Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so health and welfare, January 22, we're back. And as I indicated previously, we're going to hear from Doctor. Saroyan and Doctor. Armstrong regarding the Blueprint for Health. Just a couple of words about the Blueprint. It's an outstanding program that has become nationally known. When we introduced it twenty five, twenty six years ago and began the program, we had ideas of improving primary care and I think it's happened. And most recently, they extended out to substance use disorder through the hub and spoke. And the pilot program, which we didn't actually have but would be great to have on mental health to have primary care investment in mental health with our community health team. So it's really great to have you both here and give us kind of an update on what the blueprint is, how do we evaluate it, what are the quality outcomes, what are the benefits for patients, all those things that you know about. And thank you for this. This is a glossary of terms that Sourcer will have on the webpage for us. Unbelievable. Terrific. Thank you.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: I'll let you introduce yourselves and go ahead. Thank you. Just do a quick introduction for the record and then I'll tell you a little bit about myself. So, is Doctor. John Sorine, Executive Director of Blueprint for Health, Agency of Human Services.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: I'm Doctor. Eddie Armstrong and I am the Blueprint's Health Services Researcher. I study things.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: I'll start with a little about myself. Addy can share a bit more about her. The first third of the slides are mine, half or so, 40%, and the second half are Addy's. So just for those of you who don't know me, I'm a physician, a pediatrician by training. My subspecialty training was in pain management, end of life care, palliative care, hospice care for children, and extended into adults. I moved to Vermont in March, leaving my academic position in New York, and worked in hospice, seeing people in their homes all over the state of Vermont, including New Hampshire. And in 2022, I had the privilege of joining the state as executive director for the blueprint, and I'll build on what you said, Madam Chair, that before I started the position, I was invited to speak internationally about the blueprint. So it's known nationally and internationally, and I'll do my best for the time we have to tell you about its history, its many programs, and then turn it over to Doctor. Armstrong for outcomes and measures and why we believe in it, and don't just believe in it, but show that it's still doing the things that you, Senator Lyons, set out to make it happen. So thank you for starting with some of the background. The program is now, you're right, over over twenty five years old from first thinking about it. It was codified into Vermont statute between 02/2008. We're still very grateful to our leaders all over the state, particularly in the Northeast Kingdom and St. Johnsbury, who had the first pilot site for Blueprint. It became one of eight states selected by the federal government to participate in what we call a multi payer, advanced primary care practice demonstration, meaning that not just the state helps pay for it, but commercial insurers located in that state also help pay in addition to the federal government, and that three part multi payer aspect of our program has been very helpful, and think that's something that Doctor. Armstrong will go into more depth about. Blueprint program took on statewide scope in 2011 and was built upon individuals with opioid use disorder when it was identified both in the public, in the legislature's governor's office, and the Department of Health, that there was this very effective treatment for opioid use disorder that could become more accessible to individuals, and not just the drug itself, buprenorphine or Suboxone, but also a team around persons with addiction issues with substance use disorder to help them get their lives back. The program continued to evolve into the recent history with the Pregnancy Intention Initiative, which I'll speak about in this first part, really looking at women's health. We were fortunate enough when I started, as Senator Lyons mentioned, to undergo a look at our community health teams. These are the teams that surround individuals in the different practices and doctors' offices that they go to, to expand that team to include what became known as the mental health integration in the primary care pilot, where we were able to embed many counselors, social workers, community health workers, other mental health professionals into the practices to support individuals with a variety of mental health and substance use disorder needs. Going into 2025, the Blueprint's been involved in what we call hospital transformation, and there's also an additional steering committee which help guides our work called the Vermont Steering Committee for Comprehensive Primary Health Care. At the center of the many initiatives that our team leads and that we do is the individual Vermonter. They go to a clinic, a practice, that we call a medical home, that provides them with accessible, comprehensive care that is supported by a variety of individuals that I'll refer to you all today. Program managers that lead the program in each of our different, what we call health service areas that roughly follow county lines. I'll show a map the different areas that our program is administered across the state. We have quality improvement facilitators who really work on looking not only at what the practice wants to do, but making sure national standards are followed for what the practice is doing to make sure they're following evidence based treatment guidelines and keeping current with national trends to keep people healthy, not just at the individual level when they come in with a problem, but for prevention and for populations. And then I'll dive into our community health teams and community health team staff and what they are. That's on the glossary. That's a multi member team, multidisciplinary that includes a variety of healthcare professionals to support families in need of more than just a doctor visit or a provider visit. So I'll go on to my next slide. This is the map of how we at Blueprint have organized the state into different areas and what we call administrative bodies to oversee and implement our program. So we have our central office team and then we have teams all over the state that can be responsive to their community's needs, whether it's Newport, whether it's Middlebury, Brattleboro, Bennington. This is the structure by which we call together our leadership from all over the state. I and my team have made visits to not only these different named entities on the slide, but also to many practices. And as you can tell, except in Springfield where the administrator of our program is a federally qualified health center, the hospitals across the state have taken on the administrative burdens and responsibilities for administering our program. Those practices I was talking about or clinics, they follow a very rigorous standard, national standard defined by a National Committee for Quality Assurance to be recognized as a patient centered medical home. This is a term that had its origins in pediatrics, but has gone on to be adopted broadly outside of pediatrics to mean that care is accessible, care is comprehensive, and it's focused on the whole person so that it moves beyond what I was trained in, in medical school of chief complaint, history of present illness, medication treatment, head out in the door, which works a lot of times. But what we find in terms of taking care of populations that implementing other aspects of people's health can reduce emergency department visits, extend life, can prevent the complications of diseases like diabetes or obstructive pulmonary disease that occur. And this a rigorous undertaking for all of these practices across the state, 124. And we have, and the national organizations have demonstrated improved outcomes for individuals who are seen in patient centered medical homes, increased engagement in their follow-up and treatment, and decreased utilization of emergency departments. So I keep mentioning community health teams, and I think that, Senator Lyons, you have the memory of when this came about, but this is the part of the Blueprint program that is probably most talked about and most envied by other states, whether it's New York, Washington, California, we get quite a few inquiries from other states, is how did you do that? How did you provide members of the healthcare team, whether it's a social worker, a nurse case manager, sometimes a counselor, how does that even happen? A friend of mine will say to me on the West Coast, I'm a part of a major healthcare organization. I've been asking for a social worker for our 80 or 90 pediatricians and nurse practitioners for three years. How is this funded? Well, it's funded by multi payer participation and it really proves over time again and again, and I'll show you some quotes kind of midway through the presentation to make it more grounded, because they work to address and identify root causes of health problems, addressing mental health needs, looking at a way to have a team take care of an individual beyond and in addition to augmenting that individual relationship with the provider. So that's I think where the magic happens around community health teams. And we, I as executive directors certainly do everything I can to strengthen and build and make sure those individuals feel valued. And those services provided by community health teams are not billed for, and there's not a cost that's generated from that interaction by the health system. So to the patient, there's no cost in that moment. Did you have

