]: I do not have great insight into that. I know that private equity is quite engaged in direct primary care across the country. I don't know about the practices here. I think that's one of the strengths of the bill that you guys have passed, and I guess is now in the Senate, or I think is now in the Senate, know, the transparency provisions will give us much better view into what's going on. Another number that I remember is 25% of nursing homes, and Zuri Sung is a close colleague and testified for you, and I did watch his testimony, and I think it's very important what we're trying to do about private equity.

[Rep. Brian Cina (Member)]: Okay, well thank you, I just wondered because you brought it up, so thank you.

[Rep. Alyssa Black (Chair)]: Yeah. All right. Leslie has a question also. Okay.

[Rep. Leslie Goldman (Member)]: Leslie, and you know on the private equity,

[Rep. Alyssa Black (Chair)]: I think one of

[Rep. Leslie Goldman (Member)]: the things that came out of our bill was that nursing homes were exempt and that was very worrisome. Just was wondering if you have any thoughts about that.

[Dr. Elliott (Elliott) Fisher]: Well, you know, again, is a complicated field, I think as Doctor. Sung told you, one of the things that many healthcare organizations struggle with is their financing, their finances, and private equity can, in my view, in vanishingly rare circumstances, at least temporarily, finances. I think the emphasis on temporary is really important because, as you all heard, it's often done through these complicated purchasing arrangements, they sell the property out from underneath the organization, leave them with the debt. I don't think the focus of our testimony, my testimony today is on that topic, but I think I would not be I think we should not exempt any organizations from transparency about what's going on. And I think there are good reasons to think about wanting to limit the kinds of behaviors that private equity can the private equity playbook. So I have not noticed the exemption for nursing homes, Leslie, I'm the representative.

[Rep. Alyssa Black (Chair)]: This was good.

[Dr. Elliott (Elliott) Fisher]: Anyway, so I think that may have been an oversight or an opportunity for improvement when you go to the conference if you do.

[Rep. Alyssa Black (Chair)]: Not an oversight. I will just say that the exemption for nursing homes is for the reporting requirement, And nursing homes do federally or mandated that they report. So we do have information on that. They are not exempt from the corporate practice of medicine and exerting clinical control over healthcare providers within the setting of a nursing home. Great.

[Dr. Elliott (Elliott) Fisher]: Thank you. That's helpful.

[Rep. Alyssa Black (Chair)]: Exempt from one thing, but not exempt from everything. Well, okay, never mind.

[Dr. Elliott (Elliott) Fisher]: Revealing my relatively quick read of that bill. So there is a better path, and the National Academy of Medicine and the report shown on the right there said that we should make primary care available to all. It needs to be excellent primary care, so we need to pay more, increase primary care investment and pay differently in ways that will let primary care practices innovate and provide services that aren't covered under the fee schedule, support team based care, now widely known as advanced primary care, thanks to people like Craig Jones who really helped. I'll talk a little bit more about that later. We need a strong workforce so that we have full primary care teams and communities as we do, you know, intended to do under the blueprint, and take advantage of digital tools and technology. They called for a plan to put in place a plan for implementation, and, you know, my first take on the bill that you are considering is this is a really important step on that path. So where's Vermont? Well, I describe myself as a policy nerd, but I'm also such naive optimist that you should take whatever I say with a grain of salt, but I think we're in a great spot. You and we are all motivated by the affordability crisis, which is not just an insurance death spiral, it's an economic death spiral, that is communities, businesses are moving out of the state, young people don't want to come, and that will leave the remaining population as older and sicker and reinforce the cycle that takes us in the wrong direction. I think you and the federal government to some extent have set the table for us to reverse this trend and lead the country. We have lots of tools, strong agencies, I think the Green Mountain Care Board is essential, the AHS has a lot of resources and operational infrastructure such as Blueprint, we have SASH, hospital regionalization underway, I think that's very strong. I am not aware, and I try to be aware, of the regulatory authorities that we have, and I think the Green Mountain Care Board as comprehensive as any other state, if not stronger. And right now we have new investments that are coming that are going to enable advanced primary care to be established, the Rural Health Transformation Program, but these are seriously time limited. They're gonna run out and Chittenden is left out. So to take advantage of that, we really have to figure out the policy changes that are gonna make the innovations we develop during this first coverage, this period of the RHDP, to make sure we can sustain, we are achieving the savings we need to maintain investments in those services, and you know, I've talked to, you know, I call all sorts of people for advice and try to help understand how I can be helpful and think about where Vermont is, both hospital leaders and others, and I sense an openness to meaningful change in places that I did not anticipate a year ago. I have to be careful about the conversations, but I really, that's the deep reason my optimism if we're thoughtful and patient. And then, you know, probably the core message, one of the messages I wanted to deliver is related to some research we did, And I think I spoke about this, I may have spoken briefly about this last year.

