Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Hi, good morning. It is Wednesday, April 29, and this is House of Healthcare. We've got we have our agenda that we're having committee on discussion on a couple of things this morning, and I'm not quite sure what we're going to discuss, to be honest with you. So if things change up a little bit. But we did ask Doctor. Saroyan to come back in, and I know that you've testified a couple of times on this, but there has been, I think, some confusion amongst the committee. We hear a lot about the blueprint, but we don't really know how it works. And what the mechanisms for what you do, how you get paid, how you distribute payments. Like, what is the role of the Blueprint?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. Thank you, Chair Black, good morning, everyone. This is John Saroyan, Executive Director, Blueprint from Health coming to you live from the field service office in Hartford. So happy to be joining you all for this time together and happy to make more time as needed. One thing I'll, and I'm speaking off the cuff chair, black to sort of go to the sort of most common clarifications I think I offer as executive director. The executive director of the blueprint in statute has the ability to direct multi payer payments. That means that we don't collect the payments and distribute them, we direct commercial insurers, Blue Cross Blue Shield of Vermont, Cigna, MVP, Medicaid, and when there's a federal agreement, that's in place dollars from the federal government to go directly to practices. And let me just give you some examples if I may of the amounts. In our 2025, annual report, I don't have my usual camera set up in this office, so I am going to be looking to my right and I apologize for the awkwardness of that. In our annual report from 2025, patient centered medical homes. And when I say patient centered medical homes, for those of you who who aren't familiar with that term, that's that's a practice. That's a a place. That's a place that I go for my medical care or my kids go. It's a practice. Just a fancy word for a more evolved type of program. We we directed almost $12,000,000 to practices directly to practices for the standards that they meet to be considered a blue practice. So that was in 2025, 11,900,000 was directed to practices by the Blueprint executive director. Addition, and then I'll pause for a sec, Chair Black, take some questions and get some redirection from you in terms of where I should go. Our community health teams, that core primary care team that's dedicated, received $9,855,000 to support our practices and interface with community services. So those dollars are directed. They're not aggregated, collected and then distributed. They're directed. The patient centered medical home dollars are directed right to practices. And there's parts of S197 that would strengthen that ability to move money to practices, and there's things that we're doing right now in terms of evolving our practice qualifications that would increase those dollar amounts more. So let me pause there. Those are the totals. I can go into the per member per month's chair, Black, and I will. But but sometimes just knowing the totals and that flow of dollars is a good place to start and get clarification on.

[Rep. Alyssa Black (Chair)]: Can I ask about the Yeah, and I see you, Leslie? Can I ask for some clarification on the CHT? Okay, so we had a provider in here last week. Hannah Rabin, Doctor. Rabin. And she indicated that essentially she has on her staff multiple people that are funded through the community health team. So basically she gets a check, and then she has decided these are the people that she's going to have support her practice. She pays them. They're on the payroll for that practice. What about instances where there are people in the community health teams who, you know, you just sort of utilize hours? You know, because we've talked about a lot of cross coverage, you you may not need a licensed clinical social worker to be there five days a week, but you'll take them one day a week and then the other four days of the week, they're at other different practices. Who's how does that person who's who's the employer of that person,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I guess? Sure. No. I'm happy to I'm happy to answer that question. It's a great question, chair Black, and I think that you're you're going right to the heart of it. So thank you. So the first number I I described to you, the $11,900,000 that's distributed, that's for being a blueprint practice, and that's to maintain the the rigor of being a blueprint practice. The community health team dollars, I'll slow down a little bit, those payments and it's a stepwise description, so bear with me. Those payments flow to the administrative entity in that health service area with the Blueprint program manager and contact at each practice, working out the amount of dollars that that practice will receive based on their attributed patients and what the needs of that practice are. Now your question about how that works, fraction or partial, like, you know, hours in different places, that's a decision that's made between the practices and the program manager to figure out how best to employ the staff in the needs of that community. And flexibility is possible with these multi payer dollars.

[Rep. Alyssa Black (Chair)]: So is it the administrator of the health service area, it's the hospital, right?

[Rep. Leslie Goldman]: I mean, of our

[Rep. Alyssa Black (Chair)]: health care.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Except for North Star in the Southeast, that's the federally qualified health centers. They can work out whether and I know I know it's a lot, but let me just try to do it carefully for you all. The example you gave, chair Black, of doctor Rabin was the example of what I would call pass through dollars. So they receive dollars. They're passed through another example. And and and I'm not trying to confuse everyone, but this is where the flexibility is really powerful. Some practices prefer that the administrative entity hires that person and embeds them in the practice. And there's there's advantages to that in some in some settings, but we offer either either either option in terms of getting that person, getting that that other member of the team funded and embedded. So it's seamless. So they're a part of that practices team, whether they might do a couple days here and a couple days there, that does happen in cases. But to the patient, that's their person for that time. They're part of the practice.

[Rep. Alyssa Black (Chair)]: So do we have a sense of that 9,855,000? Do we have a sense of how much of that is pass through dollars versus how much of that is embedded? Sort of like what's the breakdown of that?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. So the the total number is is the 9,855,000. Off the top of my head, I don't have a percentage of embedded versus pass through, and I can I can loop back with my team immediately and and find out how close we can get to you how quickly with the right answer?

[Rep. Leslie Goldman]: Leslie? Thank you. Thank you, John. I'm just trying to understand. I I got confused because at first, you said 11 0.9 million and then 9.85. Can you tell me Yeah. The

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. So this is in our annual report, and I'm doing a lot of things right now, but I'll I'll I'll I'll give the link to you all. It's on page 20 of our twenty five twenty twenty five annual report. Sure, Leslie. Let me slow down and just say it once again. Actually, you know, let me can I share my screen a moment? Let me show it to you where I'm looking at.

[Rep. Leslie Goldman]: And I'm looking at your annual report, so that would be really helpful.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Page 20. Page 20. And I'm dealing with a different computer setup here, so let me make sure I pick the right screen. Okay. I think I got it. You're not looking at my schedule, are you? No. Okay, good. So at the top, the dollars that go directly to practices, the patient centered medical homes annualized for 2025, that's the 11,900,000 number. And in the description from payers to practices, all payers, including Medicare last year, are the payments that go to practices for that recognition as an advanced primary care site. So that's the first number. The second one is the community health teams, and that's dollars that go from payers to the local hospital or federally qualified health center, also from all payers that support the practices with team members to interface with community services and serve their patients. That's the 9855 number. Does that move in the right direction, Leslie, to get clarity?