[Sen. Virginia "Ginny" Lyons (Chair)]: a question? I do have a question, and you're reading my mind. You. Just to be clear, I really appreciated the math with the hospital regions, but the care that you're talking about now is delivered outside of these hospitals, is that correct? Yeah,

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: there's a variety of settings in our state that Blueprint supports. Many hospitals, North Country Hospital, St. Johnsbury, Brattleboro, just start as an example, their primary care is part of their health system. There's federally qualified health centers, North Star, many others all over the state who also participate in the Blueprint as primary care providers. And there's independent practices that participate in the Blueprint, some of which are multi site and some of which are the providers with their own shingle. We really have been able to knit together because of both the, I think, the wisdom of the program and its intrinsic flexibility, all of those practices together.

[Sen. Virginia "Ginny" Lyons (Chair)]: So some is delivered in the hospitals.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: Well, if you go into the building itself, where your primary care practice is, I guess a person would say, I was seen at the hospital. I think most, I don't know what the vernacular is currently, I guess most people say I went to the clinic, went to the ambulatory care center, but yeah, I guess some people would still say I went to the hospital. Most of the primary care settings that I've been in in Vermont are actually outside the hospital building, but there's probably some exceptions to that that I'm not thinking of. Maybe Southwestern.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, tell me. I'm trying to understand when you talk about cost of care being high in hospitals, would we lump this care in with that high care in hospitals, is it actually a different scenario?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Is it okay if I take a look here? This is Doctor. Eddie Armstrong for the record. The high cost of care in hospital is obviously a big concern. We at Blueprint don't really consider it in hospital, out of hospital because our community health team members will be embedded, so the hospital serves as the administrative entity, and they might actually just send a check to a mom and pop practice, or an independent practice, or an FQHC in the area. That FQHC will hire the staff and have them right there in their office, and they'll do all of the hiring and hours and billing and benefits and everything there. Other hospitals that are more centralized, Gifford, I think, is a pretty good example of this, will hire several staff members and then deploy them. And so they might spend two days a week here and one day a week there, and they're receiving the care either with the practice or somebody might say, oh, we have someone on call, and then they call them up if it's, say, a licensed mental mental health counselor. It's like, this person can't be driving all over this large county or this large health service area, but we want them to be right there on call. So somebody goes into a practice, and they say, oh, we've got this person on speed dial. Let me connect you with Jay. Something like that. So it really depends. I in our view, I would say it's, like, part of the hospital's total care because it's a separate funding mechanism. These these individuals aren't supported by the hospital's budget. They are supported by Zuprint. I'll get into all of how we pay for this a little bit later, if that's helpful. That is helpful. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: And it's complicated like every engineer. It's not You

