Vermont Legislature SmartTranscripts:

[Virginia "Ginny" Lyons (Chair)]: There are a couple of you who haven't been in committee and don't know everyone here, so go ahead. John Morley from Orleans District.

[John Benson (Member)]: John Benson from Orange District.

[Virginia "Ginny" Lyons (Chair)]: Ginny Lyons, Chittenden Southeast. Martine Larocque Gulick, Chittenden Central, Ann Cummings, Washington, right where you're located. Good, so Courtney, why don't you take over? Do we have testimony from Blue Cross and Blue Shield? I know you brought us some pretty comprehensive information last time we were together, and I see we also have it posted for today. So why don't you just go ahead.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Thanks so much and sorry I'm not there in person, ran into some unexpected snow in Southeastern Massachusetts has this pretty well blocked in. So I appreciate I appreciate you hearing us, this way today. I'd much rather be there. I can promise you that. And so first, I would say thanks. You know, last week, I tried to get through the majority of this data and probably did not do it justice in making sure that I hit the high points. And so joining us today, our Chief Data Officer from Blue Cross and Blue Shield, James Morrow, and I believe Doctor. Tom Weigel, our Chief Medical Officer is with us as well. What I'd love to do in just a few minutes is have them walk through that presentation in a little more detail, mostly so that we can explain what that that presentation is is telling us relative to our recommendations. And then also so that, the folks that are closest to the answers have the opportunity to hear any questions from the committee. I think, first and foremost, importantly, what what you heard from us last week was the opportunity that we have this session to advance some some meaningful work on reference based pricing that impact all Vermonters. And that's important to us. And I think I said last week as well, and I'll reiterate this week, we talk to the folks at at VOS frequently, whether that's Devin or Mike Del Treco, or any of the hospital CEOs. These types of recommendations don't come without communication with them. We take that, collaboration and that work really seriously. And we understand how some of these cost saving measures could impact hospitals. And I think Senator Morley brought that up with a few questions last week that were really, really appropriate for the conversation. That said, you know, we noticed the proposal from the Green Mountain Care Board, I think Friday of last week. There's a piece of that proposal that we're really supportive of and actively working towards already and just want to make sure the committee knows. Blue Cross Blue Shield in Vermont Vermont and hospitals are engaging in some discussions already on the the negotiation side of these discussions relative to reference based pricing. And I believe there was a portion of the care board's recommendation in their proposal that that reference that we should work towards some of these cost saving measures for Vermonters one on one with hospitals. I won't speak for all hospitals. I will say that the hospitals that we've spoken with relative to this agree that there might be a pathway here and see this as a way that we might be able to work together outside of legislation, which is really, really promising. And, you know, I would say relative to a focus on a percent cap on QHP, that 250% I did talk about last week in testimony is a number that we actually think on an outpatient basis, we get really close to just on bringing these two service lines down closer to more manageable levels. I would say the other piece is, you know, there is some concern on our end that we start to segment special groups and special populations and end up through legislation potentially doing more harm than good when we look at how we might do certain price points for certain groups of folks rather than measures that would impact all Vermonters. And so I just want to bring that to the awareness of the committee to say that any recommendations that we put forward or recommendations that we view as having impact across, you know, what we would refer to technically as a whole book of business. And again, Senator Morley did ask the question last week, hey, this is just for Blue Cross and Blue Shield. What does this look like across all hospitals and all insurers and for everyone valid? And so I want to start there. And so before I turn it over, to our team to walk through the presentation, I think we'll end up having more questions on what is shared as we dive deeper into the data, but just wanna stop there to see if there's any immediate questions before I turn it to my colleagues.

[Virginia "Ginny" Lyons (Chair)]: No. This is good. And obviously this would have a huge effect on hospitals. How this type of thing might be implemented is caused by concerns, whether it's left to the board or whether it's something we put into statute. But I think right now our goal is to understand your perspective coming from Blue Cross and Shield and look at some of the data that's here. That would be really helpful and we will have to hear from the hospitals. We will also, as a committee, be having a discussion about those things that we might include in the bill. We have a number of recommendations coming to us from the hallway conversations and also from our healthcare advocate and then also from insurers, the payers. So this is a good place to be, I think, right now.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Very good. So thank you. With that, I'll turn it over to Blue Cross and Blue Shield of Vermont's Chief Data Officer, and I think our Chief Medical Officer is joining, James Morrow and Doctor. Tom Weigel. I think they'll share their screen and then dive into detail on the presentation. And just a timeline perspective, I think we've got about twenty minutes or so left on our scheduled time.

