Vermont Legislature SmartTranscripts:

[Debra Powers (Member)]: Ann with the slight bias on the Senate floor. Hi,

[Alyssa Black (Chair)]: welcome back. So we're going to kind of continue discussion around one hundred ninety seven. We're going to have to come back to one hundred eighty nine later. Oh, the floor today, we'll come back to one hundred eighty nine. Jen's going to join us up front, so let's just give her a minute to

[Wendy Critchlow (Member)]: Alright.

[Alyssa Black (Chair)]: So we've taken an awful lot of testimony on one ninety seven, and obviously, also have our public hearing tomorrow, which, frankly, I'm really excited about.

[Debra Powers (Member)]: I'm sure. Think

[Alyssa Black (Chair)]: it'll I think it will ground us on why we're here and what we're trying to I'm hoping. I'm hoping it will ground us on what we're what problem are we trying to solve with one ninety seven? That's on

[Wendy Critchlow (Member)]: the news this morning, and it did say that it was asking for public input. Good. Hollywood. Good. Yes. Oh, exciting. Which news?

[Debra Powers (Member)]: Channel five. Channel five. Thank you. 1005. Thank you, 1005. We have a lot of

[Alyssa Black (Chair)]: people signed up already.

[Debra Powers (Member)]: Really? Yes.

[Brian Cina (Member)]: We're not at capacity yet.

[Alyssa Black (Chair)]: Can I ask? It's solid, around 40.

[Daisy Berbeco (Ranking Member)]: It's 40?

[Alyssa Black (Chair)]: That's a lot. I hope everybody can fit into Room 11. I've done it in the chamber. But I just wanted to get overall thoughts. I I thought that was a really good discussion with Doctor. Saroy and people are really thinking about what we're doing here. I just wanted to get thoughts on what people would like to see out of this bill. We've done two walkthroughs of it. We could have Jen put up the language, maybe get an idea of what we think is good, what we think is not so good. I don't know, how does that sound to everybody? It's passed by Senate. We haven't done any, yeah, which is, that's the as passed by Senate.

[Leslie Goldman (Member)]: I have 3.1. Is that

[Alyssa Black (Chair)]: 3.1 was the Senate's version of 3.1. Our thing got printed before it became as passed by Senate. But it's the same. That's what they passed.

[Allen "Penny" Demar (Member)]: An overall, overall comment. I

[Alyssa Black (Chair)]: really, really want to hear it. I do. That's what I'm hoping for. Like, everyone's overall

[Brian Cina (Member)]: I'll wait till it settles down on you. So I have a hope and I have a concern. I won't say it's a fear because I'm not really scared. It's more like a It more evokes a sense of apathy and despair than fear. So my concern is that it's very reporty and the NCSL has done research showing that legislative bodies often don't follow the recommendations of their reports, and this body has not been an exception to that. So I'm a little concerned we're gonna have lots of people reporting, And without political will or vision, we're not gonna do enough with what comes back to us. And I just feel bad wasting people's time and energy and taxpayer money on reports if we're not gonna do anything about it. So I want us to be committed to being serious about following through on any reports that we require. Then my hope would be that we use this as a chance to have a little bit more of a vision. I do see hope in the idea of the blueprint becoming a foundation of something greater, and perhaps us finally delivering on the promise of Act 48, even if it's a baby step.

[Alyssa Black (Chair)]: Oh, I love that you said that. Because the one thing that I keep thinking about this bill, there's like no vision on where we want to be.

[Allen "Penny" Demar (Member)]: Yeah.

[Alyssa Black (Chair)]: And, you know, I've actually been thinking about it in the concept of what we did last year in S-one hundred twenty six at 68. We set in place reference based pricing, but we didn't actually put in there where we wanted to be. What were we trying to solve? So, like, we're moving towards reference based pricing, but we don't have a vision on what it's supposed to even accomplish.

[Brian Cina (Member)]: Other than save money? I mean, you know,

[Alyssa Black (Chair)]: we don't even have anything in there.

[Brian Cina (Member)]: Saying that we want to do that.

[Leslie Goldman (Member)]: But we want to save And

[Alyssa Black (Chair)]: 197 has a lot of reports, but it doesn't have any intent. Well, it does start with some intent language. Not very aspirational, as I say, but where do we want to be? We talked about where we want to be, where people want to see us. What's our goal? This is a bill primarily about primary care.

[Brian Cina (Member)]: I would like to speak what you said, what is our goal? Would like to answer the question in just a

[Allen "Penny" Demar (Member)]: few

[Brian Cina (Member)]: sentences. My goal would be to cultivate a system of care in which all patients have access to primary care without cost sharing, where all providers are able to make a good honest living taking care of people, and where all payers give their fair share.

[Alyssa Black (Chair)]: All

[Wendy Critchlow (Member)]: I got there was a

[Leslie Goldman (Member)]: cult bait. I hope somebody else.

[Brian Cina (Member)]: It's on YouTube and you can easily watch it up to me.

[Debra Powers (Member)]: So can I ask you a question? Yeah. So back with back that they pay taxes on So

[Alyssa Black (Chair)]: the way it current the way it currently works is who pays into the blueprint is Blue Cross Blue Shield MVP and Cigna pays in for their qualified health plan people? What's the

[Nolan Langweil (Joint Fiscal Office analyst)]: McCarthy Legislative Council? They don't offer an qualified health plan market. They do offer a large group. The large group, yeah.

