Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: You are lost. All right, so Senate Health and Welfare were back. It's still February 25 and we are moving on to look at S-one 190. This is the bill relating to the Green Mountain Care Board reference based pricing and hospital outsourcing of clinical care. And I've invited the chief healthcare advocate Mike Fisher to come in and have some suggestions that we'll call. Ready? Since this is

[Jennifer Kirby, Office of Legislative Counsel]: long, we'll see if it helps.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Are you

[Sen. Virginia "Ginny" Lyons (Chair)]: calling me now? I'm

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: afraid I have no answers. Good morning. Mike Fisher, health care advocate. It's on one ninety, and I'll come back a

[Sen. Virginia "Ginny" Lyons (Chair)]: little bit later when we talk about chronic intestines. Good. Yeah. You're good thing.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And I'm bring another member of my team for the best. Thank you for having me in to talk about this. And I think my the overall theme of what I have to say is it's more complicated than that. Oh. And

[Sen. Virginia "Ginny" Lyons (Chair)]: That's a new phrase. Yeah.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Yes. And you, you all in this room, often recognize how you move one thing in the effects of another thing. And and so on a high level, I wanna say I really appreciate the build and the work on the build. I think it's moving in a good direction. You've heard me say before that it's, I think, vitally important that this is gonna take a meaningful step on reference based pricing for '27. And I think the bill and the edits, the proposals around the bill move us in that direction, that's good. Now today, it's more complicated for us. Well, I think, I found another good thing, is I think that it's a, the proposal that's in front of the committee does a good job of setting some parameters, some reference points, sort of tops and woes about how we move forward. Four twenty seven, I would add, and I don't think they're gonna take care of it here and now on this bill, but I would add that I think the Green Mountain Care Board needs that kind of direction from where are we trying to go. In three, five years, where do we want to be and how are we going to get there? We have been articulating for a long time in the hospital, in our hospital budget comments, that we think hospitals should be priced at about the sixth decile. In other words, a little bit more expensive than average. We're rural, we're older, it's gonna cost more than deliver care here, and that being, compared to our, using the RAN data compared to national benchmarks, that we should be at around the sixth, not the eighth, not the ninth. And that, of course, we can't do that all in one year. We have to do that with a consistent pressure over multiple years. And I think what's being articulated here is a good first step, is a good way to define that for '27.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I think we need that discussion for, I don't know, if

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: it's three or five years out. I think that's a a discussion that I think Green Mountain Care Board could use standards. The idea of applying first to the QHP is an interesting one, from my perspective, some pros and cons to it. I want to recognize we went through an exercise with regard to age rating discussion upstairs. It was a proposal to increase costs for older people by 5% and decrease costs for lower people by 5% in individual market. And we spent some time modeling that. And surprise, surprise, there are indeed dynamics in the individual market. This is gonna be complicated, I'm gonna try and say it right. In the individual market, those who get full tax credits where the the loss of the value of the subsidy when you decrease rates is more than the savings. So in other words, you can think you're reducing starting rates, increasing their profits. It literally plays out that way. And so so my main thing to say is be careful. It doesn't play out exactly the way you think it's going to, given the complexity of I mean, look at your doing percentage percentage here, that one is complicated. But it so I have some caution about what the impact of this on the individual market I I would wanna model it. I'd wanna be careful. For the small group, on the other hand, oh, man, we're in trouble. The small group is in trouble, and we spend a lot of time and we have some tools to focus on the individual groups. We have precious few tools to focus on the small group. And and further, we are cannibalizing the small group. We are allowing good risk to leave the group, leaving worse and worse morbidity in that pool. It's happening right before our eyes, and the proposals on the table, again, talking about somebody that's happening in the stairs. They'll come down here. The there are proposals the proposals on the table go in the wrong direction from our perspective. And so but and and and I believe that the proposal to apply rate setting first to QH, specifically to the small group, is intended as a first step. But I also hear it, in my mind, as a potential way to protect the small group from that cannibalism bringing down the costs into small group in a targeted way to protect that market. And I think that's a good idea. It gets an idea that's, maybe I should say, worth being explored. We have other tools. The Department of Financial Regulation is in the middle of its stop loss rule for self funded plans, and we have advocated and will continue to advocate for attachment points that protect the small group, that mitigate that. So I'm sure I spoke Greek to that's complicated stuff.

[Sen. Virginia "Ginny" Lyons (Chair)]: Some of us are going to sum up the words.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: So

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I don't personally have a really strong I hear the Blue Cross proposal to focus on a couple of individual service lines, radiology labs, versus this population proposal. I I think there's pros and cons to both. From our perspective, the important things we take to be set forward. I I will say, I would recognize that if we did do radiology criticisms this year across the whole marketplace, we would be affecting the whole marketplace, including public employees and tax and therefore, taxpayers. And, you know, much like we did last year, you did last year on the ASP. We got to see how that played out through all of the markets, including state of police and teachers. So to sum up on that section of things, I think it's important that we think everyone's staff that there's pros and cons about the different ways of doing it. And I'm very supportive of what the discussion is happening. Okay. I want one other area to talk Okay. Go ahead. And that is the outsourcing discussion. The what? Outsourcing. Oh, the outsourcing.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, yeah. That would be a good thing to talk about.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: So I want both recognize, but so I think this is, again, a place of we need to understand what's happening. Everyone recognized, I think the hospitals, the medical society team, maybe said, hey, hospitals have been doing, you know, they were religious or contracting with a provider, radiology purposes, forever. And and then and then on the other side, I think the board came in with some concern about departments that were being outsourced. And I'm not sure the language that's been discussed sort of contemplates distinguishing between those two different levels of, and I actually think it's important that we do. I run a helpline. People call our office with concerns about their bills. I honestly think we're getting fewer of these bills, but we do get these calls, but we do get calls from people who say, for instance, I went in for a procedure at the hospital and my ideology filled the, you know, so how exactly the billing you know, works across the hospital system, I think it's for us to understand. I have more concerns about the concept of a department that is outsourced. But I'll add, I'll add, from my perspective, I care a lot about quality. I care a lot about hurting people. So in network, access to free care policies. I care a lot about making sure that what happens in the hospital is counted in the hospital's budget process. And I care a lot about taxes that people are paying appropriately. Beyond the things I just said, I'm not sure why I have a great concern about an outs outsource. I wanna make sure it's captured. I wanna make sure it's done well and it doesn't hurt people. But beyond that, hey, I don't know how to run a hospital, and there's a whole team of people at 14 different places that are figuring out how to run hospitals, and they're doing what they can. And so I really wanna understand how it's actually happening, and I wanna make sure that we capture what's done with us.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. So what I would ask is if you could give us a short written summary of your testimony. There's something in there. I know it's hard. Something a little bit better than

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: the notes on my page.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. It would be good. And I know you're linked in with what the house is doing, and at some point, the all the work that happens in the house and in in this chamber is going to have to come together. Yeah. Right now, we're only focused on on one ninety and then one ninety seven. One one thing I

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: failed to say, I don't know if it's my notes, is just to recognize that the board has a draft hospital budget guidance that will score negative 1% growth rate. And this whole conversation about crisis feeds into is aligned with that, much the same way, again, as Dana speaking was. So it it actually, I think, works well together with actions of the Board of State.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you, Ms. Fisher, for your testimony. A couple quick questions. Data is a challenge in the state, as we know. So getting information on outsourcing, like really good information on what's happening and where, that something should that process be in this bill? I mean, is that the first step as opposed to just saying they can't do it?

