Vermont Legislature SmartTranscripts:

[Senator Ginny Lyons (Chair)]: Oh, I know. It's gonna be so cold out. We usually do this before we start, but I'm gonna do it at the beginning of the day. Sounds nice. And so this is great for all of us. Write down three things you're grateful for. There we go. That'll keep you connected. All right, so good morning everyone. We're taking S197, the primary care bill, which is a top priority in this building, and I think in the administration and everywhere else. So we're gonna hear from folks so we can make some progress on the bill. And then we'll be moving on to a couple of other bills that we've been looking at that are also critically important to us. So we'll start this morning with Doctor. Ann Morris. Thanks for being here. We're going to introduce ourselves once around the room for folks who don't know us, and then we'll start our assessment on these people. Go ahead.

[Senator John Morley III (Orleans District)]: John Morley from Orleans District. John Benson in Orange District.

[Senator Ginny Lyons (Chair)]: Ginny Lyons, Chittenden Southeast. Where it's in Meraki with Chittenden and Senator Ann Cummings who will be in from Washington County. So thank you for being here. We'll go right ahead. So

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: good morning, everyone. Thank you for allowing me the opportunity to speak today. I met some of you in the past, but as a reminder on Camp Bars, I have been a family physician who practices in Milton, Vermont, and I've worked with the UBM Family Medicine Residency for a decade in primary care, and as of May, I became the associate dean for primary care in AHEC at the Larocque College of Medicine. I'm also a board member of the BMS and the VTAFP, So as always, please consider these as my words and not those of my employer. But introductions aside, I'd like to start with some reflection on where we are today and how we got here. As these reflections often go, it was 04:30 on a Friday afternoon. I'd already been in clinic all day and had worked through lunch, and my patient looked at me and said, with tears in her eyes, Why does everything have to be so hard? We were talking about caring for their shoulder, one that had been injured after a fall. The pain was keeping them up at night, and despite previous recommendations from us to rest and take a napkin with the home exercises, They were continuing to use their arm at their job in the local nursing home. I was recommending formal physical therapy to speed recovery, and they said with a bit of anger, It's just so expensive. Another patient came to see me for a preventative physical and asked me to do everything that I need now and in the near future because she plans to go without insurance in 2026. Her work in preschool education, a job that requires an undergraduate degree in early childhood development, doesn't pay enough for her to afford the premium increase for insurance on Vermont's healthcare exchange. And finally, several of my Medicare patients are coming to see me at out of network costs because their plans have all changed this year, and premiums are, in some cases, now higher than their monthly Social Security checks. But they desire to stay with a provider they've been working with for years, and who knows them best despite the costs. I had a little bit of a hard time composing my thoughts into what I wanted to say to you as a committee this morning. In my world, this feels like a high stakes conversation, and I need to convince you that investing, really investing, in primary care is the right thing to do for our patients, our providers, and our healthcare system. It feels high stakes, because we are trying to please everyone, and we're proposing, in order to do this right, to invest more money into primary care, while trying to reduce the money that's going into the healthcare system as a whole. But I'm gonna try anyway. We can all agree that investing in primary care reduces total healthcare dollar spent and improves the lives of people. By now, you're all familiar with the statistics that for every $1 spent in primary care, it saves the system $13 It does that through relationship building and trust. Did you know that a provider needs to have almost 70% continuity with their patients in order to actually improve health outcome? And that the longer the continuity relationship lasts, the greater the impact on reducing resources spent on urgent care visits, emergency rooms, and hospitalizations. A study published in Norway actually showed that when that relationship lasts upward of a decade, it reduces emergency room visits and hospitalizations by twenty five to thirty percent. This directly speaks to creating an environment that is easy to access for patients while being affordable and sustainable for providers. At AHEC, we review and update our roster of open positions within the state's board. As of December 2025, there were 79 open primary care physicians in the state. We all have seen the predictions on how this number is going to continue to rise. It is not easy to recruit and then retain providers in Vermont, and for that, Vermonters suffered decreased access to care through longer wait times and the burden of having to travel farther for their care. There are many reasons that it's harder to recruit providers to rural places. It starts with having a smaller pool of people coming from these areas with interest in becoming primary care providers in the first place. It worsens by not having enough clinical training in these rural areas to increase provide our confidence during training, and make them fall in love with communities, and it's compounded by high educational debt, and the fact that rural areas traditionally pay the lowest salaries in a field that already has significantly lower salaries compared to their specialty colleagues, upward of $100,000 as an easy difference. Addressing these workforce development challenges takes a longitudinal approach that starts with introducing students to careers in health as early as middle school, and continuing these exploratory opportunities all the way through undergraduate education. It continues in medical school and residency training through early and frequent exposure to healthcare in rural communities, and culminates through a variety of programs to reduce educational debt burden that helps to attract and then retain primary care providers in these communities. Some really great examples of these works include things such as CSHIP, the Governance Institute of Vermont, Institute of Medicine, the upcoming Maple Mountain Consortium, Rural Family Medicine Residency, the AHEC Medical Student Incentive Scholarship at Elcom, and the Vermont Educational Loan Repayment Program for Healthcare Providers. I'd be happy to come back and talk about those in more detail. You will. So, once we get the providers to Vermont, we have to work hard to create a system where they can afford to practice, and where they feel that they're valued by the community and the systems within which they're providing care. This is the part of S197 that becomes exciting. In the bill, we're trying to talk about increasing total investment in primary care. We're talking about investing in primary care teams so that they can meet individual patients where they are, help them make their diagnoses more manageable, and provide the short term follow through that providers whose schedules are booking three to six months out can't provide. In order to do this successfully, I'd like to comment on a couple of things from this bill. The proposed primary care spend rate feels bold at 15%, and it would be if we were starting in 2027. By waiting to enact this until 2029, we will again already be behind the proverbial eight ball, and it will take years of data collection and negotiation to raise this rate. For true primary care reform to be able to reach all Vermonters, we need to have payers and practitioners, and we need to have all payers and all practices. Primary care is a team based sport. We can't achieve value based care and meet quality metrics alone. It is extremely important that we increase our investment in initiatives like the Blueprint Community Health Teams to allow practices to provide that integrated care in patient centered medical homes, and to keep people out of the ED and help them meet their short and long term health goals. Paying for services provided in healthcare is difficult and comes in many forms such as fee for service and capitated models. We're going to see a mix of fit in reality. It's the focus on a per member per month, the MPM, payments, like we see with Blueprint, and monthly payments, like we saw through OneCare's comprehensive payment program that will help to make a measurable difference to these practices. Finally, we need to acknowledge that regardless of practice type, federally qualified health centers, independent practices, or hospital altered, we are all seeing the same patients with the same degree of risk, the same degree of illness, and the same social and societal needs. All practices need the advantages of reducing administrative burden, including prior authorizations. A primary care provider in Middlebury ordering a CT scan has the same credentials and the same burden as one providing care in Randolph. All practices, regardless of type, also need access and investment in technology, like ambient AI technology for documentation and resources to bring things like point of care ultrasound to primary care practices across the state. It keeps people out of the hospital. In summary, I want to acknowledge that these concepts are complex and broad, and yet by tackling them, we have the opportunity to improve the health of all Vermonters and reduce the total cost of healthcare in Vermont in a meaningful way by making a bold, long term investment in primary care that provides the right care at the right time and the right thing. It gives practices financial stability while reducing administrative burdens, and allows for innovation that meets the needs of the individual communities in which those practices reside. It also creates an environment that not only attracts, but retains providers in their practices by naming the value that their services provide to their patients and their communities. Thank you. Thank