[Rep. Alyssa Black (Chair)]: I think Leah, Brian's got a question.

[Rep. Brian Cina (Member)]: And I did look ahead in your slideshow to make sure you don't bring it up. I don't see it so I figured I'd ask now. You were talking about, I'm just looking back to where it said that

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

[Rep. Brian Cina (Member)]: were listing all these things like about the tools we need. Yeah, you can put it back up. And I don't see technology on there and I'm just curious how, you don't have to answer it right now, but as you talk about ways that we might use this moment to pave a path towards a better system, how technology might be an asset in the delivery of primary care?

[Dr. Elliott (Elliott) Fisher]: Let me say that I sort of assume that, I'm sorry I didn't mention it, it's certainly in the National Academy recommendations that I'm now showing you on this. Our research program is looking at digital tools and the impact of telehealth. And so I totally agree with what you're saying. It's pivotal and the RHDP has a lot of, if I didn't mention it here, I don't say all the things that RHDP is doing, but I think it's a very technology is one of the things we can spend a lot

[Rep. Alyssa Black (Chair)]: of money

[Dr. Elliott (Elliott) Fisher]: on. We're authorized to pay for, not direct service delivery unless it's new services, I think. So I to agree with you.

[Rep. Brian Cina (Member)]: So we might be able to use rural health transformation money for the technological infrastructure?

[Dr. Elliott (Elliott) Fisher]: Very much so, it's a large part of what they're doing and I believe the Vermont proposal, which I read quite a while ago and may not remember correctly, but it has strong emphasis on technology, including interoperability of electronic health records, and so I think that's, you should have confidence that that is, and practices want to do it as well, so I don't think this is going to be a barrier.

[Rep. Brian Cina (Member)]: Thank you.

[Dr. Elliott (Elliott) Fisher]: So let me try to explain why, partially why I'm so why I think we can succeed if we as we move forward with the various things which we can move forward and we're positioned to do. So, I'm on the board of the Fannie Ripple Foundation in New Jersey. Actually, I just stepped off, but we funded the development of an MIT designed systems dynamic model that took the best evidence, hang on, I'll finish the sentence, then the best evidence we could find to understand what policy innovations with strong evidence could be implemented over what time period and in what ways, things that we know we can do and for which there is strong evidence, what could you achieve if you implemented those in a thoughtful way, sequenced appropriately? And I'll just walk you through what those evidence based interventions are, but before I do that, let me make sure there wasn't a question.

[Rep. Alyssa Black (Chair)]: No question. Have a couple people here with coughs. Had an illness go through house healthcare, so

[Dr. Elliott (Elliott) Fisher]: I think it even got over to the Senate, if I remember what

[Rep. Alyssa Black (Chair)]: I was hearing

[Dr. Elliott (Elliott) Fisher]: a few weeks ago from Senator Lyons. So here's the basic story. So the first step in the sequenced interventions is to do two things: improve care delivery and payment reform, combine those two things, because they reinforce each other, move toward the global payment, invest in strengthening primary care, improving hospital efficiency, improving care coordination, and at the same time start to do the common sense public health initiatives that aren't that are easy to do and are effective. Know, soda taxes would fall in that, so would helping people exercise.

[Rep. Leslie Goldman (Member)]: Sorry, Elliot. This is Leslie.

[Rep. Alyssa Black (Chair)]: I've been wanting one of those taxes since I walked through

[Rep. Leslie Goldman (Member)]: the door, and I've been, like, shut down all over the place. Really glad to hear you say that.