[Rep. Leslie Goldman]: Yeah, thank you. Just so I understand the flow, the money starts with the insurers and then goes from them either direct well, then you said it goes to the HSA. Right? So that's what I'm trying to understand the

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: The community health team dollars go to the administrative entity to work those best distribution plans out with practices. The patient centered medical home dollars for short, we call them the practice payments go directly to practices. So there's two flows, one from the insurers or the payers, excuse me, directly to practices and for community health teams to those administrative entities to work out distribution.

[Rep. Leslie Goldman]: Okay, so the administrative entity is the HSA?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: The administrative entity serves One Health Service area across across the state. So for example, North Star, that federally qualified health center in Springfield serves the Springfield Health Service area. Brattleboro Memorial Hospital serves Brattleboro Health Service area, which is roughly Bennington County. I could go through the whole state, I won't, but yes.

[Rep. Alyssa Black (Chair)]: Does the administrator of the Health Service area get paid? Does the administrator

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So we have a separate funding no. Great question. We have a separate, funding system that I'm not presenting to you, but that I'll describe now. So from our Medicaid dollars, we have grants that are done yearly. We work those out with every single administrative yearly. Those are grants and the program manager who leads the program in each health service area locally, their salary is drawn down from those grants. That's a separate funding mechanism chair Black than what I'm describing to you all for practices and community health teams. So there is funding to support the administration of the program for that program manager, for their geographic region. Interesting. Sure, no, it's a great question. It's a great question.

[Rep. Alyssa Black (Chair)]: I didn't know if the health service area administrator was making money to administer this. Well, who employs that?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Usually, they're in usually, they're investing quite a bit of resources and money to oversee the program just because it's it's a lot to administer. Typically, they're investing time and dollars of their staff and their infrastructure.

[Rep. Alyssa Black (Chair)]: On a yearly basis, what are about how much are these grants?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. I could give you a a summary of all of them. They they they vary. I I I could give you the the numbers for each each health service area within within the hour. I just have to go through all of our different contracts and and get you the amounts roughly. I

[Rep. Alyssa Black (Chair)]: would just I was just gonna say that it would be nice to know how much money we're spending to administer Sure.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Absolutely. And I I have some of the numbers in my annual report. If you give me a moment just to scroll to it, I can do that. Sure. Okay. Leslie, do you request I'll question? Share it and then I'll share it with you all too.

[Rep. Leslie Goldman]: Well, I could I'll let him do his thing. I was just curious who employs the you know, we have a manager. It's employed by the Blueprint or employed That was my question for one of them. There are more.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Hey. I'm gonna share. So this is on the page, same page of our annual report that I was, just showing to you all except a little lower down. Underneath, actually about halfway through on my screen, are you all still seeing that green and white grid? Yep. Okay. So the hospital employs the program managers, they're employed by the administrative entity that serves that geographic region and the total amount for program management across the state in 2025 was 1,547,000 and that comes out of our DIVA and Medicaid budget. So that's really to administer, and that's for the whole state. That's all the health service areas is the 1.5 number.

[Rep. Alyssa Black (Chair)]: Okay. There's a lot of other lines on this. Yeah. So you talked about the CHT and then the per member per month. What about all these other things?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. Let me, sure. Let me just if I could just go back to how we get those first numbers, would that be okay? I have one other slide pulled up just to to ground you all in some things I think that'll be important for s one ninety seven. And then I'll and then if I could just I I'm happy to go through the annual report section with you too. Let me just show you one other slide.

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

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: to go to I'm just going to show the breakdown of practice payments because this is really important in terms of getting more dollars out to practices. I'm just going to share this slide and then I'll jump right back to the annual report, absolutely. Patient So centered medical home payments or practice payments currently are based on our attribution methodology which I did go through. I'm not going to go through right now but it's a two year look back on which patients have a qualifying visit to be counted as attributed and it's more fancy than that but I'll just stop there. Each of those attributed patients, the payers direct dollars to the practices per member per month at a $3 rate from Blue Cross Blue Shield MVP or Cigna or from Medicaid of $4.65 We also when I was in the House Health Care earlier we also talked about some of the other performance payments which I'm not going to go into depth right now because it sounds like you'd like me to switch back to the annual report which I can do. Is that is that is that should I go back to the annual report lines, chair Black?

[Rep. Alyssa Black (Chair)]: No. I mean, if you wanted to talk about this a little bit more. Okay.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So right now, we're in the midst of creating a tiered based system for our practices so that the amounts to practices based on what they're capable of doing really would go above and beyond these amounts. As you'll see when you turn to S197, there is language in that bill to bring the commercial amount, and that's the base payment you all see on the left of your slide, to bring the base payment amount of commercials up to Medicaid. In addition to that what we are looking at is these performance payments too and also making them more focused on access, more focused on patient satisfaction and really updating them for the first time in over ten years so that they really can drive change. I'm just going to show you an example. So this is a practice example of attributed patients that total $12.80 and this is an example of what the different dollar amounts would be that that practice would receive for a total every month that they would accumulate over the year. So that's kind of what I want to say about practice payments. I can jump back to our initiatives now too, but I'll stop there for questions first.

[Rep. Alyssa Black (Chair)]: Any questions?

[Rep. Daisy Berbeco (Ranking Member)]: Maybe you could talk about the pay for performance line.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Oh, sure. So we call these performance payments and these are added to the numbers that you see on the left based on the scoring that occurs in the health service area and also in the practice. So on the far right, the quality measures relate to how that whole health service area did and those are measures affected by community, social, environmental factors and there's four there. It's percentage of adolescents who are shown to have an annual WellCare visit, percentage of children up to age three who have had a developmental screening, percentage of individuals with hypertension in control, percentage of individuals with diabetes in poor control. That's a payment that's based on how the geographic area did as a whole. And then there's a payment specific to practices that relates to their price variation and their cost variation compared to their peers in their area and that's called a resource use index score. Our team is very much in the midst, Leslie, of updating these and making them much more current and that's something I could certainly come back to you all on. Right now we're focusing on that base payment and we're also focusing on updating our performance payments so they're really getting transformed to something more current.