[Senator Ginny Lyons (Chair)]: you very much. I don't have any questions. We're gonna hear testimony this morning and then I know that you're under the stress of getting back to patients so we won't keep you but we will at some point want to hear about ADEC since I understand that significant funding was left out of the governor's budget for AHEC which is a personal concern of mine so we want to come back into this room and look at that. Thank you for your work, hon. Thank you very much. Thank you for everything we brought. Need your testimony, sent Colesta, so we'll have it online. Thank you. Great. Thank you. Alright. Next is John. We'll just follow along on the agenda that we have. Also, Rosenberg, thank you both for being here. Thank you for having us. One moment. Ready? Yeah, you ready? Okay, we are.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: Okay. For the record, I'm Sarah Rosenblum. I'm the interim director of healthcare reform at the Agency of Human Services.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: John Sorian, executive director of treatment for health patients. And

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: we are gonna say some words. We have a written statement that we are prepared to send to you if you haven't received it already. So, you will get a written copy of everything we're gonna cover today. The Agency of Human Services believes strongly in strengthening primary care, and there is a lot of overlap between the goals of S197 and the goals that the agency has for primary care. So we're looking forward to working with you and continuing to work with you on this bill. Specifically, we're looking forward to working with you on determining the appropriate timing and framework for S197, because we have a significant opportunity underway already to modernize the Blueprint for Health through the Rural Healthcare Transformation Program with the federal government right now. I will turn it to John just to do kind of a brief overview of the Blueprint. I know you all got a 101 from him last week, but just as a refresher.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: So, the Blueprint for Health is nationally recognized, promotes high quality, high volume care, including advanced primary care, specialty care, community based services to positively affect the health and well-being of the volunteers. Thank you, Doctor. Morris, for mentioning our community health teams. At its core, the Blueprint gives the agency of human services the operational structure to direct payments to practices to support their efforts to improve access and quality. And the Blueprint's successes are achieved when that funding is coupled with the community health teams that were mentioned previously, and can embed specialized clinical staff in practices and communities.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: So, you've heard testimony from us, from the agency, Joel, about the overall healthcare transformation a few times, but I think overall, and we haven't had time to just talk specifically about what's in that application related to the blueprint, which is a lot. So, we've made some pretty significant commitments to the federal government related changes to the Blueprint through our Rural Health Care Transformation Program application. Namely, we proposed doing three things. One, modernizing the payment model that is core to the blueprint. Two, examining the standards for advanced primary care with a particular lens for access to make sure that the quality payments that the blueprint provides to practices are aligning with access and other measures, quality, and gloves. And then third, developing a payment structure that reflects these standards and consolidating all of Blueprint's payments, which we'll get into in a little bit more detail, into a single payment with the hope that that will help bolster Blueprint's longstanding multi payer history that has been somewhat challenging in the past. So right now, Blueprint has different programs that some payers contribute to some programs. They all contribute different amounts. And we're hoping that through this consolidation that we've proposed in RHT, it'll be $1 amount that you're paying comprehensively for all of Blueprint services, and it'll be easier to negotiate with payers for participation. Okay. I'm gonna talk about those three things a little bit more specifically. And I will note, I don't know, you may have had an opportunity already to look at our Rural Healthcare Transformation application. If you have, I think you'll see that there's definitely still things to figure out, like specific methodologies to figure out within that application. And I do think a core part of what we hope to do over the next year is work closely with stakeholders, including the Vermont Steering Committee for Comprehensive Primary Care to figure out those details. Okay. So getting more into the specifics we do have now from the application. I mentioned above reassessing the primary care medical home requirements for access under the blueprint. That is an example of something that still has to be determined, like what specific access requirements we might be interested in. But just as examples, having after hours or weekend appointments, having remote patient monitoring capabilities, telehealth, or same day appointments for existing patients, that type of work for it. I spoke a little bit already about aggregate payments across all of the different Blueprint programs. So just as to say more concretely, you all may be familiar or you heard from John last week about the different components of Blueprint. That includes hub and spoke, community health team payments, practice payments, payments for specific initiatives like the pregnancy intention initiative, and this would lump all of those into a comprehensive Blueprint payment. And then, lastly, as part of our RHT application, we secured a significant amount of funding for new payments for the Blueprint program. There are three payments I'll highlight. The first one is a community health team per member per month payment for chronic disease management and prevention. The second is a practice per member per month payment for that increased access. So we talked about potentially revamping the access standards. Also wanna make sure that practices have the financial support to maintain those standards. And lastly, a primary and specialty care coordination for member per month payment. So, I think right now, probably a lot of this work is already being done by primary care practitioners and that they are trying to coordinate care with specialty care providers, but there isn't necessarily a payment for them to do that, and that this would further incentivize them to coordinate care with specialists and to be adequately reimbursed for them.

[Senator Ginny Lyons (Chair)]: Since

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: we're talking about this kind of basis in the Rural Health Care Transformation Program, I think it's important to point out the timeline of that program and the timeline of our commitments to the federal government. So it is really important that we execute on our commitments in this program this year so that we can secure funding for the remaining five years of the Rural Healthcare Transportation Program. What that means specifically is that by August, we need to provide a report to CMS that describes our progress on implementing these commitments. By October, we need to obligate all of our funding from federal fiscal year '26. So that's that $195,000,000 you've heard about. All needs to be, quote, unquote, obligated, which means it has a place to go and a contract has been signed and it's been approved for that landing place for the CMS. And then all the money actually has to get out the door by 09/30/2027. So the work that I just described above, the access changes, the payment changes, the in addition to the new payments, the restructuring of the payments, all needs to happen now. And we're under significant time pressure to perform in order to get more funding from the feds for future years of the program. The last thing I'll say is as part of our Rural Healthcare Transformation application, we also had to provide an evaluation plan for this work. So part of what will be assessed on to determine future funding in addition to implementation progress is whether or not we've made progress on specific metrics. So I'm sure in this bill, your goal is for primary care providers to feel the difference of this funding and feel like the system is improving. And I just want to highlight that we have committed ourselves to actually making a difference. We need to show that these reports are having an impact on population health and on the system here in Vermont. So overall, thank you very much for giving us the chance to speak with

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: you

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: today. I will reemphasize, I think we very much agree with the committee's goals of S197. I think the question is what is the appropriate timing and framework to do this work given the significant work that will be underway this year with the blueprint and through our Rural Health Care Transformation Program dollars.

