Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Welcome back, everyone. Sorry we had a short hiatus, but we're back. So jumping right back in, Doctor. Fisher.

[Dr. Elliott S. Fisher]: Sure. Well, welcome back. I'm glad everyone is well. And it's nice to be joined by Doctor. Sonoma, who I've known in many settings and respect incredibly, you're lucky to have him testifying. We've agreed that I'll try to finish up and then he can take over when I'm done. Let's see if I'm going to try to do this so I can see you all. I think it might work this time if I can get to the next slide. Why doesn't it wanna go down? Alright. Let's go this way. All right. So I think I can just do this. So some thoughts on the Actually,

[Rep. Alyssa Black (Chair)]: Elliot, can I interrupt you really quickly? Doctor. Song, how long can you stay for? I know that you have a time.

[Dr. Zirui Song]: Oh, thank you so much for asking. I think I'm totally fine through 11:30, maybe even 11:45. So yeah, I'm happy to wait. Thank you for asking.

[Rep. Alyssa Black (Chair)]: Ethan, would you mind if we move to the end? Okay, thank you. Okay, keep going Elliot, sorry.

[Dr. Elliott S. Fisher]: All right, happy to do so. So, you know, my thoughts on S197 is passed in the Senate. The big picture is I think it really lays the necessary foundation for transformation of primary care, and even as I suggested with that model, I was talking about the whole healthcare system, because it's foundational to the improvements we need. But what I think is missing in the current bill, right now we have a crisis, this fear on the part of the public and primary fear of not being insured and the clinicians that life is miserable and their practices are failing. And the current state of primary care for them is intolerable, and we have the growth of these concierge practices or direct primary care practices, which is a threat as people leave, as I mentioned already. So I got to make this thing bigger so you can maybe see it. I would strongly recommend that you make a stronger commitment, even if it is to a future state of attempt to achieve universal access to advanced primary care for all Vermonters, and then think about sending a strong shot across the bow of people who are trying to leave, who are leaving their current practice to join a concierge or a direct primary care practice. But you should do that carefully because some are probably fine if they're not charging people for a lot more for their coverage. So think about how to do that and do it carefully. Can I

[Rep. Alyssa Black (Chair)]: actually stop you for a second there? Sure. Because my dream in my dream world is that everybody is a direct primary care or a concierge and the state pays for it.

[Dr. Elliott S. Fisher]: This is a complicated area. I think the question is really what capacity the primary care practices have to deliver excellent and outstanding care, and you should probably get Craig Jones to talk about advanced primary care and just what strengths other clinicians within the practice can provide, whether it's behavioral health care court nurses who can do care coordination and complicated prescriptions, some practices that are direct primary care do that. I think the solo practice I'm less, I'm more skeptical of, even if I'm not sure a physician is the right person to deliver care coordination or behavioral health counseling. So that I just plant that seed for your reflection.

[Rep. Alyssa Black (Chair)]: Okay, I'm just thinking what if everybody, every provider was direct primary care and the blueprint essentially was the health team that surrounds?

[Dr. Elliott S. Fisher]: I think that's within the Vermont context that may be appropriate for some practices. I'm not sure FQHC should all split up into small direct primary care practices.

[Rep. Alyssa Black (Chair)]: You can have a multi practitioner.

[Dr. Elliott S. Fisher]: There are some great examples, Trellis and Maine, you know, so there are examples of exactly what you're saying, and we should not throw out the baby with the bathwater.

[Rep. Alyssa Black (Chair)]: I'll let you keep going, sorry.

[Dr. Elliott S. Fisher]: Yeah, no, you you can probably ask Zuri these, I mean Doctor. Son these questions as well, so I wanted to make sure I give him some time. So I think that the elements of the bill that are about insurer payment are strong, getting good data collection, payment parity, the per member per month supplement starting right now. I think NCQA accreditation as a valid measure of what a practice is doing or should be rewarded for is insufficient. I think you get paid for certification and they get a lot of money for it, they don't necessarily have to do anything with their certification, so I would not require PCMH certification as a condition of receiving payments, and as we talked about earlier when we were talking about measurement, focus on quality measurement of things that really matter to patients, as you were talking about CareWAC, and then think about rewarding improvement as well. That's a very concise statement for what I know is included in the legislation as they think about quality measures that should be included in the bill. I think the payment reform report is really an essential and important part of the bill, all of the elements that you have included in that long list lay the foundation for what I think is the needed transition to advanced primary care for all, and if you want them to be direct primary care practice payment, because that's all the money goes directly to the practice, which is what I think Doctor. Sung and others in Massachusetts are promoting essentially, but it would not be my understanding of most direct primary care practices. I think that payment reform report puts us in the place where we could make that transition. My only concern about that is having it led by the blueprint, and I've got probably four concerns, I would list three of them here. First is I think the capacity right now with the Rural Health Care Transformation Program falling on them, I think they have a lot on their plates. Second, I think there's a little bit of a conflict, that is, they would be likely to want to only do things with, you know, there would be likely to be biased toward strengthening the blueprint itself when there may be other things that are equally important to do as we think about designing a new payment model for primary care, so there's sort of a conflict of interest there. You know, my experience with when you give AHS the responsibility to prepare reports is that there is no transparency until you get the report, you don't know what they're doing, so that's an issue of trust, and finally, and probably most important, though I didn't write it down here, who has the authority for payment reform in Vermont? I believe you gave that to the Green Mountain Care Board, and so I think their leadership on payment reform puts them in the place where they're experienced and should be thinking about how we move to payment reform for primary care. So I would recommend that you have the Green Mountain Care Board lead the writing of the report in consultation with everybody else. I think what it ensures transparency, we all appreciate being able to go to their meetings, see their minutes on the websites, and I think that will strengthen public confidence, and then I think they have the authority, as I mentioned. I love the idea of moving this to regions, would only, in universal primary care across the Northeast, I would add Massachusetts, especially since we have Doctor. Soom here, and so think asking the treasurer to do that is the right thing to do. I would encourage you to think about how to, I think it's such an important idea, I would think about what else you might do to move this forward that might not be in legislation. Might there be a fall conference that you would get someone to host, or we could arrange to have someone host that would pull legislators from all three states to have a one day meeting about it over the course of the summer or the fall, nominating some way to get that idea further forward for everybody's consideration. And then last, I hear lots of concern about cost in many dimensions, and we hear from California concerns about primary care practice. Are we gonna get paid enough? Is Medicaid gonna pay us enough under this new model? So I think there are good reasons to think about having the proposal, developing to support our development of future proposals, a strong actuarial model that would allow us to evaluate the impact of alternative design options, alternative policy decisions to include in this, comparable to what this congressional budget office does and has to compare different versions of the legislation as it merged, and we have that nascent ability, a pretty strong ability here, but I would build a specific model around the innovations that might be included in this legislation and ask the treasurer to build it or be repaired to have, you know, over the course of the winter or next year, be able to model out for the business roundtable, for the hospitals, for other stakeholders, for yourselves, what's the impact of this bill on each of those stakeholders and on the future cost and quality of healthcare in Vermont? And that's what those models are designed to build, so I'd be thinking about a CBO analogous model, I'm sure you could get that built pretty, you know, they already exist, you can probably build stronger ones, I think. So I'll stop there, take questions, and make sure that we have enough time for you to hear from Doctor. Soom, which will be great.