[Rep. Leslie Goldman]: Thank you. Because I was gonna ask how those, four, I guess, performance measures got chosen. Yeah. Sure. Any, sort of longitudinal data of how the HSAs have done? Mean, where do you do you keep that? Is it in the annual report? I was trying to look for that, but it's a big report, amazingly. Yeah. But I couldn't find any data about those measures.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. I'm happy to go back to the report and pull out whatever information I can for you. That information is also sent to practices and and distributed. But there were there were a couple there was a question I think you asked before that one, Leslie. Help me. The first question was how are those four chosen?

[Rep. Leslie Goldman]: Yeah. Okay. Well, maybe it's not relevant anymore if you're reviewing it and updating it.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's relevant. These things take time to actually change, so I think it's really important. We really wanted to have at least two of the four measures related to our pediatric population. And in the pediatric population, screening for developmental issues in those first three years is critical to referral, to early intervention, to connecting to the parent child center, to really making sure things that can be addressed early medical, developmental are. That's that's that's a very much a national measure that we've adopted for for the first one. For the second adolescents, time of great change, Are they getting in for an annual visit to really check-in on the many social and physical environmental changes that are going on in their lives? Also something that's very accepted nationally. And then the last two related to diabetes and hypertension. Hypertension can go on for years undetected and have great consequences to people's health overall, and certainly diabetes can as well. Those numbers are based on national standards on relevance and a balance between pediatric and adults. Me go to

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

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: ask some more a specifics

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

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, oh, sure? Go

[Rep. Leslie Goldman]: ahead, Chittenden.

[Rep. Alyssa Black (Chair)]: I want ask a question about this slide here. Just so I'm understanding, because you said something and I think I understood you correctly. So, this 25¢ per member per month, it's based on these quality measures, but it's not based on the individual patient centered medical home. It's based on the entire health service area's performance.

[Rep. Leslie Goldman]: Correct.

[Rep. Alyssa Black (Chair)]: First of all, are we acknowledging that there might be some regions that are not going to perform as well on these as others? And also, what does that mean for somebody like, for instance, a one or two provider practice in Chittenden County, what difference does it make if they're really super wonderful and they've got UVM? A UVM is bringing the whole It's a great call out art.

[Rep. Leslie Goldman]: Just UVM. Mhmm.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's a great call out, Chair Black, and it's the reason why we wanna update and and change these aspects of our performance payments to make them more relevant practices. You're right on with what we've been working on and what we want to roll out. The other quarter,

[Rep. Alyssa Black (Chair)]: 25¢, is based upon how much that individual practice saved or the the cost of their patients' care?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: The the resource utilization index is a is also a nationally based, calculation that looks at total cost of care per person, and then there's a comparison process compared to their geographic area in terms of it's it's also risk adjusted. And, yes, that's called the resource utilization index. So how well with the dollars available were practices doing compared to others? How expensive, how much did their care cost? Yes.

[Rep. Alyssa Black (Chair)]: What if an individual has chosen a panel of a little bit more difficult resource intensive patient, which we'd That's where like to encourage,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: the risk adjustment comes in place formulaically.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah, Daisy? I'm curious, back to Leslie's question about the performance measures. And curious when those were selected, were they something that Vermont proposed to the feds or were they selected off of sort of a menu? Know with our global commitment go waiver there ahead.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. Yeah. No. It's a great question, Daisy. Thank you. And I'm I'm just reflecting on a detailed summary we provided the auditor with, and I can I can access, though not in this moment? So I'll give you a a summary. The development of it goes back over fifteen years to a grant that was in the late two thousands, and it was called the SIM grant, and was developed over time with the other both state investment and work that we did and also federal opportunities that we had to participate in. So those those do go back well over fifteen years and were the were the subject of much much discussion and much stakeholder input at the time and very much timely for why we wanna update. But, yes, those those those that framework that I'm presenting to you was developed over multiple years, more than fifteen years ago.

[Rep. Daisy Berbeco (Ranking Member)]: So I guess my question is really trying to get at how much do we determine which clinical outcomes to monitor versus how much is dictated from the federal level? And do we have any wiggle room as you're updating these to adjust or adapt?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. No, it's a great question. We take into consideration what what Medicaid's doing. We take into consideration, what's important to the state and our local health service areas and our department of health and what their priorities are. We take into consideration what solid data is available in amounts allowing it to be de identified and utilized in the creation of these these measures. Sometimes if a measure is really valuable, but there's just a too small an amount of of of data, it's just ineligible to be used. So we we bring in expertise and team members from many different places to present at our executive committee these thinking, these updates in our payment implementation work group which is also a public meeting And they're they're carefully regulated. We put pick from nationally standard measures, which are called HEDIS measures, and I can I can certainly

[Rep. Leslie Goldman]: Okay?

[Rep. Alyssa Black (Chair)]: That's that's what I

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: wanna know. But they're it's a combination.

[Rep. Daisy Berbeco (Ranking Member)]: Measure or making up your own. That's all I wanted to know. Thank you.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. They're mostly national measures. Yes. We have to meet CMS and Medicare's requirements so that they'll participate in our match. But we do have flexibility to adjust to some degree also to reduce the burden on practices of the number that they're already doing with. We also have the flexibility to align. For example, when One Care Vermont was operating, we realigned as much as possible with One Care Vermont measures.

[Rep. Leslie Goldman]: Leslie? Thanks, John. I'm continuing to look through your annual report, and you're actually doing a whole lot of other measures than the four that you mentioned.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: We're statutorily yeah, we're statutorily required to look at population whole population measures, yes, around chronic disease. That's correct. Yes.

[Rep. Leslie Goldman]: Okay. So that's what that is. So that's not broken down by the health service areas?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Right. That's that's actually whole population statutory requirements that we have to report on.

[Rep. Leslie Goldman]: That's federal or federal requirement? State requirement? Yeah.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. It's in

[Rep. Leslie Goldman]: our So we're Oh, in your opinion. Okay. So I was also looking at the HSA reports, and they seem kind of high level in terms of the data, that they didn't really report their own sort of individual of the four that I could see. I mean, it was a very quick No,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: it's a great great point.