[Senator Ginny Lyons (Chair)]: Is that it? Yeah, that's it for both of you. Okay, I was waiting to hear John's story. Just want reiterate

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: what Sarah said.

[Senator Ginny Lyons (Chair)]: Do have some questions that I think then the committee may also want to ask some questions. So the Rural Health Transformation grant, obviously it's grant. And then within that, my understanding has been that you'll be sending out RFPs, requests for proposals, so some of what you're talking about will come from practitioners and clinics and others to access the operational signs of So that's one question. And then it goes to BLUEPRINT. Will it only be for the BLUEPRINT folks or will it be for folks in the clinical world who are transitioning to a community health? Thank

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: you, Senator Orleans for your question. The Blueprint per member per month payments, specifically for chronic conditions like congestive heart failure, asthma, that payment will not be, in my early view right now, I can't predict the future if all these things come to be, that will be a practice very similar to the successful mental health integration we did into primary care, what we call an attestation. We will do these things and we will be measured and the dollars would then flow once those attestations were signed. So that's different from a request for proposals model. That form of increasing the per member per month amount will follow not only for the community health team for those chronic conditions, but also for the payment that we come up with for increased access for the mental health integration, because we need to fill that gap, as well as the specialty coordination that Sarah mentioned, and the potential, and again, I want to emphasize that potential initiatives for technology enhancement are available and are described in our initiatives as available to all practices, one of them emphasized independent practices. That would be, and again, I can't predict the future, that would be more based on, I think, the model of request for funds. Yes, requests, we're requesting this. Those community health team enhancements to access both so that the base payment and to the community health teams will be on that attestation. We'll have the same types of sessions. We have the form of mental health integration to get the input, describe things, have questions, and then those attestations will flow out.

[Senator Ginny Lyons (Chair)]: That's quick. No, no, this is good. That raises another question, which is if funds are going out to the Blueprint folks and that will help expansion or however that happens, then within the bill, within our bill, we have a date certain by which everyone becomes the blue trend, so to speak. Are there sufficient funds within the Rural Health Transformation Grant over the period of five years to fund those payments. Have you done sort of an analysis of the fiscal impact if all of our primary care folks become what's in the bill, come community health teams?

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: The fiscal analysis is dependent on what the negotiations finalize in terms of the dollar amount. So, that is the first step that we will do when we know what that dollar amount that's negotiated with the federal government. I think Jill spoke to in this committee, that process. We need to know those numbers.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: That's true. I think you know our 195 has been approved, but the line items have not The

[Senator Ginny Lyons (Chair)]: line items. Got it. The line items.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: But the but the other thing I I wanna highlight is we will be making changes to our budget during this year, year over year. So if, for example, a bill did pass that would have an impact like that, like, say, everybody would join in the Blueprint program, we would be we would undoubtedly have the opportunity to adjust our budget to accommodate that.

[Senator Ginny Lyons (Chair)]: Okay, and so then my other question was, in the bill we're looking for a sustainable funding process for our primary care going forward. It sounds like this grant is really a first step to operationalizing payment reform, but it doesn't have within it a sustainable funding pathway, which we're going to try to include in our legislation.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And that's, I think, where we wanna work with you for

[Senator Ginny Lyons (Chair)]: need to work together.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: For timing and and and blending of those center lines.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: Yeah. So I I will add that as part of our overall health care transformation application, we had to include a sustainability plan in that. The work that we outlined here for the blueprint, I think very much sets us up if Vermont chooses to participate in the AHEAD model, which includes a primary care component. And he did speak to AHEAD as being a pathway to sustainability for much of our rural healthcare transformation initiatives.

[Senator Ginny Lyons (Chair)]: Wind back briefly. AHEAD model may sound new or a refreshment. Folks who are here.

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: Yes. The

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: A HEAD model, which stands for achieving healthcare efficiency. Equity.

[Senator Ginny Lyons (Chair)]: So we changed it from equity

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: to efficiency. Affordable. Affordable.

[Senator Ginny Lyons (Chair)]: It's a great acronym.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: I don't know. The federal government loves acronyms.

[Senator Ginny Lyons (Chair)]: So and we don't we've just

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: yeah. Yeah. Yeah. So Vermont was accepted to participate in the FF model in 2024 under the Biden administration. That federal model is a cooperative agreement, which means that it is an agreement between the state of Vermont and the federal government that required negotiation to get to an agreement. That agreement was signed on the last day of the Biden administration last year in 2025. And since we signed it, the Trump administration has made a number of changes to the AHEAD model, and we will have to renegotiate and sign another agreement. So that is why I speak to whether or not Vermont chooses to participate in the AHEAD model, as we'll have to renegotiate. The main we could spend all day talking about the AHEAD model, but the main components of the AHEAD model include a hospital global budget component, a primary care component, and newly under the Trump administration, a geographic entity component. So, there is overlap with what's in S197, honestly, and trying to move primary care payment in the state of Vermont to more of a value based payment, that is very much reflected in the AHEAD model in its new form, which includes four different primary care payment pathways that providers can choose between that basically run the gamut from fee for service with the little bonus payment all the way to basically full on value based So,

[Senator Ginny Lyons (Chair)]: there is a payment model in there, and the global payment, hospital global payment is something that we've also been looking at separate from our heads.

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: Yes. Yes. And the one

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: thing I'll add just from a timing perspective is that if Vermont chooses to participate in the in the head model, we would do so beginning in 2028, so something to think about in the context of the timeline of this bill. Okay.

[Senator Ginny Lyons (Chair)]: Thank you. So you were is there anything else? I stopped you in the middle, so I No. We're we're good. Alright. So I guess for us, I understand the Rural Health Transformation Grant will do a great deal to support the regionalization that's going on with the Act 68 transformation work, very much with the primary care work that's embedded in this and embedded with the advisory committee that we put in place. And then as you have said, timing is important. Think it so it's critical for us that we have something coming out of this committee before crossover, and then the house will look at whatever we send them. We need to have some harmony structured with this. We can't depend on the Rural Health Transformation Grant to do everything that needs to happen. There are a lot of policy decisions here, and then there is, of course, a sustainable funding piece that's critical. We have some testimony a little bit later on that. And then we have Choms sitting behind you, and I'm thinking we also have polymetric analysis that's so critical, as you said, about how we're measuring our population, about public health and population based improvements. Yeah. Specifics will be important. This is the first time. Questions?

[Tom Morris (CEO/CFO, OneCare Vermont)]: I got the 500.