[Alyssa Black (Chair)]: But not necessarily their self funded plans, unless the self funded plan decided that they wanted to pay into. I think at some point they said at least 2,000 for Mars. I think we got this morning last year on that. And then Medicaid obviously pays in because we've and Medicare used to pay in under our previous demonstration project, which has now ended. So they're not paying any currently to the blueprint. And that's like the last, I don't know if you remember in the budget this year, there's like bridge funding that was essentially the state paying what Medicare used to pay. And the whole point was to get us to the new demonstration project ahead, which keeps moving out. Well, don't want to say it's moving ahead. It just keeps getting pushed back.

[Debra Powers (Member)]: So my question, is it possible to have all these entities put in line or is it pretty much?

[Wendy Critchlow (Member)]: Apparently there's a lawsuit.

[Nolan Langweil (Joint Fiscal Office analyst)]: There's not a lawsuit. I would say it's unclear As I understand it, correct. So the the state is preempted under federal law from regulating the self funded plans

[Debra Powers (Member)]: that are administered by third party administrators. There is some ability for the state to regulate third party administrators. As

[Nolan Langweil (Joint Fiscal Office analyst)]: I understand the way programs are currently implemented, the Blueprint contributions are not coming from third party administrators on behalf of the self self funded plans. Whether they could, I think, is an open question. The lawsuit, the litigation that Doctor. Sarayan mentioned had to do with our Alt Hare claims database and whether we could require third party administrators to report their self funded contract claims to D Cares, the AuPair claims database. So I don't want to conflate the two because they're different. So we do, as I understand currently, the claims tax, the health care claims tax is paid on behalf of all claims that have accrued from services to Vermonters, people covered by plans regulated or offered to people from the state, whether they are administered by third party administrators or fully commercially insured insurers. So I think it's an open question.

[Alyssa Black (Chair)]: And maybe Nolan can help get some of the questions. Does Medicare or Medicaid pay the claims tax? So many dollars. That's done by the insurance.

[Nolan Langweil (Joint Fiscal Office analyst)]: And that's largely because we cannot tax the federal government and we don't tax the state. We are the state.

[Leslie Goldman (Member)]: Really super clear, isn't it?

[Alyssa Black (Chair)]: Did you have?

[Allen "Penny" Demar (Member)]: No, no.

[Alyssa Black (Chair)]: Oh, sorry. Thank god. Leslie?

[Leslie Goldman (Member)]: Well, I think I'm trying to understand what S197 is about in a way. Because is it just a payment reform bill? Or is

[Alyssa Black (Chair)]: it a bill that really is

[Leslie Goldman (Member)]: ignoring the role of primary care in our healthcare system and how we believe that primary care is essential to improve health of Vermonters, so that we're investing bigger than just the payment reform system. It seems like an opportunity that I don't want to let go by From an aspirational point of view that we can just do more of the same. And right now it feels like it looks a little bit more of the same, maybe as we were talking earlier, just spreading more of the same. But I'm not really sure how. When you look at the numbers, a lot of people are already involved to help the HSA. So I'm not sure of the changes. I'm a little hazy on that. And how this bill does anything other than a lot of reports. I would like to see a real commitment to increasing primary care spend and really talk about that and what our goals would be and what we're asking for. That's a big deal, I know, but we know it's 35% of health care and only 5% of the spend. So how do we get from here to there? So is this bill the vehicle for that? I I was hoping so. But I don't know that the intent section is strong enough because it is only about payment reform. And I think we've learned enough about primary care to understand the essential role it plays.

[Alyssa Black (Chair)]: Why do we keep studying it?

[Leslie Goldman (Member)]: Yeah, do we We keep studying already know the answers. We already know that we want to What do we need to know in order to actually do something?

[Debra Powers (Member)]: Don't we know enough now to actually do something? And I found both the measures.

[Wendy Critchlow (Member)]: I keep seeing the same measures on all of these, like it's diabetes or hypertension. I find the measures lame. I do essay, right away, there's like, my opinion right now, we're all not well, and we can't measure that by your blood pressure or your, you know, There's just no good way to measure how we're affecting good health in the primary care setting. Do we need a diagnosis? What is it that we need to say that good care is happening in the primary care setting?

[Alyssa Black (Chair)]: I know I've been harping on quality measures.

[Leslie Goldman (Member)]: I know.