[Rep. Alyssa Black (Chair)]: I appreciate your comments regarding the blueprint and their responsibility for this. I think those are questions that, I know I personally raised in the committee so far. I appreciate those comments. Anyone have questions for Doctor. Fisher before we move on to Doctor. Song? Really appreciate you coming in with us and sorry for the interruption. And thank you, Doctor. Zaun, for being with us again, like a totally different topic.

[Dr. Zirui Song]: You so much for having me. Elliot, thank you for your wisdom, as always.

[Dr. Elliott S. Fisher]: And yours. I learn a lot from you. I will see you all later. Take care.

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

[Dr. Zirui Song]: Take care, Ally.

[Rep. Alyssa Black (Chair)]: Hi, thanks for joining us. I just thought you were an expert on private equity in health care, but little did I know you were also primary care.

[Dr. Zirui Song]: Thank you. That's very kind of you. My colleagues and I have done a lot of research on primary care over the years, especially in recent years regarding state investments in primary care, similar in spirit to what you're discussing. And as a practicing primary care physician, I do often think about this, the state legislation regulatory options, what states have done, what we've studied, what we've learned from other states, and how it really funnels down to the front lines of care delivery and what happens in our clinics. I see patients in primary care two days a week, two half days a week. So two days out of the week, I go in and try to kind of continue living the spirit of what primary care is meant to be on the front lines for our patients. It remains a humbling experience. It recenters me every time I'm in clinic. And when I come out of clinic and go back to the research and policy world, it really is helpful to think through what states are doing and its impact on the frontline providers. Also, many of the things you've heard from my colleague Doctor. Fisher and others probably involves the changing landscape of the workforce. Primary care physicians retiring earlier, leaving the workforce, dialing down their FTE portion in clinical practice, or exiting to the more free market models of concierge and direct primary care. I have a similar feeling about direct primary care, as you just noted, Chair, which is that in an ideal world, we ought to have every patient have access to a personal physician in a direct primary care kind of mechanism. How we get from here to there is rather complicated. It's both a financing issue. It's also a workforce and training issue. But I have sort of that kind of North Star as you do too. So I'm happy to talk about primary care from many of these perspectives. I have some prepared materials that I can put up as slides. But I also would be happy to if you wanted to start with key areas of the discussion that you want to dive more into, I would love to start by listening to you and get a sense of how I could be most useful without simply going through my prepared materials.

[Rep. Alyssa Black (Chair)]: Love to see your slides. I think Leslie has a question, and then I have a nagging question that maybe as you go along, we'll we'll fill in answer a little bit.

[Rep. Leslie Goldman (Member)]: No. My my question was for you to present your idea. Oh, well,

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

[Rep. Leslie Goldman (Member)]: Maybe not in public yet, but but but the idea of access and how do we measure

[Rep. Alyssa Black (Chair)]: How do we measure? Well, I'll just say that some of

[Rep. Leslie Goldman (Member)]: us listen to Doctor. Rosenbaum's podcast about primary care and she says, How

[Rep. Alyssa Black (Chair)]: do you measure or how

[Rep. Leslie Goldman (Member)]: do you value the immeasurable? And that was what we were thinking about primary care is what do you actually measure to understand the value?

[Dr. Zirui Song]: Got it. Okay.

[Rep. Alyssa Black (Chair)]: Think the thing I've been thinking about through this, because this is yet another sort of primary care reform or, and I put in quotes, saving primary care. And Doctor. Fisher uses it. We're in crisis. And that we're framing the question as if primary care is something to be saved.

[Dr. Zirui Song]: And

[Rep. Alyssa Black (Chair)]: in every state legislature, within Vermont, we've gone through all these various payment type reform. And I'm wondering, and you said this in your opening a little bit, have we done too much? In our effort to save primary care, have we inadvertently destroyed what makes it special and valued? Have we, in an effort to save it, sucked the value out of it?

[Dr. Zirui Song]: What a great question. My gut sense is

[Rep. Alyssa Black (Chair)]: Hold on for that. All I just want you to know, I think about this step 20 fourseven. That's really sad.

[Dr. Zirui Song]: I'm with you. I'm with you. Yeah, I'm totally with you. What a deep, profound question. My gut sense is no. I think about this rather constantly as well. Maybe just as a quick point of background, I currently serve on Governor Healy's Health Care Affordability Working Group for our state, which started a couple of months ago. Primary care is a big part of that discussion. My work on the working group actually has focused a lot more on prices, quantity, spending growth, payment models, actually more so than primary care, just from my training as a health economist more broadly. But we have a part of the working group dedicated to primary care that one of my other colleagues is leading. And this is very central to the broader affordability effort of total health care spending for our society. As you know, much of it financed by taxes and workers' wages, especially wage growth in the commercial sector. We, as a society, are essentially financing health care spending growth through lower wage growth and on the tax side through deficit spending at the federal level and a lot of personal and business taxes at the state level. So the reason my gut senses no for your question is that we have tried to save primary care, which is a phrase that I use too, not really in an advocacy sense, honestly. I just think if we think about what policy efforts for primary care have been trying to do, it's been trying to stop the bleeding. We are actually losing workforce and access in primary care just as an aging population demands more of it. The two things are going in opposite directions. And that's why it's a crisis type feel. So I think saving primary care is the right framing. And let me

[Rep. Alyssa Black (Chair)]: ask you a question, though. Are we losing workforce because what we've done in our efforts to improve? Have we dumbed down primary care?

[Dr. Zirui Song]: No, I don't think so. I think we're losing workforce and access because of economics, honestly, because of incentives, rational behavior, free market, and economics. I think the policy efforts have been incredibly well intentioned. And I can illustrate very quickly how well intentioned they have been and and part of the reasons why they haven't worked. This is all federal and state, honestly, and more of a federal history, which we don't need to spend a much a lot of time on. So I can quickly go through that. Yeah. That'd be great. My slides. Okay. I just sent a request for sharing my screen. Thank Okay. I hope you can see my screen here, which is a slide with a green background. Okay.