[Virginia "Ginny" Lyons (Chair)]: Perfect. That's perfect timing. Thank you.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Good morning. I just wanna check if you can hear me okay.

[Martine Larocque Gulick (Vice Chair)]: Yeah. Yes.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Perfect. Okay. I'm going to share share the slide deck. Okay. All right. Can everyone see that screen okay? You

[Virginia "Ginny" Lyons (Chair)]: might wanna make it full screen. We've got all you know, we've got the slide on the side. If you can.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Is that better?

[Virginia "Ginny" Lyons (Chair)]: That's good.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Perfect. Perfect. Okay. I'm James Morley. I'm the chief data officer of Blue Cross Blue Shield Vermont, and I also work on analyzing provider information with Courtney and Tom and and others here. And I'm going to start on this slide. This is some information that we have access to via our relationship through the Blue Cross Blue Shield Association through their analytic arm, which is called Blue Health Intelligence. And this is a dashboard that helps us understand our cost relative to the Blue system regionally and nationally. Nationally. And And there's there's a lot of information on this dashboard here, but we've pulled out particular aspects of it that I think are important to look at in relation to lab and radiology. And then just one thing to understand is that this is pretty robust dataset. It covers about 50,000,000 lives that are insured through the Blue Cross Blue Shield plans across The US. And this is one high level piece out of the plan performance analytics. On the top is Blue Cross Blue Shield of Vermont in blue versus the New England regional national average, which is orange. So you could see on the left side, Blue Cross Blue Shield comes in at $1,017 per member per month, and the New England region is $714. So we're about 40% higher in cost per member per month than the New England region. The national average is a little bit lower at $6.65. And then on the right hand side, this analytic tool allows for age and gender adjustment. And the way that works is the New England regional and the national are adjusted to match the demographics in Vermont. So you'll see that when age and gender adjusted to match our population, the regional average goes up to seven sixty two and Blue Cross Blue Shield Vermont stays at ten seventeen. So while age and gender is a component, it it raises the comparison somewhat, but it doesn't explain the total difference. Any questions on that first line of data?

[Virginia "Ginny" Lyons (Chair)]: No. That's good. And it mirrors the data that we've had in the past with respect to cost in Vermont relative to other parts of New England and the country. Good. Thank you.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Okay. And then what we do is we start to dig into this $1,017 a little bit to understand exactly what the driver is. So this gets split in the bottom half by service category, inpatient, outpatient, which is the hospital services, and then professional and retail pharmacy. And then, again, Blue Cross Blue Shield of Vermont is in blue compared to the regional in brown and the national in orange. You can see that the real outlier is outpatient, which is the second set of bars over, where Vermont is about double the regional average. So we're at four thirty two. The regional average is two ten. That's where we start digging into a little bit more detail to understand what the cost drivers are in that service category.

[Virginia "Ginny" Lyons (Chair)]: Oh.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yep. Was there a question there?

[Virginia "Ginny" Lyons (Chair)]: Nope. We're fine. Okay.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Alright. This then helps us understand particular service categories. And some of these tags may be a little bit hard to read, so I'll describe it a little bit. But what this graph does is if you're at the red dot in the center, you're exactly equal to the national average for cost. And then on the the vertical axis is the trend component. So if you are to the right on the horizontal, it tells you how much more costly we are in Vermont than we are to the national average. So the further to the right, the more costly. The higher you are on the vertical means that your trend is increasing at a greater pace than the national average. And then each of these service categories are represented by dots on the graph. The larger the dot, the bigger component of the spend. And this is specific to outpatient that we just saw in the last graph being high. This large dot that is the furthest over to the right and the highest is for medications in the outpatient setting. So those are the most cost and the highest trend. The next is this is radiology services that are coming in almost $80 more expensive than the national average and growing at a faster rate. And then this yellow is lab services, and then the next dot over is procedures or surgeries. So

[Virginia "Ginny" Lyons (Chair)]: is there a way of talking about this in terms of high cost and high utilization?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yes. Yes. That's exactly on the next slide is where we can get into some of those those issues, whether it's utilization or unit cost. So, you know, sort of the last takeaway is we don't really want our services to be in this upper right. This is where it's the most expensive and growing the the fastest. You'd be preferable to be in the lower left where you're lower cost and growing at a lower rate. And then we expect with the act 55 changes that this large light blue dot will get smaller in total spend and also become, you know, lower trend and closer to the average. So over time, we expect this this large dot to come down, which leaves us, you know, looking at radiology and then lab services as the next areas.