[Senator Ginny Lyons (Chair)]: It's not simple. I would appreciate your testimony, but also if you have other information that helps us understand what you are doing with RHT. I know we're all in this together, but some further information would be helpful. As I know the money isn't there yet, we won't know for a while, but when that comes forward, we wanna know what does that support and how will it support transformation where? Yep. Yes. And if. Senator.

[Tom Morris (CEO/CFO, OneCare Vermont)]: I just wanna make sure I get

[Senator Ginny Lyons (Chair)]: Uh-oh. Look at them. 50,000

[Tom Morris (CEO/CFO, OneCare Vermont)]: foot level, let's just say, right? This is basically taking money through insurance providers. I'm thinking through my head, Cross Blue Shield, maybe Medicaid, maybe Medicare, creating some kind of funding system in the blueprint it sounds like to me, going to the primary care providers, and then Also somehow adding in the rural transformational dollars as well, but the part I'm concerned about on that is these are one time dollars.

[Senator Ginny Lyons (Chair)]: That's his concern. Because once you give it out

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: I know.

[Senator Ginny Lyons (Chair)]: There are expectations. So the question about how do you make it sustainable, we don't wanna put it up here when it should be here, and how do we fund it? Exactly the question.

[Tom Morris (CEO/CFO, OneCare Vermont)]: Okay, and the money's going, I think it says monthly in the bill, the primary care physicians, which is good for your business, I would say, of the bank, getting more money than current.

[Senator Ginny Lyons (Chair)]: Yeah, So we don't lose them.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: No, haven't.

[Senator Ginny Lyons (Chair)]: Yeah, no, yeah.

[Tom Morris (CEO/CFO, OneCare Vermont)]: But it seems to me, this is basically, this section of healthcare is becoming universal. It

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: could be.

[Tom Morris (CEO/CFO, OneCare Vermont)]: For primary care physicians? Could just

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Yeah. I think that the opportunity with the federal government has to be maximized, and I think Jill spoke to that the other day. I think the opportunity for Vermont with this bill and the work that we wanna do with the MS, with Jen, with you all, is to really make sure we leverage all of those things, and then we get the timing and the order right, and statutory and the policy aspects right, and we wanna do it well quickly. But I think your 50,000 foot level sort of big description is in the ballpark.

[Tom Morris (CEO/CFO, OneCare Vermont)]: In the I didn't get a home run.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: It's in the ballpark. It's in the ballpark. Did you want me to say anything about the plan? No. What is he gonna do? It's like Grammarly Justice.

[Senator Ginny Lyons (Chair)]: Grammarly Justice. Alright. Senator, that raises some questions. The rural transformation federal grant can't be used to pay salaries, so that money can't go to primary care physicians. It can be used to buy equipment. I love it. And the problem which we've tried for years, we know because we've lost primary care physicians. If you're in a rural area and your patients are primarily on Medicaid, you can't survive. And so we've been but our rural areas are primarily poor. So we're trying to find a way to allow physicians to survive reasonable comfort because if you become a specialist, it'll make a whole lot more money and. So the whole thing is how do you you know, not everyone wants to live in. Why not? I don't know. They come from New York City, and they say

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: it's lonely.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Best skiing in the country. That's right. Well, if

[Senator Ginny Lyons (Chair)]: you're tonight, I'll send them home.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: Anyway Can I can I try to get some of that?

[Senator Ginny Lyons (Chair)]: Yeah. Jeff, you may. Yeah. Of course. Yeah.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: You're I really appreciate your comments. You've clearly been listening to Joel.

[Senator Ginny Lyons (Chair)]: I'm a bunny chair.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: The rural healthcare transformation dollars cannot be used to pay for salaries, as you said. The context of the testimony you just gave, because the blueprint is, the services within the blueprint are not currently reimbursable. We are allowed to use the money to pay for these per member per month payments I laid out. I also want to add, though, that a significant portion of our rural health care transformation dollars are related to work force, but that we could spend a whole hour going through those.

[Senator Ginny Lyons (Chair)]: Okay. Well, we will get to that.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: And we will get to that, but I appreciate your comment related to the workforce need, and certainly we can come back at another point in time and walk you through all those different initiatives as well as the funding for that in rural healthcare transformation. I don't know. You

[Tom Morris (CEO/CFO, OneCare Vermont)]: hit it. Okay. That's right.

[Senator Ginny Lyons (Chair)]: It's helpful. This is good. I think everyone's starting to get into their own state. Good. Thank you. Thank you for having us. Alicia, did you want to add anything to the conversation?

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: I don't have any additions. I'm just here for question and answer support if needed.

[Senator Ginny Lyons (Chair)]: Do you have any dollar figures for us or fiscal appeal or Not today.

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

[Senator Ginny Lyons (Chair)]: Yes, you may. Thank you.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: I will join fiscal office. The all payer, sorry, the blueprint payments went away. They were tied to the end model negotiation. Right now we're paying ePrint pure state dollars. Is that part of the new Ed conversation? 100%. Trying to reconcile how ePrint would be same as would be through temporary through the RCP or how they'd be and no longer these paid dollars, but it would be some planting versus maybe some high level.

[Sarah Rosenblum (Interim Director of Health Care Reform, Vermont Agency of Human Services)]: No. It's a good question. Again, I think we could change the budget as we go along. So we end up participating in the AHEAD model and that negotiation goes well. And we get to which this is, I would say, priority area for all the signatories on the AHEAD model agreement, is that we get Medicare participation in the blueprint. If we achieve that, then I think we can reassess our overall health care transformation dollars so there isn't a supplement supplementation issue. But for now, I think we wanna cover cover blueprint at least for the next five years. We don't know what's gonna happen in the ahead model negotiations.

[Dr. John Saroyan (Executive Director, Blueprint for Health)]: And we can use our STP for that. Exactly.

[Senator Ginny Lyons (Chair)]: Okay. Thank you for that question. And if you don't mind, when you're sending in your testimony, if you could add a comment similar responding to no one's question. Okay. It's very helpful. Yeah. Sure. Happy to. Alright. Great. Alright. Good. Thank you. Thank you. And this is not the last time we will see you. No. Our names are. Morris is here, Tom. Thanks for coming, Kent.

[Tom Morris (CEO/CFO, OneCare Vermont)]: It's probably great.

[Senator Ginny Lyons (Chair)]: Well, it's good to see you and we're glad you're here. I know it's a difficult time. You're stepping away from one care, but I would just like to say for folks in the room that the work that you've done is really outstanding. I appreciate it. And so if you could just maybe give us your testimony and then we'll see where we go.