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

[Dr. Zirui Song]: All right. Thank you. I know that Elliot covered some of this. This is part of the workforce shortage that's much of the underlying foundations of the crisis that we face. What I want to illustrate with this is simply the point that even for medical students and residents who match into primary care tracks of medicine residency programs, only about onethree of them stay in primary care by year three. Doctor. Fisher's daughter, one of my close colleagues at Mass General, she was a primary care resident, a chief resident in primary care. And she's practicing primary care locally in your state, which is incredibly inspiring and a great story. She's now an educator of residents in your state in primary care. And one of her residents is now doing the same thing in Vermont. And I have colleagues. And I myself as a graduate of the primary care residency program and still practicing primary care. The worry is that fewer and fewer of us coming out of primary care training tracks actually stay in primary care. And you can see that most of our colleagues are going into hospital medicine. And so inpatient hospital medicine has pulled most of the primary care trainees. This is across the country. And so you have these estimates of big shortages. This federal quick history, well intentioned, which is part of my gut answer to your question, is essentially that on the left here, in both the Biden administration and now the second Trump administration, CMS has taken action to try to pay primary care practices more. In 2025, there were these new primary care advanced care management codes, advanced primary care management, APCM codes that were added to the fee schedule. And they would allow you to get pretty large, pretty substantial per member per month payments if you just code them and bill them as a primary care clinic in this country for a Medicare patient. And then in 2026, just this year, the Trump administration followed up on the shoulders or the heels of the Biden policy and put in three more codes that similarly primary care practices can bill and receive pretty substantial amounts. And this paper that I wrote last year shows just down here at the bottom left. The twenty twenty five codes give you this much, just literal dollars per member per month. And the twenty twenty six codes, which were for behavioral health integration, if you had a patient who needed behavioral health co management in your primary care practice, if you just bill one of these three codes, you would get this many dollars per member per month. This is substantial. It's real money, quote unquote. And it's not yet clear what this will do for our primary care practices. But what does history teach us? History teaches us that of all of these new codes we've added into the Medicare physician fee schedule to try to save primary care over about twenty years, generally speaking, for the vast majority of them, they are billed in less than ten percent of cases where they could have been billed. And that lesson is so striking. This is a great paper done by my colleagues here and elsewhere, which showed that all of these new codes we've tried over the years at the federal level, alcohol counseling, smoking counseling, behavioral counseling, weight management counseling, wellness visits, advanced care planning, chronic care management, transitional care management, I bill some of these still. We still do this. It's just a nationwide the billing rate, as you can see in this red box, the share of eligible patient visits where you could have billed this and gotten a subsidy and you did not bill it, is large. So the share that's actually billed is less than 10% in almost all of these cases. So what does that teach us? I've talked about this with lots of colleagues across the country. What does this teach us for efforts to save primary care? Well, one lesson is just by putting a new code into the fee schedule and putting money behind it doesn't mean that those dollars get to frontline primary care. You have to make sure that the practices are billing them or actually doing them. More important than billing them is actually doing the work behind the codes. That's a slower transition. That requires you to hire more people, have the infrastructure, create the time to do the counseling, and then, oh, by the way, build a code. The second federal lesson, which is a study that my colleagues and I just published this is my colleagues at the Urban Institute in DC is this overall question of, if you just compare two recent years in your top right corner of the screen, you should see 2017 and 2023. If you compare these two recent years and you ask, as our nation's population has gotten older, as more people have gotten onto Medicare, and as Medicare has had to spend more on people needing more care, including primary care, do you think we as a country have spent more on primary care? We probably should be spending more on primary care even if we were not subsidizing it. Just by aging alone and need alone, we should probably be spending more on primary care now than six or seven years ago. Or you could say as a share of total spending, we probably should be spending a little more on primary care now than a bunch of years ago because people just need more care and your good old office visit, it's still the most voluminous, most frequent medical service that's done in this country. Well, that guess, that educated guess that we're probably spending more is perhaps not surprisingly not true. We're actually spending less as a country, both in absolute terms and as a share of total for primary care. And you might ask, why is that? For twenty years, we've added these new codes. We've tried to save primary care. There's been a crisis that's been slowly brewing forever. Maybe we're just frogs in the hot water that's brewing. But it's not like we don't know how are we still not spending more. Well, one of the takeaway lessons from this study is if you try to save primary care through the physician fee schedule, it doesn't work that well, because at the end of the day, primary care only takes home 28% of all office visit spending. So if you try to subsidize or save primary care through office visit codes, 72% of that subsidy is taken home by specialty colleagues. This is not to say anything. This is nothing negative about our specialty colleagues. They do office visits, too. They do a ton of them. They take home threefour of office visit spending because they're doing a ton of office visits. It just tells us that this is not a great mechanism for trying to save primary care. So I'm going to skip over these couple of things. States are trying to take a different approach, as is Vermont here, which is shaded green in this map. We have a study recently from last year that is basically summarizing five states that have initially moved in this effort to save primary care by increasing investment or spending in primary care. These states are listed here. These are the bills. These are what the bills are trying to do. I'm sure you know all of this already, and it's all in the public domain. So the details are less important than the spirit of multiple states rowing in the same direction. But I do want to talk about some of the details. With Rhode Island as the first mover, as you know, my colleagues and I did an initial evaluation of this. I can't believe it's about seven years ago now, this study. But basically, we looked at the first few it was actually the first seven years from 2010 to 2016 of this Rhode Island effort to invest in primary care. And look here. It looks really favorable. And I thought they did an incredibly thoughtful and good job at designing this package of state level policies to try to invest in primary care and make health care more affordable. Rhode Island, I think, deserves a lot of credit and gratitude from other states for showing how one version of this could pan out. If you look at total spending in Rhode Island, which is this blue line, it slows relative to the control group. So Rhode Island's total spending this is just in the commercial sector definitely slowed relative to the control group. And the control group is pretty well matched. You see that before Rhode Island did this, the three years before, health care spending was essentially growing at the same rate. The declines are pretty parallel. And then Rhode Island slows down. The key question is, did Rhode Island's total health care spending become more affordable because of the primary care investment? So we sought to answer that question. And unfortunately, from a primary care perspective it's only unfortunately from the primary care perspective, but still fortunately overall. Spending slowed not because of the primary care investment per se. Spending slowed largely because Rhode Island also layered on top hospital price controls, price growth caps. That does the heavy lifting in terms of total health care spending growth slowing down. But the primary care side is still rather substantial. I've just plotted this out recently working with the Rhode Island Office of the Health Insurance Commissioner, our prior colleague, Chris Kohler, our current colleague, Corey King. Credit to Corey for supplying us with this data. But this is total primary care spending in Rhode Island, total aggregate in terms of millions. They have moved a lot of investment into primary care. Over here, dollars 48,000,000 total in primary care in 2007, and by 2023, dollars 84,000,000. Underneath this total, I am showing you this orange subset that is non fee for service primary care spending. So Elliot mentioned this. You've discussed this in the past. When you want to save primary care by adding investments into primary care, should you do it on the fee for service fee schedule, or should you do it off the fee schedule? In Massachusetts, I've been a part of this grassroots effort to work with our state legislatures and our state policymaker colleagues on this question because we currently have three state bills in the current legislative session on primary care investment. And the three bills are all rowing in the same direction. They have some key differences. But one of the questions in this last handful of years is, how do you do this kind of investment? Rhode Island has demonstrated that they've done basically most of this investment, if not all of it, through non fee for service mechanisms. So as the blue line has grown, as total primary care spending has grown, the non fee for service portion of it has grown in parallel. So that leaves you this gap in the middle, which is the fee for service portion of it, that's pretty much stayed the same. If you squint, you might say it's declined a little bit. I would just say, roughly speaking, it's pretty much stayed constant. The real growth in total primary care investment has been the non fee for service portion. And so I only have a few slides. And where I wanted to end with you and then we could hopefully have a lively discussion is, how do you do this in the non fee for service part of our world? And why would you not want to invest in the fee for service way? Like, you could do the fee for service type of investment. It's a viable solution for sure. Many stakeholders might actually prefer that option. It's just that if you do it that way, there are some trade offs that are worth thinking through. So we might if you would like, we could definitely dive into that a little bit. Here are our three bills in the current legislative session in Massachusetts. The bill in the middle here is led by Senator Cindy Friedman. The bill is a primary care investment bill. It's a thoughtful, serious effort, substantive. And it also includes a lot of help for community health centers and behavioral health. The bill here on the left is Representative Rich Hagerty's bill, also rowing in the same direction, thoughtful, serious effort to invest in primary care. Its key distinction here is that it has a primary care stabilization fund, and I want to describe what that fund is to you in a diagram in one second. The bill on the right is sponsored by Representative Greg Schwartz, who's a primary care doctor himself. And this bill, same thing, rowing in the same direction, serious substantive effort to help primary care with a Medicaid GME component. The bill here on the left with the Primary Care Stabilization Fund speaks to this orange part down here. How would you design a non fee for service kind of investment in primary care? This is the Green Mountain Health Board kind of thinking that Elliot was talking about. If you write a kind of investment that is off the fee schedule, how might an independent body or any state agency, whether it's on the executive side or the legislative side, think about designing this kind of approach. So that's where I want to land. I just want to give what you and Elliot said about concierge and direct primary care one other piece of evidence here, and then we'll go to the primary care investment design. So the motivation for giving you this little bit of background is simply that it's not that the federal government is the only entity trying to save primary care. It's not that states have been the only entities trying to save primary care. The private sector has also tried to do something about primary care, too. Its approach is quite different. It offers a competitive alternative to traditional primary care practice. This paper from last year down here describes what concierge models look like and what direct primary care models look like. It describes their differences as well as their similarities. It describes the intended main effect of making primary care easier, more enjoyable for doctors to practice in and more profitable a lot of the time, and making primary care easier and more enjoyable and more accessible for patients, patients who can afford it. And it talks about the spillover effect onto the rest of the primary care system, the so called traditional practices who, in the short run at least, are left with fewer hands on deck to practice primary care but more patients in need of a primary care clinician. So it talks about that kind of emerging reality. But the point I want to make here is that while the private free market has responded to the primary care crisis in this way, it has also tried to do other things. It has tried to respond. It has provided this kind of alternative practice model that's membership fee based or retainer fee based in other specialties too cardiology, radiology, surgical specialties, endocrine, pediatrics, psychiatry since the 1960s. It's in a lot of places in our health care system. So it's just growing, and the companies behind these are growing. If you look at a more concrete quantitative sense of how much this is growing in primary care, I can offer this study that was just published last year that gives you from twenty eighteen to twenty twenty three the lower bound numbers. This is the number of doctors, the number of nurse practitioners, and the number of physician associates or physician assistants that have gone into concierge and DPC practices nationwide. And we break it down by state. It's a lower bound because these are clinicians and practices that we know for sure are now concierge or DPC. But there are a lot of practices on top of these that we just don't know for sure. So we're being conservative with our numbers. Conservative numbers show you that the number of doctors has gone up from 3,700 to 6,300 nationwide. Increase. The number of practices have gone up from 1,400 to 2,400 across the country. That's a very similar, roughly 70% increase. The clinicians share who are MDs or physicians in these practices has gone down from about twothree to less than 60% or roughly 60%. That's a bit of a decline. That means that as these practices are growing, they're being increasingly staffed by non physician colleagues who are incredibly important and wonderful to work with and keep our primary care practices alive and afloat and absolutely necessary. It's just showing you that the forms of labor have changed a little bit. Of course, physicians are higher cost forms of labor. Our MP and PA colleagues are lower cost forms, less expensive forms of labor from the labor market perspective. So practices are making that trade off. But one of the striking features that ties back to our private equity conversation, if you recall back to that discussion earlier on, was that while the pursuit of concierge and DPC practice has been motivated by the desire for autonomy and independence, You might hear this from our primary care colleagues in many settings. They say very compellingly, and I think they're totally right, that the corporatization of health care delivery writ large, including private equity but not restricted to private equity acquisitions, has made it feel like we have less autonomy and less independence as primary care clinicians in the real world. And so there's this desire to recapture the joys of practice, to recapture autonomy and independence. And that's a big motivator for leaving primary care traditional practices and going into concierge and DPC models. The striking evidence, though, is that while this migration I won't say mass migration. I just don't want to overstate this. But while this migration of clinicians out of traditional practice is definitely happening right in front of our eyes, Independent ownership is actually dropping. The percent of concierge and DPC practices actually independent owned, where you have autonomy and independence, has dropped from 84% to 62%. What has taken its place? Corporate ownership, corporate affiliated ownership. That has increased fivefold. And so this is another illustration that the economy knows where to go. The private sector, the free market knows where to go. It knows where the demand is. It knows where the supply is moving. And even as physicians are pursuing autonomy and independence again, that very autonomy and independence is shrinking because concierge and DPC practices are increasingly corporate affiliated. So let me get back now to this is my last slide. This is or maybe second to last. But this is basically the last thing that I wanted to show you. So where we've landed is the federal government's tried to help for twenty years. They've done a lot of hard work. Honestly, I think we should give a lot of credit to our federal colleagues over multiple administrations, Democratic, Republican. It hasn't mattered in this perspective. Saving primary care has been rather bipartisan. CMS has worked really hard, but their tool is the fee schedule. And so they've tried over and over again with new codes for twenty years and you've seen how that's played out. It's been substantive, meaningful subsidies to primary care, but most of the time, primary care has not been able to bill and get those. Whether it's lack of capacity, lack of hands on deck to do this in the clinic, just not enough time, not enough opportunity to do the counseling, build those codes. That's been the reality. And yet our federal colleagues are still trying. They haven't given up. Twenty twenty five new codes from the Biden years, twenty twenty six new codes from the So second Trump that's the federal story. The state story, as you know, we're living it. And the private sector story we just went through. So this is where I want to take a quick pause and just finish with, if you were thinking about designing the state level investment in primary care, what are your fee for service options and what are your non fee for service options? So let me pause here, maybe answer any questions, and then I'll finish with this last part.