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: did not copy for a simple

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: committee interview. I mentioned our hub and spoke program. Vermont in 2011 expanded what was known as, again, I'm going refer back to the 90s, methadone clinics or opioid treatment programs for individuals who need intensive daily checks and medication with the advent of new drug therapy for opioid use disorder. Vermont, through the Blueprint with the Department of Health, expanded our availability, it's now at 88 different sites, and this is so that individuals who go to their practice, their clinic, whatever they call their doctor's office, their nurse practitioner's office, provider's office, this care is integrated into that. So we try to decrease stigmatization, try to make sure people with opioid use disorder can get that treatment at the same place they get their hypertension treated or their diabetes, and their providers are supported by our educational programs, by our quality programs, to make sure, if that's what they want, if that's what they want, that they can get it at any one of these many sites. Our Pregnancy Intention Initiative aims to increase access to preconception counseling, has been shown to improve maternal and infant outcomes by asking, do you intend to become pregnant in the next six months and to tailor the person's intention to what fits best with medical care, whether that's a long acting reversible contraceptive, whether it's preparing for a healthy pregnancy, and payment for this program is based on the population around the state for 15 44 year olds. Currently 44 practices joined and even just recently in the last six months we've had some additional practices join. Part and parcel to that work is not only the quote medical aspects of the care, but also looking at what other aspects of the person's life might be identified to create a referral for or a warm handoff to someone else on the team for a mental health need or a need around other parts of their medical care. I think probably one of the most moving emails I've ever gotten in my career was from an individual who chose around Christmas a few years ago to write to me directly, I'm pretty sure that email came directly to me, saying something like, I have been looking for this type of mental health support for several months or years, and then I got to meet a counselor in my GYN practice, and they had helped me to really address a lot of the mental illness. It was one of those emails that you just, they chose to write to me and share that story. So, not just primary care needs community health teams, subspecialty care, whether it's for opioid use disorder, OB, GYN, we also affect those subspecialists too by providing that extra help. And then I think this is my last, no, have two more. Is, I'm trying to see where I'm at with the timing of. The mental health integration primary care pilot built upon the strengths of the blueprint and what we had learned from those additional initiatives to add more support for mental health, substance use, housing, transportation, you have power, do you have internet, do you have a refrigerator? All the things that people in this day and age, and for some time, to stay out of the emergency department, some of those basic things that can really affect not only the health of the individual, but the health of the family as well. So we're being aimed and we've been successful in putting more support into those practices, adding education opportunities, and really working to improve the amount of ahead of time looking, screening practices do to identify things before they become major life threatening issues. And some quotes. So, a Blueprint program manager, this is one of the individuals who oversees our program in a particular area of the state. We're not just improving systems, we're building a stronger, more connected future that addresses social drivers of health. Through Blueprint's supported initiatives, we are shaping a responsive collaborative system that rises to challenges and delivers on the promise of a healthier community. From a community health team member, Blueprint's community health teams connect people to resources that address the full spectrum of health needs from housing and food insecurity. Because we're local to the area, we understand the unique challenges Vermonters face in each community and can tailor our approach to support them effectively. And lastly, a clinician before I turn the slides over to Doctor. Armstrong, a family going through a major transition shared how grateful they were to have support during the process, not after. Without Blueprint's integrated care model, they likely wouldn't have received help at all. Being able to connect with a clinician in the moment within their trusted medical home made a meaningful difference. It allowed them to navigate the emotional challenges of change with guidance and reassurance rather than waiting until things reached a breaking point. Very well said, that's something certainly is very relatable as well. May I turn it over to you?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: All right, thank So so again, for the record, I'm Doctor. Adi Armstrong. My doctorate is in mathematics, so I am not the medical kind of doctor. I will if you need urgent care, I will turn it over back to Doctor. Sarai. But I'm here because I do a lot of the program evaluation, and I do a lot of statistics and studies about what's happening, did it work, should we continue doing this. First, I want to start a little bit about how do we pay for the blueprint. Obviously, we have hired a lot of people. They're doing a lot of work. How do we pay for this? That has to be a big question on everybody's. To get into that, I'd like to start with a few definitions because it's early in the legislative season, and here's a bunch of words you don't know. A value based payment system is a type of payment system that pays for the outcomes of care rather than the amount of services you've done. So instead of paying you every $5 for every person you see, we will pay for something else in a value based system. How many people are successfully managing their diet? Things like that. Most blueprint initiatives are funded through per member per month, PMPM, per member per month, payments that are made by all sorts of payers, different insurers. Some if it's a self funded plan, some of those pay in, some of them don't. I'll get into who all those people are in a couple of lines. And the amount will vary depending on the program. Obviously, some programs are more expensive than others and depending on the practice and how they're doing, all those things that you wanna pay for, that quality outcome you wanna pay for. This type of payment, this per person kind of fee, is called the capitated payment. You're lot of it coming back to haunt you. And these are part of many value based It's a sort of value based thing. So that gives you some of the terminology that we'll use and that you might see in other places of discussion. More dental definitions. If we're gonna pay you based on things that gets done, not based on the number of times you do something, we have to figure out a way to determine who we're paying for, and we do that via what we call an attribution. So we attribute a patient to a practice depending on an algorithm, and we use a standard algorithm for everybody who's paying into the system across the state. Our algorithm actually looks at insurance claims because we still have a claims based system. If we didn't have insurance claims, we would have to come up with something else. So we look back two years and study primary care visits and say, here's a specific list. It's a giant list. If you want it, it's available. We will happily send it to you. I'm certainly not gonna read it. And say, you know, how many times did you have this primary care visit? If someone's tied and say they go to a naturopath and, you know, a doctor, osteopathy, both, then whoever got the most recent visit will get that patient to the attribute. And that's because we don't want to implement a system where we accidentally multidimps and have you pay for somebody twice in different ways. The other component of a lot of our payment mechanisms is a performance payment, and this is a a piece of that capitated payment where we kind of pay a bonus if you're doing very well on certain measures. So we'll select the quality measures, and Blueprint calls them performance measures. We review those every so many years. We're undergoing a review of this kind of time span right now as we say, okay. Did we achieve our goals? Do we wanna keep paying for that? Is that the right measure? Is that the right dataset to collect that measure on? All of those things.