[Virginia "Ginny" Lyons (Chair)]: And there's a

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: And this is just an example of some of the the detail at the code level, which splits it by splits the per member per month cost into utilization or unit cost. So for this particular service area, which is this is an exam, a tissue exam, you could see that we're higher on a per member per month basis than the region. So the region is one eleven, and we're coming in at three zero three. But in addition, we're utilizing almost double the services. So the region is 45 services per thousand members, and we're coming in at 88. And then the bottom is the unit cost, which shows that in addition to addition utilization being higher, unit cost is also higher. So the tool allows us to split it down to the level to see what the drivers are.

[Virginia "Ginny" Lyons (Chair)]: Can you go through that one more time for the committee?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Sure. The top is the for this particular, the one that's highlighted, this tissue exam by a pathologist, it shows the plan is at $3.03. The regional average is a dollar 11. So we're almost three times as costly on a per member per month basis. And that that expense is made up of utilization and unit cost. So on a utilization basis, the region has 45 services for every thousand people, whereas the plan is coming in at 88 services, so almost double the utilization. Some of that is a factor of almost all of these types of services happen in the hospital setting. There's not a lot of opportunity for lower cost settings either in the professional or in other sites of care for this to happen. So a lot of it flows through the hospital outpatient department. And then the bottom breaks out the component that's due to the unit cost, the per service cost. So the region is at $2.95, and the Vermont is coming in at $4.15. So we're higher in utilization and higher in unit cost with unit cost, which is causing the total overage. So it's both components are contributing to that. Any questions on that?

[Martine Larocque Gulick (Vice Chair)]: Yeah. I have a quick question. It is a lot higher than the region, but it's even more higher than the national average. Nationally, a lot more of these treatments are done in primary care settings that are not based in hospitals or what why I'm just wondering what is it about Vermont's hospital usage that is such an outlier.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Know? Do you wanna do you wanna comment on some of the national I mean, England tends to be more expensive than the national to as a starting point. I think the network in Vermont, you know, is sort of limited as far as other opportunities for lower cost settings. I don't Tom, is there more that you wanna add?

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Or No. And I I don't know if we need to focus so much on this particular example. This is more of an example that we can actually drill down by code level for these different categories to figure out is it utilization, is it cost, is it both? So I I think focusing maybe less on this particular example, and moving into the

[Martine Larocque Gulick (Vice Chair)]: A lot of my constituents ask why it's so high in this state, and so it would be nice to have a real response.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Well, I think the next slides give some more of that information, where where we we really see that that high cost.

[Martine Larocque Gulick (Vice Chair)]: Vince, now I'm

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: gonna flip to another sort of set of data that we have from another source. We're working with a consultant to understand reference based pricing, and the consultant took our laboratory spend and aligned it with the Medicare clinical lab fee schedule. And then each of these six hospitals, which are the larger prospective payment system hospitals, this is the percent of Medicare for lab services. So it ranges from 358% of Medicare up to 941% of Medicare. And what we understand is the benchmark is more around 90% of Medicare for these types of services. So there's a big component of that additional cost that's from the unit cost being higher than than many of the other benchmark areas.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Yeah. And for those of you familiar with the RAND data, which I think a lot of you are from last year, a lot of the charges on average fell out for commercial around, let's say $2.50 percent of Medicare. Lab is a little unique. Medicare actually benchmarks themselves after commercial lab reimbursements, so it's almost a bit of a circular issue, argument here that they base their prices on commercial. So Medicare's lab at 100%, is about where commercial is. You know, looking at other larger plans that tends to be actually closer to 90% of Medicare. So, rather than comparing to the R250 benchmark for a lot of items, lab is closer to a 100% or 90%.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: And then this is just oh, I can go back. Is there a question?