[Rep. Leslie Goldman]: I was just wondering if you look at it at that level too.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. Yeah. Yeah. So what what my recommendation and and we have kind of pulling back the curtain and and sharing with you all. I and the team and our field staff for the health service area by health service area descriptions, and this is this is in the second half of the Blueprint annual report. Actually, why don't I why don't I show you one, Leslie? And then I'd actually like to talk you through where some of the the detail comes. So I'm gonna I'm gonna scroll to that section if I may and then I'll share my screen. So I'm gonna scroll to let's see. Where do I land? I'm going to scroll to scroll to Randolph. So this is and I'm sorry, that's that's too far through. I'm gonna scroll to Rutland. So let's scroll to Rutland. This is page 45. I'll share my screen and I'll just talk you through where where it gets more granular and how we directed that. And this is true of all the health service areas, but I'm just gonna share my screen here again on Zoom so I don't mess this up. Okay. You should be looking at community engagement through team based care and other accomplishments and seeing a sort of a highlight in blue of the Rutland area. Okay. Looks good. So where I, it's a question, Leslie. This past year, what I requested for there to be particularly more concentration and focus on is contributions from our our quality improvement facilitators who work with all the practices in their area. So for each health service area I wanted our quality improvement facilitators to submit summaries of their relationships, what they're seeing in their own data locally and what they worked on, what their accomplishments were and what their continued challenges were. So in this and this is just a couple or just one example of what's going on but you can see here this group looked at emergency department utilization and how the relationship between local primary care and the hospital could work to have greater primary care access. So I did by health service area ask for specific examples of what they're working on and I allowed them to choose what examples they wanted to share.

[Rep. Leslie Goldman]: Was there any data over time about that or they haven't it wasn't ready for that. They just started a new, let's say, implement a new initiative. So you didn't have actual data on that yet?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That really lives within the administrative entity and with the quality improvement facilitator. I could certainly request it and get that information back. We have presentations throughout the year from quality improvement facilitators. For example, we had one from the Barry Hills Health Service area with lots of longitudinal data that was presented to us. And I just limit what's in the annual report to a certain extent of not bringing all that here, but certainly could send you examples.

[Rep. Leslie Goldman]: I think one of the reasons I'm interested I'm not sure if this is the right time to so you don't have an answer to this since the chair thinks it's a bad idea. But I'm looking at 01/1997, which is looking at the blueprint to really expand its scope. So, I'm just trying to understand the capacity, how it and how it is in your what I see in your annual report and how the expansion is implemented, I guess. Is a question that makes sense?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I see it as a I understand and I think I get your question. I really see us as transforming and making the program even more relevant, bringing greater amounts of of practice support in terms of dollars to our practices around the state, creating the the opening for greater commercial contributions in a way that's stronger than in current statute. I see it as many things of really strengthening the ability of the blueprint to serve as primary care in Vermont's framework and also to grow it to include more practices. For example, practices that don't transform to patient centered medical homes or under NCQA to actually have all practices participate. I see it as yes, I guess I don't use the word expansion, but I'm also kind of a word. I love words. So I'm always thinking about words, but I see it as really transformative and something that will bring our program into the 2020s and beyond.

[Rep. Leslie Goldman]: If I may? Yes. So transformative to me is an interesting word because to me it means change. We're taking a and transforming it into b, alchemy, however you wanna look at it. And what I'm trying to understand is how you're using your current model as established and understanding, like you say, longitudinal data and then how you apply it. Maybe we could say spread. I don't know what the right word might be.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: We're we're using our current model as established as a a multi payer vehicle to direct funds directly to practices. That's that's the chassis. That's the that's the that's the engine for change. That's what's unique about Vermont and the statute that we have here to to allow these multi payer payments to to go out, to pay for standards, to pay for community health teams, to reward performance.

[Rep. Leslie Goldman]: So is spread a good word? I mean, you're spreading your infrastructure, your chassis to more practices. Would that be fair that

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: To more practices and to practices who already exist more substantial support.

[Rep. Leslie Goldman]: So I would be curious if it's not too hard to take one health service area, Rutland, whatever you think would be a good example, and just see over time the impact of this on population health. Because that's what we're talking about. Have the four things that you brought forth and I know that there are others, but you may not have data on that. But looking at data over time, I guess.

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

[Rep. Leslie Goldman]: How successful is this model? I mean, if we're looking at spreading the model, you spread Sure. You could say transform. How effective has this model been? So, therefore, is this a good idea to use this model to spread?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. Absolutely. I think that, I'll answer in a couple different ways. We've presented to you all the effect of our investment, into mental health integration and embedding, mental health professionals and community health workers into into our practices. That was a wonderful example of something that happened in time with an investment that we were able to show the early stages based on medicated data in changes of utilization and cost. We also, previous work that's been done about the blueprint, both qualitative and quantitative, have showed its positive effects on provider retention, patient satisfaction, and shifting cost. So we do have ground to stand on, shoulders to stand on from many past evaluations, which I summarized in a document that's still up on our website related to the blueprint and also many other programs. So that's that's the evaluations of the past. The evaluations of the future, I think, really get to your point in a more scientific way require a significant investment of dollars to actually compare Vermont's population to another similar population in the country that does not have blueprint at all. So to really give you the most rigorous scientific answer about outcome, that investment would be have to made be made in the future or every year to look at, for example, what its impact is. So we're standing on our past evaluations. We're standing on what we hear and we're standing on what we've been able to evaluate with the most recent investment for mental health integration. To actually evaluate into the future every year would take a higher level of rigor to really measure every year.

[Rep. Leslie Goldman]: I love the idea of comparing to a control population.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I love it too.

[Rep. Leslie Goldman]: Yeah. That would be cool, but I get it.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. Yeah. Happy to talk to you more about that. Chair Black, how am I doing here? Am I getting to some of the questions you and the committee have? I'm happy to

[Rep. Alyssa Black (Chair)]: I think so. What is the appropriation that the legislature makes that is for the blueprint?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So I'm to refer us back to the section of the annual report that gets back to dollars. So let me just scroll back there a moment. Thank you for your patience. I am literally scrolling so that you don't have to watch. Oh, I went too far, sorry. Simple answer is there's no specific appropriation for the blueprint every year. There are based on our attribution methodologies, it's really been built into the budget Medicaid. It's just built into the budget for Medicaid. We're paid through Medicaid, they follow our attribution methodology. The rest comes from commercial insurers. But there's no specific appropriation for the blueprint every year that I can point to.

[Rep. Alyssa Black (Chair)]: I mean, it's paid. So, it's paid by both Medicaid and commercial payers, the administration of the blueprint, basically your office. And we don't know how much it costs to run your office?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That's all in our blueprint report too. I can scroll to that as well. I have that I'm sorry. I'm jumping around in the annual report. So let me go to to that. The let me let me I'm gonna I'm gonna share my screen so I can I can get to that too? I'm gonna share my screen. Am I sharing this green and yellow, white grid again?