[Dr. Elliott (Elliott) Fisher]: Powerful lobbies against you, public health innovations. Can talk at another time or I can answer questions at the end about the models that I think we should adopt from Maryland who have been doing this for a while. But those two things together do improve health. Relatively quickly take people with chronic illness who are not yet sick and keep them from getting sicker, but they also reduce utilization through simple care coordination, helping people be able to be seen in a primary care office, for example, and not have to go to the emergency room. So those two things, those innovations together, did I go backwards? How am I doing this? There we go. So the second step is to capture share and reinvest some of those savings. A critical step, one of the challenges with ACO models is that everyone keeps the savings and there's nothing left to reinvest in. They split the savings between providers and payers, and we ought to capture some of that and reinvest some of those savings so we can reestablish an innovation fund. If one does that, one overcomes two barriers to success of this kind of innovation model, which is that we can't afford on the first round to do most of this stuff, right? It's expensive to take primary care, to improve primary care delivery, or it may be, we think so, it may not be, but we'll come back to that later, but these things can expensive to fully scale. So you start to take the savings that you've achieved and reinvest them. And by the way, we have the Green Mountain Care Board who can help us capture those savings, so this is not pie in the sky. That creates a virtuous cycle. Can you see me? I'm trying to That roll my fingers around in some creates a positive feedback loop in the systems dynamic world that dramatically accelerates the full adoption of the innovations that we want to adopt. Finally, when you have enough savings, you can do the big expensive things which are keeping everybody healthy, you know, you're doing so you cannot, you're doing investment in jobs, strengthening schools, helping strengthen housing so people live in decent housing conditions that are not suffering. And when you do all those things under this model, this is what you achieve over twenty five years: a 20% reduction in chronic illness, a 14% reduction in per capita health care costs, a 20% drop in the low income population because people are now able to work, but the biggest number that sits there is that 9% increase in what the model labeled productivity, but that's the gross domestic product of the communities where you do this or the state where you do this. That's a huge growth in income that will make other people want to move to this state. I just, I wanted to run through that because, you know, I'm, I believe that implementing this kind of longer term strategy is what we are well positioned to do in Vermont, and I know the Fannie Ripple Foundation would be anxious to help you. So any questions about this before I go on since I've was given a pass and maybe run past the thirty minutes initially proposed?

[Rep. Alyssa Black (Chair)]: Oh, go ahead, Wendy.

[Rep. Wendy Critchlow (Member)]: So your idea would be to take these numbers and translate that back into the savings and reinvest that into primary care? I mean, I love seeing these numbers.

[Dr. Elliott (Elliott) Fisher]: Well, you don't get these savings in the first two years, they accumulate over time. I think the notion of understanding the positive feedback loops that occur with new payment models, improving primary care, reducing hospital costs, and having, you know, over time, but then if the hospitals don't need to be full, then we can reduce the size of the hospitals, allow them to focus on the things that hospitals do really well and where they make their margins, which is in procedures, and short acute illness hospitalizations, they don't do very well at taking care of people who are just unstable and could be treated at home, as I think we've all been talking about now for almost a year. So keeping people the investments that can keep people safe and healthy and at home will allow us to, you know, reduce unnecessary utilization, which there, you know, all of my early research was about just how much unnecessary utilization reinforced by subsequent work showing the magnitude of waste in The United States, largely from failing to treat chronic conditions or prevent their progression and from putting people in a hospital when simply because you didn't understand that they didn't need to be in the hospital or the emergency room physician couldn't figure out what was going on with them because they didn't have access to records. Does that kind of answer your question? Can't see your body language today. Next time I come I'll make sure I have this so I can see the grimaces as I

[Rep. Wendy Critchlow (Member)]: I'm shaking my head.

