 Okay, good morning. This is the Senate Health and Welfare Committee and it is March 11th Friday. It is crossover day, which is an exciting time for all of us here in the State House. We're working double time for sure. And I would like to counsel and join fiscal folks triple time. So we have three bills that we're looking at to finalize today, a final markup and vote. And the first bill we have is S285, a bill relating to healthcare transformation. Jen Carby is here with us. And Jen, I think we have a new draft of the bill. Is it 4.1? Right. Yes, that 4.1. Okay, so why don't we start with that? We'll just go through the bill and you can identify for us. I know a lot of work obviously happened outside of the room yesterday with agency human services agreement and care board and others reviewing the draft. So it received some comments and they're, they're editing in the bill. Why don't you go through and we'll, we can talk about each one. You want to take a minute before you start. That's great. Okay. We're good. All right. Good morning, Jennifer Carby, Office of Legislative Council. We are looking at draft 4.1 of S285. And I sent this around to you all last night and to a number of stakeholders, the ones who I was remembering have been involved and encourage them to forward it to anyone I had left off the list. I'm just wanting to get people an opportunity to see it before this morning. But we're, I highlighted in yellow the changes from the prior draft. So in the first section, the first change is in the title of the section and I changed it from hospital global human designs to hospital value based payment design. Can I ask a question? Can I go before you? Okay. I was just thinking that as we putting this in as a title and I think it's a great just for the section. It's just for the chapter right for changes. Is there a definition of value based payment in the chapter itself? I don't believe there is necessarily a definition of value based payments. I think it's a, it's a concept more than a defined term. Okay. But this isn't going in statute. This is just a session law provision that is appropriating funds to create a process for distributing value based payments and then it says including global payments. Okay, so at some point, it doesn't necessarily, it might be helpful to have that definition of what a value based payment is and how inclusive it is and what it means because I think, as we, and I'm feeling that frustration as I talk with my peers in the Senate, they're asking questions and then then you have to go through this whole explanation if there were. So let's, let's consider working on that and whether it happens right here. That's, it doesn't have to happen right here, but we could move it along to other committees and make sure that at some point we have a common understanding. Yeah, and I'm able to see if there is CMI or others at the federal level have created a definition that would make sense for us to use your, I wouldn't want ours to be unintentionally under or over. Perfect. Thank you. Yeah, so they know if you're potentially adding definition of value based payments. If there is anyone watching who is familiar with a good federal definition, I encourage you to send that my way, please right away. Send it to Aaron. Thank you. All right. Thank you. That was my question. Great minds. And the reason I was making that change is just because we had used that added that language throughout based on our recommendations from, you know, and even though there isn't a definition, it's expected that this is a broader. This captures more than global. Right, because of the way the language now online. So we're still looking at this process. This is all about hiring consultants to assist the board in developing a process for establishing and distributing value based payments, including global payments. So it doesn't necessarily mean exclusively. All right, then on the second page, so we're still looking at this process, developing this process for distributing value based payments from all pairs to Vermont hospitals that will do a few things move away from deeper service, provide predictable sustainable funding. And then you see, this is where we had that solely language yesterday that you talked about taking out. So now say take into consideration the necessary costs and operating expenses that was a request that came in from the hospitals. So, so that's one proposal for your consideration that the payments have taken into consideration both the necessary costs and the operating expenses of providing services and not be based on historical charges. So that they agreed to take out solely. Right, I think that what was expressed was that they were comfortable taking out solely as long as there was this added concept of operating expenses that aren't necessarily just cost based. So my suggestion is that you go through if there's something here you'd like to flag flag it if you're okay with it will just continue. I also note that in what came in this morning from Mary Kate Mullen from by say primary care. Her request would be instead of talking about not being based on historical charges that not based. I think she's potentially back solely on historical reimbursement. And if we're using features data that data was like reimbursement about not charges, I think we'll leave it as charges that opens up a whole new discussion. Yeah, that's, remember this has to hopefully this bill will get to the house. I'm not making that. So then no other changes in that section. I don't know if there's anything more in that section that you want to look at or just go through. Okay, section to the only change in the first part is just that I added the word system so it's talking this is the 2.5 million to the green line care board. And it had said to build on successful healthcare delivery reform and I think throughout we've been talking about healthcare delivery system reform. And it's making that consistent. Can you remind me. No one was a 2.5 billion the original request from the demand here for you know that was the three million that was our three million and this is where we look for 500,000 for other work. Okay, thank you. That piece of your. Great. And then the other change that is here on page. Okay. Is a new subsection. This is based on recommendations from Patrick flood. He had talked to he had recommended. The agency human services to identify the funding necessary for community agencies to effectively implement the redesign and provide the proper level of services. I thought if they were identifying the funding necessary, it would make sense for them to actually report that. So I put in a report, you don't have to keep that. The agency human services would like you to take out the, they say he won, but he too doesn't make sense that he won take out he and it's entirely but as written, this would direct honor before and I put January 15, 2024. Just looking at the timeline for the green mountain care boards expected work on the community engagement process and development the plan which seemed like it was projected to go through 2023. And by January 2024, potentially there would be an idea of what that plan looked like. So honor before January 15, 2024, the director of health care reform at AHS would report to a number of committees including in the Senate this committee finance and the amount of state funding that would be necessary for Vermont's community based health care and social service providers to effectively implement the plan developed pursuant to subsection a of the section as it relates to community providers and and to ensure they are able to provide the appropriate level