[Alyssa Black (Chair)]: I know some of you are probably not really thrilled with me. I don't know. You know I either. This is a citizen legislature, and this is a discussion, so I'm going to bring my own personal. I worked for close to thirty years in a practice. These quality measures, this is somebody like me sitting down in an office documenting that a measure was met. And I don't know the value. And I think about, know, they always use the same to the diabetes with the hemoglobin A1c under seven. First of all, to even think that it was by nine, okay, nine, it was seven. The fact that the implication is that a healthcare provider, and this is why I keep going back to that it's really about the relationship between the patient and the provider. It's in the payer's best interest that everybody have a hemoglobin A1c under nothing. Does anyone really think that a provider is going to be sitting there with their patient with uncontrolled diabetes and not care in trying to get that person's diabetes under control. And then to measure whether or not you've been able to get your patient's diabetes under control completely removes all the social determinants of health and the things that are in that person's life that is a challenge for them. I mean, is it great that you have a community health team so that you can have a dietitian to be able to that you have access to the resources that your patients really need, which is what I think the beauty of Blueprint actually is, is that they provide the resources so that a provider with that unique relationship with that one patient has the ability to be able to connect that patient with services that can actually help get their diabetes under control. But to pay a provider an extra quarter because they're treating to the test means that we don't trust that a provider cares about whether or not somebody's diabetes is in control or not, or hypertension. So what do you do? You overmedicate somebody so that they become hypotensive, which is not great either. And it's as if somebody would be sitting in front of you and they have hypertension and you don't even address it or care about it. You're provider. That's why I keep harping on quality measures. That and it's somebody like me sitting in an office going into every single individual diabetic's charts and coming up with a CPT two code to be able to report to an insurance company what that person's hemoglobin A1C was. What difference does it make?

[Daisy Berbeco (Ranking Member)]: Totally disagree. And you know what I Alyssa and she knows I totally disagree. I think quality and accountability need measurement. I think you can't, Leslie, you can't change what you don't measure, including your diabetes. And I think we have standards in American health care. Health care is a science. And that's why we need to measure it. I don't trust all doctors. Heck no. There are bad actors out there. And it's unfortunate. And I don't think that measuring is at all about not trusting them. But I think it's about having high standards of care, about safety. It's about also efficiencies. If we maintain level standards, it's easier to align and have expectations. And also, I think, learning across our systems. So I think the measurements are absolutely worth it. How are we going to have our facilities be accredited or certified, I'm not going somewhere that's not accredited. We talked about that when we talked about the health plans in what the hell was that, May? I'm not going somewhere that's not accredited. And if you're not measuring all this stuff, you're not following NCQA, you're not going to be accredited.

[Alyssa Black (Chair)]: But we have lots of practices that don't go for NCQA accreditation. I'm not going there.

[Daisy Berbeco (Ranking Member)]: I'm just saying I disagree with you, and this is a citizen legislature.

[Wendy Critchlow (Member)]: So, I'm making my point. It somebody, a patient, as somebody who is practicing, it reduces somebody to a diabetic. They're no longer a person in the practice. They are a diabetic that you're treating that disease. I think you have to look at the overall patient. If we're just reducing it to a diagnosis, then that's what they're getting paid for. I think it totally changes the trajectory in how you're treating that patient.

[Debra Powers (Member)]: That's how I look at it.

[Wendy Critchlow (Member)]: Diabetes is on their chart, you're looking at it every time they go in. I just hate the way they measure it in that way. What if I go in? I'm not a diabetic. How is the doctor going to get paid less because I don't have a standout diagnosis that can be measured every time? I just look at it like it should be a whole person. It should not be a diagnosis that we're looking at every time someone goes into a doctor's office.

[Daisy Berbeco (Ranking Member)]: I think it's like the blueprint we are, right? Want people to get healthy, and that sometimes is incrementally addressing health problems.

[Wendy Critchlow (Member)]: Every single time they go in, we're going to just measure that one thing, and that's going to be how they're reimbursed. The doctor has to be laid and focused on that one thing in order to get reimbursed accordingly. I don't know. I just find this

[Alyssa Black (Chair)]: backwards. Brian and then Leslie? So

[Brian Cina (Member)]: guess I would start by saying I agree that we've created a system where our efforts to improve quality have They drive a culture where people then search for how to do that. So now the money flows towards coders to look for how do you make as much money as you can, to look at how do you document. Have to worry about providing the proper document. It's like making providers jump over hurdles or through flaming hoops and then giving them a treat, but then they figure out how to jump through that hoop better doesn't necessarily solve the problem. So I think we have to be careful about that. I question how far do we go with quality measurement and what are we really measuring? And just as an example of that, the Trump administration just announced $139,000,000 in grants to transform behavioral health, they're looking at things like, just one example I'll give you, wearing continuous wearable device data interlinked with electronic health records at quote, unprecedented scale to predict and prevent behavioral health disorders and promote healthy behaviors. So are we gonna have people wearing collars now, where their medical record's gonna be recording their behavior? You know what I mean? Where are we going? Where is this headed? So I think we have to be careful about that. That, to me, seems extreme, honestly. Granted, I wouldn't mind making money for not smoking if there was I can get $10 a day, and they were tracking me to make sure I didn't smoke. I don't know. So maybe there's a benefit to that, but I think we need to really think about how far are we going to go to track quality and what's really valuable or not. And I did email you all that little thing I said earlier. I wrote it down and emailed it to everyone.

[Wendy Critchlow (Member)]: Just now.

[Brian Cina (Member)]: Like a minute ago.

[Leslie Goldman (Member)]: That's fine. I'll get into that topic. And I'll follow-up

[Alyssa Black (Chair)]: on that. You did remind me of something, which is, we have had a profound loss of independent practices. And we hear from practices all the time about administrative burden. And when you add these layers of quality and administration, it incentivizes and rewards the scale that is able to have administrators administrating and you cannot have an individual or a small practice be able to, I'm not going to say game the system, but a lot of quality measures and meeting it is gaming the system to get the payments. And when you are so small, you cannot game the system because you don't have. And that is one of the reasons that we know administrative burden is why we're losing independent practices. And we're trying in this committee, we talk about it all the time. Independent primary care, independent health care is, frankly, has higher quality measures and costs a lot less, but system. And we're trying to sort of remove our primary care from a hospital based setting. We know that it's driving up costs. And, you know, a lot of what we've done in an effort to improve quality has ironically flipped it and it's causing behavior that we didn't want in the first place. Leslie?