[Rep. Alyssa Black (Chair)]: Elliot, I'm sorry if I make you repeat this. I actually was distracted by a slide I was looking at on my computer. I'm getting the output in this model. I don't think I quite heard what the inputs, the initial input is to get to these outputs. Sure. Well, like when you say care delivery, what type of changes to care delivery are you talking about? Also payment reform, what types of payment reform are you referring Great

[Dr. Elliott (Elliott) Fisher]: question. You know, details are provided in that article, which I can certainly share with the committee. There are about five or six things that fall under improving care delivery, that is ensuring access to primary care and improving primary care efficiency, increasing access for low income populations to primary care, such as increasing FQHCs, hospital efficiency, and things like preventing readmissions. So it's a portfolio of about a handful of innovations, interventions, I'm sorry, that have all been shown to work well and can reduce, improve health and reduce utilization. The second thing is payment reform, because fee for service payment reinforces fragmentation, it leads to overutilization, it has this weird effect on accountability, which is we have different accountability systems for physicians, for hospitals, for nursing homes, for suppliers. And what you'd really like is to have someone be responsible, and that's where Global Payment to a care delivery organization, they suddenly have a very strong interest if they're paid under either capitation or with the earlier models where a global payment target and then get if they reduce costs under fee for service shared savings, but both of those give the organizations, you know, a very strong incentive to reduce utilization and by doing two things: get rid of inefficient care and improving people's health. And, you know, the Congressional Budget Office reviews of Accountable Care Organization concluded strongly that primary care focused accountable care organizations have been successful, and the recent theory is that the recent evidence is that some of the incentives have not been strong enough, and so the newer Medicare shared savings programs and LEAD model this year really offer healthcare organizations the opportunity to capture all of the savings themselves. So there are very strong incentives to do those things. Does that answer your question?

[Rep. Alyssa Black (Chair)]: It does, thank you, thank you very much.

[Dr. Elliott (Elliott) Fisher]: Good. Glad to Any other questions about this before I go on?

[Rep. Alyssa Black (Chair)]: Actually, I do want to ask you a question about something you just said regarding ACO. You said that there has been evidence that ACOs have shown, did you say savings?

[Dr. Elliott (Elliott) Fisher]: Yeah, substantial savings and substantial improvements in the health of their beneficiaries and the quality of care and Are

[Rep. Alyssa Black (Chair)]: those short term, medium term, long term? They

[Dr. Elliott (Elliott) Fisher]: begin to occur, and I just spoke with someone who runs a network of, who runs an organization that supports primary care ACOs, and they're getting about a 6% savings year on year from starting to see improved health quickly. When Peter Pronovos talks about their Medicare shared savings program, ACO, they've done really well, they've managed to improve blood pressure control and diabetes dramatically in their population, and those were things that started to happen within a couple of years.

[Rep. Alyssa Black (Chair)]: Leslie has a question.

[Rep. Leslie Goldman (Member)]: Yeah, thanks, Elliot. Is there also when you talk about payment reform and incentive not to give care at all? Yes, exactly.

[Dr. Elliott (Elliott) Fisher]: Of course, if you just do simple capitation, we learned that in 1980s when we had capitation, the simplest way to make money is just not take care of people.

[Rep. Leslie Goldman (Member)]: Yeah, so how do we avoid that in this model?

[Dr. Elliott (Elliott) Fisher]: Because these payment models all have what's called gated shared savings, or gated you do not get your savings, a share of the savings, unless you improve care. And it really has changed the way the model works. Admittedly, I'm an advocate because I help come up with the idea and help write the section on the Medicare shared savings program with Mark McClellan. But as they've learned, it took a while, but as they're strengthening the models, I think they're really showing much, they're showing impact, and the CBO review said it's strong not for hospital owned ACOs, or there's no evidence for hospital owned ACOs, which maybe aligns with sort of what our experience was in Vermont with One Care, but I still think it's the right way to go in the longer run, and rooting them in primary care is what I would recommend.

[Rep. Alyssa Black (Chair)]: May I ask you, keep asking this question of everybody, what other specialty or segments of our healthcare system do we tie their value or worth or their reimbursement to savings across the whole system? Other than primary Outcomes. Or outcomes. Well,

[Dr. Elliott (Elliott) Fisher]: we're stuttering our way forward. The move toward value based care is certainly strongly endorsed by the Center for Medicare and Medicaid Services. They're advancing these models and have made some, I think, major improvements recently in the models that was introduced in the winter and will be eligible for people to join. So, but hospitals have some incentives to reduce utilization. They're penalized if they have readmissions be high. That doesn't necessarily reduce the total cost of care. I think the, you know, we could do more, and I think they're, you know, to incentivize everyone to reduce the total cost of care. And I think that there are at least several of our hospital leaders who see the current path focused on revenue generation is the only way to maintain the survival of the organization. They think that's a flawed model in the long term in these conversations I have with various folks, and that we need to move toward models that might lead to a sustainable healthcare organization in communities where we have to work to figure that out. But I think that this kind of change to incentives that reward you for keeping people healthy and out of the hospital and able to then reinvest those savings is really important.