[Rep. Leslie Goldman (Member)]: Can you just what's the word in the top of your tile or whatever your face is covering a word? So the idea of a common and what's the word? Fund. Fund. Okay. Thank you.

[Dr. Zirui Song]: Got it. I'm so sorry. I realize I'm on the upper right hand corner for your screen.

[Rep. Leslie Goldman (Member)]: Yeah, no worries. I really appreciate that. Yeah, thank you.

[Rep. Alyssa Black (Chair)]: I will just editorialize a little bit.

[Dr. Zirui Song]: I

[Rep. Alyssa Black (Chair)]: was a billing manager for a primary care practice for almost thirty years. I've seen every single one of those codes come along, and I can tell you why they don't get billed is because of the documentation requirements that go with them.

[Dr. Zirui Song]: Oh, great point. Yeah, I should have mentioned Thank you.

[Rep. Alyssa Black (Chair)]: The administration just to document and it doesn't mean the service isn't being done. It means that it's too onerous to document.

[Rep. Leslie Goldman (Member)]: Yeah, was what I was looking at. People are doing all that stuff.

[Dr. Zirui Song]: Exactly. I was totally going to say this too. When I talk to practices about these codes, they mentioned documentation, so I should have mentioned it. And then when I think about how we're trained in primary care and what we do in reality every day, we're doing this counseling all the time. We're just not billing an extra code for it. Yeah, you're As totally

[Rep. Alyssa Black (Chair)]: if you're not counseling your patient on alcohol misuse if you've identified alcohol misuse or cigarette, any of it. As if you're not going to do it just because there's not a code to do it.