[Leslie Goldman (Member)]: You know, I was really thinking about drivers of health at the same moment you said that I bought it. And I think that's pretty well established that medicine only contributes to 20% of a person's health. But look at the amount that we're investing in this very tiny, narrow piece of it. And I'm sitting here wondering, well, maybe this is just a payment reform bill and nothing more than that for primary care. And leave it at that and not think about anything more than doing what we can do to improve primary care sustainability. And when Doctor. Rabin was here, I thought, God, I want you to be my doctor. She was amazing. And I had this vision of all these tiny little independent primary care practices all over with people having access. And as you all know, I did primary care for thirty seven years. It's really hard to change people's behavior when SNAP benefits are paying for soda. Your A1C is going to be high. I don't care. I could add more drugs, but that's my only recourse. And that is not a sustainable process. It just puts money in pharmaceutical pockets. So it's a lot of frustration about what actually changes behavior and what actually makes people healthier. And I'm not sure that we're in a position to start to do that back in this bill. But I do think we can do primary care payment reform and really have targets. Like Massachusetts, like you said, we want 15% by 2030. I don't care, whatever. I'm making that up. Actually, pressure the system to put money into primary care and support independent practices. I worked in an independent practice. I stopped working in an practice because getting paid was impossible. It was horrible. So I walked away and got employed by a hospital. So until that system is doable, we were going to have people employed by a hospital because someone wants to do that administrative nonsense. So all of it is a morass. And what I would love to see is the skill simplify it all so that primary care gets supported.

[Alyssa Black (Chair)]: I

[Debra Powers (Member)]: just had a question about the language in the bill. As introduced, it says one of the goals was to reduce the amount of defined primary care practitioners spend on administrative tasks from an average of 50% of practitioner time to an average of 10% of practitioner time, is that still in the bill that we're looking at? I believe so. It

[Nolan Langweil (Joint Fiscal Office analyst)]: takes a different, the bill that came to you takes a different approach to

[Wendy Critchlow (Member)]: primary care. Can

[Alyssa Black (Chair)]: you point to us, Mayor, it took the turn in the bill that we have in front of us. You said that it took a different approach to administrative.

[Nolan Langweil (Joint Fiscal Office analyst)]: It just took a different approach to the primary care issues.

[Debra Powers (Member)]: Oh, okay. It's I mean, they don't if there's anything. It just seems like a terrible waste of human capability to provide quality healthcare to have it be spent in this way. And it's sort of a measurable metric on them, she would.

[Alyssa Black (Chair)]: Let's have our administrative burden representative. She'd know the iterations.

[Debra Powers (Member)]: Jessica Byron from Millennium Society. Would say where the bill addresses that currently is less through a specific measure or number, but asking the in use test, or fill currently drafted tasks, a group coming back with more of a concrete payment reform proposal and that group would look at how to measure quality and what quality factors would be. So rather, it doesn't have a set goal, but it does include that in any next iterations of payment reform as a serious consideration.

[Wendy Critchlow (Member)]: What about the administrative payment? Karen was talking about.

[Jessica Byron (Millennium Society) [time-bound override]]: It does not include that same measure of the hours. I think there was a lot of conversation among primary care clinicians of what is included in that statistic and actually a concern that one concern if you are measuring that in terms of hours, are you just then hours of clinician time and speaking of practicing to the tests, do you then just hire more administrative staff to do those tasks and we're not actually simplifying the administrative tasks? So is that actually accomplishing the goal when you're just looking at the hours of clinical time spent on administrative expenses or administrative requirements? Do you believe that testimony at some point on what would be the right sized percentage to provide this kind of care? Percentage of what?

[Debra Powers (Member)]: Of funding for primary care

[Alyssa Black (Chair)]: providers Percentage versus of total spend, healthcare spending?

[Debra Powers (Member)]: I guess, because there was just, we'd provide 35% of the care, 5% of the spend. And there was something in the teens, I seem to remember 15% or something, that was somehow something that would truly work. Yeah, we took testimony on,

[Alyssa Black (Chair)]: because there is, and the bill started frankly differently, and if you remember we walked through, I don't remember the number now, but 433. No,

[Debra Powers (Member)]: that's just the medical.

[Alyssa Black (Chair)]: The other one where basically it contemplates like a Rhode Island system of ratcheting up the percent.

[Nolan Langweil (Joint Fiscal Office analyst)]: Is a bill. The bill that came to you does ask the agency to establish a target. Because

[Debra Powers (Member)]: we also are testimony that primary care providers are providing a bunch of care for free because their full patient needs that kind of care. But if you are talking about where the money is spent in the system wide, like perhaps a specialist isn't providing care for free, I don't know, it just seems that the care that's being provided

[Alyssa Black (Chair)]: should

[Debra Powers (Member)]: be able to be complete and thorough and be paid at a rate that recognizes that specialty of taking care of a whole person. So just in terms of vision,

[Alyssa Black (Chair)]: I am going to put a question out there, keeping in mind what Karen just talked about, like the vision of a percent of spent. I wanted to get everyone's thoughts on Doctor. Som, which is, I believe, what Massachusetts is working on. The idea that primary care is a public utility and a common fund. What did everyone think of that when he was sort of presenting it to us?