[Rep. Alyssa Black (Chair)]: Great, thank you. I will go on. Maybe I won't. No, very well. So

[Dr. Elliott (Elliott) Fisher]: primary care is essential in a crisis, and I think we have three major options. You know, doing nothing is not okay, it's the path we're on. It's neither wise nor kind to the clinicians who are working in primary care or a population which, as we all know, can't even afford to go see their primary care physician under these high deductible payment models that more and more people are exposed to. And Doctor. Sung spoke, you know, not only about private equity in the Senate, but talked about the primary care shortage that is impending. So, you know, option two is increasing investment in primary care under current payment models, and I think we have to do this, and you're on that, this legislation helps put us on that path. You know, for advanced primary care, we actually designed the model, the blueprint under Craig Jones, is the model for rural advanced primary care across the country, and the recently published report by the Milbank Fund that was written by Howard Houghton and Craig provides insights for states on how to move across the state to advanced primary care, and many of those elements we know, we are well prepared to do, the blueprint is there as the structure upon which that could be built and is an important asset for us. And, you know, committing now to this, committing now to, which has some, this bill has some elements in, would make many think again, I believe, you know. I think many physicians, they saw hope, might say, Well, maybe I don't need to shift to direct run rate care. We'll talk more about that when we get to my comments on the bill. I think the third option is to innovate what's called universal primary care, cover everyone. There was testimony in the Senate on this. I think it might be great, and I'm actually, you know, enthusiastic, and, you know, in part because Massachusetts has got practical solutions to many of the challenges, as does California, it's efficient, you know, if move primary care out of the insurance system, there's some real advantages, you know, insuring against expected costs is incredibly wasteful. Why would you pay your insurance company to pay for your annual, dental exam, which you're going to get every year anyway, you just add 20% or 30% to the cost of doing it, it's terribly wasteful. It's called administrative load in the technical language of economists. But there's a second feature that I think is really important, and that is, you know, poor practices in hospitals that are dealing with tons of different methods and rules and performance measures that are put on by each of the different payers, and so moving toward a model where there was a simple system that could take out, you know, a simple payment model, could combine some primary care with capitation, some which I think is where most people will want to land for reasons we can talk about in questions, but you might even have multiple health insurance plans, but they all ought to use exactly the same way of paying them and holding them accountable. And then, you know, I think it's a wise investment, as I've been arguing. Primary care is a tiny share of total spending, and if we do it well, it has a potential to save, and so I think investing is wise. Question?

[Rep. Alyssa Black (Chair)]: No questions. Okey doke. I'm sure

[Dr. Elliott (Elliott) Fisher]: I'll so, however, there are real barriers. We lack the essential information required to do either option two or option three. What are the current costs? I think our last report was from data before 2020, I can't remember the exact year of the primary care spending report on Vermont, I think it was 2019 or something like that. You know, there are, you know, most states are setting targets for primary care spending based on the percent of total cost. First of all, I think the evidence is it's really not working yet. No one, you know, it's not slowing, it's not increasing investments in primary care, but it's also pretty deeply flawed if you do it as a percent of total cost. If you're a really high cost state, and I think we know one, it's where we're all sitting, you know, if it's the most expensive state, then you're going to give primary care in this state a huge amount more than you would in any other state. So I think we need to do some serious work about, you know, what are how is our current payment system working, what are practices receiving, and then figure out what are some wise ways to increase that investment. I think we're uncertain about how to pay, you know, is it full capitation, somewhat mixed? How would we do risk adjustment? What about quality measurement? I mean, getting the incentives right, as I think I spoke about earlier, is so important. You know, one of the challenges that I will come, I'll probably, I will repeat myself because I think it's important, you know, the patient centered medical home, it pays people to put in place processes and maybe to do a bit of quality improvement, but it does not reward them for improving care. It's a payment that they get, and there's, you know, we've seen that just adding payments to primary care, whether it was in Britain or elsewhere, does not necessarily improve quality. I don't know how many of you recall the stories about expanding payments to general practice in The United Kingdom, and there was an epidemic of primary care, of general practice owners starting to buy fancy cars, you know, because they love the additional income, but we need to hold them accountable for the additional income they're getting, and we need to figure out put that kind of accountability into place.