[Virginia "Ginny" Lyons (Chair)]: Well, I just wanted you to go through what each of the bars represent on the graph. I think

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yeah. So each of the bars represent one of the prospective payment system hospitals, and the they're labeled as hospital a, b, c, d, e, and f here. So the lowest hospital is at 358% of Medicare. The next one is 618% of Medicare, six thirty one, and then all the way up to the highest at 941% of Medicare fee schedule for lab services. So each one represents a hospital in the network.

[Virginia "Ginny" Lyons (Chair)]: And do you know which hospital, where what hospital c can you name hospital c for us?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Can we name the hospitals, Tom or Cory's? Yeah.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Courtney? This hospital C in this example is Northwestern Medical.

[Virginia "Ginny" Lyons (Chair)]: Okay. And would you mind I mean, could you label each one of the hospitals for us? And is this out of the report? This

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: comes from this comes from our claims data.

[Virginia "Ginny" Lyons (Chair)]: Okay. Thank you.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: And this is the same view of the six hospitals for the radiology services. The lowest hospital as a percent of Medicare reimbursement is at 755% of Medicare. The next highest is $9.32, and then it goes all the way up to 1292% of Medicare fee schedule for hospital A.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Yeah.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: I'm going back, sorry. Go ahead, Tom.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Sure. I mean, going left to right, I think it's UVM Medical Center, Rutland, CVMC, Southwest Vermont, Northwestern Medical, Brattleboro.

[Virginia "Ginny" Lyons (Chair)]: That's helpful. Thank you. And the critical access hospitals are not included here. What would they look like?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Critical access hospitals are are we're actually working on that analysis now. So the critical access hospitals are actually in a in a similar range as the prospective payment hospitals. And there's the same amount of variability, I would say, on those hospitals, but we're still digging a little bit further into that calculation for them.

[Virginia "Ginny" Lyons (Chair)]: And just to take a big step backwards into your little bubble graph that you had earlier, if we put critical hospitals in there and overlaid them with x-ray radiology data as well as the lab data? What would that look like?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: And you're referring to this chart right here?

[Virginia "Ginny" Lyons (Chair)]: Yes. Yeah.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: So the critical access hospitals are already included in this assessment.

[Virginia "Ginny" Lyons (Chair)]: I know they're excluded. Right?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: No. They're so this out of this dataset, they're included included here. Yes.

[Virginia "Ginny" Lyons (Chair)]: And are they are they so are they included in the infusion drugs then? Yes. No.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yes. They're included across the board here, and they're also included in these totals here. This is for Okay. Is delivered for Blue Cross Blue Shield of Vermont members, all claims data.

[Virginia "Ginny" Lyons (Chair)]: Got it. Okay. Thank you.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yeah. Sorry. The only place it flips is when we get to these individual assessments for lab and radiology. We just looked at the prospective payment hospitals at this in this analysis.

[Virginia "Ginny" Lyons (Chair)]: Okay. So the PPS are here.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yes. Yes. And we're working on the critical access hospital impact on the same scale right now.

[Virginia "Ginny" Lyons (Chair)]: Alright. Thank you. It was a lot of work.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yeah. Important work. Yes. To to get it get it all lined up.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: I was going to Jimmy, I was gonna go back to the senator's question on Sure. Why the prices are so high. And and Tom kind of laid it out in saying, you know, our our perspective on that are part of our perspective, part of the story is what we see here in the pricing on these highly utilized outpatient services that are, are driving up the cost of, you know, the and we talked about it earlier, part of it is the utilization. So we're utilizing the services at double the regional rate. And then the unit cost of each service is also significantly higher than both the regional and national rate. So when we go into our research to say, okay, where can we really make some impact on this overall number? We look at these two service lines, and we find these prices. And so back to the question earlier, and I think it'll be on our next slide, we're looking at some real money here where we might be able to affect that question.

[John Benson (Member)]: Yes.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Okay.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: And this is on the left is this was based on twenty twenty four claims experience. So the overall outpatient costs for these six hospitals, and this is in millions, was 607,000,000. We're at 459% of Medicare. We made an adjustment in the second column over here to account for the Act 55 drugs in the outpatient. So when reset those drugs at 120% of ASP, ASP, this total dollar spend goes down to 488,000,000, which is 369% of Medicare. Of that 488,000,000, lab is 71,000,000 and radiology is 108,000,000. And lab overall for those six hospitals was at 659% of Medicare. And the lab was calculated at 300% of Medicare, which is a 54% reduction. Radiology, the $108,000,000 in claims, which was at 1129% of Medicare, was brought down to repriced at 500% of Medicare, which is a 56% reduction. The new overall outpatient spend goes from $488,000,000 down to $389,000,000. And the new percent of Medicare ends up for outpatient overall 294% of Medicare. That's a 99,000,000 reduction or about a 20% decrease in overall outpatient, overall spend for this group of hospitals.