[Debra Powers (Member)]: I loved that. I just really thought that made a lot of sense. It's so inequitable now on so many different levels. That just made a lot of sense.

[Wendy Critchlow (Member)]: I think when you change the vocabulary of things, change the trajectory of things. And I think that did it for me. Like if you start talking about it differently to people, they'll change. Like I said, I think right now when people get sick, what do they do? They go to the emergency room and they pet themselves. They go to the emergency room. It's just the way we think now. But if you take primary care out of the system and make it the utility that it is and change the conversation around it, I just think we could make it something great, really good.

[Leslie Goldman (Member)]: Long time. No, no, that was rhetorical.

[Wendy Critchlow (Member)]: Yes, it was.

[Alyssa Black (Chair)]: Anybody else want to weigh

[Debra Powers (Member)]: in on the common fund? Just one little addition, you think about, I guess maybe I'm channeling part of

[Daisy Berbeco (Ranking Member)]: your movement here, but if you think about

[Debra Powers (Member)]: the amount you already do spend on Ministry of Health, if we just took that same pile, put it in here, quality care, accessible to all, equity. I

[Lori Houghton (Member)]: agree, the way we talk about things can change the culture and change the way we do things. I do believe that this committee, for at least as long as I've been on it and before that, probably deep down has believed that. And the real question is, how do you make it happen? And yes, we spend a lot of money on health care. And this committee and other committees have tried for many years to move that needle, and it hasn't worked. So that's what I want to get to. I don't care what we call it, but how do we finally move that needle?

[Alyssa Black (Chair)]: I think it's a really great point. What you're saying, which kind of ties to Leslie about what is this bill anyways. And this bill seems to be We talk an awful lot about transformation in this committee and what I find things that are supposed to be transformed really just become sustainability. Is this transforming primary care and the mechanism in which we pay for it? Or is it just making it more sustainable? Because all the efforts that we put in in the past, which you just alluded to, kind of built on this model, which has become unsustainable. Should we just prop up and sustain this or should we think of a new funding model? I know I'll send the question to you.

[Lori Houghton (Member)]: Yeah. So I know I've missed some of the testimony and I apologize for that. But when I read this bill, I think we are doing more of the same because it doesn't matter what the blueprint comes back and says they need to make it work funding wise. It's still our requirement as a state to put that money in, and we've never been able to do that.

[Alyssa Black (Chair)]: My thought. Thank you. I got Allen, and then I got Daisy.

[Allen "Penny" Demar (Member)]: Okay, the first line on page one, an act relating to payment reform for primary care. There's a lot of other stuff in here that's happening about addressing primary care. That to me, that's confusing. I think with all the reports and everything else, it's on warranty and I think we should get back to reforming primary care. The other thing we haven't realized, and I don't know, maybe I'm not that tough on it, but the transformation of rural health care. I think that's going to have an effect down the road. I don't know what year, but are we going to put ourselves in a predicament that that's going to injure us? Who knows what's in there? I don't know. Think that's primary care is going to be within the five years, it's going be on the table.

[Alyssa Black (Chair)]: To your point, Franklin, I'm not sure I see anything in the bill that actually doesn't pertain to primary It all does in the So a lot of different reports. Talk about rural, particularly rural primary care, because we That's the whole scene. Should we be continuing a payment model that has led to deep inequities between rural and more suburban? I'm not using urban, so we really don't have any urban. Should we be moving to a payment model that actually is far more equitable and too

[Allen "Penny" Demar (Member)]: rural? According to transformation, whole state's rule, right? I think they've eliminated Chittenden County or Burlington.

[Debra Powers (Member)]: Yes. It depends on the method. Yeah, that's true.

[Allen "Penny" Demar (Member)]: And the other thing is, we talk about prevention, and you talk about diabetes. I have a primary care doctor. You can look at me and say, hey, he doesn't follow the directions of his doctors. I got primary care, he tells me what to do, he tells me with medicine, he tells me how to do this, he goes to I've never been to a dietitian. You can't make people do something that they don't do. So I don't care how much you pay a primary care or Blueprint for Health to give you the right areas to go to, it takes people to do what they're told, I guess.

[Alyssa Black (Chair)]: You make a great point, which is we're currently measuring your primary care provider on what we can do.

[Leslie Goldman (Member)]: Exactly. But

[Alyssa Black (Chair)]: let me ask you a question. First of all, I should ask you, do you value your primary care provider? Yes. Do you like them? Okay, great. Do you like them because they hound you about your hemoglobin you want to see? Or do you like them because you think they care about you?

[Allen "Penny" Demar (Member)]: We're friends, we've become friends. I've been going here for probably thirty five years. We become friends, we talk openly about my health, and what do I tell him? No, I haven't lost weight. He keeps telling me that, but it takes two. The primary care can direct you, Blueprint for Health can direct you, but the patient has to be part of the solution.

[Alyssa Black (Chair)]: So what you value is your long term relationship with your friend.