[Sen. Virginia "Ginny" Lyons (Chair)]: When you say you are doing well, you mean fat individual on the computer.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: The practice. The practice might have a high rate of people with their diabetes in control. So if their diabetes is under control, as a whole practice, they'll get a little bump. Got it. Thank you. Other questions on these different things? Awesome. Alrighty. So who pays? Commercial insurers, the big three in Vermont are Blue Cross Blue Shield of Vermont, Cigna, and MD Peak. They pay in for all their commercially insured lives. Arista plans. So Arista, that's a term on your sheet. It's a big app that made it so that people can administer their own health plans if they want to. So that includes self funded plans, administrative services only, Medicare Advantage plans, all sorts of things. Not all of them contribute. Some do. The state employees' plan, for example, is a big self funded plan that does contribute, so they do pay into the blueprint, but some of the smaller ones don't. Some small insurers, Aetna has a few 100 lives in the state. They are not contributing at this time. They're quite small. So some of the smaller insurers do not intervene. Again, some do, some don't. And, of course, out of state insurers, it's hard for us to track them down. So if somebody has insurance through California, it's very difficult for us to do anything about it. Medicaid pays into the Gulick County CMHC and CHT, which are our two core initiatives, the first two that started, and those are the two that commercial insurers pay into. Medicaid is the only payer that funds the Spoke Initiative, the Pregnancy Intention Initiative, and it was the only payer that funded mental health integration as well. So it is the only one who's funding some of our newer initiatives. Medicare. Medicare is a tricky one. Medicare only pays into the blueprint if Vermont as a whole is participating in one of their Medicare national models. So Medicare has had a variety of models over the years. Up until January 1, they were participating in the blueprint because Vermont was part of what they called the all payer model at the time. Starting in January 1, Medicare was not paying it. Yes. I know. She's shaking her head. I agree, senator Lyons. That is, it's kind of sad. So the state Vermont backfilled, and so Vermont is funding Medicare the same amount of Medicare's contributions for the Blueprint that ended up being around $5,800,000 and then another $5,000,000 to the Sash program, which is not part of Blueprint, but Medicare used to pay into that too. Going forward after 2026, we're not entirely sure, because Centers for Medicare and Medicaid Services, CMS, have declared that there will be no more state specific models. So Vermont is gonna have the luxury of saying, hey. Medicare, we're Vermont, and we wanna do this. If it's not a national thing, we might not be able to get them on board. We're not sure yet. Lots to think about in the future, but that's that's where the Medicare things sit. It's right now, we're out. Yes. Vermont teachers

[Sen. Virginia "Ginny" Lyons (Chair)]: are have you moved anything off of Blue Cross Blue Shield in Vermont to I think it's called Humana or something. Is that part of Cigna or

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: I do not know the answer. I don't actually know the answer. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's separate. Okay.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: I believe they're self funded plans of some type, and I do not know the answer to that. I think Humana and Cigna are not related, but I'm not sure if the Vermont teachers, now that they've made that move,

[Sen. Virginia "Ginny" Lyons (Chair)]: probably correct. Right. We have closed. We'll need to add it to the commercial insurers and some flavoring.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Then Carly,

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: I was

[Sen. Virginia "Ginny" Lyons (Chair)]: like, yeah. I don't don't believe so. I think, I mean, we can look at it, but because the state administers or regulates, we can regulate the self funded governmental plans. And in fact, for the teachers, it's through being high, which is an interreducible insurance association regulated by DFR. We can tell them they have to participate. Okay. If they're not already covered by others. Thank you. You very much.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Other questions on who is paying it when? Perfect. So what does it actually look like? This is the payment methodology through June. July 1 is the new fiscal year being scheduled.