[Virginia "Ginny" Lyons (Chair)]: So when we're talking about Blue Cross and Blue Shield and you're looking at all of this data, who's included in this? Are these just the QHPs? Are you including any of the population that you administer through BSI?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Yes. This includes all of our covered lives, including the federal employee program or members that come from other states that receive that have Blue Cross coverage from another state that had services here in our network hospitals.

[Virginia "Ginny" Lyons (Chair)]: Hey, that's good. Thank you. That's helpful.

[Martine Larocque Gulick (Vice Chair)]: Yeah, that was kind of getting at my question earlier about cost. Our utilization is so much higher and that is, so you've got 88 compared to 45 regionally. That's not just at hospitals, that's across all care locations?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: The 88 was just outpatient hospital, I believe, on the prior slides. Yes. And then the last the visual this is sort of the same data just laid out a little in a visual way. The blue bar so each across the bottom is the six different hospitals that Tom named earlier. So hospital A, B, C, D, E, and F. The blue bar is the outpatient overall all services outpatient percent of Medicare, which for this hospital was four seventy six. The dark green bar is the outpatient percent of Medicare after the act 55 claims were adjusted down to a 120% of average sale price. So for this hospital, outpatient overall went from four seventy six down to three sixty one. And then when you make the adjustments for lab and radiology to 305100% of Medicare, it would leave hospital A overall for outpatient at 291% of Medicare. And then hospital B goes from three ninety down to two fifty two. Hospital C goes from three twenty seven down to two eighty six. Hospital d goes from four eighty seven to three twenty six. Hospital e goes from five nineteen to three twenty nine. And then hospital f goes from four hundred and ninety eight percent of Medicare for outpatient to 340% of Medicare for outpatient after all those adjustments.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: And just to clarify, you know, we had said that the kind of the average for lab is 90 to 100% of Medicare and the average for radiology is about two fifty percent of Medicare. So, we're trying to be cognizant of the stability of the hospitals and if we went to those numbers in one year, I don't think there would be much stability. We worked on the numbers for the 300, 500% caps.

[Virginia "Ginny" Lyons (Chair)]: Sounds like you have an assistant back there.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Yes, she's trying to help.

[Virginia "Ginny" Lyons (Chair)]: Well, that's good. So thank you for that comment. That is a concern that's been running through the minds of many of us about how precipitous this all happens. I mean, last year, with the change in the in the infusion drugs and then we're coming up on some reference based pricing changes that doing this all at once could cause some real chaos. That's just a comment. You're muted, I think.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: For the committee, and I'll go back to our opening comments. When we said, you know, rather than focus on specific groups or subsections of Vermonters, part of the recommendation here, and you see it in this last slide, is that when we start to look at numbers, whether they're 250% for specific groups, focusing on these services that we've identified as high end utilization and high end unit cost, and bringing them down, not even to industry standard to Doctor. Weigel's point, but three, sometimes three times or double that even in being sensitive of hospital stability. You'll notice that that these outpatient percentages at hospitals get really close to that two fifty percent. And this allows the whole system to be able to deliver these savings to all Vermonters rather than just subsets or specific groups and populations.

[Virginia "Ginny" Lyons (Chair)]: So if we were to look at a comparison with the Northeastern part of the country or national data and and put a little bar graph up for rather than, you know, what would it look like? What how would it look compared to the hospitals that we have here?

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: I I think on outpatient, the ran data land somewhere around 200 and 50 is where the orange bar should be.

[Virginia "Ginny" Lyons (Chair)]: Yeah.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: And what our consultants told us, the reference based pricing, they took they took our claims and they're repricing them as Medicare because we don't have that ability and so what they said was, Gee, all these hospitals are high on outpatient 400 to 500 plus percent, but if you can tackle lab and radiology, it actually brings them back down in line, closer to national for outpatient.