[Wendy Critchlow (Member)]: That's immeasurable. It is, it is.

[Leslie Goldman (Member)]: So what makes the patient part of the solution?

[Allen "Penny" Demar (Member)]: Because when he tells me to take my sugar count every day, and I take every two weeks, I'm not following orders.

[Leslie Goldman (Member)]: So what would it take? So that's one of the questions. What would it take, I don't In today's society I wrote it up, but I don't want to put you on

[Allen "Penny" Demar (Member)]: the phone. I don't matter.

[Leslie Goldman (Member)]: Okay, because you're just sort of this model person that we just have an opportunity to think about. Mean, we all have our version, right? Some of us smoke cigarettes, whatever. So, sorry. You guys So I guess the question is, how do we engage people? How do we engage someone like all of us who have our quirks and not, know, I don't know if that answers what you've

[Allen "Penny" Demar (Member)]: tried to engage people and educate people on their health now for years and years.

[Leslie Goldman (Member)]: But the point is what you're saying is that we're measuring primary care providers on what people are not engaging in and And their own does this bill do more of that? So are we perpetuating that dynamic?

[Debra Powers (Member)]: I think you're more likely

[Alyssa Black (Chair)]: to have more trust in your provider and what their recommendations are if you trust them that they care about you. So if you don't have a relationship with your provider, a longitudinal thirty year relationship, you're less likely to trust that provider when they say, when they recommend that you get a pneumovax. You're more likely to trust them when they say, hey, let's switch you to this medication. I mean, Allen, but you're more likely to test your blood sugar every day instead of every two weeks.

[Leslie Goldman (Member)]: If you have a trusting relationship with somebody. But thirty years is thirty years, right? And even with a thirty year relationship. So, okay, we put a lot of emphasis on primary care and relationship and the more I hear, the less I'm convinced, even though we all love being around someone we're comfortable with and feel they care for us, but it's not changing behavior. So what? I'm getting So jealous

[Wendy Critchlow (Member)]: why should the primary care be dependent on someone like Allen to get paid more?

[Debra Powers (Member)]: I think that's what said, right? I

[Wendy Critchlow (Member)]: mean that was all due respect. But if you knew that your doctor might get a little bump in pay, would you do the right thing? Like, it's No.

[Alyssa Black (Chair)]: If Allen gets sent to the endocrinologist because he won't test his blood sugars, Why is the endocrinologist not getting paid based upon his? That's the thing I struggle with.

[Debra Powers (Member)]: That's right,

[Alyssa Black (Chair)]: Brad. Oh, Daisy. Yes. Oh, it's gone.

[Debra Powers (Member)]: How do we know that our colleague here doesn't have a better health outcome in being with us here today because he had

[Alyssa Black (Chair)]: that thirty five minutes. Yeah.

[Daisy Berbeco (Ranking Member)]: I think it turned no. I'm sorry. There could be a lot of positives that we're seeing or measuring, and

[Debra Powers (Member)]: that has been good, which is why I have a problem with measuring.

[Lori Houghton (Member)]: A couple of thoughts. One, I don't think I'm with Daisy that we can't get rid of quality measures. I do believe we should, and this committee has tried, to coordinate, align, all of that. And how do we make sure we're measuring the right things to know we have qualified people and are making our population healthier. So I don't think we need to throw it out. I do think we need to find a way to make it work. The second thing is we keep talking about thirty year relationships with our providers. I think we need to remember that those of us that are younger than the people at this table not me, all of us, younger than us that's not how they use health care.

[Alyssa Black (Chair)]: Exactly.

[Lori Houghton (Member)]: And so we haven't talked about that. So I think about my son and his friends, and they're turning 18, and they're going to be able to do their own thing, they're not going to look for a doctor that they have a long term relationship with. If we were in other states, they'd be going to CVS to get their health care or Costco or something. So I think we need to keep that in the back of our minds as we start looking at this. I see we need to reform payment to providers, and we need to reduce and align quality measures that make sense to make the population healthier.

[Wendy Critchlow (Member)]: Don't call it transparency. I need to recall her.

[Daisy Berbeco (Ranking Member)]: I know what I was going to say. It's just that we're sitting here in this room. And yes, we've had lots of testimony through this year about what we need to make better and ideas of how to do it and great testimony from folks like Doctor. Song, which I thought was very interesting, intriguing. And I think there's so much we don't know, and it seems outrageous that we would sit around this table and between the eleven, twelve of us, come up with how to fix health care in Vermont. That's absolutely outrageous. And I think that we need someone to tell us what to do. And that's why I look forward to this public hearing, Because I think we can't discount and I'm not suggesting that anyone at this table has. I know we all really share respect and value for what people, what patients and providers are going to tell us they need us to change for them. But I just think, looking at this bill, it's, yes, more of the same, too complicated, and three, I want to hear, what do my constituents think of it? Is it going to fix the fact that they can't even afford to get to any of these providers? I don't know. I feel like I'm really looking forward to hearing from the public about this bill. I'm not jazzed about it. I don't think it changes that much.

[Alyssa Black (Chair)]: I'm so excited for Thursday. Really. Me too. Really. I want to hear what people value. And no offense to anyone sitting around the room, because you all have really important perspectives. My

[Brian Cina (Member)]: wearable device just told my medical resident.