[Rep. Alyssa Black (Chair)]: How do you hold them accountable? I mean, how do you measure accountability?

[Dr. Elliott (Elliott) Fisher]: Can talk a little bit more about that fully. I think you actually have quality measures that are meaningful upon which they need to make progress. You include some health outcome measures like reduction in emergency department visits, you require processes that we know are more important than, you know, or additional processes. Let's take next day, for example, same day visits and overnight telephone calls. I think every practice ought to be able to do that, because it's been, you know, and but then be tracked on how whether they're reducing emergency department visits, whether they have waiting, you know, so do we track the outcomes of that? I could give a whole talk about quality improvement and how you do it with run charts, I think that's really important, think we're underutilizing the strengths that Vermont has in meaningful, disciplined quality improvement in VPQC, but those are the things I'd so you show improvement, Senator, and I'm really waxing too long on these answers, so just interrupt and tell me to shut up, you got the point.

[Rep. Alyssa Black (Chair)]: No, I've been going on and on this whole session about measurements and everything, but I think you actually hit on it, sort of what you really want to measure is you just want to measure access.

[Dr. Elliott (Elliott) Fisher]: I would want also to measure other things, that people are getting, you know, the right, that their blood pressure is getting controlled, we should do that for everybody, the diabetes, and we should do it with run charts that show progress, you know, red, green, and orange signals that just tell you whether you're bad or not.

[Rep. Leslie Goldman (Member)]: Good there.

[Rep. Alyssa Black (Chair)]: Did you have a question?

[Rep. Leslie Goldman (Member)]: Yeah, we've been having a conversation about healthcare being a business versus a public good. How do we, right now in Vermont, it seems more of a business model. And I was just looking at the Massachusetts bill and they're talking about primary care should be a public good for every resident. How do we make that's a huge culture shift, a shift from a business to a public good, and I'm just wondering what you thought about that.

[Dr. Elliott (Elliott) Fisher]: Well, so I think there I know the people in Massachusetts and California who are pushing this idea of a public good, I think it but I disagree on the not a business, because I don't think it's not a business. I think it is we have nonprofit organizations all over the country who are foundations, they're businesses, they have a mission, they track their capacity to deliver on a mission, so I think this is about, the way I interpret and hope we can think about the public good is this is about creating a way that covers everybody and ensures that no one falls through the cracks, and so treating it as, you know, I got, you know, the other kinds of public goods we have, whether it's a public utility, everybody needs electricity, everybody needs primary care, but there's still businesses and we hold them accountable through the structures of accountability that we have. Is that a helpful answer?

[Rep. Leslie Goldman (Member)]: Well, I'm wondering if both can be true. Yes.

[Rep. Alyssa Black (Chair)]: I think

[Rep. Leslie Goldman (Member)]: that's where I'm stuck, you know, that dynamic of business versus, so maybe it's not versus, it's yes and, and how do we manage that?

[Dr. Elliott (Elliott) Fisher]: Yeah, think it's totally yes, and. I get my power from Green Mountain Power, they're a public utility, you regulate them, thank goodness, so they have to come provide me power on the top of our hill when the trees blow them down. So we expect them to deliver electricity at lower cost or steadily, you know, with improved efficiency. And so I think considering that kind of model for primary care, we believe everyone should have it. Now, you know, this cover everyone universal primary care option three, well, we've got some work to do to get there, and I certainly wouldn't advocate jumping there, as I fear that the original version of this bill pushed too quickly with many unanswered questions.

[Rep. Alyssa Black (Chair)]: I actually have a question about what you have in here as far as political barriers.