[Sen. Virginia "Ginny" Lyons (Chair)]: I just do have one question about who is paying. Yes. I know the answer, I think it's a question that we probably should ask. Absolutely. And that is the commercial insurers who participate. Some of them don't pay it, and yet their patients are still going to Blueprint practices and taking advantage of the community health team. So is there a deficit related to that? So we,

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: because it's a capitated system, we have a hard time actually counting number of services versus number of pay. But, yes, there are definitely people who either are not insured, whose insurer doesn't pay in, who have insurance out of Florida because they work remotely from Florida, something like that. And they will, and the Blueprint does not tell turn people away. And the Blueprint community health teams don't say, oh, sorry. You're not insured. Right? We we serve everyone. We, Blueprint, I'm not the person out there doing the work. The Blueprint community health team members serve everyone in the same way, no matter what their insurance is, whether they have insurance. We have, for a long time, I know I have done this before, and I've written a report that Blueprint published a few years ago, the Amity 51 report, Doctor. Will remember the number if I don't, that talks about what happened and what the differences are and how this shifts a little bit of burden off certain part of you, not a part of you, because we can't capture money from people who are insured, right? And so you can kind of see in this chart what's going on, who's paying what. Medicare, of course, as we talked about, not paying anything this year. In commercial insurers, the PCMH payment is $3 per person per month, so $36 a year for a commercially insured individual. And then there's the performance component that we mentioned, where if a practice is doing very well on our selected quality measures, they might get an extra 50¢ per person per month. And if they're not doing very well, then they will get no bonus for this work. The CHT payment, the community health payment, was $2.77 per person per month. So this totals, depending on how well the practice is doing, somewhere around, you know, $5.75 to $6.50, basically, is we could think of it in this range. That's not actually very much. That's, you know, a cup of coffee a month, especially as coffee rockets towards $10 a cup. And that provides all the services that Doctor. Soraya was talking about earlier. Commercial insurers do not pay into our other programs at this time. Medicaid pays a little bit more for that base PCMH payment, and the reason for that is many, many years ago, ten, fifteen, something like that, the Medicaid program combines two payments into one. It really is $3 for the Blueprint, and then there's the extra little dollar 65 that they combined and gave to the Blueprint for care coordination services, which the Blueprint provides to everyone. That is added in there. Then it's the same performance payment, the same core CHT payment. And then the scope payment, that's a very intensive payment. We have an RN and a licensed clinical mental health or drug and alcohol counselor available to those patients. And so that's more staff, more hands on, higher credentials always. And so that's a higher payment for spoke, DHDs. And then the PII, if it's a PII specialty practice, they get $1.25 per person per month. And it is a PII. PII stands for Pregnancy Intention Initiative. Thank you so much. The CHT is $5.42 And up to June, the Mental Health Integration Initiative, MHI, is not funded right now. We're out of money, so we're finding ways to make that go on. That's our hope.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: Sponding the truth.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: We have Yeah. We don't have additional money to pay out until the start of a new fiscal year. That's right. And how but we we had an appropriation. We have sent all that out. We have the staff. They're still employed. They have money to pay them, but we don't have additional money for this year.

[Sen. Virginia "Ginny" Lyons (Chair)]: Maybe the RHT will help. Hopefully, that's our That's

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: the beginning of it anyway. Yeah. That's another one. For example so I like to put this little example out there so you can actually kinda get your hands around what a practice gets. If a practice has about 1,500 attributed patients, so they see they see more than this, but these are the ones that we can count, and say, 1,500 attributed patients, they receive payments between 4,500 and about $5,000 a month, depending on how they're doing on their performance team. That's around 55 to $60,000 a year. Then the community health team, which may go to the practice so they can hire staff or it may go to an administrative entity who hires staff on behalf of the practice, gets about $50,000 in print, to imagine. So look, he's been a chunk of money. For your reference, about 75% of blueprint practices are at least that big. So most of our practices in the state are getting at least that much money, somewhere between 55 and $60,000 a year. And about 20% are double that size and get a lot more, but those are usually multi doctor practices or FQHCs are bigger. Questions on the actual dollar value.

[Unidentified Committee Member (Senate Health and Welfare)]: What happens when Medicaid stops funding certain parts of this program?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: So if Medicaid stops funding so right now, we don't we have no concerns about that. We are welcome to Medicaid funding at this moment. If Medicaid were to stop funding parts of this program, if we don't have another source of funding, then we would have to shut the program.

[Unidentified Committee Member (Senate Health and Welfare)]: Yeah, I'm just thinking about the federal dollars, right, and what they'll cover.

[Sen. Virginia "Ginny" Lyons (Chair)]: I didn't hear your question. I'm just thinking about

[Unidentified Committee Member (Senate Health and Welfare)]: the federal dollars coming in to help Medicaid, and the rules associated with that, what they will cover, what they won't cover, I believe. Yeah. And so I'm just thinking ahead.