[Dr. Zirui Song]: Right, exactly. Yeah, the code is well intentioned, and we haven't been able to save primary care through these codes. Can I mention another thing about the codes on the fee for service front? Yes. So I just did not include all the slides on that. I've worked through those slides with our state legislative colleagues for all these recent years. And we could spend a lot of time on that. But if I try to summarize it, if you live in a fee for service context, the challenge of trying to do this primary care investment is that you are limited first by state authority, as all of you know, the ERISA preemption issues. So it's difficult in most states. Vermont actually is special and an outlier in this case because of the way you've set up the board and the way you could do this. But in most states, if you live on the fee schedule, you basically can only touch the fully insured lives, Medicaid, state employees. And so in most states, that's less than 50% of the population. And of course, federal employees, the self insured through ERISA, and the VA, and Medicare. Everybody else, you can't really directly ask their insurance provider, their carriers to spend 1% more on primary care every year, like the Rhode Island Spirit. So that's one thing. The other thing, which I think is much more of a market economic reality, is that in every state, you have differences in market power between provider groups. So when you ask primary care spending to go up by 1% each year, let's say, as a share of total spending, that just turns out to be a different dollar amount per person based on your market power and based on what your payer mix is. So there's this inherent inequity that's driven by market power forces of doing this on the fee schedule. And the other thing is if you say our state goal is to increase primary care spending by a certain amount, well, then a provider organization can achieve that goal, because it's a spending goal by either raising prices or raising quantities. Spending is price times quantity. And so then the immediate question is, would you, as a state, on the fee schedule if you work on the fee schedule, would you want the incentive for your providers to be, let's negotiate for 30% or 10%, whatever percent higher prices so we've checked that box, we've met that spending target? Or if we don't have the market power to do that, do I have to get my physicians in and just crank through the treadmill of more visits, more visits, more visits? Do it through volume to check that box of additional primary care spending. That was a reality facing a lot of state discussions. I've sort of experienced that this is a very substantive part of the discussion. Because if you think through in any given state, Okay, what do our provider delivery landscape look like? Do we have a lot of independent practices without so much market power? Do we have large health systems with large market power? It shifts the way you think about this because some of the providers in your state can easily meet a spending target by increasing prices through price negotiation, especially if the ERISA preemption means that the state can really oversee fully insured commercial lives. Because then for that fully insured market, if we just increase the prices per unit of primary care services, we're going to meet that spending target. But that's probably not the intention. It's part of the intention, getting more money into primary care. But using market power leverage to do that without changing delivery of care on the ground is probably not the full intention. Similarly, if your small physician practices in a state don't have the market power to raise their prices and must crank through the volume lever to meet the spending target, then is it our intention that we want to simply have those small practices work 1%, 510% harder on volume just to get the RVUs in to meet that spending target? I think that the burnout version of the world in primary care probably argues against that. So these are just two things, if you work strictly on the fee schedule, we have to contend with. Now, so the alternative, obviously, is what would you actually do if you step off the fee schedule? So we've had this discussion in Massachusetts. As many of you know, Massachusetts, through last year, a last year's state law established a primary care task force. A lot of great colleagues in the task force. All of their meetings are online and on the Health Policy Commission website. And they've talked through a bunch of these details as well. I'm providing you a version of this in this diagram that is it's meant to be one example. Not here intending to persuade you or push this or advocate for this in any way. I just want to show this as an example of one thought process of if you actually step off the fee schedule and avoid the fee schedule problems, market power, payer mix, a risk of preemption, not being able to touch all the lives in your state, or touching only a small share of lives in your state. If you wanted to overcome those problems, how can you do it? So this happens to be in a paper forthcoming in JAMA next month. And the title of the paper is what you see here at the top. And the motivation is when people flip on the light switch, they expect electricity to flow. When people turn on the tap at the sink, they expect clean water to flow. Electricity and water are examples of public utilities. Because they're public utilities, they guarantee some level of universality. There's some intention of universality there. Elliott's first slide, if I could recall, was that primary care has been long thought of as a common good, just like other public utilities. I mean, the National Academy of Science, Engineering, and Medicine, in their landmark 2021 report, literally called primary care a common good. And so we tackled this issue of if you step off the fee schedule and you approach primary care as a common good in this public utility sense, how do you actually finance this and pay for primary care and organize it in this way? What this diagram shows is the idea of a primary care common fund. If you treat primary care as a public utility and less so as a set of on a fee schedule, a set of codes on the fee schedule, then you can pay for primary care from a common fund. Now, the common fund can start with no new money. So the idea here is not actually strictly attached to state investments in primary care. The actual concept doesn't have to have you putting more money into primary care. The actual concept just starts with all of the purchasers of primary care today, states, Medicare, other federal, I mean, Medicare and federal employees and so forth. But we can just think about it as Medicare. States, Medicare, commercial plans, self funded plans. All of these are our major purchases of primary care today. They spend roughly 5% of health care spending on primary care today. They spend it through the fee schedule. And the idea is if they simply put the same amount of dollars into a primary care common fund, this is before you even increased primary care investment at all, you could, through a primary care common fund, directly disperse primary care spending to the practices. You could still do a fee for service if you really wanted to, but you could do it in a non fee for service way. As Elliott talked about, as National Academies, as the American Academy of Family Medicine, the American College of Physicians, the Society of General Internal Medicine, all of these national bodies have essentially argued for this, that primary care either should be or could be, they vary in their intensity of the language, paid for in this non fee schedule, non hamster wheel, more of a population patient based holistic way, per patient per month, PMPM. So you could do this. And of course, as Elliott said, there are many stakeholders in many states worried about total cost. What does this do for the rest of the delivery system? I can tell you there are also, you think of this as universality of primary care, you might receive questions right off the bat of, well, does this mean the rest of the health care system? Is this a slippery slope towards a single payer type of thinking? And I would emphatically at this point say no. This is distinctly different from single payer.

[Rep. Alyssa Black (Chair)]: I'm sorry, I'm laughing because you said that. I'm like, that's good. We can only think that we can't say.