[Virginia "Ginny" Lyons (Chair)]: Okay, thank you. And then one of the questions we'll have to ask is how many of these services are contracted services? Obviously labs are independent entities in some cases, so it's a different it's not the hospital itself, it's a separate laboratory. I know how that's taken into consideration at a policy level. Probably not your Questions committee. Thank you. This has been terrific. You know, we we get it. We understand what you have here. I know when we looked at it last week, was kind of a that we saw the first slide and thought there's no way we can cover this in five minutes. And thank you for coming back and clarifying what's here. Really helpful. But the and the original reports from which the data has been extracted. We have the what is that? The BRG Consulting. And we have the RAND report.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Then we also have access to the analytic application that's offered through the Blue Cross Association, which was the first set of slides. Yep.

[Virginia "Ginny" Lyons (Chair)]: Yeah. That was good. Alright. Thank you for that. Mhmm. So given that Blue Cross and Blue Shield has done so much work in this area and then you've put the primary care is excluded, I saw in at least one of the slides.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: I can just go back here.

[Virginia "Ginny" Lyons (Chair)]: Oh, yeah. It's the slide on outpatient services.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Right. Yeah. So primary care would come in this professional category, but what we've been digging into was this outpatient one, which is the hospital services.

[Virginia "Ginny" Lyons (Chair)]: Okay. Yeah. So we wanna exclude any primary care clinic associate affiliated with the hospital?

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: Right. Yeah. We were just looking at this hospital outpatient section that's right here. We did not we didn't pull any further detail for this presentation on the professional section, which would cover primary care.

[Virginia "Ginny" Lyons (Chair)]: Okay.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: But you could see our relationship for primary care. We're at two twenty six, and the region is at one ninety nine. We're, you know, we're a little we're a little bit above, but we're not this to the same degree that outpatient is above. So we're more in alignment.

[Virginia "Ginny" Lyons (Chair)]: Okay. So what are we with primary care? What? '1 ninety second through twenty sixth. The twenty sixth. Right.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: This would be all professional services, so it would be primary care and specialty care in in this grouping.

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Right. Although we don't have a lot of specialty care that's outside of the hospital, most of that falls under outpatient. And, you know, what Blue Cross's plan is, we're we're putting together the numbers that you had seen at the very end of the deck for all the hospitals, and we're going to come up with kind of a total impact both from a percentage basis for outpatient and for the hospital, and a total dollar impact and, you know, work with those hospitals in contracting. What we found last year is when we tried to make changes in November after all the hospital budget orders, people were, you know, scrambling and struggling to make cuts when that wasn't in their budget. So, our plan is to go with the hospitals with this data to the hospitals in about three weeks. So, ideally, if if we're able to make impacts on lab and radiology at the Vermont hospitals, that will work into our rates and their budgets.

[Virginia "Ginny" Lyons (Chair)]: Senator Cummings has a question. Just for clarity, when I go in for my annual wellness visit with my primary care provider, she spends about a half hour with me mostly going over the results of radiology, which would be a mammogram, and about a quarter blood work they take out every year. Is that radiology and labs counted as labs or as primary care? Is primary care just including like her feet for service for the time she talks to me?

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Correct. And the the lab and radiology is separate. So, yeah, if I get it, if I go to the doctor and I, yes. That's the answer.

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: The the the doc the physician portion would be in this professional section and the lab and radiology, most likely if was received from hospital services would come in this outpatient blue bar here in that example.

[Virginia "Ginny" Lyons (Chair)]: Could you say that out loud so we can confirm what you just said? Our goal is to increase access to primary care. Arguably, the more primary care you get, the more labs and radiology you are likely to see. Just taking a kid in to have a throat culture is a lab. School of Earth used to do it, but now it's a hospital lab. That's- It is. It's the catch 22, always.

[John Benson (Member)]: Yeah.

[Virginia "Ginny" Lyons (Chair)]: It's called the healthcare. Yeah.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: I think, you know, from our perspective, Senator Cummings is such a great example of why the prices in these two service lines are so important because, know, as we know in other legislation that we're working on, or you're working on, and we're talking about, as primary care reform moves forward and we begin to find ways have folks with better access to primary care, you're right, some lab and radiology services might in fact be ordered more frequently. So to have those prices aligned, with lower percentage of Medicare costs when we get to that point is gonna be really important.