[Dr. Elliott (Elliott) Fisher]: Can I talk about that?

[Rep. Alyssa Black (Chair)]: Oh, yeah, sure. I'm sorry, I thought you were moving on.

[Dr. Elliott (Elliott) Fisher]: No, no, I'm not done.

[Rep. Alyssa Black (Chair)]: Okay. Good. So, you know,

[Dr. Elliott (Elliott) Fisher]: I was on the business roundtable primary care committee that was running for a while in the fall. I speak to a fair number of business leaders and even hospital leaders who say, woah, how much is this? Are we going to just pay more? Is it going to increase to all of it? Are insurance costs going to go up? Well, who's going to pay for it? Is that me? Is that business? Is it taxpayers? Is it the hospitals? I think they're all quite concerned about that. And then on the other side, you know, who knows whether it will actually save money and how it will do so and at whose expense? And those are questions that I think we need to we would really do well to address, and I'll come to those in a second. I think the second worry right now is, you know, I'm amazed that Steve Loeffler does not have completely gray hair yet, you know, and the hospitals are all, not to mention AHS with the RHDP, with the regulation, the regionalization and now the Rural Health Transformation Plan, you know, there's just a lot on people's plates, so doing those are what I see as the barriers.

[Rep. Alyssa Black (Chair)]: I think I have

[Dr. Elliott (Elliott) Fisher]: But I'd love to hear others that you think, because I could fix the slides and make them better.

[Rep. Alyssa Black (Chair)]: No, I've just been thinking a lot about the approach that we as policymakers, you tend to ask the question, what problem are you trying to solve? And then you identify what you think is the problem. And that is what you start working towards. And I've been thinking about this in terms of primary care. So, what problem are we trying to solve? Is primary care a problem? No. Primary care has a lot of problems, but primary care, it seems as though the biggest barrier is that we don't actually value it, which leads me to the might it actually save money? And we're asking the question, if it can save money, why are we asking that question? What if comprehensive, accessible primary care, what if it doesn't save money at all? And why should it save money? If it's something we value, shouldn't we be paying for it? Why are we trying to make primary care save the whole entire rest of the system saving costs?

[Dr. Elliott (Elliott) Fisher]: Such a great question. Which

[Rep. Alyssa Black (Chair)]: is why I wanted because I saw that. Might it actually save plenty of like, why? Curious if it does or not.

[Dr. Elliott (Elliott) Fisher]: So I think, you know, was reflecting there, you know, I was reflecting there the conversations I've had with people who worry that spending more in an already really expensive health care system not they're not going to support it if they'll oppose it if it feels like it will. And on the other hand, I believe that the slide I showed you earlier about improving care delivery has to include investing in primary care, changing the payment models, and then that it actually might save money, and I think there's strong evidence that it can, that what happened in, you know, in the ACO at University Hospitals Cleveland is they did reduce, they lowered the cost of care in large part by improving primary care. I am confident that we could help people stay out of the hospital by, you know, next day visits and access to telephones for good advice, but if we also don't do something about the hospitals who will want to keep their beds full and their emergency rooms busy, that's where they make their money, we have to partner with those other things. So I think maybe a better question would be, might it actually contribute to saving money? And if so, how? Is that a fair answer? Or at least an understandable answer.

[Rep. Alyssa Black (Chair)]: Yeah, I just think that when we ask the question, we create policies and we create structures to answer the question. And maybe if we just stopped asking that question and we just did things to support and value primary care, like we say we support and value it, that maybe savings would be a happy accident.

[Dr. Elliott (Elliott) Fisher]: I would not be surprised if they were, I think it's fair to say that. At the same time, I think we're going to really want to have structures of accountability so that we are getting the performance that we know is possible in primary care, and we can see it, you know, again going back to Doctor. Prelnovost and there, you know, they have run charts, this little curve that shows how you're doing and improving and care for your practice, they have it for every practice, hundreds of practices, and they are able to say, Well, you're not doing it, and so if you don't start improving, we're not going to keep you in our system. So I think accountability is a fair thing for us to ask if we're going to invest additional resources, which I know we should do, I believe in advanced primary care, I believe in primary care, it needs to be great, and we need to hold them accountable for improving their performance and support them in doing it, because most of them don't know how to do it. That's why we have VPQ. They don't really