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: It from my perspective, it's maybe a little bit of both. It it there may be things that make sense to define as as, you know, we should allow for. Mhmm. And for sure, I would turn to the board and say, we want you to collect data from the hospitals and the hospital budget process to really understand.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, and assure us that we're not losing provider taxes. Right, exactly, yeah. My second question is, when we're thinking about the reference based pricing either for services or for populations, is there, I have no idea, but is there a scenario where you could do both? Or is it an either or?

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Well, think we're talking about transition here. I think ultimately, my perspective is unique to you all. But I think the question before is of what are we doing in this one year as we're transitioning again. And that's why a little bit I say, it's close and close to both. It's important that we make the staff.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, other questions? We're good. Thank you.

[Unidentified Committee Member (Senator)]: Thanks, Martine.

[Sen. Virginia "Ginny" Lyons (Chair)]: And we'll hear from you again

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: on 01/1997. Absolutely.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so Jess, why don't you come up and we have some decisions to make on 01/1990 and we're gonna start making decisions and having a committee conversation, but I think before we can have the conversation, we need to look at where are the critical decision points in the bill, and we've heard from hospitals and others the board, about sections of the bill and I don't know what's happened in the hallway conversations. Some of us have had ideas about how to proceed, so let's go through the bill and you can help us identify some of the critical decision points that we have. We're going to do markup on the bill Friday, I believe it's on schedule. Yep. And tomorrow, we have tomorrow. Friday. And we'll probably be well, our goal, just for all of us sitting here around this little table is our goal is to finish some markup and present a draft to full senate before crossover. And that goes for a number of the bills that we're looking at now. So we're getting final testimony and final ideas,

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: and

[Sen. Virginia "Ginny" Lyons (Chair)]: then we're gonna go walk through with Jen, identify decision points. Next week, you have a lot of good reading and witness testimony, and we can come back It would have been a robust opportunity for community discussion. But that's where we are with this right now. Here you are.

[Jennifer Kirby, Office of Legislative Counsel]: Here I am. Jen Harvey, the now house of legislative council. I will put S-one 190 up.

[Sen. Virginia "Ginny" Lyons (Chair)]: And I will be meeting with Jen to talk about maybe some of the proposals that we might want to consider going forward. I'm not making decisions for the committee, but there are clearly some areas that we would want to discuss and to refer from one group or another group and trying to put those together. I'm gonna try and do that for us with Jen. All right, so

[Jennifer Kirby, Office of Legislative Counsel]: this is S-one 199 relating to the agreement, care board reference based pricing, hospital outsourcing, clinical care. So, first section deals with reference based pricing, and particularly the language in here, the booking requiring hospitals to help insurers to express their provider contracts going forward, express the rates for all items and services as a percentage of Medicare or another credit card. It's not known by the Green Medicare Board so that there is kind of consistent terminology and apples to apples numbers being used. And it also requires hospitals. Hold on a second.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Just a question for you, madam chair. How do you want to do this? Do you want us to or ask questions as we go through or how do you want to or wait till we're through it and then discuss?

[Sen. Virginia "Ginny" Lyons (Chair)]: No, I think that we're gonna start, we'll walk through and we'll try to go through at a fairly low level. And so if you have a question, then as Jen finishes this section, then we should ask those questions. Good?

[Jennifer Kirby, Office of Legislative Counsel]: Yeah, I'm fine with the question whenever you want. Think the the extent you can start figuring out where you need either language, clarifying language, or want to do something different than your mental health. Lean forward while you are away. So we're on

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

[Jennifer Kirby, Office of Legislative Counsel]: Yeah, so for provider contracts starting in October, and I think we've a couple of word suggestion to add about contracts, I think both entered into or amended or renewed on or after that date, that everything would be shown as a percentage of Medicare, start get people's heads around the reference based pricing aspect. It also directs hospitals to get a unique national provider identifier and use them on all claims filed on or after that date when something is provided through the off campus department of a hospital. I mean, you've heard from the hospitals and others that that is coming as a federal requirement on a slightly later timeline than what's contemplated in the bill, so you may wanna think about what makes sense from your perspective or timing. Requires hospitals when making public the charges for items and services as they're required to do under federal law for hospital price transparency that hospitals include in their machine readable files pricing information shown as percentage of Medicare rates, as well as in dollars and cents disaggregated by the payer plan. And then there's some language in here about the board establishing a default percentage of Medicare above which hospitals cannot accept payment for any newly established CPT codes, unless the Board has established a specific reference based price for that item or service, and the Board has suggested some different language and different approaches to some of this, instead of having default percentages, setting some maximums to go into effect in the shorter term, and having hospitals target their highest price, and I think maybe highest utilization, certain items and services, and also, and similar requirements on the mature side. Some of this is things you've heard about but aren't reflected.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right. Bill hasn't produced. You have to decide where you want to go with this. Okay. So, So, when we get the G, we're finished with the reference based pricing. Right. And the reference based. So what I will suggest is that we go back through this and then have an opportunity to fully understand what is in each section and how it relates to our decision making. Because I know there's a lot here. You know, talks about contracts and budgets and how to relate that with rate setting and who's doing it and the overall. The timing of these things becomes really critical.

[Jennifer Kirby, Office of Legislative Counsel]: Yeah. Yes. And I'm trying to look through some of the testimony, at least the testimony I had printed out to flag for you when you've had specific suggestions from, mostly what I have is from hospitals, medical society, and Vermont Care Board. We have also all three together. One of the hospital ones is actually one I didn't mention about the provider contract. He said whose responsibility it is to express the rates in terms of Medicare percentage. And when you and

[Sen. Virginia "Ginny" Lyons (Chair)]: I sit down, we'll try to sort out how maybe those things fit or don't fit. We could do that. But right now, we can also start to think about that. It says Medicare bottom line. And or another benchmark. Mhmm. What might that I'm just

[Jennifer Kirby, Office of Legislative Counsel]: It could just confuse the issue. We're trying to get everything, so it's a I think there are some services that are not reimbursed by Medicare. Oh, okay. Some items are services, and so so I think it was the expectation that there would be some for which a different mental health have to be used.

[Sen. Virginia "Ginny" Lyons (Chair)]: And it's consistent with language that we had in the bill last year in Red Act 68.

[Jennifer Kirby, Office of Legislative Counsel]: It's then it's the board that determines whether it's appropriate.

[Sen. Virginia "Ginny" Lyons (Chair)]: You know, the hospitals will help with that as well as insurance.

[Jennifer Kirby, Office of Legislative Counsel]: I don't people don't have things to say on language, you want me just keep going? How do you want to handle this?

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, you'll be actually good. Should we pause right now since we're at the stage? We went to see.

[Jennifer Kirby, Office of Legislative Counsel]: Okay. But the IV goes. We were at the

[Sen. Virginia "Ginny" Lyons (Chair)]: end of the reference phase of our section.

[Jennifer Kirby, Office of Legislative Counsel]: I think we got through it and we went back up into it. Got

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: it. Right.

[Jennifer Kirby, Office of Legislative Counsel]: And so, just as a reminder on the NPI, hospitals getting an NPI, unique national provider identifier for items and services delivered in off campus department of the hospital. The hospitals testified that the new federal require federal law requires hospitals to do that by 01/01/2028 in order to continue to make Medicare for services delivered in those hospice sites. But there are not the Centers for Medicare and Medicaid Services have not promulgated their rule, their regulations yet. And so I think the request from boss was to allow the federal process to play out and let the state process follow.

[Unidentified Committee Member (Senator)]: I don't on reference based pricing, the board setting the race, right? Yes. And this is saying one service divided by all working positives, and I don't know where it says this. I don't think it says it in the same service. But the board may change rates per hospital for that same service, or have different rates, Jen.