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

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. So in terms of cost, we have all of our payments out. We have our staffing, our program management, community self management programs, and then our training contracts, our spoke provider training center for health and learning, our pride center. We have our contracts related to Medicaid, analytics, CAP surveys, qualitative analysis, quantitative analysis. And I'm gonna have to get you that number. I don't want to keep looking around in the reports here, Black. I've taken up enough time. So let get you that number.

[Rep. Alyssa Black (Chair)]: No problem. Am I correct? Just as I was scrolling, looking, so data and analytics contracts. So we're paying vendors well over a million dollars every year to evaluate the things that we collect?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That's that's really to meet the requirements in our our statute for the the numbers that we we produce both for the performance payments and also for our annual report. It's it's usually separated into into two large asks from our analytic vendor one is around performance payments. We also rely on them for our attribution methodology as well. The patient experience of care survey is also statutorily mandated. The blueprint is required to do that every year for the whole state, and then we have what some of those smaller numbers are, which was the remaining dollars from the appropriation for mental health integration. But, yes, that's that's the 604,600 plus 260,000 is to perform the analytics that we are statutorily required to do. Correct.

[Rep. Alyssa Black (Chair)]: Leslie, did you have a question?

[Rep. Leslie Goldman]: Well, I'm thinking about when you're looking at these numbers, I'm also thinking about 197. I And don't think there's any money in 01/1997. Right?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So

[Rep. Leslie Goldman]: it'll end up increasing the Medicaid budget. I'm wondering, you know, with this

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: trend, January like

[Rep. Alyssa Black (Chair)]: where those costs

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: first, 2027, the dollar amount that's paid to practices, and I'm gonna share that screen again to make sure I'm doing this correctly. The dollar amount that's paid to practices, Leslie would match the Medicaid base amount. Instead of this commercial payment being less than the Medicaid amount, one section of S197 shows the $3 going up to, let me just tell you where it is, it's on page three from health insurances her insurers in amounts at least equal to Medicaid payments beginning in 2027. So that is the budget implication not relevant to our state budget relative to commercial insurer contributions that's written in language for s one ninety seven.

[Rep. Leslie Goldman]: And what would be relevant to the state budget?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Nothing as written. The last time I looked at it, there is nothing relevant to the state budget.

[Rep. Leslie Goldman]: So the state minute, your request won't change for the next budget is what I'm hearing.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I'm sorry, just rephrase that. I apologize.

[Rep. Leslie Goldman]: I'm just saying that we're not looking at any more money from a request from you for

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: our state. Correct. I last looked at it, yes. And tell me if I'm wrong, but yes, correct.

[Rep. Wendy Critchlow]: But there might be an increase in commercial premiums that folks pay to cover that additional?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, we'd have to hear from our commercial insurer partners on what impacts they're having. I know that in some of our early discussions, we know that there's interest in shifting to value based payments. For example, taking value based payments that one commercial insurer might do on their own and actually using those value based payments and making them part of the blueprint, that would be a way to shift a value based payment program that they already have into something that the state of Vermont has throughout. But how they go about doing that, I I I can't speak to. That's that's one example of of of cost shift rather than cost increase.

[Rep. Alyssa Black (Chair)]: I'm on her annual report, now and it just goes back five years, but towards the end of the report where you have sort of the measures, quality measures.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah, let me I'll go there with you.

[Rep. Alyssa Black (Chair)]: Other than COVID, I guess when I'm Okay, do you want I'm on like 60 to 70 something. I'm not really seeing any appreciable difference over the years. And granted, it goes only back five years. But first of all, most of these were already meeting the targets. And I guess I'm just trying to I'm trying to discern whether or not all this investment has We hear the anecdotal that we really appreciate the support, say, of the community health teams. We hear that we need the per member per month to sustain our practices. I guess I'm wondering, it seems like we're spending an awful lot of money this each year coupled together between Medicaid and commercial payers. And it doesn't seem like we're having any appreciable difference in the things that we've attempted to measure that are supposed to be quality. I Once guess

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: you meet a target, it's important to continue paying for it. Once you meet a target, if you were to stop paying for that target, you certainly would risk it dropping. I mean, point of the blueprint is to uphold standards. The point of National Committee for Quality Assurance and Patient Centered Medical Home is to maintain those standards. We want to make them even better. So I think that the opportunity here is really to build upon what we have. And yes, the stories count. They matter, they make an impact on Vermonters, they make a huge impact both on people's experience and life and cost as well. They really are the heart of what people call the triple aim and in terms of rigor of evaluation within our fiscal responsibility within our history we are one of the most rigorously evaluated state healthcare reform programs in the country. So everything that I continue to work through critically with a scientific mind with a story and narrative based perspective in terms of human experience points to the strong utility of this program and the necessity to make it even better. I think that the improvements that we've been able to make since COVID have been substantial and there are many more to come. And I want to continue to show that to you all in a more clear, in a more straightforward way by making the program better.

[Rep. Alyssa Black (Chair)]: Do we have a sense, do we ever study or look to data on whether quality is actually improving or if we're just getting better at collecting the data.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Absolutely. The presentation I referenced before in the Berry Health Service area had lots of data on improved measures. We've had presentations before about patient centered medical home and ED utilization. We've we've have all sorts of specific topic presentations through the year to executive committee in our field staff leadership meetings that speak to very granular stories with data that I could I could bring to this group for sure. I I try to bring that whole state perspective, but if if the if the committee really wants to hear some of those more specific cases of of where impact has been made, I'll I'll find a way to improve it.

[Rep. Alyssa Black (Chair)]: I think you locked up on us. Think we might have lost him. Oh! Oh! Well!

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's not just you, was on here too.

[Rep. Leslie Goldman]: Yeah! Great! Can you remind me about the Elliot Fisher? Could you help me,

[Rep. Alyssa Black (Chair)]: what day was Elliot Fisher? Was last Wednesday, Thursday, last Thursday.

[Rep. Leslie Goldman]: I was looking for the slides, can we ever get his slides?

[Rep. Alyssa Black (Chair)]: Well it appears as though we've lost Doctor. Solo. Oh my god.

[Rep. Brian Cina]: Okay.

[Rep. Alyssa Black (Chair)]: So maybe he will rejoin us. Interesting conversation.