[Alyssa Black (Chair)]: I have Leslie.

[Leslie Goldman (Member)]: I think we have an opportunity to do something beyond this bill, and I really hope we can. I think, and that's important, if it's not beyond this bill, then I don't really care. I think it's just more of the same. So I am, and I said this earlier, but I'm just going to say it again, really intrigued in the idea of primary care as a public utility. And that's a common good. And we talked about that in the context of hospitals. Hospitals today are common good. But okay, so let's say primary care is a common good. Let's agree with that. Or public utility, as he was talking about. And making a case for a common fund. And I am very interested. That would take us beyond where we are. And I really would like to

[Alyssa Black (Chair)]: sit up. And would not cost us to start any more than what we spend right now. It's the same amount. It's about 5 percent. Everybody puts 5% into the common fund.

[Leslie Goldman (Member)]: But it expands who puts in.

[Alyssa Black (Chair)]: Yes. And that's what it works in.

[Leslie Goldman (Member)]: Yeah. That's a really important start. And then how it gets distributed.

[Alyssa Black (Chair)]: Then we can talk about things like, okay, we start with 5% and then how do we build upon that? And which gets to the point of, I think, how this bill started and the other bill that we had on our wall of spend targets, where it would be a much easier mechanism to essentially have to be able to reach those spend targets if everybody is putting into a common fund. Managed by the treasurer perhaps, who

[Leslie Goldman (Member)]: does that work.

[Alyssa Black (Chair)]: Allen, did you have something? Thought

[Allen "Penny" Demar (Member)]: By the way, I just got a clean bill of help the other day. Just finish that off.

[Brian Cina (Member)]: Until they have a new measurement tool that you

[Alyssa Black (Chair)]: primary care will look out. If I

[Leslie Goldman (Member)]: may, you said something really important. It really depends on what you measure, and Daisy, I agree with that. But you said Pneumovax. Now, what kills older people more than pneumonia? Nothing. And what prevents pneumonia more than anything? Pneumovax. So it's a really simple way to measure whether people are getting the primary care they need. So I think that there are measures that make sense. I

[Debra Powers (Member)]: think there are. This is maybe an additional benefit. If we have access to primary health care, many of these practitioners have said, look, I can do the dermatological risk, there are many things I can do without having to go to the specialist. And then we have the flexibility in employment,

[Allen "Penny" Demar (Member)]: like

[Debra Powers (Member)]: does this really lead businesses, does this allow them to do more, to grow, does this allow the property taxes not to be spending so much money on education related healthcare? Does it actually relieve, have the effect of relieving system wide a lot of the cost pressures we have across the board? And I just wonder, don't know where that goes, but I always felt bad that people were stuck with maybe an employment situation they didn't want to be in or shouldn't be in because they needed healthcare, they chose a job that maybe wasn't their best job, there was all those things. And I love the mobility and the lifting of social cost.

[Alyssa Black (Chair)]: And I did want to say something about quality measures, and Doctor. Saroyan touched on this a little bit today. I don't think I'm advocating getting rid of all quality measures. I think we need to modernize what we're actually measuring. He said that, I mean, he talked about that they are in the process of modernizing the blueprint and what they measure. And I think about because the quality measures that we measure right now have been around the hypertension, the hemoglobin A1c, immunizations. The developmental screening may

[Leslie Goldman (Member)]: be the only one that has impact for children.

[Alyssa Black (Chair)]: But what I was going to say, oh, there's an asthma one that there's going to be improvement. We have medications for diabetes that we didn't have ten years ago. I mean, just look at GLP-1s and in the treatment of co occurring heart disease in diabetics. I was looking at one of the measures in asthma that Blueprint does and how it's gotten so much better. It's because there's actually it's in children. There's actually now a method of inhalation that is able to be I mean, remember we did a bill a couple of years ago and we had to put in that thing about covering asthma medication? It's because the delivery of asthma medication is better than it was ten years ago. The method that kids can actually get albuterol in or what other drugs we use. So you have social determinants. Communications are better, and they are leading to a lot of these things, which is why I'm just advocating we need to modernize and we need to measure I just feel like we need to somehow measure the things that have been very difficult to measure because they're unmeasurable. But we've had multiple witnesses because I've asked, what would you measure? And they all come back with access

[Leslie Goldman (Member)]: Patient satisfaction. Patient satisfaction.

[Alyssa Black (Chair)]: And even Doctor. Sarayan today said, Yeah, they're kind of moving in that direction. So maybe that's what we should be basing some of this on. Debra?

[Debra Powers (Member)]: So this is very simple. I'm slowly learning how complex the healthcare system is. And I'm not setting any of that aside. I just think the bottom line in La Mafayette is affordability. I don't go to my doctor and I love her. She's fantastic. But I don't go because I feel healthy, so how do you get me in there? It's affordability. I don't want another bill. So I think everything we do, everything we push, everything that is processed should just make it more affordable.

[Alyssa Black (Chair)]: If everybody could go and they didn't have to worry, would people go when they needed to go rather than waiting? Your doctor, by the way, is getting measured on their quality and you're dinging them

[Wendy Critchlow (Member)]: because you're not just as big doing.

[Daisy Berbeco (Ranking Member)]: If you get measured

[Wendy Critchlow (Member)]: on your going to the doctor on a regular basis, your doctor is getting dinged because you're not going.