[Tom Morris (CEO/CFO, OneCare Vermont)]: Sounds great. Alright. And to those who know me, great to see you. To those who know, my name is Tom Morris. I'm the CEO and CFO of One Care Vermont. One Care is an administrative entity that managed ACOs going back to 2012, and just concluded this at the 2025. So we're here to speak to S197 and the pain relief reform initiative described within. I have personal experience in that. My team and I developed and operated a program that they called the Comprehensive Payment Reform Program, CPR for primary care. It's a little bit if it's on the cheap. The names suck. Since 2018, and it's very similar to the model that is described in this bill. I have lived experience on the administrative side of this program. When I was thinking about what to say here today, think it's first to say, I think that this is great, clearly, the BCGRS program that I still care about a lot, and I think they did a lot of really good things, independent primary care practices. But they also just wanna shed some light on the administrative effort it's going to take to make this a success. So I think what I'll do is start with the goals of the CPR program, what we're trying to do with it, because I think they're very germane to this bill, probably important to note first. And then I'll shift into just lessons learned, having administered this for a number of years, seven years, and what I think it's gonna take to make this All right, first, for any these pain relief forms, my primary goal has always been to move the business, finance, revenue generation back, and move patient care forward. And I think it's important to recognize primary care practices of all types, they're both businesses and health care delivery organizations, both. So to the extent that we can reform the way they're paid and the way their business works and make it easier, that energy can be redirected to patient care. So pay reforms don't always do that, but that's that was a core purpose of this program for us, one hundred thirty one care, was to simplify the resident calculation, get more revival and stable, knew how much they're gonna get every month, the payment date, and hopefully that alleviated some of the business side stress, and they could reinvest that time and energy into patient gifts. That's always been a priority in mind, whether it's hospital global budget payments or fixed payments or the CPR program, is to try and simplify the business side and enhance the patient care. Second is to invest in primary care. I share many of the thoughts that were articulated earlier today. We can invest in primary care. I think there's a lot of positive downstream impacts that come from that. And using this platform, this fixed payment idea was a way for us to do it. So we come up with a financial model. We would also link to the total cost of care trans, I'll talk about that in a moment. But one of the goals and the aims of the program was to increase how much primary care practices received relative to the service. At the '25, we were at about 150%, so they're getting 50% more than they otherwise would have received on average under fee for service, and I think that's a great thing. There's a lot of literature and research that suggests that it is a high value investment. The third is this type of model approach can be a great platform to develop incentives that hopefully get everybody moving in a similar direction and prioritize areas of focus that we all believe will have value and important for our healthcare system. And an example of that within the CPR program was in twenty two or three, we offered a higher reimbursement tier to practices that had integrated mental health supports. And they could do that in different ways, gave some flexibility. It could have been a contracted psychiatric nurse practitioner that they had two days a week. Could have been a partnership model with a designated agency in their area. But if they had some sort of a way to offer dental health supports to their patients, basically through the primary care practice, we were willing to offer a higher reimbursement rate. And just about every practice took us up from that, and they developed a model. So I think that this kind of chassis or this framework can be really effective to help steer the priorities of the health care system and primary care. So next, I'm gonna Those are the goals of the program. I think it was successful, in my opinion. Of course, it biased a little bit, but we grew the program from three practices, organizations in 2018 to, I think, '19 was the most we had most, and so clearly that showed me it was a good program. They talk to each other, I think the growth is a really strong signal. We also saw through data that the CPR practices often outperformed their peers in quality ventures and areas that they're focused on. That was also the evidence of the success of the program. So my role in it, not a physician or a healthcare delivery person, but quite as we have in many ways. But it takes a lot to administer these programs. So I'm gonna go through a list of thoughts I had while creating this bill. I think it's just important for us all to know these these thoughts going into it to make it a success. I'd love to see this program being a success and live long past one care. First, a program like this needs very active management. The health care system around us changes all the time. We've seen many changes through our journey at one care where there's mergers, practices add providers all the time, and they lose them, they're internally released, internally released. We've seen hospitals divest from their practices, they become independent. We've seen that go the other direction as well. There's lots of change that occurs, and these practices, in a program like this, need somebody to talk to them, to call and say, hey, this is going on in our world. Business happens, right? And somebody to help solution. I would always tell practices, if you have a change coming, let me know ahead. Keep your secret, but we can help solution get out in front of it so that this type of fixed payment or pain reform framework works with their change and does get in the way of change. So that is to say, there needs to be a team of people who are running this program, who are there for the practices, who help support them, answer questions, and just ensure they feel taken care of in this model. Second, something I've learned through time on this part of these paper reforms is that the spirit of the program matters, how it's run. Paper reforms on on paper are neither good nor bad. It's what you do with them that matters. And you can take a hospital global budget and make it a great thing for hospitals. You can make it completely bigger. So it's really important to think about how it feels. I have to learn from this. I'm a finest person, but often very quantitative, but how the programs feel does matter. Feels like this is a good thing, a support, one can go with the practice, you're gonna get better engagement, better vibe, and that goes back to having that administrative team to run it and ensure that this works well. A little bit more technically here. I think one of the biggest barriers to getting this program up and running and getting success for a long period of time is gonna be on the payer side of the equation. You need payer partners to work with you and collaborate. Medicaid, Vermont Medicaid's probably gonna be your best friend. I'm not saying that just means that you should.

[Senator Ginny Lyons (Chair)]: But we know that. We have high regard.

[Tom Morris (CEO/CFO, OneCare Vermont)]: Me too. They've been a great partner with us and have really helped us work to make the CPR program possible, so I have a lot of confidence there. Medicare's a totally different thing. They really don't offer any customized arrangements. Ahead is out there as potential. There are a lot of other public stock, off the shelf Medicare programs, MSSP, things like that, that have potential for some payment reforms built into them where they can turn off the fee for service reimbursement instead of pay a monthly fixed payment, that's not gonna be easy. I think it's gonna be really difficult to find that arrangement with Medicare that will make this kind of program work. Commercials, true. Candidly, in my experience, it's been a difficult area to work with, to get everybody on the same page and work together. I think the legislature could use this topic to compel commercial insurance to participate, but beyond just the compelling them to to play volume, we really want them to engage and to partner in it, but in a way that supports the initiative, but also stays a little bit hands off. I think any initiative like this, you need to give the entity running it some independence to figure it out and work it if there are too many cooks in the kitchen, it's gonna be a distraction and make it difficult to operate this program. Wrapping all that up, really the first step to make this thing possible is to have upstream arrangements with payers that can make this technically and practically one. Shifting around, I really like the idea of no co pays in the patients in the primary care setting. First thing that came to mind is, one, we just have to remember the fact that I've been demonstrating the practices since I needed it. And then second, it's an area worth monitoring and feedback from providers to be way more important than any guy at the city today. But one worry is that there aren't any co pays of some people showing up in the primary care practices for things that aren't the required offices that perhaps so it's worth monitoring if it's really free to to go to the primary care setting, making sure that people go there for the likely things. Next on my hit list here, we built in a linkage to the total cost of care as well in the CPR program, and the reason I like it is that over time, healthcare costs grow. Primary care reimbursement hasn't kept the case. We saw a 5% increase in the total cost of care, did not typically see a 5% increase in how much primary care we specifically. So I like building a linkage there, that as the total cost of care grows, primary care keeps pace. That seems like a really good idea. I will say, technically, it's very nuanced. Their payer mix matters. So for example, your average Medicare patient has a much lower percentage of their health care costs in the primary care setting because of the amount of higher acuity costs outside the primary care. Payer mix will matter. Kind of interestingly, when you look at primary care spend on a PMPM basis across payer lines, Medicare, Medicaid, commercial, they're all kind of similar. There's not a huge variation there, so there might be different ways to think about that, but in general, I really like the linkage to some sort of public cost of care as well as to go to primary care in specific