[Jennifer Kirby, Office of Legislative Counsel]: Yes, that is my understanding. There's not a requirement that the rate be set

[Unidentified Committee Member (Senator)]: Consistent across all

[Jennifer Kirby, Office of Legislative Counsel]: across all hospitals because they may have different needs. The hospitals may have different needs. And utilization and care mix.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Because so a larger hospital like Rutland is different from smaller hospital like Gifford, and so the rates may have to be adjusted based on their

[Unidentified Committee Member (Senator)]: Does the Green Care Board of Medicare get any information from the AHS file? Does the Green Mountain Care Board the five zero one is the scientists, right? The only way you can appeal is go to the Supreme Court way I understand it. And

[Sen. Virginia "Ginny" Lyons (Chair)]: That's not in this bill. No. No.

[Jennifer Kirby, Office of Legislative Counsel]: No. No. No. General. Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: Just general. Yeah. Adjust. Okay.

[Unidentified Committee Member (Senator)]: I just

[Jennifer Kirby, Office of Legislative Counsel]: Maybe. So But

[Unidentified Committee Member (Senator)]: Just wanna make sure it's done. I mean, that's all. Right.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: That's okay. That's Yeah. And on that same lines, is this gonna be I see where it says it in here, but is it a collaborative process, rebound care award with the hospitals, or are they just going to say, Here's your rate, whether you like it or not, that's what you can get in charge.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's a regulatory entity.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I understand that, but things work much better when they're done collaboratively than when they're done by a handout. So we wanted to be successful for that.

[Jennifer Kirby, Office of Legislative Counsel]: The board has not gone through the rulemaking process yet for what the specifics of setting the record based prices looks like. So, I don't think we know yet what they are proposing. Rule making process will involve some collaboration and public comment because that's what the Vermont Administrative Rules Procedures Act requires. But whether the, and I think you may get different takes from the board and the hospitals and the health care advocate's office now about whether the hospital rate setting process is collaborative or more

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

[Jennifer Kirby, Office of Legislative Counsel]: Think there may be some, it may be some in the perception, it may be subjective, and I don't think we know the details yet.

[Sen. Virginia "Ginny" Lyons (Chair)]: I will say, one of the things that we have consistently emphasized in this room and also in the Health Reform Oversight Committee work is a collaborative approach to change and transformation. So I think that message is clear. If there's a place that we feel we need to put it again, we can put that again. Understanding that at some point a decision has to be made based on the financial sustainability of the hospice and the cost effectiveness of core people who are getting coverage. Yeah, it's a balance and we frequently need to rely on goodwill. And so far, it's been happening. Diane, I'll let you comment. I don't really want to get any comment at this point. And the Lord is your representative, get that. So, we'll just leave it there. So okay. We're not doing a markup right now. Right? We're just oh, we're learning. Alright. Let's just build so that when we look at the testimony that we've had and we put it together, we understand the changes that we're making. Right. Because the healthcare did give us some high level ideas that we could get to. Yes. And when we have it in writing, we'll be able to see it. It's all from memory, right? Insane evidence.

[Jennifer Kirby, Office of Legislative Counsel]: So I'm just pulling up sort of from my own recollection as well, the language that was passed last year around reference based pricing, and so when the statute requires the board to establish reference based prices, it requires them to consult with health insurers, hospitals, other healthcare professionals as applicable, Office of Healthcare Advocate, Agency of Human Services in developing reference based prices, completing ways to achieve all Caroline 19.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's actually Yes, that's right.

[Jennifer Kirby, Office of Legislative Counsel]: So that's language that was Right, it covers that. That was addressed last year. That I remember that was talking about. And then I think some of that may flesh out in more detail when that, well, my dad just developed. Thank you. It's hard to be a new one. It is. I know. Yeah.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Some of

[Jennifer Kirby, Office of Legislative Counsel]: them we have to remember what what you did last year.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so. So

[Jennifer Kirby, Office of Legislative Counsel]: are you wanting to move on? I think your 197 witnesses are here, I don't remember what time you

[Sen. Virginia "Ginny" Lyons (Chair)]: were supposed Yeah, so we'll continue this discussion tomorrow when we have

[Jennifer Kirby, Office of Legislative Counsel]: the bill up, but I

[Sen. Virginia "Ginny" Lyons (Chair)]: wanted to give you a flavor for what it is that we're doing from here on until we actually act on the bill. Aye, thank you. So we're gonna move on to S197 which is our primary care bill and we have folks in to testify. I. Joanna Grafton Gray. Read. That's here. She's They're all wait. That's fine. They want to. We need to we don't have a full switchover for this because everybody's

[Jennifer Kirby, Office of Legislative Counsel]: in this. Come on in. Come on in.

[Unidentified Committee Member (Senator)]: Yeah. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, I don't

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: think that's her.

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

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Okay. So

[Sen. Virginia "Ginny" Lyons (Chair)]: we're not gonna keep telling people to just came in. Joanne, you're here. You're gonna sit right at the head of the table. Perfect. And there is another chair that's being reserved. Michael, we could just open the door a teensy bit, then we'll feel a little better about Okay.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I think we could just face. Better.

[Jennifer Kirby, Office of Legislative Counsel]: I won't be able to hear.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. I got there and eat that. Everyone can just shout.

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: Just for now, Nausica is right here.

[Jennifer Kirby, Office of Legislative Counsel]: Good morning, everyone.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Hi, good

[Sen. Virginia "Ginny" Lyons (Chair)]: morning. Good morning. Just take your time and get settled in. Thanks. So, as a reminder for us, this is establishing a primary case care payment reform program and we're really looking at how can we expand our blueprint program, how can we be more inclusive and getting folks at a lower cost, lower out of pocket, lower premiums, and to So that's where we are. We'll be making decisions on this bill based on the testimony that we hear, Among other things. I'll go

[Jennifer Kirby, Office of Legislative Counsel]: ahead and get started. I know that we have

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: a packed agenda. Thank you for the opportunity to testify today on S197 and it's a bill to expand access to primary care in Vermont. My name is Johanna Degrathen Reed, and I'm here today as a public policy manager for Vermont Businesses for Social Responsibility. VBSR supports investing in primary care by establishing a streamlined primary care payment system that will promote the public good. We believe that by increasing access to primary care, we improve the health of Vermonters and reduce the risk to overall health care system and system costs. VBSR businesses, employees, and communities are facing some serious challenges accessing affordable health care, as you all know. As Vermonters, we all know that family members or neighbors who have had challenges finding a primary care provider, that is why we've signed on earlier in the session in support of S 97 with the Vermont Medical Society, the Vermont Nurse Practitioners Association, the VTAFP, the Vermont Chapter of the Academy of Pediatrics, and the Health First in support of primary care access in Vermont. The primary care workforce shortage is increasing due to stagnant reimbursement, administrative burden, high burnout rates. At current staffing rates, as you all have been hearing, Vermont will be short of approximately three seventy primary care providers by 2030