[Dr. Zirui Song]: Well, So I mean, it depends on the setting. It depends on the audience, of course. But there's a conceptual thing of we've been talking as a country about single payer Medicare for all and parts of health policy reform. But this is distinctly different because we're just talking about primary care here. For all of the stakeholders and entities in our health care system, our broader ecosystem, who would want to oppose single payer or oppose Medicare for all. And we, of course, understand how that's the last twenty years have taught us very clearly what that looks like. This is distinctly different. The 95% of current health care spending that's going outside of primary care, you can just leave untouched, unchanged, status quo. You've got the same private insurance, same public insurance, the same negotiations over fee schedules and RVUs and ACO contracts. That is undisturbed. So yes, it's asking 5% of our current health care system to think about primary care differently, but it's also saying to them 95% of your current status quo is not intended to be disrupted here. That's the basic thought process. How do you start this conversation about thinking about primary care as a public utility through a common fund without creating the 95% of backlash that would come in a broader single payer conversation, which this is not. And we wrote it as not that. And I could not be more clear about this, but our paper really spells this out. That is not the intention. The intention here is not a slippery slope. But what it does allow you to do is get out of the problems with investing in primary care on the fee schedule. And the final thing I wanted to mention is this plus legislative growth down here at the bottom. So right now, America spends 5% of health care on primary care. What if you wanted that to be six? Or if you're Rhode Island, you wanted that to be 11? Or if you're California, you wanted that to be 15? Whatever your goal is, the primary care common fund can be the destination for current spending plus any legislative growth. And it's the same thing you would have done. You would have assessed your commercial plans to please spend more on primary care. You would have required Medicaid to please spend more on primary care. You might have had an eleven fifteen waiver or an agreement with CMS that for our Medicare population, for our older patients, we want the same kind of primary care investment. Whatever the vehicle, the intention of investment in primary care can all land in the common fund just as it can stay on the fee schedule. But the common fund avoids the problems of the fee schedule. It allows you to touch all of your state's lives, allows you to think about primary care like a public utility, not as a commodity that is higher priced or lower priced depending on what insurance you have, not as a commodity where our investment is either available or not because you have this type of insurance or you don't. It's sort of antithetical to the idea of a public utility. And so I have here four bullet points that we talk about in the paper outside of the mechanics of the advantages of a common fund. Let me just spend one minute on this. Consumer freedom. Why is consumer freedom a part of this? You might find some of these phrases to be a little bit unexpected or odd in this kind of discussion. But consumer freedom is really important because right now, a lot of patients are locked into health insurance through their jobs. As you know, America, this is a employer sponsored health insurance kind of world for half of our patients in this country, half of the country's lives. And if you wanted to switch a primary care doctor, it would be hard. And if you switched jobs or switched plans, you would fear losing your primary care doctor. That'd one of your first questions. Do I still keep my doctor? The primary care common fund solves that problem. If you switch your doctor, the common fund just stays with you because it's an investment directly to the practice. It's that you can switch your doctor if you want to and if you can switch a job because your primary care relationship is connected between the common fund to the primary care practice. You can switch any jobs you want. And even if your employer sponsored health insurance changes for your other 95% of health care spending, you can just stay with your primary care doctor, at least, because that primary care practice is just paid through the common fund. It's not an employer sponsored requirement of you having to pick a plan then pick a doctor. So there's real consumer freedom there. This is not simply coded language in any way. This is actual consumer freedom that we don't have if you invest in primary care on the fee schedule. Purchaser alignment, that's obvious. That's purchaser alignment. State choice is really important here. This is not a federal top down kind of thought process. Some states would want to pay their primary care practices still largely fee for service. You can still do that. Some states would really want to move heavily into per patient per month, like Rhode Island. You can do that. And some states would prefer a hybrid system where you keep a portion of primary care spending fee for service, and you move the rest into a per patient per month population based kind of payment. And you can do that too. So state choice, whether it's a Green Mountain Board or a health policy commission in another state, or each state has a different kind of public body for this, you can make those types of choices. This could be a regulation. This could be a legislation. It's flexible in that regard. So we actually substantively mean that there's state choice and purchaser alignment. Administrative burden reduction is quite clear for any of you that have seen how practices are run. If you are a primary care practice receiving these many different fund streams from many different payers, public and private, they've all got different rules and different payment rates and different contracts. That's just a lot of administrative work. And they also have different quality measures. If they all pooled their funding into a primary care common fund and you are now just receiving one revenue stream for all the patients in your practice, there is absolutely administrative burden reduction. The quantification of that, like how much administrative savings you would get, differs a lot by the type of practice you run, but it can be quite substantial. And if you, as a primary care practice, can turn your administrative costs into margin, that matters a lot. And so again, this is not coded language, but this is a substantive thing. Philosophical compromise. We talked about how this is not the traditional single payer for all of health care spending, because this is distinctively not that. This is also not your usual free market, let primary care just be a commodity type of approach either. From the left and from the right, this is pretty much a compromise in the middle. Many advocates of more free market or market oriented approaches, they value consumer freedom a lot. They value state choice a lot. They also value administrative burden reduction a lot. Our colleagues at the federal level from both Trump administrations have really prioritized burden reduction for America's doctors. This achieves that. And so the philosophical compromise, which we have two paragraphs on this in the paper, it just lands right in the middle. So let me stop here. This is just, again, one example of doing a non fee for service approach to primary care investment. California did pass a bill last year that says this kind of, basically. We don't have to spend much time on that. So this is not totally out of left field. In our paper, we talk about the precedents that states have for funding a public utility like this. So I will stop there. This is just one example. I don't want to be trying to persuade you or advocate for this. This is just one example of how you do this off the fee schedule.

[Rep. Alyssa Black (Chair)]: You may have done that. I was going to ask you if you can send me your paper. And your slides. And your slides, yes.

[Dr. Zirui Song]: Happy to.

[Rep. Alyssa Black (Chair)]: Yeah, if you want to take the slide down so we can have a conversation, so we don't have you in a little teeny tiny box. I think one thing that I'm struggling with a little bit is, in my experience Okay, we acknowledge the entire fee for service structure is not designed for primary care. In fact, it disadvantages primary care more than any other specialty that there is. It has been designed for other care, for specialty care and procedure based care. One of the problems that I have with people saying, Well, you should just spend more, It's just reiterating the failed. We admit that fee for service fails primary care. So why on earth would we be increasing it? Which is why I love your common fund. But what we tend to do is when we change a payment model, we then feel like we need to justify why we're paying it, which is why we end up with meaningless measures, measures that measure value to the payer, but don't really measure value to the actual patient. And so how do you balance, how do you do no harm by establishing a new payment method? How do you not create harm by overanalyzing it and making it prove its worth? It's like we make it prove its worth.

[Dr. Zirui Song]: Yeah, I resonate with everything you said. It's so striking that over the last thirty or forty years or so, we have thought a lot about the value and the worth of primary care. And every primary care program and its evaluation has been tasked with trying to show that it saves money on total health care spending, which is an incredibly high bar to levy onto primary care. We have not asked our wonderful, amazing specialty colleagues and the other 95% of health care spending to prove worth in that regard.

[Rep. Alyssa Black (Chair)]: Thank you. Or prove your return on investment.

[Dr. Zirui Song]: Sure. Yeah. And look, they save a lot of lives. They do amazing things. And in some situations, like if you're a transplant surgeon, your worth is in the person living after the transplant. And it's kind of like a clear thing. So I can understand why primary care is always tasked with that because we have this gatekeeping kind of function. If we do our jobs well, shouldn't we prevent disease, and shouldn't we prevent health care spending downstream? So I understand the ethos of that. But I think, as we've done in our Massachusetts discussions all these years, we've thought a lot about what are the relevant measures of success for a primary care investment. There's pretty broad agreement. Just my personal testimony from my personal summary of the discussions over the recent years. I think we have pretty broad agreement that we should not peg the success of a primary care state investment on total spending reductions or slowing of total spending downstream. That is essentially not the goal and it's probably asking for too much and may set this up for failure if that's your metric of success. But instead, ask what's important in primary care. You can start with the patients of what patients value. One of the things that is immediately clear when you do that is continuity. That continuity piece, we have rarely measured in academia, believe it or not. We have some papers on it. It's not that we have nothing. It's just that for every 100 studies on primary care, only a few try to measure I would say less than a few try to measure continuity. But patients, especially these days with PCPs retiring or going to concierge, one of patients' foremost concerns is, will I get to keep you? Will I still have my relationship here? Continuity, great measure of success. There's a nice review paper, sort of evidence in academia that shows continuity of primary care is correlated with better outcomes. Now, it's not a randomized controlled trial. It's not hard, hard proof, but it's pretty compelling. So I would say measure continuity. Then there's a whole bunch of easy quality type things that we do have to be thoughtful about this. You don't want to get carried away with quality measures where you go to this sort of teaching to the test menu of box checking exercises. So the thoughtful process is pick the few things on quality that you think really matter. They can be the types of measures we've had for decades, like the HEDIS type measures. It can be that. So for a person of this age, what is the mammography rate, the colonoscopy rate, the vaccination rate? It could totally be that. We've done that for a bunch of years. I don't think it's transformed primary care. We've gotten dollars into primary care through that mechanism. But we could probably do things differently. You could have measures like downstream hospitalizations, ED visits, chronic disease management. You could do that kind of thing. You could also have slightly more, maybe you would argue, creative measures, like simply behavioral health integration. The measure is, for all of your patients with behavioral health comorbidities, do you have a strategy, a co management strategy? Hey, by the way, today, you can take advantage of new CMS codes to do that. There's extra money on the table. But do you have a strategy for that? That itself is a kind of quality type measure. It's more process than outcome, but you can do that. So we can have a much longer conversation about what you would actually measure. But fundamentally, I agree with you that we don't want to overdo this to the point of making this a box checking exercise of diminishing the value of what we're trying to get at here. We are trying to preserve a field that to most people feels like a common good in a public utility that is increasingly becoming a commodity, in large part thanks to our colleagues in the free market who are trying to do the best they can to provide a better quality of life for our colleagues. And I don't fault any of my colleagues for leaving for concierge. I know the reasons and I'm happy for them that their lives are easier. I just worry about the rest of us in the traditional practices that now have a harder time filling the needs. And so in the short run, if you're not gonna train 10 times more PCPs coming out of residency every year, you need a short term solution for filling the gap. And I think the Common Fund is one example. Again, this is not an advocacy exercise. I think it's one way of thinking about it that gives you a framework for avoiding the problems of the fee schedule, which I do think are real. A lot of states are still on the fee schedule path, and it's just a limited approach on the fee schedule.