[Senator Ginny Lyons (Chair)]: Data. This

[Tom Morris (CEO/CFO, OneCare Vermont)]: one's gonna be tough, too. So this relates to the payer side of the equation, but for whomever runs this type of program, you're gonna need data. Total cost of care data will be really important if you're trying to link primary care reimbursement to that in some way, but I can't speak to monitoring in sec. You just have to have data to ensure you're getting the outcome that you want here and to troubleshoot and problem solve along the way. With all good intents, we there's plenty of mistakes that happen in the pain of the form where all Medicare will make mistakes with the pay fee for service or claims that should have been zero paid under our arrangements. You don't even know that's happening unless you have taken it. So there needs to be some way to get the data feeds, total cost of care feeds to whichever entity runs this. Without it, they're gonna fly blind. So keep that on your list of priorities, figure out the data solutions so that this type of program can work. That has a linkage also to quality measures. I think there should be some sort of a quality component whenever we're investing in any part of the health care system. It's reasonable to me to ensure, of course, some accountability for outcomes. I like the idea of claims based measures from an administrative standpoint. Gonna cite a lot of them here. I will say, though, that some of the best population health measures require clinical values, so that's probably a phase two or a step two initiative, but things like diabetes control, hypertension, you need clinical knowledge. You can't fully assess that with claims on well, but in general, I need to simplify the administrative burden is a good idea, and in my view. Very similar to many of the concepts I just articulated, there's got to be active monitoring of the program using the data. You can't set this up on January 1, and let it run through the calendar year, and then look backwards at it. Like I said, things happen along the way. There's problems, there's changes, and they're much easier to fix and address if you catch them early. When whenever we found a problem that existed for too long, it's became difficult. The magnitude of change, whether it's a financial reconciliation or something like that, just get bigger and bigger and bigger. So having active monitoring that catches issues, catches problems really quickly is gonna be really important to make this smooth and successful for practices. My last four are a little bit more conceptual and less tactical. I just wanna say that a program like this is a big responsibility for whomever runs it, and this is something I took very seriously at One Care. When a practice says, okay, you can turn off my fee for service, but I'm now counting on youth. My monthly cash flow, that's a big two. And early on in One Care's journey, we wanted to build a small balance sheet so that we had some flexibility if there wasn't a shift. We didn't get a payment from a payer in time. When there's some other cash flow or in the process with the payers, we need to make sure we get things done and have some flexibility to, in short term, maybe supply some cash flow or something like that. It's a big deal for these practices when they agree to turn off their ordinary, well known revenue stream and rely on something else. It's important that there's somebody running this type of program who's there for the practices, can help troubleshoot, and even has access to some cash if needed to smooth things out if or when the problems are terminated. Iteration is going to be really important. The model that we rolled out in 2018 is quite different than what we ended up with in 2025. Every year, we made adjustments. Too much changed the problem, but we often got really good feedback from participants. We had an idea. We thought it was great, but they would bring up something really important and credible. So next year, say, you know, that was a really good idea. We're gonna make this adjustment to the program. The point in saying this is in whatever bill language you land on, I recommend making sure there's enough flexibility to allow the administrative entity, whoever runs this, to make those iterations through time. Get participant feedback. The feedback from your providers is going to be really important, and just create space to do that. Similarly on innovation, this is a great platform to test new ideas out. Giving that entity some leash to do that, try new things, I think is really important. That's how we learn that one care would try something, others really get a gift. Sometimes it worked great, sometimes it didn't. That's the process. That's how you learn and make these things better over time. And at really high level, I think the universal truth of containment, often in many cases in life, is that you solve one problem, you create another. And the exercise in this is, okay, great, we can move practice off of fee for service and address some of the problems with that concept idea and create a new paradigm. Through time, over years, you have to ask, are the new problems better than the old ones? Sometimes it's quicker, yes, we're in a better space now. Sometimes, no, you have to say, actually, you know what, new problems are worse. And sometimes you just don't know yet, but I think it's really important for our community, state for government, and whoever runs this, to think about that. When you shift this paradigm to a fixed payment model, there are new risks that exist, and how do you evaluate and test those to make sure that this is a net positive engagement and program over time, and it's value add to our state, the providers, and the patients this sort of thing. So to wrap all this up, I think, yes, I think this is a great idea, clearly. I care a lot about the CPR program, but in reading it, I'm keenly aware of the administrative lift it's gonna take to make this a success. I think that's my biggest message here, is to make sure that the resource and work necessary to do this properly, because if it's not resource, I think there's real risks or practices that it goes with.

[Senator Ginny Lyons (Chair)]: Thank you. And it would be great to have your testimony sent into Calista so we have it on our So a lot of details in there, specifics, some of which belong in the bill and some belong as the administration of all this happens. Thank you. Good question. Thank you for your work. It's my pleasure. You're teaching us a lot.

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

[Senator Ginny Lyons (Chair)]: So we have online Wayne Altman, who's a professor and chair of family medicine from Tufts University. Is he up there? He was. Okay. Let's see. Hello? He'll be back on. Okay. Good. Hello. Oh. Hello? I'm here. He's here. So welcome, doctor Altman. And, you know, before you begin, just a couple words to to those of us on the committee and in the room. We understand that you are going to present some ideas about funding, payment reform, the bill. Significantly, need a sustainable funding source and an overall process for keeping our primary care system alive. So your thinking on this is very welcome and I know we'll be continuing with this discussion as we go forward. So thank you for being here and please introduce yourself for the record and then we'll we have your testimony and we'll listen as you go along.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Well, good morning. Thank you so much for inviting me to be here. Thank you, Senator Lyons, and to the health and welfare the Senate Health and Welfare Committee. My name is doctor Wayne Altman. I'm a family physician in Massachusetts, and I'm chair of the Department of Family Medicine at Tufts Medical School. And I'm the leader of a grassroots movement that has been working for seven years to establish primary care legislation in Massachusetts. And we're very excited. We we think that 2026 will be the year that we will pass historic legislation, but I would love Vermont to beat us and do it first. And so I have some slides to share with you all, and I'll try and get through them quickly. And I invite you to interrupt me and ask questions if you have any. Even though I talk fast, feel free to interrupt me. I don't believe I'm allowed to share right now. Is there a way to allow for sharing?

[Senator Ginny Lyons (Chair)]: We're working on it.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Okay. Thank you so much.