[Sen. Virginia "Ginny" Lyons (Chair)]: if we continue on our

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: current groups. With changes to federal programs, 2027 will reveal new health care challenges for Vermonters, especially those who rely on Medicare and Medicaid. To ground this in our conversation today, I want to just quickly highlight some data points. These are from representative Becca Ballon's official website breaking down the Medicaid changes in Vermont. Right now, approximately 168,000 Vermonters, 26% of the population, get their insurance through the Green Mountain Care, the VT Medicaid program. Seventy five percent of all adults who are covered by Medicaid in Vermont are working. It covers thirty seven percent of all births, forty one percent of all children, twenty one percent of adults ages 19 to 64, fifty three percent of working age adults with disabilities, seventeen percent of Medicare beneficiaries, and sixty two percent of nursing home residents in Vermont. We have the potential loss of up to 45,000 Vermonters who are at risk of losing their health insurance or having their premiums increase dramatically, whether they are covered by Green Mountain Care or the Vermont Health Connect. It's estimated that the federal bill could cause Vermont's uninsured rate, one of the lowest in the nation, to double from three to six percent. So in this context that we meet with you today, and our hope is to address some of these challenges with S197 and the goals of expanding crucial healthcare in Vermont, specifically, wanna comment on a couple of sections of the bill today. First, we want to say that we support not only the format that's proposed in the primary care reform program, but also an assessment of the funding landscape for increasing allocations to primary care spending to the creation of a workable and practical program that is right sized for Vermont. Additionally, for clarity of the primary care spending allocation target and consistency with existing statutes, PBSR supports the PCP definition as followed, specifically in the testimony that was given earlier by Jennifer Kirby. You all have that full list includes family practice, internal medicine, pediatrics, general practices, nurse practitioners, naturopath, osteopaths, obstetrics and gynecology, and preventative visits, as well as chronic care management and nursing facility providers. We want to make sure that we also comment specifically on standing in favor of the reimbursement structures, favoring procedures and interventions over primary care, unfortunately, right now. And for every dollar spent on primary care, there's potential return of $13 in overall health care savings according to the Commonwealth Fund. This is because strong primary care leads to better health outcomes, fewer emergency room visits to hospitalizations, and more effective management of chronic conditions. In 2020, as you all have heard already, only 10% of total health care spending in Vermont was allocated to primary care. For these reasons, we support the following proposals in S197. In order to advance a clear pathway for access to primary care in Vermont beyond 2027, we also support the creation of the reports, the Universal Primary Care Report that's included as an amendment in this bill. While we recognize the healthcare landscape is changing quickly, we believe it's timely to use that research that will be done for 2028 recommendations to inform Next Stats as an explicit part of this process as well. To conclude, without affordable, accessible, and available health care in Vermont, our economy is less stable, communities are less vibrant, and VDSR works to incentivize and support efforts to promote the development of an affordable access to healthcare, while remaining focused on our goal of decoupling health insurance from employment, ultimately.

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

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: Now is the time to act, prepare for the changes coming in 2027, and ensure that we cut costs for primary care while expanding access for working Vermonters. It is for these reasons and many more as outlined in the primary practitioners themselves in the testimony of SY-ninety seven that VBSR supports this bill's passage into law this year.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions? I think that sounds great. The details though, you know, we're still working on details about how to finance this, and I will share around the table that I'm reaching out, to sort out how we can improve Medicaid reimbursement. I know it's a big concern, whatever we might be able to do. Questions for Joanna.

[Unidentified Committee Member (Senator)]: More for you. I agree with everything you've stated there, the sheets hit the nail on the head for me. How are we gonna do that? The shelf collecting aggregate payments from participating payers in order to provide the habitated member for a fund payment to participate in primary care practice. So that revenue's gonna come from somewhere, especially to get going, right? Yeah, yeah. So in my mind anyways, you can't pay for Medicare. You might somehow, I don't know to do the Medicaid switch there against you kids, then you got your insurance.

[Sen. Virginia "Ginny" Lyons (Chair)]: Which is part of the discussion that we were having on 01/1990 and that's the QHP hub and expanding that and then making it attractive for our self insured folks to join in. So all of these things are linked. And then the question would be, you were talking about the study that's in there, so there has to be some kind of an analysis going forward, like actuarial analysis, where you're thinking of that. Maybe you could elaborate on that section. On what specific part of the study? Well, model, what kind of model we use for the funding and how do we analyze it so that can be part of

[Johana de Graffenreid, Public Policy Manager, Vermont Businesses for Social Responsibility]: the- I think that's part of why it's so important that we take this time while we're reviewing how to create these cost savings ultimately for Vermonters. So we also take a moment. We'll have the full picture by summer twenty twenty seven about the changes from Medicare and Medicaid. There'll be more updated information from our insurers who we'll hear from at that time about the rate provisions and changes that are happening there. It's hard to say before then and without this group coming together specific recommendations for that time. But that's also part of why we think it's so important that those conversations happen then and that we go ahead

[Sen. Virginia "Ginny" Lyons (Chair)]: and plan out for that ultimate challenge. Frankly, it's not. About collaboration. Yes. Thank you for that. And can we get your testimony? Yeah, that'd be And very any further comments that you have regarding the analysis and how you think it might work from a business perspective? Because we need that in this room. We need to understand small and large business perspectives and how we can move in the right direction. I think the regulators need that, Insurance companies need that. Hospitals need that. Primary care folks need it. Yeah. Thanks. Terrific. Yeah. Thank you. You. Courtney is here. Is there anyone I'm just looking. Nope. There's nobody from a distance here. So I think who has I'm

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: just getting ready. We'll,

[Sen. Virginia "Ginny" Lyons (Chair)]: Courtney, did you wanna go now?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, thanks.

[Sen. Virginia "Ginny" Lyons (Chair)]: That'd be great.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Nice to be here in person today. Yes, that's true. It's a lot more fun than being on the screen. For the record, Courtney Harness with Blue Cross and Blue Shield of Vermont. I did send some written remarks into Calista earlier, mostly so you all could have them. I'm going to try and be brief, knowing that there is with a lot of folks. And I'm really happy and pleased to hear the conversation around collaboration. As most folks are aware, this type of work, especially around primary care and the complexity and the outcomes that Vermonters are depending on, frankly, depends on collaboration across all levels. I wanna start by saying Blue Cross and Blue Shield of Vermont is the largest payer into the Blueprint currently. We're proud of that, happy to do that, and support that work. Have And we made some potential improvements to the blueprint known to our partners at AHS and our regulator? One of those is around quality outcomes. And frankly, some of the recent reports on the blueprint have left us wishing that there was more. I think that this bill has the potential to walk us down that pathway as long as it's named explicitly as a goal and objective. I would say, secondly, while we're happy to do our part, proud to be the largest contributor in the blueprint, It's been really hard for us to access data around how dollars are impacting our members, specifically with the community health teams. And again, I'm not saying anything to the committee that we have not already voiced to other potential partners in this work. That said, I think that if we can really focus on access, quality, data sharing, and collaboration to put together some parameters in this legislation that can effectively meet the goals of what I would refer to, and I'll steal this from Secretary Samuelson, a modernized blueprint. We can create something over the next couple of years that is more future focused than I think what the current model is. And so Blue Cross and Blue Shield, as a payer, has a lot of hope for that process, has a lot of optimism about what the people in the room can bring to bear from that planning process. And part of my comments, you'll see a recommendation for a slightly elongated timeline. I have a tendency to believe that fast is slow, and slow is fast. And if we take an extra year, we might be able to assure Vermonters that the quality metrics, the accessibility outcomes, and frankly, the payment model is something that's been worked on, planned out, and decided amongst the group of folks that will all be participating in the outcome. With that said, you also see in my comments, and it was referenced earlier, there are some states that are already, and have been for several years, running a really interesting tiered capitation poll, and it's one that we shared with AHS. It's one that we'll be talking about with them relatively soon. From our perspective, and I'll say this briefly, not always well received, which is why I'll try to say it briefly, we have two quality programs of our own that we operate, and those, you saw yesterday in our presentation, we have a significant amount of data and a significant amount of opportunity to understand what those programs actually provide to our members.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm gonna ask questions that I always ask. How can we integrate that data with what we have at the board or others?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I think that's exactly to the point of this legislation and collaboration, that when we talk about being the biggest contributor or serving a third of Vermonters, we may have historically not always been chomping at the bit to share all of that data. I think we're in a position now where we're actually excited about it. You saw some of that yesterday.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, this is so good. Good.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Good. And frankly, it's necessary. If this is going to be successful, I think we have to really learn as much as we can from the data that we have to inform the path forward. I was going to go down a little bit of a tangential pathway and talk about a family history of farmers. And I said to someone in the cafeteria this morning, if you set up a primary care provider in their kitchen for free, they still wouldn't talk to them.