[Rep. Leslie Goldman]: John said they need a Johnson connection and will rejoin.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Okay. Have something. I

[Rep. Brian Cina]: will leave the Johnson to yes. I

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I have never had that happen. I am really sorry. I I don't it it kinda gave me like a jolt, like I needed to be connected to a continuous EEG monitoring EKG monitoring. That was that was a little frightening. I guess I guess I'm a little too reactive. But, yes, though, the blueprint is really there to keep these standards. That's that's what we wanna build upon. I'm sorry, I don't know why that happened. I really apologize.

[Rep. Alyssa Black (Chair)]: No problem, happens. Okay, any more questions?

[Rep. Leslie Goldman]: So we had a testimony from Doctor. Fisher. I think you know him, right?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Elliot? Sure. Darkness.

[Rep. Leslie Goldman]: Yeah. On his slide 11, and I was just raising this and you don't have it in front of you. I'd be curious to know your thoughts or reflections on his comments that he had some concerns about conflict of interest and those kinds of things. And I didn't know where that was coming from and I didn't know if you've come across that, but just curious to know if

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure, tell me. I'm going to it. Just tell me more, Leslie, conflict of interest.

[Rep. Daisy Berbeco (Ranking Member)]: If you'd

[Rep. Leslie Goldman]: leave him. Slide 11. I don't get I can't see.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. It's We're almost there.

[Rep. Leslie Goldman]: Yeah.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So this is testimony from February, March or April. It was April.

[Rep. Leslie Goldman]: So it just happened. It was the date was,

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So April 16 written testimony?

[Rep. Leslie Goldman]: He sent us slides.

[Rep. Alyssa Black (Chair)]: He had concerns. April 23. He had concerns about these initiatives being led by the blueprint based upon, the capability. Well, he No. I really

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: wanna get to this. This is really important. I'm looking at Elliot Fisher for this biennium. I don't see slides posted, but I could be looking at the wrong place. It also could

[Rep. Leslie Goldman]: be under someone else's name. The exact same thing, and it wasn't there. So I don't understand that process, but his slides are on what'd you say the twenty third? Thursday, April 23. April 23. So if you go to the committee webpage and then

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Oh sure, do it that way. Yeah, yeah, yeah, I got you. I'll do it that way. Yeah, thank you. Hold on, let me see. Oh yeah, no, thank you for bringing that to my attention, goodness. Okay, let me just get there. Okay, so Elliot spoke S197 primary care presentation. Imagine the current path, a better path, where is Vermont? Primary care is essential. Thoughts on S197 crisis, insurer pain. Okay, I'm going share my screen Leslie so you can tell me which part of it you're mentioning. I'm getting

[Rep. Leslie Goldman]: good So it's third bullet.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Oh, yeah. I mean, I guess you would have to ask him. I know what he's never brought that up with me. I'm not sure what he means by conflict and trust. I can't speak to

[Rep. Leslie Goldman]: Well, I just wanted to let you know that he brought it up. So if you had you know, if you wanted to pursue it, just so you know that that Well, I'm

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: going to And

[Rep. Leslie Goldman]: we did receive that testimony.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. Yeah. I'm going to the Rural Health Equity Conference that Dartmouth puts on in just a couple of weeks and I'm sure I'll see Elliot there. I can absolutely bring it up with them. But thank you for pointing that out to me. Know anything else the committee can tell me, please. I did not know that was there. I did not catch that in the slide deck.

[Rep. Alyssa Black (Chair)]: Doctor. Saroyan, so I'm not sure how to ask these questions, to be honest with You know, as we've been working on this bill and thinking about this bill, and well, in particular, I've been thinking a lot about like the role of the blueprint. The role that the blueprint plays currently and has. And I've also been thinking a lot about, obviously, quality measures, everybody, I keep harping on this. And it seems to me that we measure. We measure because we care about population health. And it feels as though population health, like who does that add value to? Does it add value to the patient? Does it add value to the provider? Or does it add value to the payer?

[Rep. Leslie Goldman]: Is why,

[Rep. Alyssa Black (Chair)]: well, guess I think that the blueprint does amazing things for population health. I think they do amazing things in supporting a provider so that they can deliver the best care for their patient, to have the resources to be able to offer their patients. But really, it's a population health. And who benefits from that? Guess I'm just thinking who really benefits from that is the payer. But why is the blueprint why are we inserting population health into what is really just a singular relationship between a patient, an individual patient and an individual provider. And I'm kind of looking at sort of the funding of the blueprint and like where things go. Why don't we just take that $11,000,000 and pay providers more? And take the blueprint out of that relationship.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. So let me try to, I'm trying to just get a couple of things, a lot of thoughts coming to mind, Share Black. I relate as a physician who trained in the nineties when quality was very much taking up national, statewide, local attention because of patient deaths, because of mistakes, because of errors. Unintentional, good teams, great teams, amazing stuff, pediatrician. I was involved in some of those very early efforts at our children's hospital. And so I see, when I when I hear when I hear you talking about the the the larger measures of population health, I hear that that is a component. I really relate it back to what I as a clinician, I as a member of that team can know about how I'm doing with getting the results I want for the group of patients I'm treating. For me early on in my career, it was pain management. Then it moved to hospice. I wanted to know, I wanted that feedback. And I think there's been some testimony on S197 from providers that would align with me to some degree that we are clinicians, we're practitioners, we're students of the work forever. We take an oath to do that and we want to know how we're doing. We want to improve. So that's one component of, yes, I absolutely hear you that the pop I I hear what you're saying. But in terms of meaning to me as a physician, as an executive director, I wanna be able to provide that meaning as best I can for giving data back to teams so they can continuously improve. The standards that exist that we pay for in Vermont are really meaningful in making sure that all the in between time that happens outside and sometimes inside but outside that clinicians patient interaction. And you're right, it's precious. It needs to be preserved. It needs to be emphasized. That is the core. That is what we want to serve. And we know that our system, our living environments, our patients, our family members, us, ourselves have needs that exist outside of that visit. We want to continue paying for that and showing that there's value to it so that it continues to exist for patients. That's really meaningful in terms of impact, both measured and unmeasured and in terms of standards of what's going on in other parts of the country nationally and statewide. I feel very grounded in this work and certainly seek to present it better in the future and with better information within the ability that we have but I guess some of the of the lenses that I've experienced coming into the area coming into this position maybe are I see it as very patient focused and family focused work I see it extremely much I see this investment very much in patient and families still and the quality of their experience not just measures that are you know could go without.