[Sen. Virginia "Ginny" Lyons (Chair)]: We've got a lot of thinking ahead. You're absolutely right.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Yeah. And so we, for our purposes, the Medicaid line you see there is built into what is known as our global commitment waiver. Correct. And so that helps us out a lot, and it helps the state out a lot because it keeps things going for us. Other question comes these are great questions. So my favorite part, I get to show you lots of data and say we're actually making a difference in what does the blueberry achieve. One of the things, as I start this slide that I'm gonna mention is value based and capitated payment models really require a different take on how do you assess this. Because even if you're paying per person, even counting what gets done becomes not as simple. You don't have a piece of paper every time someone did a thing, and so you can't just count all these pieces of paper. We really think quite hard about what we're measuring and how it demonstrates our impact. I don't have too many graphs to bore you with, but I could do this all day. So the first one I like to show is we've spent all this money. What happens with it? Is it is there anything different happening here? So this graph is from our Vermont all payer claims database. So payers in the state, all the big ones, all the commercially insured plans, whether or not they participate in the Blueprint, they're required to send money to to send the data, not only, to the all payer claims database. And ERISA plans, the self funded ones, many of them send, but not all of them have. So that they can kind of shoot. It does cover our around 450 to 500,000 Vermonters every year, so it's a pretty big chunk of the state. Our data says it's pretty good, and then we do have an uninsured population that, of course, we have a hard time getting data on, naturally. But this shows us this data set, and it is the total per member per year allowed amount. What's an allowed amount? It's the payer's obligation, so the amount the insurer paid, plus any copay or patient share, so any patient amount. So it's kind of a good proxy for how much was paid for that service. And this is the total claims amount per member, per person over the last five fiscal years. These are fiscal years '20 FY 2024 and in June '24. We are proud of this, I think, for obvious reasons. We are consistently seeing that Blueprint attributed lives, and when we calculate this, it doesn't matter if they paid in or not because it's all the data. So these are all the people who went to Blueprint practices and met our attribution algorithm are consistently That's a great thing to work quite into that. For your information, this is not inflation adjusted. These are just the raw numbers. So, yes, they're going up. Inflation is real. You're looking at it. We all know. Question. So maybe claims database is called It's called BHCURE. C h c u r e. And it's located Green Mountain Care That Board manages is correct.

[Sen. Virginia "Ginny" Lyons (Chair)]: I was just thinking, and then when we talk about claims,

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: are we talking about actual clinical? So these are insurance plans. So the medical plans plus the pharmacy plans. Thank you for asking these things. Yeah. So they're both So including prescriptions that you fill in your alcohol pharmacy.

[Sen. Virginia "Ginny" Lyons (Chair)]: The

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: next graph that I'm gonna show you is more in relation to our mental health integration initiative. This is our newest initiative, so we're really excited to evaluate, tell everyone about this. And this is the proportion of individuals who had mental health and substance use needs as evidenced by a claim that had those codes on it. We have another giant list of codes that says, this is what all these are, and who also had an immediate event. So how many of those people had the emergency department And why is this graph interesting? Well, fiscal year 2020 was kind of a base year. 2021, fiscal year 2021, that's 2020 to 2021. Think you remember what happened then. Mhmm. Oh, yeah. So we stopped we humanity in general stopped going out even to the ED. Yeah. So we see this big nose dive, but then it immediately picks back up. So we see people are going back. But what's really interesting here from a mathematician's perspective is the trends are apparent. Both lines move down, both lines move up, both lines move up a little bit, but just kinda over. And then in '23 to '24, Blueprint implemented the mental health integration initiative. And suddenly, they're not very long. Blueprint patients are now going to the emergency department less when they have mental health needs, and their other patients, people who go to other primary care practices, are continuing to kind of climb back up for the future.

[Sen. Virginia "Ginny" Lyons (Chair)]: How much of that can you attribute as it continues to go down in 'twenty four to the mental health clinic that was established in Burlington?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: So that is a very hard question because

[Sen. Virginia "Ginny" Lyons (Chair)]: Tease it out.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Right. We we have a hard time teasing that out because some of that is in claims, but some of it isn't. And so we would have to do some interviewing and things like that. Yeah. Other questions on this guy. Why are we studying ED visits? Again, we have a hard time counting what our community health team members do because we don't build plates. There's no we don't make them write down, and then I did this, and here's these 10 codes, and send this to us. It gives us a good proxy for seeing a diversion in care. Like, ah, something else is happening. As we get more data, we'll be able to look at more things. Speaking of ED visits and mental illness, this is a measure of practices and the rates at which we follow-up with patients who have had an emergency department visit for mental Again, 2021, you'll notice this one, it's calendar year. This is from a different dataset. It's from V Cures, but it's from a different selection of that data. It's calendar year data. 2021, there's that COVID year. It was easier to follow-up with less people went. Always easier to do that. And then it starts to go back down, and again, from 'twenty two to 'twenty three. 'twenty three calendar year 'twenty three is that fiscal year 'twenty four, half of it. That's when we started this mental health integration issue. You can again see that we're starting to get better at this. We've got people in place who can do that follow-up, who can really make those connections, reach out, and get people there. One of the reasons I'm so excited to finally share this with you, and you have already all seen this, but claims data is a little bit laggy. We are a couple years behind, and that's one of the big things that we think about as we're considering performance measures, as we're considering our evaluations, everything is, if it's all claims derived, it means we're about two years slow in getting our data, because it's January 26 and I'm showing you data through December '23. That's always a little bit tricky. As we update in the Blueprint our performance measures, other things, we're looking at other sources like e clinical quality measures. Those come out of EHRs, and that gives providers a more real time source of, Oh, this is actually what's happening this year, not couple years ago.