[Jennifer Kirby, Office of Legislative Counsel]: So think He's a great one.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's terrible My grandfather did. Yeah.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: But, you know, I say that when we talk about accessibility, sometimes it's easy to see this pie in the sky of, like, if we build it, everyone will slot there. If there's more providers, if it doesn't cost money, I I think we also have to better understand over the next couple of years, like, what's actual number of folks that will come in and take advantage of this plan, and then how do we use that number to determine success? So I say all that to say we've had the luxury of sharing some thoughts and ideas. I think some language that we would really appreciate in this bill to feel really comfortable about where we're at, where we might go as a partner, is really around some direct language around quality, around accessibility, around how we'll know a certain number of years down the road if it's successful or not, and just better understanding the timeline. Frankly, when we talk about the reference based pricing conversation and this conversation and other conversations, there's a timeline that leads to a really nice, we think, confluence of factors two or three years down the road that have us in a much better position. And I would be remiss if I didn't talk about the rural health transformation funds and all of this. We've got a really unique opportunity to leverage those dollars for this planning process.

[Sen. Virginia "Ginny" Lyons (Chair)]: I did speak with the director of healthcare reform about this the other day. Some

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: of these things, Carolina, I'm just trying to go briefly over.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's great. I get it.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I get it. But ultimately, at the end the day, we would love to be supportive. There's just a couple of weeks in here that would make it easier for us to

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: go after that.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I know you've got, your testimony has a list of moving toward, and obviously the bill includes some quality metric and some inequality analysis. And I know when we heard from also talked about modernizing the blueprint in terms of quality. So having specific recommendations, and then looking at you, I know I'm gonna be looking at others for that as well, But we put together that sort of meet everybody's acceptable standards, including our stuff.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I'd be happy to do that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, great. Okay. Questions? Can I make a comment? Yes. Quick comment.

[Jennifer Kirby, Office of Legislative Counsel]: What's a quick

[Sen. Virginia "Ginny" Lyons (Chair)]: comment? Quick comment. I agree that the timeline is super important and two to three years is probably realistic. I just have to talk. It's really hard to speak to our constituents and our community members who are suffering today. I think that it's going to be another three years or that's going to be two or three years. It's just really hard. Yeah, so I was gonna say the can is getting really dented.

[Jennifer Kirby, Office of Legislative Counsel]: It's bit clap. Yeah,

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: I think, and this is just anecdotal, but part of what I've seen in, maybe we call it forced family fun rather than collaboration, is maybe it's gone on talking about it long enough, that if we put some timeline to it and some years to it, even if it's two years out, it's better than twenty years, Vermonters need it, and they frankly expect it from us at this point.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, thanks for your information. As the man said, inertia was a powerful force.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Yes. Why we all took physics. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Most people in here did not take

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: physics. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. Jordan, is Jordan there he is. How are you? Jordan Neste, welcome.

[Jordan Estee, Vice President of Government Affairs, MVP Health Care]: Yes, good morning. Can you hear me all right? Yeah,

[Sen. Virginia "Ginny" Lyons (Chair)]: we can probably close the door now. Good morning. Welcome. And why don't you introduce yourself for the record, I've been in committee before, and we'll follow your testimony.

[Jordan Estee, Vice President of Government Affairs, MVP Health Care]: Great. Just can everyone hear me all right?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes, very well.