[Rep. Brian Cina]: Brian? I think I understand the point you're making, but I'm a little confused. Is it helping the patients and the families, like this focus on population health? Is it helping them because the providers are improving how they deliver services? Is it helping them because they're able to provide a wider range of services with these payments, like greater access to nutrition, counseling, or follow-up with nurses, etcetera? How exactly is it? Because I can see how it helps the payer. I can actually see, I could probably see how it helps everyone in Articulate, but you're the witness, so I kind of would like you to do it. Sure. But I'm curious if you could say more, like is that what you're getting at, in terms of how it's helping the patients and families?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I'll give an example. Standards related to children for newly diagnosed asthma. Medicine is always advancing, it's changing, we as practitioners have to keep up. I've had periods of my experience certainly early on in my training where standards would have really benefited some of the practitioners in the community I was working with so that they raised their standard in terms of managing children's asthma, whether it was the peak flow meter that they gave, it was an inhaled steroid instead of just liquid albuterol, which did nothing. There's aspects of our work that provide standards to really keep patients and families, whatever Vermont or it is, whatever practice they walk into holding on to standards, whether it's a few years into their asthma or at time of diagnosis. I as a clinician absolutely I make the diagnosis, I get the meds started and I want a team around me to really help adherence to help follow-up. Same could be said for diabetes or hypertension too. Yes, it is absolutely starts with that sacred relationship between the provider and the patient and hypertension can be managed with many other things in addition to the medication I as a physician write the prescription for. I want them to avail themselves to self management, which we also oversee as blueprint. I want them to avail themselves to nutrition that community health teams do, and I want my practice that I work within to be able to, connect them to other services, take their phone calls off hours, maybe help them stay at their job with an adjustment in medication that I, as a practitioner alone, seeing patients going from person to person in my calendar couldn't handle all the needs that they have outside of that visit. So that is what we direct payments for. And I do strongly believe that there's value to that.

[Rep. Leslie Goldman]: I'm

[Rep. Brian Cina]: hearing that it is a very simple way to put it, but what I'm hearing from you is that investing in improving standards for population health actually improves the quality of life for individuals.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Healthier? Yes, yes. And that's been rigorously looked at too many times. I think that healthier patients help everyone. They help families, they help employers and patients and providers need a level of support to keep going. And these are the types of supports that we provide that are unique. There's tremendous value to it. At the same time, I really appreciate all of your questions too. And I appreciate the skepticism. I sincerely mean that, I do.

[Rep. Alyssa Black (Chair)]: Do you want to

[Rep. Leslie Goldman]: take I can wait. A

[Rep. Brian Cina]: I feel like it takes it in a slightly different direction, so I can wait.

[Rep. Leslie Goldman]: Okay. Go ahead. Pulling in a totally different direction. I

[Rep. Alyssa Black (Chair)]: actually wanted to respond to something, but go for it.

[Rep. Leslie Goldman]: I just wanted to bring this article up. I don't know if you think that's appropriate.

[Rep. Brian Cina]: Sure.

[Rep. Alyssa Black (Chair)]: I agree with you. I think you're actually making my point, which is that it's essential that providers have access to the resources that their patients need. The care team, the people who can do follow-up. I mean, that's absolutely essential. And that seems to be the role of the community health team. Talking about maybe I'm saying this incorrectly. I see the blueprint as a community health team on one side. And then on the other side, just this sort of sustainable support for practices to do stuff that they should be paid to do anyways, and we're just funneling $3 or $4.63 every month to them. Oh, and then an extra quarter if your health service area manages to do really well. Seems to be why are we involving Blueprint in what is essentially a relationship that should be paid for by the insured or insurer, and we're inserting all of this population health into a justification for paying pittance to sustain a practice. We we

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: track we track the number of unique individuals seen by our community health teams, and we publish that in our annual report. The number of people who are seen by our community health teams is a fraction, a very important fraction, but a fraction of the total number of people served and served well because practices are maintaining those standards and are able to use their staff and use their time to continue providing that high level of personalized quality connected care independent of the community health team. We actually track it so we see how many people are served specifically by community health teams versus the hundreds of thousands of individuals served by those practices. So those paying for those standards and getting those practices really to continue with hearing them, fee for service dollar amounts, they just couldn't. The the community health team is really, really important, but the power for serving many more so that whether I need a community health team person or not, I know that my child is really going to get the standard of care when they go into any practice in Vermont. That is something that has not, in historic times and my experience, has not proven to be capable of really supporting existing with only fee for service payments. Those value based payments are what provides that integral whole person side of health as opposed to visit to visit, chief complaint to chief complaint.

[Rep. Alyssa Black (Chair)]: That's what one hundred ninety seven is essentially doing, is it's creating a capitated model. I guess what I'm saying is perhaps the blueprint should be sustained for creating a mechanism for these community health teams and having the resources, which frankly could be funded through something that the insurers have to fund and if we could get all insurers if we did it with a claims tax. So there's that. Because we haven't even gotten into the fact that very few payers are actually paying in now and everybody And is benefiting from that doesn't mean that we can't still develop methodologies and payments of a capitated model rather than fee for service to You say that there's no way that they can sustain themselves with fee for service. Well, I realize that in our current world, That it's doesn't mean, again, we pay the wrong fees for the wrong services is the problem.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Think you getting to Yeah, go ahead. Sorry.

[Rep. Alyssa Black (Chair)]: I'm just trying to say that one doesn't one does not preclude having the other.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I I think that I'm trying to decide where to jump in in terms of what would be most helpful. I I think that to get to where you're talking about planning and I I see this as existing in s one ninety seven too, planning and describing and figuring out the component you're talking about would require about five or six months to do. I see what you're talking about in terms of future states still being in this report in terms of a design that's due.

[Rep. Alyssa Black (Chair)]: Leslie? And then back to Grant.

[Rep. Leslie Goldman]: So we had testimony from Doctor. Song. Have you come across him? He works at Harvard. I really love this because he was making a case of primary care as a public utility as opposed to a business. So we've had some conversations with the committee. Is healthcare business or is it a common good? And that was really interesting. And he's making a case for a common fund. And there's a figure in his article he published in JAMA on May 20, so not quite out yet. But that includes all the insurers paying into one primary care common fund. Cause right now we only have Medicaid and commercial, but he was talking about state funds, Medicaid, federal funds, state funded funds, commercial, everything into one fund and then distributed. That seems like a really interesting idea. Wondering, I'm sure if this is you probably haven't heard of it and maybe you haven't. I just thought it was worth seeing how Yeah, much thank you, Leslie.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I chair the vaccine purchasing program, which also is a statutory inclusion of the Blueprint executive director, and I was just prepping for our rate setting meeting coming up soon in May. And I I look at the contributions from many, many insurers into buying vaccines at a better price. I'm oversimplifying, I know, but look at that model and go, wow, this is a great model. Chair Black, I do have a commitment in ten minutes that I don't wanna break. I'm just saying that out loud. I certainly can break it, but I just wanted to say that as a time kind of marker for you.