[Senator Ginny Lyons (Chair)]: Did you do it? Okay. You're set.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Very nice. Can you see those?

[Senator Ginny Lyons (Chair)]: Yes, this is good. You can if you wanna expand them to to the whole screen right now. There you go. Perfect. Thank you.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Okay. So we call I'd love to do is share with you the legislative effort we've been working on in Massachusetts. As I read about s one ninety seven, which is really fantastic legislation, it was really amazing how much we have in common. Without comparing notes, we've really come to a very similar place, which is very heartening. We call our legislation primary care for you or PC for you. The burning platforms are, I think, quite familiar to you. Primary care access is very problematic. The cost of health care is exorbitant. It bankrupts individuals, families, businesses, and frankly, it's devastating to state governments and and municipalities as well. There are huge health disparities. And one thing that's interesting is you may notice if if if you or a family member needs to see a mental health professional, most of them are cash only or concierge, if you will. And that evolved about twenty or thirty years from now. And right now, if we don't fix primary care the way we're paying for primary care, in five or ten years, that's where we'll be with primary care, that the majority of primary care will be cash only concierge. And imagine if there are health disparities now, imagine how much those will be exacerbated. Further, there's a huge problem with primary care pipeline. As my friend likes to call it, it's a parched primary care pipeline. What's interesting is this study from 2013 that looked at the average salaries of primary care doctor as compared to a specialist. That's the blue line, and it goes up and down over the years. The red line is medical student choice for primary care, and it's in parallel with that. So I have a good friend who said to me, it's not that it's not that complicated, Wayne. You need to put more money into primary care and pay more people pay people more, and they'll and they'll medical students will come. When you get to about a ratio of about 70%, medical students flock to primary care. In addition to fixing the pay, we have to fix the job. The administrative burden is off the charts, And, to get, people to to come, we need to fix the job and fix the pay. In terms of the access crisis, though, it's not just that people aren't coming. It's that people are leaving. In Massachusetts, I don't know the data in Vermont, about one third of primary care docs are over 60. People are retiring. People are retiring early. People are leaving their profession. People are decreasing their hours shifting to concierge. And every time people leave or decrease their hours, they leave the same workload behind for the rest of us, which furthers burnout and creates this vicious cycle. So we this is a real crisis. And in Mandarin, this is these are the two characters for crisis. If you take these characters individually, it's danger and opportunity. The danger's real. I don't think I need to convince you of that. S one ninety seven is the opportunity we have to address this crisis. So our legislation has three goals, overarching goals, better health, better health equity and fewer health disparities, and then decreasing the overall cost of care. This is the primary care triple superpower. There's ample evidence that shows when you increase investment in primary care, you get better health, fewer health disparities, all for an overall cost, lower cost. You get more for less. And yet in in our infinite wisdom as a country, we've decided to invest about 5¢ for every dollar in primary care for health care dollar in primary care, where our peer nations are at about 15¢. Okay? And so the the way we we hope to get there are through these six objectives. And I'm pretty sure four or five of these six are part of s one ninety seven. Doubling primary care investment, creating a prospective monthly payment instead of fee for service, removing co pays and deductibles from primary care, financially incentivizing primary care transformation, And the one concept that is not part of your legislation is removing primary care from health insurance, although there's some mention of it, and then establishing a primary care advisory body. This is our primary care advisory body. It was passed last year. We have a task force. I'm one of 25 members of this task force, and there's a whole long list of people to try and be very inclusive of all different stakeholders in this task force. I have sent these slides to Calista so you you will have access to these slides. And so what we're shooting for is a three year ramp to get to 15%. This task force is actually suggested an eight year, we sort of compromised it, five year. We still would like it sooner than that, but you can front load it. So we're working on that. There's a lot of momentum. This is an old slide. There's now like 25 states that are working on primary care investment in doubling primary care. We also have what we call our transformers. I call this primary care candy. This is all the stuff if we had adequate resources in primary care that we would want to invest in and offer to our patients in terms of advanced primary care services, things like integrated behavioral health, addiction treatment, health coaches, community health workers, group visits, all the good stuff that we could and should be offering our patients in a very advanced primary care way. This is our payment model. I think it's similar to yours. We take a baseline, we double it, and then we adjust that doubling based on quality, based on risk of patients, and based on the number of these transformers that people attest to adopting. Interestingly, in in our legislation, exactly the same as your legislation, we are proposing a menu of 12 quality measures of which a practice would choose six. Of those six, we're also proposing that two of them are based on patient experience and that patients should have a large voice in determining what is considered quality. We also, like you all, are proposing that the risk of a patient, how complicated the patient be part of the formula so that you're not incentivizing cherry picking where people exclude patients who are too complicated. But the problem with these formulas is that they only account for medical risk and not social risk. We propose a formula that accounts for social risk as well. So this is our Massachusetts, 7,000,000 people, a few extra people compared to Vermont. We have 4,000,000 commercial, 2,000,000 Medicaid, and 1,000,000 Medicare. Our 4,000,000 commercial are in the two shades of blue on this slide. Why I'm emphasizing this is because the darker blue are the commercial self funded plans. These are the employer based plans, and ERISA law says that state government can't tell ERISA plans or employer based plans what to do. So if you enact legislation to creating a payment model for primary care and doubling primary care investment and doing all these wonderful things, it won't count for the self funded folks. And for us in Massachusetts and for most of the country, that's 60%. So that wouldn't account for 2,400,000.0. Okay? So we have a workaround. It's called the primary care stabilization fund. This fund extricates primary care from insurance and assesses the insurance companies and some others entities, which we'll get to, and then pays the money directly to primary care. This essentially becomes direct primary care for all. Another way to think about this is single payer for primary care. In Vermont, in in Bernie Sanders land, I think you all understand what single payer is. This is single payer for primary care and we think it is the right way to manage primary care payment because insurance in any industry is for unexpected and catastrophic outcomes. Primary care is neither unexpected nor catastrophic. Insurance should have nothing to do with primary care. So the virtues of this fund are that it doesn't exclude the 60% of commercial patients who have employer based plans. Delaware passed legislation that doubled primary care investment but excluded the the self funded plans, employer based plans. Less than 20% of their citizens benefit. It hasn't moved the needle, and they really regret that they didn't account for this factor. So Albert Einstein said significant the significant problems we face can't be solved at the same level of thinking we were at when we created them. We need to do something fundamentally different if we're really gonna solve this existential crisis of access and affordability and primary care. These are the 10 states that have reached out to us, and Hawaii becomes our eleventh state from yesterday, that have reached out to us inquiring specifically about this primary care stabilization fund as a game changer in their primary care insurance. Of course, the elephant in the room, what you started with when you introduced me, is how do we pay for this? Well, we did a simulation looking at our legislation, and it showed that it pays for itself in four years by dramatically decreasing the cost of overall care, predominantly through decreased emergency medicine, unnecessary emergency medicine encounters, and unnecessary inpatient visits. We have other folks who say that four years is ridiculous, and it's probably closer to one year that it will pay for itself. Let's compromise it two years. I still haven't answered your question, which would be, how do you pay for it at least in the first two years even if it's gonna pay for itself after that? And this is our answer to that question. We think that commercial payers, large hospital systems, the pharmaceutical industry, and urgent care could all kick in a little bit to pay for primary care investment until it pays for itself. We