[Debra Powers (Member)]: That's not going meet my deductible. Go 40,000 a year.

[Alyssa Black (Chair)]: Yeah, yeah. It's separate. Rate. Great point

[Leslie Goldman (Member)]: though. Is. But it's really important. But they're very distinct. It's like you're being measured on what you're not willing to do because it's too expensive. I mean, it's idiotic.

[Debra Powers (Member)]: It's not something. Wendy,

[Alyssa Black (Chair)]: did you? No, I just wanted to say that.

[Wendy Critchlow (Member)]: We're asking doctors to be measured on something that is so abstract and subjective. I'm sorry, those measures, they're always the same. They're always A1C. And if you don't have those, we're only measuring Someone showing up at a doctor's office. I think it's the only other measure we really

[Alyssa Black (Chair)]: But we measure Have you seen someone for a preventive visit within the last amount of time? Yes. Which

[Leslie Goldman (Member)]: was of ED visits. A

[Alyssa Black (Chair)]: then there was a measure of ED visits, which are going up as we're also increasing schedules being filled with So if you

[Leslie Goldman (Member)]: have your ED visits going up, then that's of that area. I

[Brian Cina (Member)]: just wanted to say that We were focused on measuring the providers when most of the power is in the hands of the patient. And that I believe someone threw out the number 20%, but the last I looked 16% of the social drivers of health was access to care, and 34% was healthy behavior, and the other 50% were other factors. So if 34% of what's driving health outcomes is the behavior of the people, then we should be creating policy that promotes healthy behavior. And so removing cost sharing, and perhaps even providing other incentives for going for your yearly physical, and providing through primary care, providing better nutritional advice. I mean, I would even go so far as to say referrals to gyms and gym memberships should be part of our healthcare. Because aerobic exercise, I've learned this recently in my effort to address my issues, one hundred and fifty minutes a week of aerobic exercise can prevent so many diseases and can improve mental health. I'm having a hard time doing that, because now I have to buy a gym membership, but I'm going do it because it's cheaper than cigarettes. But that being said, but not every human is going to come to that conclusion, or put the work that in, that I've put in to come to that conclusion, without access to care. So imagine if we create ways to incentivize access to care that then incentivizes the healthy behaviors. I don't think measuring the provider's testing is the way to go. Maybe it should be how many gym memberships are being used? I don't know, how many of your clients are accepting new Maybe it's rewarding the patient instead of the provider. Maybe we should be incentivized, because they're the ones whose behavior matters. I don't know. I could go off about it further, but I think you get my point. I do. Interesting. That

[Alyssa Black (Chair)]: was one of the other quality measures I met. One of the biggest ones was screening for colorectal cancer. For what? And the quality has gone through the roof. It's great. We also have PoloGuard, which we didn't have before. Your only way to screen was a colonoscopy, which nobody ever would.

[Brian Cina (Member)]: What age are you supposed to get that at?

[Alyssa Black (Chair)]: I think it's down to 40.

[Leslie Goldman (Member)]: 40, have a family history too.

[Brian Cina (Member)]: Yeah, know. I haven't even been to a primary care physician in probably ten years.

[Leslie Goldman (Member)]: Saying. They

[Brian Cina (Member)]: charge me too much to go for something that I get that's not useful.

[Alyssa Black (Chair)]: All right. Sorry. So, super excited about tomorrow. I think it's going

[Wendy Critchlow (Member)]: to be great. We're going

[Alyssa Black (Chair)]: to table our discussions on 01/1997. We have very active discussions. We obviously know exactly where we're going. Anyway, it's a great discussion. Thank you everybody.

[Brian Cina (Member)]: Before we go up, this is policy related. If anyone is interested in hearing from patients who've benefited from psychedelic therapy, we're eating lunch in the cafeteria, and there's some people who have come here who would really like to connect. So feel free to find me and talk to them.

[Debra Powers (Member)]: Mushrooms. And

[Alyssa Black (Chair)]: by the way, just want

[Debra Powers (Member)]: to go eat those.

[Daisy Berbeco (Ranking Member)]: I think that's so great.

[Alyssa Black (Chair)]: And I'm actually really super excited about it. At the end of the session when we're kind of in that hurry up and wait thing period of time. You know, I already have it late. So we're going to take some testimony. What are we taking testimony on?

[Brian Cina (Member)]: On psychedelic medicine, the president just signed an executive order that's going to fast track clinical trials. So if we have time, I would like us to hear from some national figures on Zoom. There's also people who, if we could give them enough notice, would be willing to fly to Vermont and meet with us in person, including some possible high profile people, would make it exciting in the end.

[Alyssa Black (Chair)]: Not joking. Michael

[Leslie Goldman (Member)]: Pollan. Yeah. How about Michael Pollan?

[Brian Cina (Member)]: I'm not gonna say their names on the record and then put them on the spot.

[Alyssa Black (Chair)]: We don't know how long we're gonna be here.

[Brian Cina (Member)]: Exactly. So this it's probably gonna be months, so we have plenty of time.

[Alyssa Black (Chair)]: Alright. Alright. Thanks, everybody.

[Wendy Critchlow (Member)]: Keep off my flag.

[Alyssa Black (Chair)]: You can

[Allen "Penny" Demar (Member)]: come back after