[Virginia "Ginny" Lyons (Chair)]: Yeah. I'd hate It'd be interesting to see if our utilization rate is because we're doing better getting people to have an annual mammogram and enable the physical. Or is it do the hospitals requiring things that maybe they don't need to require? Or how much of it is defensive medicine? Overutilization is a concern that really started this discussion about a long time ago. But it may be that they were just doing the job. But the point

[Martine Larocque Gulick (Vice Chair)]: of the defensive stance, right, is to keep people out

[Virginia "Ginny" Lyons (Chair)]: of the acute care world. Defensive is to keep you from being sued. All right. We haven't talked about malpractice. Well, we also haven't talked about let me ask this question of Blue Cross and Windshield while you're here and then we probably should wind down on this one. But the uh-oh. Oh, quality metric analysis. So you're doing some so there are there is quality analysis of clinical work and clinical protocols and Blue Cross and Blue Shield has collected data on treatment modalities and then you also base some of your decisions on how folks are treated under whether it's primary care or whether it's specialty care. You look at what's the best way of treating a patient with x y or z. True or false? That true? That Blue Cross and Blue Shield does that?

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: So the Blue Health intelligence data that we now have access to can rate providers based on quality and also appropriateness of care. So did somebody order the right number of imaging studies, etc. We do have access to that data.

[Virginia "Ginny" Lyons (Chair)]: Okay, so then my next question is one, I don't know whether you can answer that right now or not. It's a twofold question. One, report that information about treatment protocols to other entities including say Rebound Care Board or do you keep it yourself? But the second question is are you willing to share clinical outcomes data and protocols with DPQ and others so that we can get to a place where everyone is using the appropriate clinical making appropriate clinical decisions?

[Dr. Tom Weigel (Chief Medical Officer, Blue Cross Blue Shield of Vermont)]: Sure, we have new access to that data. We have not been able to make use of it yet with any of our programs or share it. Our data team is focused on the numbers that you've been seeing in front of you to roll that out into contracting. And we'd be happy to discuss, you know, how we can help on the quality measurement side for the state.

[Virginia "Ginny" Lyons (Chair)]: That would be helpful. I mean, we do have comments about that in our primary care bill and having quality outcome measurements really important in order to move forward with this. And you can't really make a decision about how much is too much in terms of testing for others if you don't know what you should be doing. Anyway, again, I want to say thank you for this. It's a lot of work that you've done and we appreciate your putting it together and bringing it to us.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Thank you very much. Appreciate the opportunity.

[Virginia "Ginny" Lyons (Chair)]: For having Good. Yeah. And there's a lot in here that will inform our decisions on S-one hundred ninety as well as other goals. Thank you.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Thanks so much.

[John Benson (Member)]: Thank you.

[Courtney (Blue Cross Blue Shield of Vermont representative)]: Thanks for

[James Morley (Chief Data Officer, Blue Cross Blue Shield of Vermont)]: your time.

[Virginia "Ginny" Lyons (Chair)]: Good, thank you. We're gonna move ahead but as the healthcare advocate is in the room, I'm gonna ask you, I know that you had some suggestions for us. He probably doesn't have time for a Are we talking about primary care at the moment or We're talking about S-one 90 and we're talking about primary care both. So just, do you have recommendations that you might

[John Benson (Member)]: be able to bring to us as pediatrician? Yes. We have some recommendations, particularly around access to primary care. Okay. And actually steps that we take in the near term. All right,

[Virginia "Ginny" Lyons (Chair)]: so we're getting you again on the schedule for that. Perfect. As every time we come in here, start talking about reference based pricing and what we're doing for outpatients and then all of a sudden we're talking about primary care. So the two are very much interlocked and we can't do one without the other. So one hundred ninety and one hundred ninety seven have to somehow be in balance. Yes. Thank you. Thank you all. So we're gonna we have a guest from Southeast District. Gents. Online or in person? Right here.

[John Benson (Member)]: So everybody's not good. Good morning.

[Virginia "Ginny" Lyons (Chair)]: Good morning. Good morning. So I know that you had asked to testify on a bill that is an H bill that we will not take up until after crossover, but I think we're mostly interested in listening to your whatever comments you have within the next seven or so

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: of the next seven Absolutely. Thank you. You so much for having me this morning.