[Jordan Estee, Vice President of Government Affairs, MVP Health Care]: So good morning, Chair Lyons, members of the committee. For the record, my name is Jordan Estee, and I serve as Vice President of Government Affairs at MVP Healthcare. MVP is a not for profit regional plan serving about 600,000 members across Upstate New York and Vermont, including about 40,000 commercial members here in Vermont. So at the outset, I just want to very much reflect a lot of what Courtney had said, that MVP supports the intent of S197. Strengthening primary care is the right goal. It's a critical goal. It's a shared goal. My remarks today are really going to be focused more on the design choices in the bill being very critical to what this looks like and ultimately how successful it could be. I think from our view, details are going to determine whether we're truly enabling health, modernizing the preventive care system or simply rearranging spending within the existing sick care model, which I don't think is what any one of us want. So my comments today are really gonna focus on three core design questions. First, what counts as primary care? Second, are we paying for activity or are we paying for outcomes? And third, how do we strengthen accountability while also preserving innovation and driving overall transformation? I think it's I've read the bill, my reading is that many of the most important decisions I think will be made later through rulemaking, especially definitions on what spending counts. But I think the language that gets adopted here is gonna determine how much flexibility remains to get those details right. So I wanna start with the person, patient, right? I mean, every patient wants the same basic things. It's to stay healthy when they're well, it's to return to health when they're sick, it's to prevent their condition from worsening over time. So I think the question before us is what kind of a system best supports that goal? Now, the bill establishes a primary care spending target, but in our view, the more basic question is what counts as primary care? The definition is the mandate. I think if we need to be very careful not to define it too narrowly, limiting it to traditional office based encounters, kind of the historical view of what primary care was. And we don't wanna reinforce that model. We instead, I think wanna ensure that we're reflecting where care is going. And that's team based, it's prevention focused, it's technology enabled, it's community supportive, it's proactive instead of reactive. And that's the type of broader focus that we think is necessary to really accelerate meaningful transformation. So before we lock in a benchmark, we should be very clear about what we're actually buying. It's not news to anyone around this table or in this room, but for decades, our system has been organized around sick care. So you get sick, you go see the provider, issued a prescription, a treatment, you return to health, right? It's an appointment, it's a diagnosis, it's a prescription. But in our view, modernized prevention, where the system is going is about sustained health improvement. So that's something much broader. To that point, the pandemic has accelerated change. Telehealth has become normalized. Remote patient monitoring has been expanded. Patients are more comfortable engaging in their health digitally. Providers have adopted new workflows. The tools exist now and they will continue to evolve in our view to support health between visits, not just during them. So again, this kind of longer term vision of primary care, it's no longer just a place you go. It's a long term relationship supported by care teams, by technology and by community resources. So again, we have to be very thoughtful about how we define what we're calling and classifying as primary care. And if we're focused heavily on the office visit alone, and to be clear, office visits, primary care practitioners are and will continue to be the quarterback and the backbone of the system. But we will continue to still the system towards that and not towards the much broader view of where we think prevention is going. If we design a system around health improvement and empowerment, we can get transformation. So this type of whole person care really depends on sustained and trusted relationships between patients and their care teams and providers over time. The hardest part of health isn't writing a prescription. It's what happens in the last mile. And what we mean by the last mile of care is behavior. So whether someone actually changes their diet after they're being told they're pre diabetic, right? Whether they take their blood pressure medication consistently, whether they engage in their health proactively between visits, our view is that prevention really succeeds or fails in that space. So, we describe this internally as at MVP, and this is part of like our transformation work as empowered well-being. What that means is to us is equipping patients with tools and supports and infrastructure to help them manage their health 20 fourseven, between visits, not just during them. So we should really be looking to strengthen those long term relationships in whatever we design here and not fragment them. Prevention also increasingly requires what we call end of one care, and that's care tailored to the individual. So what that basically means is two patients, two diabetic patients with identical A1C levels could require entirely different interventions, right? And technology now gives us the opportunity to personalize care and supports in real time. So the future is not how we've approached population health in the past, which is still important work, but it also is kind of looking at the individual, their unique healthcare needs, their unique circumstances, and what kind of tailored approach and what collection of tools and resources are gonna help them proactively manage their care. And again, this is really going back to how we define primary care, and ensuring that we've designed it in a way that's flexible enough to kind of enable the transformation and the acceleration and the modernization of the preventive care system. Patients' expectations in general, I think have also changed just like they have with every other industry. And those expectations aren't uniform. So a working parent may need a same day telehealth visit at 7PM. A retired farmer in a rural area may need a trusted provider who makes house calls. An elderly patient with multiple chronic conditions may benefit most from remote monitoring that prevents a crisis before it happens. One modality doesn't work for everyone. And what I'm sure everyone around this table agrees on in a rural state prevention can't depend on a forty minute drive during business hours. So a system designed around, again, kind of the historical traditional office visit based primary care system as the default unit of care, we feel will consistently miss the patients that are hardest to reach. I think that very much is in line with Courtney's example about his family. So the pandemic showed care can be delivered flexibly without sacrificing quality. And we would encourage the committee to design an approach that rewards engagement, now comes across all modalities, in person, telehealth, in home, digital, community based, and not privileged one setting or another. To us, flexibility is not about convenience, it's about access. When we think about preventive care, we need to invest in the drivers of health. So if we're serious about prevention, we have to invest in what drives chronic disease. So that's nutrition, it's sleep, it's physical activity, it's stress, it's substance use, social stability. We can't medicate our way out of a nutrition problem. A modern preventive healthcare system should allow primary care investment to include things like health coaching, behavioral health integration, lifestyle medicine, community health workers, remote monitoring, medication management, and D prescribers. So these are the clinical levers that really reduce A1C levels, or they improve blood pressure control, and they prevent hospitalization. So again, we don't qualify under the bill's definition, we risk funding volume over outcomes. Now, the 15% benchmark is calculated largely from claims, or appears to be on my reading. But many of the most impactful investments under this future state vision may not generate claims, like health coaching, digital tools, interoperability infrastructure. If we qualify spending based on historical claims, office based visit encounters, the system could favor again billable visits over preventive infrastructure. So it's our view that we need to explicitly and robustly count non claims investments. Or the benchmark runs the risk of measuring activity and not actual health. Accountability has to be clear and measurable. You know, we're gonna mandate increased investment, I think patients who are in funding that investment should really experience change, and that's assurances and expanded office hours, improved access, telehealth availability, things like that. I know we need to clear expectations around these things, because more money alone doesn't guarantee greater capacity or access, and it doesn't guarantee better care. So we have to tie in our view investment to measurable expectations. And this leads to a bigger issue, then I'll wrap up. Spending targets alone don't guarantee outcomes. So they answer one question, how much are we spending? Doesn't answer the more important question about are people getting healthier from that investment. So if acute care costs rise, often outside of any health insurers or payers control, you look at specialty drugs that are increasing dramatically the costs every year, total medical spending rises with it, right? The benchmark rises too. So you can see a scenario where you're increasing real primary care investment, but still falling short of that target. So fundamentally, it's something worth considering that tying reform to a percentage of total spending, what's the risk of anchoring the system to continued cost growth, right? Also want to just point out a structural equity issue here. And I know it's something that based on testimony and reading the bill language that the committee intends to try to address, fully insured plans like MVP and Blue Cross will be required to comply. But self funded employer plans, cover a substantial share of the Vermont's commercial workforce, would presumably be exempt under federal law. So if the mandate only applies to the fully insured market, we run the risk of concentrating all of the compliance obligations and requirements of this law on a shrinking segment of the market, like potentially further accelerating the shift of employers into self funded arrangements, which I don't think any of us want. So that dynamic doesn't strengthen the system and it can create competitive imbalances. And a larger issue, hitting on outcomes, spending targets guarantee outcomes, we should be asking when we measure quality, not did we screen for diabetes, but did A1C levels of the patient cohort collectively approve, right? And then we should be rewarding providers you know, and the collective care teams and infrastructure for driving that result. We shouldn't be asking, did we document hypertension? We should be asking, did blood pressure control rates increase? So outcomes based accountability changes behavior. In our view, it aligns incentives toward prevention, sustained disease control, long term stability. In closing, I would just say Vermont has a real opportunity in front of it. The bill's not simply about increasing primary care spending, it's about deciding what we pay for and allowing and stimulating the evolution and transformation of the primary care system to meet the modern needs in 2040 and not necessarily what it looked like in 2015. It's about deciding what we pay for, it's about defining primary care thoughtfully in a way that reflects those long term relationships that add a one personalization and the drivers of health. And we really think that if done properly, this bill could really strengthen prevention. If we count the infrastructure that supports health between visits, that empowered well-being, last mile of care idea, the bill can drive real change. And if we pair investment with measurable outcome expectations, patients can see real improvement. The goal is not necessarily to spend a certain percentage on primary care. In our view, it's to help patients stay healthy, return to health and prevent deterioration over time, fund the infrastructure to allow that true transformation and evolution to occur. If the payment design reflects that ambition, we feel that Vermont can really be a leader here. So thank you for your time. I welcome your questions. Chair Lyons, I will submit written testimony as well.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, thank you for that. I was gonna ask you to do that. Appreciate it very much. And thanks for taking the time to comment quite thoroughly on that. I did notice some comments about the improved relationships between primary care and patients and building those personal relationships, which means you're not an AI person, and I was trying to remember the word for that but I don't know what it is. It'll come. Senator Benson and I are thinking through. Is it Luddite? I don't know but you're not Luddite. That's the That's the opposite. So I did hear you talk about telehealth, so you redeemed yourself.

[Jordan Estee, Vice President of Government Affairs, MVP Health Care]: Well, to that point, I think AI is absolutely a technological advancement that's going to allow practices to free up more time to focus on delivering care. Right. So that, know, when I talk about technology and the infrastructure, there's just endless opportunity across the spectrum. You know, we've seen so much evolution in that respect since 2020, and that's only going to continue to accelerate. So, you know, we should be taking advantage of every tool and opportunity and resource again, to give patients, their providers, their collective care team, the resources necessary to help people be actively engaged in their health 20 fourseven. I mean, the goal is to keep, you know, to get people healthy so that they don't need to go to see the doctor in the first place, right? And that's a much broader view of primary care and prevention than we've historically had.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. And I do have a question for you. It's the same question that I ask and I always ask of Blue Cross and Blue Shield and probably of you, and that is the ability to share data, particularly within the primary care blueprint work. You talked about interoperability, which is key, but also then the sharing of data for outcomes analysis. Absolutely,

[Jordan Estee, Vice President of Government Affairs, MVP Health Care]: absolutely think that it's foundational to what I'm talking about to kind of empower the type of preventive care system we envision, right? And that's not just claims data, it's kind of a full three sixty view, what we can be collecting, aggregating, and using to, again, to help patients with spotting trends, get ahead of things. It's all of the above. And that's something we talked about a lot internally, some of the challenges we have. And I don't know that it's necessarily so much in Vermont, but we see it a lot in New York, which is where most of our membership is where it's just such a fragmented system of data. Like we have a hard time getting access to our patients' data outside of what we have for claims, right? Which is we've already paid that. Need more data just to be more proactive. And at the end of the day, we philosophically strongly believe it's the members' data. It's not the plans' It's not providers' data. It's not hospitals' data. So we would strongly support moving in a direction that really reflects that view and allows the system collectively to leverage data in the most appropriate way, again, to best engage in members' health.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Thank you again for your time. Appreciate it. And I think we're going to move on to Margaret Reynolds of Cigna and we look forward to your written testimony.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Thank you for the time. All right.