[Rep. Alyssa Black (Chair)]: And we have, I mean, in the past through our ACO, we have had per member for months. And my concern with is the inverse of the fee schedule. With the fee schedule, the financial incentive is to provide as many services as possible, but in a value based or in a I'm stopping using value based because I hate it.

[Dr. Zirui Song]: Me too.

[Rep. Alyssa Black (Chair)]: In a per member per month, the perverse incentive becomes to have as many patients as possible. Right. And so with access be, you know, like that continuity measuring that continuity and access to ensure that your panel sizes are not too big.

[Dr. Zirui Song]: Yeah, perhaps we should set up another time to talk, because I do think we should dive into this.

[Ethan Park (Vermont Healthcare for All)]: I'm sorry, didn't even notice the comment.

[Dr. Zirui Song]: I should run by 11:45 to make my daughter's lunch thing at her school. In a couple of minutes, I think so risk adjustment becomes an issue we have to contend with in a per member per month payment design. I would love to spend another hour with you diving into how we think we can do risk adjustment in primary care. At Mass General Hospital here, we went through a very instructive and, in many ways, painful lesson of doing this back in 2017. I've studied it. I've talked about it at various talks. If you move away from fee for service towards a prospective per member per month capitated primary care arrangement, you do open up the box of other questions you have to answer. And I would love to go through those with you and show you one example of how we did it and all the pitfalls we experienced and how to avoid them. So that's one thing. The other thing, as you said, is how do you prevent getting as many patients into your panel as possible and then doing as little as possible? So the quality measures allow you to defend against that a little bit. And then I think you'd have to get into the data. The primary care common fund has to be transparent. And the way we wrote about it in this paper, this type of mechanism, not only is it a payment mechanism for primary care, it's an accountability mechanism. You no longer have to chase down multiple plans to try to figure out whether they're doing the right thing for primary care. You have one body that's going to report everything. It can be as transparent as our Massachusetts Health Policy Commission with annual meetings, all public, just showing the data. You can do that kind of thing. I think that would be very helpful. But you would need some data infrastructure to make sure that we avoid the problem you just raised. And I think on risk adjustment, it's tough. It's tough to get it exactly right, but I think you can get it pretty right and certainly better than the fee for service treadmill. Can I actually, just for the sake of balance Yes? Can just I'm cut

[Rep. Alyssa Black (Chair)]: you off because you have to go. But if you want to keep

[Dr. Zirui Song]: Just for the sake of balance, and you can erase this from your memory if you would like. So just in defense of fee for service, if I could say one thing conceptually, fee for service in primary care per se perhaps has not been the culprit. It's just the level of the fees. So imagine if every primary care visit were $1,000,000 I don't know that fee for service per se would have been the problem. You'd probably be trying to ratchet down the fees because they're probably too much. So one issue is the payment mechanism. The other is just flat out the amount. And when we design a common fund idea, again, the common fund itself, that's not your total solution either because if you underfund the common fund, if that's too small, it's not going to solve any problems. So the amount matters just as much as the mechanism. And we do have a lot of colleagues in primary care who love their fee for service. We need to recognize that. And there are some things like vaccinations, depending on your views about vaccinations. If you think it's a good thing and we should try to get everybody vaccinated according to our vaccine schedules for kids and adults, then you might not want to capitate that. You might want to just do that on a fee for service basis because it's like one right thing, you get paid. Do another right thing, you get paid. So there are ways to think about fee for service where it in itself as a mechanism isn't all bad. It actually avoids risk adjustment problems. The one thing that's good about fee for service is if it's a good thing that you should do in primary care and you wanna pay for it per unit, you don't have to worry about whether the patient is healthier or sicker and paying the sicker patient more and the healthier patient less. You don't have to do that. So in some sense, it's a mirror image. If you walk away from fee for service into a capitated arrangement, and I'm emotionally, spiritually with you in that direction, you do have to answer the risk adjustment question. You have to answer the at what level do you price the common fund question. I'll send you the paper. I do think this is the right direction to go. It's a little more nuanced than one is bad, the other is good.

[Rep. Alyssa Black (Chair)]: Thank you. It doesn't matter what topic we have you in on. We end up having to get cut off, and we could go for hours more.

[Ethan Park (Vermont Healthcare for All)]: Thank you so much.

[Dr. Zirui Song]: I really appreciate it. Thank you for the privilege. Take care.

[Rep. Alyssa Black (Chair)]: Hi, we have Ethan now that we You've been waiting very long.

[Ethan Park (Vermont Healthcare for All)]: I'd just

[Rep. Alyssa Black (Chair)]: like to say I may or may not have written that last paper. Did you see the bottom? Did. So you just picked

[Rep. Leslie Goldman (Member)]: it up. I saw that, and

[Rep. Alyssa Black (Chair)]: there was a top of a plate. That

[Ethan Park (Vermont Healthcare for All)]: was so cool.

[Rep. Alyssa Black (Chair)]: Thank you for joining us today.

[Dr. Zirui Song]: You so much.

[Rep. Alyssa Black (Chair)]: And hanging in there with us.