[Virginia "Ginny" Lyons (Chair)]: Know this was their day, I know it's the cap day.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: The cap day. So I really appreciate you speeding us in just so I could speak to this bill that's currently named H534. So this is a bill that relates to community action agencies in the state statutes. And so one of the unique features of community action agencies is that we actually do appear in the state statute, and there's a number of guidance that is in the state statutes that maintains how we operate. And so comparatively speaking, I've been in front of you before, this is a relatively mild bill. This is pretty light, all things considered. And so what this bill does is modernize some of the language. And so there's some outdated language in the statutes. So we wanted to shift that to reflect our current professional standards. People first. Replacing older terminology with terms like individuals with lower income, which is a better reflection of how we speak about the people that we work with. It also clarifies planning requirements. And as I'm sure you're aware, we conduct a comprehensive needs assessment every three years, and we incorporate those into an annual community action plan. That is required through our, we receive community service block grant, CSPG funds. That's one of the requirements that goes along with those funds and that we work with OLEO on to make sure that we are adhering to that level of accountability. And the most substantive change in the statute is around board term limits. And so rather than having a fixed term limit in statute, this bill requires that each community action agency or board adopt its own term limit policy through its bylaws, which is consistent in keeping with how nonprofits operate. And so the way that the board language, the bylaws was in the statute was kind of wonky, a maximum of ten years, and you can't serve more than five consecutive years, which logistically creates a lot of challenges for maintaining board service. And so we're just asking that community action agencies be able to set their own term limits in the board by law suits. And I think that was three or four minutes. That's it. That's it. That's it.

[Virginia "Ginny" Lyons (Chair)]: It's nothing like Caucasian S-ninety one.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: Nothing like that. Yes.

[Virginia "Ginny" Lyons (Chair)]: Didn't the federal regulations set term limits?

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: I'm not aware if the feds did.

[Virginia "Ginny" Lyons (Chair)]: Long time ago. But I know local government, because that was me, didn't have a term limit, but there were people that represented the low income community, people that represented, I think, social service, all had time.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: That was set by the Feds? Yes. So the way that it's currently in statute is that it is set by the state, again, that it can only be a maximum of ten years. That's And

[Virginia "Ginny" Lyons (Chair)]: then you can

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: always, that's about as long as some people want, even more than some people want to serve. Any questions about healthy pork? Relatively light ribs?

[Virginia "Ginny" Lyons (Chair)]: No, that's good. I mean, you just put us ahead about three weeks.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: That's fantastic.

[Virginia "Ginny" Lyons (Chair)]: Thank you.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: All right. Well, you so much.

[Virginia "Ginny" Lyons (Chair)]: And maybe we just give one thing for us. Just tell us what CAPs are.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: Community Action Agency. Yeah.

[Virginia "Ginny" Lyons (Chair)]: Tell us what they are for committee as a whole, like what Rookie do and this generalization.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: Sure. My name is Joshua Davis, and I'm the executive director of Southeast Vermont Community Action. And so we serve one of Windsor County, down in the Southeast Corner. But community action agencies were started and we were on poverty over sixty years ago to be hubs for federal funding that comes from the feds through the state into local communities. And so the idea is that we have maximum feasible participation of people that are impacted by the programs that we operate. We operate a wide range of programs, and so to know one community action agency is to know one community action agency. But typically, you'll see community action agencies have programs like weatherization or a head start program. We also have community action agencies that operate crisis housing supports, run shelters, run food shelves, but it just depends on the context of the community that they're in. But we are in every community across The United States. And in Vermont, there are five community action agencies. And collectively, we have a partnership called the Vermont Community Action Partnership. And so VCAT, we're often here providing testimony to get all our high perspective on things that are community. Any questions about So like V Go. V Go is a Right. They do only the weatherization aspect. And so NECA would be Oh, Go. And CBOEO, Capstone, and Barack are our sister organizations. You're up to sleep. Absolutely. You so much for your opportunity. And who's in the

[Virginia "Ginny" Lyons (Chair)]: car room today? Oh, good.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: Yeah, stop by the car room. We have maple candy and warm, friendly haphazation.

[Virginia "Ginny" Lyons (Chair)]: Thank you for coming in.

[Joshua Davis (Executive Director, Southeast Vermont Community Action - SEVCA)]: Thank you so much. I appreciate your work. What everybody is saying. I appreciate

[Virginia "Ginny" Lyons (Chair)]: That's one. We got one person. Okay. All right. So, we're

[Courtney (Blue Cross Blue Shield of Vermont representative)]: gonna

[Virginia "Ginny" Lyons (Chair)]: go off live and we'll