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

[Jennifer Kirby, Office of Legislative Counsel]: Hi, thank you Chair Lyons and members. My name is Margaret Reynolds. I'm here today on behalf of Cigna. I did submit written testimony, so you should have that. I'll be brief in my comments.

[Margaret Reynolds (Cigna)]: I know there's others who want to testify. Cigna operates in the large group market here in Vermont, and we really gear ourselves towards value based contracting. So, with the per member per month tooling that's proposed in this bill, we have concerns that it's not driving toward health outcomes for our patients, but just toward head counts and running people into primary care. We certainly encourage the use of primary care and do that both virtually and in person with our members and our plans. The only other thing I really wanna highlight for this committee's consideration is last year, you enacted major reforms in S-one 126, or Act 68, That includes reference based pricing and a move for global budgeting, and you just want those considerations of payment reforms as you move forward with this. We think it could add a layer of complexity. Just want to keep that in mind as you look ahead in your conversation. Certainly encourage the intent of this bill in wanting people to go for primary care, especially in managing their chronic conditions, and would like some flexibility and some value based payments to be considered. Okay, and we have that

[Sen. Virginia "Ginny" Lyons (Chair)]: in your testimony. Yes. How would, do you have suggestions for how that consideration might be place in legislation?

[Margaret Reynolds (Cigna)]: Maybe optionality rather than mandating it. Oh, I knew that

[Sen. Virginia "Ginny" Lyons (Chair)]: was gonna come. Yeah, think

[Margaret Reynolds (Cigna)]: you could read it on my face. So yeah, maybe some optionality where value based contracts are in place. Again, if you can prove that our members are having health outcomes driving toward better health rather than just going forward check ins when they're safe, I'm not really sure that. It might be more towards rulemaking, where we could kind of step that out, but happy to consider maybe more concrete examples and get them to you for your consideration. Okay, thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, for sure. Questions?

[Jennifer Kirby, Office of Legislative Counsel]: Okay. Breathitties, so Thank you for

[Sen. Virginia "Ginny" Lyons (Chair)]: being here. Thank you. And you're new to Cigna.

[Jennifer Kirby, Office of Legislative Counsel]: We're relatively new to taking over Vermont. Been a six year for little over six years. Understood. Yeah, thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, our healthcare advocate, and I know there are two of you, do you want to sit together?

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Let's see if that interface. Oh, yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Have two things from you. Our slides and. Yes. Yeah.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I'm Mike Fisher.

[Jennifer Kirby, Office of Legislative Counsel]: I'm Eva Zadas. So

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I think I'll just sort of make a high moral statement, and I'm gonna turn it over to Emma, does want to share this. We at the HCA, I really appreciate the conversation about finding new ways to quality and support primary care. Yes, we've been talking about that. At the same time, forgive me if I express a little bit of, I feel a little burned about these kinds of efforts over the years and what their outcomes have been. We spent over $100,000,000 on one care and the all payer model, there were some good parts of that, and there were some parts that did not work according to plan. And more importantly, or as importantly as that $100,000,000 we spent eight years where whatever question like this was asked, how do we fund primary care, we said, oh, it'll happen through this effort. And so I think that was eight years of not getting a job, not being able to focus on job, strategies to actually make it more than people. So I appreciate that your committee, others have framed up, and there's discussion about a new model, I'm sure it will work, but we wanted to come before you with some much more tangible now things that we think should be considered to support remote access to permanent care. With that,

[Sen. Virginia "Ginny" Lyons (Chair)]: all All right, so now we have

[Emma Zadravec, Office of the Health Care Advocate]: the Good, good. Right, so, yes, as Mike said, we're here to talk to you a little bit more about ways that you can influence or control primary care spending and Vermonters' access to pre primary care through existing mechanisms and vehicles now. We're gonna focus in on those vehicles, which cover a significant portion of the population. We'll talk a little bit about Medicaid, which is about 25% of Vermonters or around 152,000 people. Medicare, coupled with Vermont's Medicare Savings Program, QMB, we'll talk about qualified health plans on and off exchange and the Vermont State Employees Health Plan. On this slide, we've outlined possible actions that the legislature could take to advance its goals around primary care through mechanisms that exist now. And we've also sent you out a letter, which I think is something else to go a little bit more into that. So as I said, 152,000 Vermonters have Medicaid. The good news is that Medicaid, all Medicaid enrollees, regardless of your type of Medicaid, pay $0 now for primary care. So that's fantastic. Vermont is also unique in terms of, I think we are the only state in the country or one of the only states in the country that manages its own Medicaid program. So rather than farming it out to a private health insurance group, we do everything in house. We have a prescription drug list. We have a fee schedule. We already do all of that, which is great. And one thing, one more background piece before we talk about actions I wanted to note is that when One Care existed, the attributed population had their prior authorization requirements waived. And so there was a significant portion of the Medicaid population who had those prior authorizations waived. That ended last month. On January 1, Medicaid enrollees now have those prior authorization requirements again. That's a significant change both for primary care providers and for Medicaid patients, which covers

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And I'll jump in, the state is now engaged in a process of moving towards a Medicaid global budget, and it is our understanding not contemplating a waiver, waiving for the prior authorizations for that population. We actually think the waiving of the prior authorization for Medicaid in one care was one of the highlights, one of the things that worked well.

[Emma Zadravec, Office of the Health Care Advocate]: What are some actions that you would have now? Could, since folks on Medicaid in Vermont already have access to $0 primary care, you could look at lowering co pays for other primary care related services that you deem integral to primary care. So that gets kind of at the question of how do you define primary care and what services are related and integral to getting that kind of healthcare. Can also ask the Department of Remote Health Access, which governs Medicaid to increase reimbursement rates for primary care services that are paid for by Medicaid. So again, that covers 25% of the state's population.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: I'll jump in again. I think it would be important to know where we stand on Medicaid reimbursement for primary care. I think we're doing pretty well.

[Sen. Virginia "Ginny" Lyons (Chair)]: 110%.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Comparison to the rest of the countries. Yeah. But I think that's certainly a good one. Yeah, it sounds like a lot of them. Yeah. And I believe

[Emma Zadravec, Office of the Health Care Advocate]: there are some struggles around implementing the family plan Medicaid investment that was passed by the legislature last year, which has a 90% federal match. That money also goes to primary care providers. So, last bullet. You could also direct EVA to eliminate Medicaid's prior authorization requirements, which was a significant benefit for primary care providers and patients.

[Sen. Virginia "Ginny" Lyons (Chair)]: The best questions is questions on them. Sure. For lowering the co pays, do your data around how much of a deterrent those co pays are for people getting primary care?

[Emma Zadravec, Office of the Health Care Advocate]: Not on hand. I could certainly send you more information about the Medicaid copays. Copays range from $1 to $3 and when people receive services at hospitals and they have Medicaid, they would be eligible for financial assistance, but lots of primary care is delivered outside of hospital spaces, and they don't necessarily have a financial assistance program. Alright. So that's Medicaid. Medicare, a huge portion of the state is also. Medicare is a federal program, as we know. However, the state of Vermont has the Medicare Savings Program. All states have a Medicare Savings Program. It's Medicaid funded, so there's sputtering money matched there. This year, January 1, actually with the implementation of a huge increase in our income limit for the QMB program, qualified Medicare beneficiary. People who have QMB pay $0 for primary care. They also pay $0 at the hospital doctor's office. It's an amazing program. We are so proud that Vermont has increased that limit. We went from 100% federal poverty level to 150% federal poverty level, and the legislature could further increase it in the coming years. There's huge federal match money for that. It brings a lot of money to the state and allows people to access the care they need. Washington, D. C. Is the highest 300% level.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And so just to say thank you legislators for passing the mask, you expanded access to credit and care significantly for a population of people who we think cannot possibly afford the 20% co pay. So that was a really important step, and there's room to go for it.