[Ethan Park (Vermont Healthcare for All)]: I know. Fire alarm and everything. For the record, I'm Ethan Park. I'm with the Vermont Healthcare for All organization, which is the organization that's been around since 1998, advocating for universal health care and improvements in access and affordability. I'm not an academic. I think we've heard plenty of academicians today, and I'm not a provider, not a doctor or anything like that. I'm just an average person. But before I get into S197 and some specifics, you might be curious as to who I am and why I'm here. Many moons ago, I was born in Brattleboro Memorial Hospital, but I've lived in five different counties in the state of Vermont over the course of my life. And I was a dairy farmer. I had my own dairy farm up in Irisburg, which is Orleans County, about twelve, fifteen miles from the Canadian border. And at that time, I had no health insurance. My wife and daughter had no health insurance. Many of my siblings and relatives had no health insurance. And when you're in that situation, you basically avoid going to the doctor. You just at all costs. You don't go to the doctor unless you absolutely have to, then you're at the ER or something. So that's the situation we were in. And then inevitably, some things came up on the farm. We had a hospitalization. My wife and my daughter broke her leg. Those kinds of things. Then you get the shock of the bill, and you're thinking, this is unbelievable. How are we going to pay for it? And as a private pay, uninsured person, you're actually subsidizing everybody else, the commercial and everybody else, because the hospital will charge you the very highest charge master rate. And if you don't know that you can go in and try to negotiate a lower rate, they'll shoke you for that full amount. So that was very distressing to me and decided I should try to do something about this situation. This seemed unfair, and people I talked to up in the kingdom had similar stories. And I I I came down here to Montpelier to to not to testify because it was a public hearing in 1988. I got away from the farm, drove down here, and it was a big hearing down in Room 11. It was a bill sponsored by Peter Welch. You may recognize that name. And the companion bill in the House was sponsored by Paul Poirier. And it was basically a universal healthcare bill. But it was doomed to failure because it was basically just subsidizing private insurance, the same way that the Affordable Care Act does now. And Blue Cross Blue Shield came in and opposed the bill, that was the end of it. Anyhow, after that, I helped to found and was the original president of an organization called Vermont Consumers Campaign for Health. We had a little office down here on Berry Street in Montpelier. We had a part time staff. We had a board that had a couple really highly esteemed physicians on it, including Milton Terrace, who's internationally famed public health policy physician. And Elliot Fisher used to come to our board meetings occasionally. So, worked really closely with state senator Sally Conrad, who was chair of Senate Health and Welfare at the time. We tried to make some progress on these issues and we really didn't get anywhere. And then in '91, Governor Dean appointed me to represent low income people on the Vermont Health Policy Council. You might not know what the Health Policy Council is or was. It was in Vermont statute, and it was also required by federal law. And we wrote the Health Resource Management Plan and administered the CON program, a certificate of need. So now, I think I'll skip ahead. Know the history in there as well as I do, probably. But with s one ninety seven, I I think this is the only vehicle you have this session to try to move the needle a little bit, right, toward what I think we all feel is necessary is to treat healthcare and particularly primary care was said, like, you could call it a public utility, you could call it a common good, call it a right, whatever it is, but we as a society, we we should care about each other. We shouldn't have a situation where some people can afford care, others can't. Some people avoid care because they're afraid of the co pays and deductibles and so forth. So I think s one ninety seven is a vehicle, and I think the political calculus around this kind of thing is rapidly changing just in the last year or so because of the crisis that's coming. I mean, already seeing this precipitous drop in the number of people on the ACA plans. Next January 1, the new federal rules around Medicaid will go into place, And AHS is gonna be in the role of basically cleaning out the Medicaid roles. So I think this impending crisis deserves a new look and a new acknowledgement that maybe we can get there even if it's step by step. So as far as specifics on the bill, as you know, the bill, as introduced, is quite different from the bill that came over from the Senate. It was quite a bit watered down to the point where some people were saying, this bill just looks like six studies and not a whole lot other things. There's a few little minor shit in there that are good things, but basically it's six studies. So what can we do with six studies? And the suggestion I would have is on the section four, which is the primary care spending report, one of the six studies. The recommendation I would have is, first of all, the study should be done by the Green Mountain Care Board, not by AHS. I think it just makes a whole lot more sense to have that study done by the Green Mountain Care Board. And the primary care definition used in the bill as it came over from the senate is from the AHEAD model. Now I was told, and I haven't absolutely checked this, you may want to have your alleged counsel check it or something, but I was told that the head model definition of primary care does not include mental health or substance use disorder treatment. So I think a better definition would be the one that's already in Vermont statute. It's at 33 BSA eighteen twenty three, the perfectly good definition of primary care that includes mental health and substance use treatment. Then the other thing on this study is we want to make sure we get all the payer categories. So this is a study to see what's the total amount we're spending on primary care, but we need it broken down by payer categories, not just Medicare, Medicaid, and commercial, but

[Dr. Zirui Song]: we need

[Ethan Park (Vermont Healthcare for All)]: the federal, the military, and the private pay, the out of pocket. And in coming up with that study, there should be a reference to the 2015 study, which was done by Robin Lueders when she was at the agency administration. And actually hired an actuary that did a lot of incredible research to come up with the numbers in that study, and hopefully wouldn't have to repeat all of that if the 2015 study was used as kind of a touchstone. Then so what what do we do with that that cost study? Now my thought was if you have the costs broken down by payer category, you could say, which of those payer categories could we publicly fund in order to create universal access to primary care? But there's a lot of questions around that. There's tons of questions. There's the operational. There's classic, how are you gonna pay for it? Where's the money gonna come from? All that stuff, the implementation, the cross border issues, do we need of federal waivers or not? Can we do it without waivers? I think all of that stuff is really more than we could expect you folks as part time legislators to be able to really come up with. So my idea would be to have an independent advisory group to look at these issues using the cost estimates from the study and come back with some recommendations to the legislature for here's how you might proceed. So in h four three three, there is actually a a advisory group that would have advised on the whole comprehensive care, but we could take that language from that bill, maybe tweak it a little for primary care, and put it into S197 as sort of the next step. Okay, we fund the study, now here's the commission that's gonna look at how to move forward. And then finally, and I think either Elliot Fisher or Doctor. Song mentioned this too, is to is just to tweak the intent in s one ninety seven so that it incorporates examining, at least, the feasibility of moving toward universal publicly financed primary care. And also, the title of the bill would also need to be amended to accomplish that.

[Rep. Alyssa Black (Chair)]: Thank you. Any if you could send us your suggestions Yes. We would really appreciate that. I normally would go over, but I have three members that need to be somewhere, and then I have two others that have to be somewhere else right at noon, and then we would lose our quorum. So does anyone have any questions? Oh, this makes, as you were talking about 1988, it's a great time to mention that we will be having a public hearing next Thursday from five to seven in Room 11.

[Ethan Park (Vermont Healthcare for All)]: Great. Yeah. I did it by forty

[Rep. Alyssa Black (Chair)]: eight years ago, probably. Right. It was? '38. 'forty eight. 'thirty eight. Yes. 1984 or 1988. 'eighty eight. But you've been doing it all these years.

[Ethan Park (Vermont Healthcare for All)]: All these years, right? I'm sorry

[Darren (Legislative Counsel/Staff)]: to just cut in, but we only have thirty seconds. You're suggesting that we take section three of h four thirty three and and and insert it in lieu of section eight of s one ninety seven?

[Ethan Park (Vermont Healthcare for All)]: Or create a new section in S197.

[Darren (Legislative Counsel/Staff)]: Okay, so we can leave Section eight for you, but you're encouraging us to include that piece of page four thirty three.

[Ethan Park (Vermont Healthcare for All)]: Yes, I think that would lead to the next step after we get the cost study, then a commission to

[Rep. Alyssa Black (Chair)]: They just written some suggestions.

[Ethan Park (Vermont Healthcare for All)]: I think I did one version earlier, but I've I've made a couple corrections, and I'll make sure as soon as I get home, I will send it to the committee assistant. Thank you. Yep.

[Rep. Alyssa Black (Chair)]: Thanks, Darren. Thank you.

[Ethan Park (Vermont Healthcare for All)]: Thank you, chair Black. I really appreciate the opportunity.

[Rep. Alyssa Black (Chair)]: Thank your patience too. Okay. We will be back fifteen minutes after the floor. My dad was over 96. And walk of life.