[Sen. Virginia "Ginny" Lyons (Chair)]: So you just flew over getting clinical data from EHR, so maybe explain briefly how you might change your data set from claims to clinical EHR?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Of course, so this is a really complicated topic and quite honestly,

[Sen. Virginia "Ginny" Lyons (Chair)]: I don't want to You don't have electronic health records using real time clinical data rather than claims that come in three months, four So months,

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: as you all know, people have to submit claims, and that takes time. Then the insurance company has to process the claim, and that takes more time, and then after that's all done, they have to send it to our claims database, and that takes even more time to send it over and get it altered. Electronic health record, the provider has put in the information right away, and then the record itself can compile and give you this month's report on how many people had high blood pressure, how many people had this. And so that gives our providers, not us, because we can't actually access their electronic health records, but it gives the providers a more real time view of what's going on with their patients. Which is why EHR is so critically important in our statewide health transformation. Exactly. Is that the acronym in the parentheses? Yes, so here it's titled that. The TPSFUI EATSTERP is the acronym for this title of the So the HEDIS FQM measure is thirty day percent with a follow-up visit after a mental illness. It's a measure that says that. That's the name. You're really interested in health measures, HEDIS is one of the big organizations that defines, This is how you shall measure this throughout the nation. This is one of our nationwide measures. Love that acronym. Thank You don't need to worry about it too much, I brought.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, I think that's

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: And there's even more details about it in our glossary.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Yes. And so, despite all of my love for data, I do think our providers say it best when they are talking about our impact. I need the B for community health care. They are the most important people. That really, we hear something like that and go, Wow, we're kind of embarrassed. So thank you so much for giving us the time today to go over this. I'll turn it back to Doctor. Soraya to close us on.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: Sure. This is our team, and I'll unshare my slides, Senator Lyons.

[Sen. Virginia "Ginny" Lyons (Chair)]: So why are we going through this? Because it's basic to the primary care bill that we're looking at and one of the issues that we face in evaluating that bill is actually developing a payment process for primary care that benefits patients and providers. And I would say represents the blueprint. Someday the blueprint will be the blueprint and we won't need a blueprint. So it would just be the blueprint. It'll just happen, right? No, we'll always

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Let me rephrase. That's the humorous fun thing.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, this is great. I really appreciate the time you've taken. I do have a question for you, actually. So as we're looking at the cost savings that we get from the blueprint, and those were not, And then the whole return per visit, all the good things that are happening. How are you measuring quality outcomes for the patient? How do we know that this investment with the community health team is resulting in people improving or preventing chronic illnesses later on? Do we have a crack?

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: I'd start with the question and then defer

[Sen. Virginia "Ginny" Lyons (Chair)]: to you. You knew I

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: was gonna ask this question. Our annual report, which is due in I think about nine days, has some very patient specific data related to Blueprint practice participation versus non specific to conditions so that you can actually see specific conditions where it benefits them individually and groups to be in a Blueprint practice. That's the Doctor. Seroian high level, can't wait till the annual report gets out so you can actually see those graphs, and I'll defer to Doctor. Armstrong for more detail, but we're absolutely moving in that direction in the coming years too in terms of our performance payments, I hope.

[Sen. Virginia "Ginny" Lyons (Chair)]: Go ahead, did you wanna make a comment?

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Okay, sure. So, One of the things we do, and I'll just share this with you now, is we send every practice a profile every year. We bring individual practice that contains about 30 measures of how many patients have diabetes, that, are they just their diabetes A1C out of control? Meaning overnight. How many patients have high blood pressure? How many of them have that blood pressure under control over here? All of these types of measures, and so we just send that out to our practices. We include the statewide versions in the annual report that everyone can see them, that way each practice gets their individual description of like, here's what we're paying on, here's why we care, this is how you're doing on it, this is what you can do about it. Then our quality improvement facilitators can go to a practice and a fresher says, I'm really not happy with the way my hypertension, high blood pressure, and control measures come out. What are some things we can do? The quality improvement facilitator can work with the practice and say, Okay, your workflow looks like this. Is there a way we can get your patient's blood pressure cuffs? Or is there a way we can do this kind of follow-up so that everybody has their medication on time? Whatever it is the individual practice level wants to work on.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes, in general way, it's really difficult to identify what you're preventing for an individual.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: Yes. It's not