[Emma Zadravec, Office of the Health Care Advocate]: All right. Now I'm going talk a little bit about the qualified health plan markets, both on and off exchange. Individuals in Vermont buy qualified health plans through Vermont Health Connect on exchange, and some individuals could buy them directly through the carriers, MVP and Blue Cross Blue Shield of Vermont, and many employers, employees get their health insurance at smaller businesses directly through carriers and those are qualified health plans as well. That's about 70,000 covered lives in Vermont. So again, a significant population. Some of the things that the legislature could do now, they could require that beginning in plan year 2027, all QHPs provide first dollar coverage, $0 deductible, and $0 top hearing for primary care office visits. Currently in 2026, there are several qualified health plans that offer three to four primary care visits or mental health visits for free. Those are offered both by Blue Cross and the MVP. But it's by no means all of the QHP, but three to four primary care office visits for free may not be enough. So that is something that the legislature could do. The legislature could also direct the Green Mountain Care Board to condition approval of QHP premiums on carriers that demonstrate meaningful investment in primary care. They can establish minimum reimbursement requirements or minimum primary care spending targets. So that's another existing avenue to work with.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And I just wanna recognize for the first one, if you went down that path, you'd wanna recognize the limitation of people in Huntington's and would be outside of our ability to use.

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

[Emma Zadravec, Office of the Health Care Advocate]: I believe the 2027 plan year design with QHPs just kicked off, so it's happening now. Alright. So next, the Vermont State Employees Health Plan, 24,000 covered lives. So the state of Vermont offers health insurance to its its employees and their family members, about 24,000 people, significant chunk of people. It is a self insured plan, which means the state controls the plan design and the offerings and cost sharing. The legislature could work with the state of Vermont and the Vermont State Employees Union to ensure that the health plans that are offered to the state employees and their family members provide first dollar coverage. So again, that's $0 deductible, zero cost sharing for primary care services. The state could even increase the reimbursement rates for primary care services paid for by those lands if they wish to. That's a significant portion of the population with existing ways that you could influence and advance your primary care goals. But it's not everybody. Legislators do not have an existing mechanism, direct mechanism, I'd say, to advance primary care goals for folks who are fully uninsured or who have self funded employer insurance, who have Medicare and their income limit is over the QMB, Medicare Savings Program, or if they have TRICARE or another federal program that Vermont was not eligible. So with respect to that population, we would recommend designing a simple and cost effective delivery method, One that maximizes dollars going to primary care providers, ensures low cost or free primary care to providers who do not have it already, and creates the least amount of new administrative overhead and for providers and patients alike.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Yeah.

[Emma Zadravec, Office of the Health Care Advocate]: Yeah. Ahead.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Interesting. Yeah.

[Unidentified Committee Member (Senator)]: Pretty neat. So what you're saying, I think, is let's do something now. Let's let's get some dollars going, some investments going where you you can actually make a a big change to some of these a lot of them are lower income individuals and staying. Am I first of am I saying that

[Emma Zadravec, Office of the Health Care Advocate]: correctly? Some of them.

[Unidentified Committee Member (Senator)]: Okay. You're you're you're not but you didn't provide how you're going to fund it. Okay. So, I like that. So you've given half of

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: the equation, right?

[Emma Zadravec, Office of the Health Care Advocate]: Okay.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: Well, so the answer for that is in different categories for different populations. Think, I'll just focus on the MSP one for a second, just to recognize that the state invested $5,600,000 general fund to do the increase in MSP that we did that went into effect, Jason Woodford. It was great. And it is projected to save, I don't know if you can, nothing to do all of it from memory, but significant return on investment, not only new access to primary care, but for the population of people who are newly having their Part b premiums paid. It represents almost $35,000,000 of money that is significantly coming from the federal government to help them pay their Part B premiums, money in their pockets. And I just wanna say that out loud because can you think of another thing the legislature has done recently that targeted economic relief to such a new population of that size. That that that was a major success. There are Vermonters throughout your district districts and throughout the state who are signing relief that they don't have that $202 premium coming out of their Social Security benefit every month now and have that money to put food on the table. Was a damping, sponsorship question. But my main point is that it is significantly good, it is a very good investment of state dollars to help out people in that quitting population, Medicare Savings Plan population, then they're going to go higher. That would be general fun. I think for the things that we said about the qualified health plans, that significantly impacts rates. If we're saying that you need to get a free, more free access to primary care, then we need to understand how that would impact the premium rates. And who would pay this?

[Sen. Virginia "Ginny" Lyons (Chair)]: It's a chance, it's a

[Emma Zadravec, Office of the Health Care Advocate]: It's plan designed, too. All of the qualified health plans have to be within an actuarial value standard, and so you might bring down the cost of primary care visits and related services, and you might increase the cost of some other type of care offered by that plan. So, there might not actually be an increase to the premium based on the design. Every year they design them within those constraints. So, trying

[Sen. Virginia "Ginny" Lyons (Chair)]: to move hospital care to primary care is part of that and the reimbursement rate is over here to here is part of that. So it might all sugar up, but there's still that. Yes. The balance.

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: And I think that gets us to the conversation we were having this morning about the promises of reference based pricing and ability to tailor payments to a sense of the types of care we're in. So

[Sen. Virginia "Ginny" Lyons (Chair)]: it's always the,

[Mike Fisher, Chief Health Care Advocate (Vermont Legal Aid)]: what do you

[Sen. Virginia "Ginny" Lyons (Chair)]: call that thing you put on your bumper? The sticker? That there.

[Emma Zadravec, Office of the Health Care Advocate]: Is. Thank

[Unidentified Committee Member (Senator)]: you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. This is great. Thanks for having it here for us. We've got fifteen minutes left and Jen, I'm not sure we need to start going through everything. Did you want to make any comments at all about where we are? We've had a lot of testimony. We have decision points. We will go through the bill. We have some final testimony tomorrow morning from the treasurer's office and one of the hospitals in our country. And and that should not take up a full hour tomorrow morning, so we're gonna start with discussion and markup of the bill. I don't know if we need to do what the enforcement is. Don't comment. I know. Was thinking of them.

[Jennifer Kirby, Office of Legislative Counsel]: Jen Kirby, Office of Legislative Counsel. I mean, I have been working with some of the stakeholders on Yes. That's for sections one through three.

[Sen. Virginia "Ginny" Lyons (Chair)]: You wanna just talk with us briefly about that or should, let's wait for tomorrow morning. I think

[Jennifer Kirby, Office of Legislative Counsel]: we do tomorrow morning, then we could then, we'd be good

[Sen. Virginia "Ginny" Lyons (Chair)]: to have people from AHS and VMS here, because obviously their proposal done. Okay. I know. We ask for some hallway conversations, that's happening, and we'll continue with it. As I said before, I am gonna meet with Jen this afternoon and I'll try to consolidate some thinking that's been going on and where we are, and then we can, we'll have it all out on the table. It'll be fun. This is the fun part. This is one of most fun. Sausage making it. It is. That's good sausage.