[Rep. Leslie Goldman]: So if I may, just to end my thought, if you could use that idea to funding primary care, that would be very cool.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And S197 really opens the door for greater participation from self insured plans, whether that ends up But there is an avenue in S197 regarding greater participation in the system we have at the same time that there's sections of it which envision the system we could have?

[Rep. Leslie Goldman]: A lot of reports. That's a little just seems like 01/1997 has a lot of reports. Brian?

[Rep. Brian Cina]: Yeah. That it kinda this kind of ties into my question, the current conversation, believe it or not, which is I'm wondering how we could use s one ninety seven as a vehicle to build on the blueprint as a foundation for universal primary care system? Because it seems like there's elements of the blueprint that already are creating sort of, it's like we're collectively, we're pooling money from different sources and then reinvesting it in these capitated payments or whatever you want to call them. Sorry if I used the wrong word.

[Rep. Alyssa Black (Chair)]: No, it's

[Rep. Brian Cina]: great. But their allowance or whatever it is, their monthly allowance that we're giving the providers. So it would seem that if we could coordinate all payers, I hate to say that word, but if we can co because it triggers the ACO thing, but if we could coordinate all payers through the blueprint to give all primary care providers a high enough monthly payment to be able to there might be a way we could just guarantee all patients access to primary care without cost sharing, and that would be cool. Then maybe when there's the fee for service, the additional stuff, the things that primary care providers have to do fee for service for, that could be where maybe there's negotiation around who pays what. If someone has private insurance, they have their copay. If they have Medicaid, they don't. But I'm just curious, what are your thoughts about the potential of the blueprint becoming the foundation for some kind of universal primary care system that improves population health through better coordination of payers and providers and patients?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Thanks representative Cina. My first priority right now is making sure the system that we have holds together and stays and strengthens. There is no doubt in my mind that practices when receiving value based payments for their attributions is robust and current, that there's a lot of things that they that they can do above and beyond how they're already stretched right now. There's no doubt in my mind that with more robustly funded community health teams with more members, there's there's latitude to provide services with no billing. So I do whether we get to the state that you're imagining, I I can't I I I don't I don't have the financial sort of reckoning or foresight to to be able to say with confidence, but this is this is directional work in my mind, and it's it's meaningful. It's not just incremental. It's meaningful directional work to provide for more people with higher quality.

[Rep. Brian Cina]: So would it take like I know there's a lot of reports in this bill, but if we were interested in looking at that option, it sounds like we would need a different kind of report in the bill than is currently there. Because the current reporting wouldn't necessarily give us the information needed. Is that true? Like would we need a different kind of financial analysis or?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: May ask to get back to you on that, but we can look at it right now. I can go into the different reports with you now if that would be helpful in the time I have remaining.

[Rep. Alyssa Black (Chair)]: Let's table that for now. Yeah. Let's continue the discussion and we can continue the discussion. I know you have a hard stop. Mhmm. And Wendy has a question. What time do you have to be? You've got till what? 10:30. 10:30. Okay.

[Rep. Wendy Critchlow]: I just thought it was interesting when you did ask, because I'm not sick, I just have allergies, but when you asked who this benefits, whether it's the person, the provider, or the I think this would benefit the community, and I think if you sold it that way, I would really be interested in a report that if you had all the insurance providers paying into this blueprints, if you had Cigna, if you had everybody paying into it, what that dollar amount would be, that would be because everyone's benefiting from this program. People who have Cigna are benefiting from this program. It would just be interesting to know how robust this program would be if you had everybody paying into

[Rep. Leslie Goldman]: it. That's my question.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Sure. No, thank you. It's a great question. Within the limitations of the system we have with Vermont healthcare utilization and the VAH, there are limitations as I think you all have heard me say before in terms of forcing submissions of of claims from all insurers though s one ninety seven does give the executive director a more strong and specific ability to request that type of information from insurers, Wendy, to get to what you're asking about?

[Rep. Wendy Critchlow]: Did we all just not go through a pandemic together?

[Rep. Leslie Goldman]: We all

[Rep. Alyssa Black (Chair)]: are in this together and a good robust primary care infrastructure benefits everybody. It benefits the community. That's what benefits. I would just add to that, that we can't mandate that self funded plans contribute, but

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: That was the supreme court case. Right? Gobe versus Liberty Mutual, I think, in 2016 or '17.

[Rep. Alyssa Black (Chair)]: But all payers other than Medicare, I think, and Medicaid, but they're doing it anyways. All payers do play pay a claims tax. Yes.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: You're you're pushing me a little bit out of my I heard I heard Lori say yes. It just was that Lori's voice?

[Rep. Alyssa Black (Chair)]: Yes. I said yes.

[Rep. Leslie Goldman]: I'm gonna to waste your money. Wendy, it's amazing.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yes. Really I really call up my colleagues at DFR, cheer Black, when we we get into that question, but, that that sounds right. I it's just not my

[Rep. Alyssa Black (Chair)]: Alright. We're gonna let

[Rep. Leslie Goldman]: you go.

[Rep. Alyssa Black (Chair)]: Okay. Okay. Thank you for thank you for sticking with us.

[Rep. Leslie Goldman]: I know that this was,

[Rep. Alyssa Black (Chair)]: you know, unexpected, but I'm glad that you No.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I I really appreciate all all of you and all of your time and enjoy talking really sincerely. So thank you.

[Rep. Leslie Goldman]: Thank you. How capable you are being able to respond so spontaneously. So thank you. Thank you.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Oh, thank you, Leslie. Appreciate it. Bye y'all.

[Rep. Leslie Goldman]: Thank you. Bye. Alright.

[Rep. Alyssa Black (Chair)]: We are gonna take a fifteen minute break. Oh, I think I learned yesterday that's probably

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I do take

[Rep. Leslie Goldman]: quite a few minutes.