[Tom Morris (CEO/CFO, OneCare Vermont)]: think

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: that that's a very teeny tiny haircut that they'll be taking, and it's very much in all of their interest to invest in primary care because primary care dying is very bad news for these three bolded entities. The urgent care folks might not mind, but the large hospitals, the commercial payers, and the pharmaceutical industry needs primary care and should be willing to spend a few pennies to invest in primary care in that first year or two until this pays for itself. By the way, in the ten years after, we projected Massachusetts $1,600,000,000 of savings conservatively. And this is this is potentially a complete game changer. We have 24 folks who've endorsed this legislation that are on this slide, our Massachusetts Medical Society and the University of Massachusetts Health Care System. And I'll leave I'll I'll conclude by saying that current health care system is so broken and we know it's broken and the fundamental reason is because it's based on profit and it's legislation that would allow health and equity at least to be on an even playing field. And I'll stop there.

[Senator Ginny Lyons (Chair)]: That's a lot. Thank you. It was a lot. Yeah. So as you're talking through I'm going through the slide on what about the first four years, and you're talking about some assessment on commercial payers or large hospital systems or pharmaceuticals. How is that how does that look in terms of boots on the ground actually happening? What does that mean? Does your legislation have a specific fee or tax on these different entities?

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Yes, it would be an assessment and it would

[Senator Ginny Lyons (Chair)]: be a

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: temporary assessment on these entities because if you didn't do any of this and you just said to the insurance companies pay double now but we don't want the overall pie to increase.

[Tom Morris (CEO/CFO, OneCare Vermont)]: How do you how do

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: you increase one slice one slice of the pie and expect the whole pie not to increase? You have to expect that something's gonna come down elsewhere in the pie. And but the point I was making is if you say to the insurance companies, you're gonna double your payment for primary care, well, then they're just gonna pass that expense onto consumers. But if you ask everyone to have some skin in the game, then and and and legislate that they can't increase premiums based on this increased primary care cost. That's how you control costs for consumers and not make it unfair for the payers to have to bear the whole burden, if that makes sense.

[Senator Ginny Lyons (Chair)]: So in terms of administration, so in our state we have our Green Mountain Care Board that oversees hospital budgets. We have a Department of Financial Regulation that work with insurance companies and rates, health insurance rates. And then we have our Medicaid, our public programs. Are you thinking about a separate administrative oversight for Massachusetts primary care program?

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Yes, what we're talking about there is the primary care stabilization fund that in our state would be overseen by our Health Policy Commission or our Executive Office of Health and Human Services and perhaps the folks in Medicaid out of EOHHS would oversee this primary care stabilization fund because they know how to do that. That's what they do. So, yes, there would be another body that but it would be very low bureaucracy. Right? Think about it. We're just passing money through from the payers to the practices. There'd be not all the bells and whistles that insurance companies have with prior auths and denials and and all the things, know, they'd be spending insurance companies spend, like, 30¢ on the dollar for that administrative cost of primary care. We would be spending, like, 5¢ on the dollar for administrative cost.

[Senator Ginny Lyons (Chair)]: Right, thank you. I mean that's similar to what's in our bill with Diva overseeing this, our Medicaid folks overseeing it. What you are talking about also sounds very much like an ACO.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: I see the similarities.

[Senator Ginny Lyons (Chair)]: Yeah. Similarity. Okay. One of my senator Benson, you asked a question.

[Tom Morris (CEO/CFO, OneCare Vermont)]: Yeah. I just wondered whether you would share a copy of your draft bill if you have one with us so we could just compare that to what we're looking at in place.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Of course. I sent Calista the PowerPoint slides as well as a two page description of this primary care stabilization fund and the advantages of the fund. Can also send her the actual legislation.

[Senator Ginny Lyons (Chair)]: That would be good. Mean, we've got the three things that you talked about on our webpage, but having the bill might be of interest. Thank you.

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

[Tom Morris (CEO/CFO, OneCare Vermont)]: I'm just curious, you know, we heard testimony, and you listened to it earlier about the federal money that's coming in. How is Massachusetts looking at those funds also in terms of setting up for this transition?

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: I do not know the answer to that question. It's above my pay grade in terms of what Massachusetts is gonna do with their rural transformation money, but I can imagine a mechanism by which some of the rural dollars, especially in Vermont, even more so than Massachusetts, could go into the primary care stabilization fund to help pay for this primary care investment until it pays for itself.

[Senator Ginny Lyons (Chair)]: Okay. We have another question from our life counsel. Okay. Hi. I'm Jen Harvey from

[Jen Harvey (Office of Legislative Counsel)]: the Office of Legislative Council, and I'm the drafter of the bill. Curious, when

[Senator Ginny Lyons (Chair)]: you talk about

[Jen Harvey (Office of Legislative Counsel)]: taking primary care out of health insurance, how that fits with the ACA requirements around minimum essential coverage, and how the plans can sort of comply with federal requirements while not covering primary care. Okay.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: So, you know, there are legal aspects to ERISA. There are legal aspects to the Trump h r one bill from July, and there are legal aspects with ACA. We have an attorney that is an expert on these things in primary care who prepared a a memo for us describing how this legislation and the scheme that we we just described is legal on on all counts. And I could include that too if that would be helpful.

[Dr. Ann Morris (Family Physician; Associate Dean for Primary Care, AHEC at UVM Larner College of Medicine)]: That would be great.

[Senator Ginny Lyons (Chair)]: Good work, that would be terrific. Thank you. Now to know the unexpected events. Sounds good. Any other questions from the committee? Doctor. Alban, this has been very helpful to us. Thank you for sharing. And we may go back to you. I understand you also worked with Zuri Song and we'll probably be bringing him in at some point to testify as well. Appreciate Doctor.

[Dr. Wayne Altman (Chair, Family Medicine, Tufts University)]: Song is a good friend. He also is the person who came up with the idea of the primary care stabilization fund that bypasses ERISA. He's one of the smartest people I've ever met. So I encourage you to do that. I'd be delighted to come back if I can be helpful and really appreciate the work you all are doing in the great state of Vermont.

[Senator Ginny Lyons (Chair)]: Well, thank you and good work in the great state of Massachusetts. Okay. Thank you very much. We're gonna move on from 01/1997. We've got a lot in our heads here. And I know that we're it feels like we're behind. I think we can accomplish everything we need to this morning on all of our bills. Do you have an interest in a five minute break? Sure. I'm happy to go off