[Rep. Leslie Goldman (Member)]: has a question. Well, some of us listen to podcasts by Doctor. Lisa Rosenbaum. You've heard of her, right? Yeah. So she talked about what is meaningful is not measurable. And to me, that describes primary care. Because how do you measure prevention? How do you measure the strokes that didn't happen? How do you measure the MIs that didn't happen? And primary care is so that's why I really struggle with what we measure in primary care because it seems too narrow in this moment, but not sort of looking forward to a more Does that question make sense?

[Dr. Elliott (Elliott) Fisher]: Oh, it totally makes sense, but I think we can measure much more effectively than we are and need to think about it and can do it. I'll give you several examples, I think there's some simple tools that allow one to evaluate whether a primary care practice is implementing effectively shared decision making, that is, you know, it's a three question survey. I'm just writing a paper with a colleague who developed the measure, but I can't remember it off the tip of my tongue. So we can measure the quality of patient engagement and shared decision making, which fundamentally flips the way care is delivered to focusing on what's important for patients. I think, you know, and I think we can, over time, track whether practices are reducing hospitalization rates for their patients, which is I think would be a measure of not just fewer heart attacks, but, you know, fewer exacerbations of heart failure or chronic lung disease. You know, there's some tools that let us, you know, that are currently available but need to be refined, that allow you to measure how well a practice is reducing the risks of future ill health that practices can have. So I think we're not prepared right now to choose them, and I think that's one of the strengths of what I think is the report in this bill on how to move forward with primary care payment reform.

[Rep. Alyssa Black (Chair)]: Oh, I'm sorry. Yeah, go ahead. Mean You were a primary care physician. Yeah. I mean, you still are, but you're not practicing, you indicated. What do you think a patient values? Not a population. What do you think an actual patient values in a primary care provider?

[Dr. Elliott (Elliott) Fisher]: What a wonderful question. Well,

[Rep. Alyssa Black (Chair)]: guess what I'm asking is, what do you think it is and isn't that what we should be measuring?

[Dr. Elliott (Elliott) Fisher]: And I think first of all, we should talk to patients. So if I were sitting in whatever agency you charge with coming up with proposed measures, I think understanding patient experience, and I gave you one measure of that, I think patients want to be included in decisions that are really powerfully effective, that affect their lives. That would be one. I think people want empathy, they want someone who they trust, they want someone who listens to them. These are, you know, listening is actually one of the three elements in the shared decision making survey. So I totally agree with you, we can measure it, but we should not give up on measuring those just because we can't do them out of claims data. That's not a sufficient answer.

[Rep. Alyssa Black (Chair)]: I guess, how do you measure patients ultimately want to know that someone cares about them. Yes. And how do you measure the sense that an individual has that this person cares for me?

[Dr. Elliott (Elliott) Fisher]: Know, Karen Lueders, there is a whole field of people who develop measures of patient engagement, assessment of empathy, and I think the surveys we now use are first missing many of those dimensions, and second, they've done on tiny samples. I think, you know, and I've written articles in the past about embedding measurement in clinical care. Gene Nelson at Dartmouth has done a huge amount of work around, as is John Wasson, in terms of what are some simple tools that practices can use so that they can know whether they're addressing exactly what you're asking, did I feel cared for, did I feel heard? So I don't, we should probably come back to, well I'm not gonna show the elements of your bill for the specific reports, but I think it's a very Oh wow, poor Zurich, I'm pushing back on Zurich, damn.

[Rep. Alyssa Black (Chair)]: All right, can you hold on a second? Sorry, we have to evacuate.

[Dr. Elliott (Elliott) Fisher]: I am running over so far that

[Rep. Alyssa Black (Chair)]: I'm Hi,

[Dr. Elliott (Elliott) Fisher]: Elliot. Hey, Zuri, how are you? I'm good, thanks. How are you? I'm better than I deserve. I can't see you because for some reason my screen won't let me see who's in the room. Oh, okay. No worries.

[Rep. Alyssa Black (Chair)]: At least at least have us safe.