[Sen. Virginia "Ginny" Lyons (Chair)]: so different. Having said that, over time we can see the results in terms of chronic illness outcomes. It's a broad spectrum. I know the focus has always been on diabetes. That's probably the easier one to measure for a lot of different reasons, and same with cardiovascular disease, but there are others. And also then stabilizing some folks who have chronic illnesses and ensuring that they don't get worse over time. I know why I keep asking this is I think it's really important to the program or to what? What it is, but the auditor came out with their report saying how poorly the quality metrics were being measured and quality was being measured. And for those of us who have been committed to this type of practice, that was disturbing to see knowing the difficulty that you have in those measurements. Looking forward to the report.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: Sure, and we had an executive committee meeting just last Thursday where Doctor. Armstrong and others on our team presented a look forward at some of these clinical measures that can come out of an electronic health record to really look where we're going with our performance measures. Lots to say about that. And I hope you'll invite us back for

[Sen. Virginia "Ginny" Lyons (Chair)]: We'll get there. Yeah, no, as we go through S197 Yeah, that'd be great. I'll be back.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: Come back soon.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, there was another question in there. Oh, The downgrade didn't come back. So we'll come back to this very definitely. But having quality outcomes is key to all of this.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: And I will also comment that when we were doing the Mental Health Integration Initiative, we had an extremely successful start review that we repeated pre and post chart review. I did not feel like I had two hours to share all of the great things that had happened with you, but that was a really impactful look. It was a sample. You can't review what your chart can say. It gave us a really impactful look. Absolutely. Before, this is how many people were being screened, and after, this is how many people were being screened. This is how many people we actually connected to a therapist. That gave us a really good look at those kinds of measures. As we update our mental health initiative, we're looking at what they're called PROMs, Patient Recorded Outcome Measures, which is a specific form that people will be filling out. We're looking at transitioning to these more formal ways of measuring those studies. Good. And then so I

[Sen. Virginia "Ginny" Lyons (Chair)]: do have I didn't hear the wrong question. So it's good. So one of the concerns that this is probably more a question for our insurance companies. However, as you've indicated, you know, it's kind of a voluntary process for what primary care docs can receive in terms of value based payments, payment per month. And what from what I understand that at least one of our insurance companies has its own little blueprint model. And do we get that data? And we don't know if we get all the data from the work that they're doing. So somehow integrating integrating their data might make it more uniform, might save some money on the insurance side or the public insurance side, your side of things, don't know. But having an integrated payment system or integrated fund would help reduce some of the stresses and strains that we're seeing about lack of participation or taking advantage of what we have and what they don't have. Mean, so we get into the nitty gritty, is there any discussion going on, for example, with Blue Cross and Blue Shield about the sharing

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: of their blueprint model I'll answer that question a few ways. They're members of our executive committee, so they're represented and they actually presented, I think almost two years ago, that program. Second point is that I just did a site visit in Windsor County two days ago, and providers were asking and stating, how can I summarize, Couldn't this just be pushed into the blueprint? Does it really have to be something else that we, does it have

[Sen. Virginia "Ginny" Lyons (Chair)]: to I've been asking that one for so

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: many That happened, that came up from some of the providers in the room. Good. And then the third thing I'll say is, we actively invite, I set the agenda for the executive committee and would welcome presentations of data by our executive committee members and stakeholders. Our March meeting's really full, but I've even called extra meetings. So, would

[Sen. Virginia "Ginny" Lyons (Chair)]: You can lead a horse of water.

[Dr. John Saroyan, Executive Director, Vermont Blueprint for Health]: You say the words, Senator Lyons, and I will invite them. Thank you so much for all of your time, we really appreciate being able to be fit into this busy morning. Well, it's terrific.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. And I appreciate all the work that you're doing. You know that. I mean, we all do. So it really is a step ahead for Vermonters. It's unfortunate that we're seeing the rug pulled out from under the federal level because really that's what's happening, both Medicaid and Medicare and other ways. We'll try to do what we can do going forward and I know that Diva's working hard on this for what's coming with Medicaid and we'll just see what we can do here. I know the FQHCs might be better off. Turn to them for a lifeline to see what happens. Yeah. Okay, thank you. And as long as the committee doesn't have questions, Thank we're you. And the glossary of terms is precious. Thank you so much. Alright. She's good. It's Jen. We're gonna do a walk through of 197. Alright. Let's let the room settle out a Are

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: you coming right back, center?

[Unidentified Committee Member (Senate Health and Welfare)]: I hope so.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. I got it. I don't want you to leave. I mean, I want you back. Take a two minute break.

[Dr. Adi (Addy) Armstrong, Health Services Researcher, Vermont Blueprint for Health]: We'll go up on a few minutes.