of services to consumers. And then for purposes of this section, we've defined community based health care and social service providers and I put in the same groups he had. So it's the FQHCs. He just had designated agencies I included the special service agencies assuming you would want both home health agencies area agencies on aging adult day providers, residential care homes, nursing homes. He did not have assisted living for instance, and I wasn't sure if you would want that or not they did not put it in but wanted to play it providers of services addressing homelessness and community action agencies. So a lot for you to think about here. This was a, this was a long conversation between a month with this really comes from Robin. This does not come from Robin and yeah, where is it? Where is it? This right this comes from Patrick flood. Oh, that's right. Okay, I know. Okay. And through Shayla let me send you something asking you to please take out one. Yes, they say take out one. I wouldn't wait to. There's no purpose for you to if there's no one, but I recognize their objection is what you want. Well, the question we have let's flag this and then the question I would have is how essential is this work to the design at transformation work was this something that would be a fact step. This is potentially a next step. Yeah, I mean it's looking at what it would, you know, I think we need to talk about this a bit yesterday but as I understand the proposal it's really looking at what the plan is calling for and if there's it. is looking to shift services to the communities what is the capacity of the community providers to deliver those services. Yeah, so I'm you know if we put that we layer this and then the design. Everything has to happen all at once and we would like to see the first step so I'm not unhappy about removing that at this point I think it is a next step but I can listen to other members of the committee. I think it is very important. So for putting a date out that is right you cannot I picked sort of what what seemed like the earliest reasonable and rational not even necessarily the earliest possible date, given the timeline for that process work you could put it out, you know, a year or two. For 2026 I wonder what would, would it still be timely, but it's I think it absolutely is necessary if the data. One thing to think about to as you're asking for important two years from now, two years to know what you'll be thinking about what information you will already have. And long as information is important it may not be important to you to years from now, because you might be already past this. So just think about you're the one sooner, where you put a flag in it for next year. Now, I'm sort of feeling that way. And we might be able to refer to this kind of assessment later on. Yeah, you may also want to make sure it continues to be on the agency's radar, which I expected as already but but just this particular concern about not just planning for things to shift to the community, but what is the capacity between the agency and the services. Okay, let's do that. Let's take it out here but then I see Mike Fisher, but you can remind us where you think you might insert it will also So now, it's not a bad idea is just it's not, it doesn't feel timely for everything else in the bill. And there are a lot of people who are ahead of this so a lot of people are ready to do all this but Okay, so then we get to section three section three is the result of the work between Ena and Robin after this committee during yesterday. And this is so it's now called the development of development of proposal for subsequent all payer model agreement and it includes an appropriation. The director of health care reform and AHS in collaboration with the Green Mountain care board and I think in earlier versions, there's been consultation happening and you talked with them yesterday about who's driving things. So in this case the director of health care reformers name first but it's a collaboration with the Green Mountain care board. And they're directed to design and develop a proposal for a subsequent agreement with Sam and I to secure Medicare's continued participation in multi care alternative payment models in Vermont. The proposal shall be informed by the community and provider groups of process that for conception two of this act so that's where I wanted to reference. And delivery system transformation work and designed to reduce efficiencies lower costs improve population health outcomes and increase access to essential services and that's language that is used in that section to the design and development of the proposal shall include consideration of alternative payment and delivery system approaches for hospital services and community based providers, such as primary care providers, mental health providers, substance use disorder treatment providers, skilled nursing facilities, home health agencies and providers of long term services and supports. It says the alternative payment models to be explored must include at a minimum global payments from hospitals, geographically or regionally based global budgets for health care services, existing federal value based payment models, and broader total cost of care and risk sharing models to address patient migration patterns across systems of care. It also says the alternative payment models must include appropriate mechanisms to convert fee for service reimbursements to predictable payments for multiple provider types, including those described in subdivision to the production phase that was the list of such as primary care, mental health etc. Include a process to ensure reasonable and adequate rates of payment and reasonable and predictable schedule for rate updates and meaningfully impact health equity and address inequities in terms of access quality and health outcomes and the design and development of a proposed agreement with CMMI for Medicare's participation in multi care initiatives, which may include engaging consulting and analytic support. The following steps are appropriated from the general fund in FY 2023. And it's 550,000 to the agency of Human Services and 550,000 to the Green Mountain Care Board. This is taking the 500,000 that had been allotted for other purposes in the bill and the 600,000 that was the board had requested for their work on the Medicare. And it's combining those and then splitting them in half. So that was the idea that Senator Hardy mentioned yesterday and that looks like what they have agreed to. And we know that this, you know, it's going to approach, but they agree to it at this point. That they have, they sent the language. Yeah, this is, this is their language. Yeah, it worked hard yesterday. Did you have a question? No one has to. Before Jen was on to the next section. I'm ready to move on. I don't know if they're ready to move on. Yeah, no. So I never got an answer to whether the $500,000 is the right, this section four. Yes. I never got an answer as to whether the $500,000 for HIV strategy. Actually, I think that comes out. I think that comes out and gets excluded and I didn't think about that, but I think, thanks. Yes. We're almost half of what makes up the, the 1.1, they get split up in section three. So I think that it's just, yeah, gone. And I just realized me as the fellow green house fell on the floor that I make me their course. Let me know when it's up. All right. So, so section four. Would just be wouldn't be set section a would just be the language that was that section a with the HID steering committee continuing this work to create one health record for each person that integrates various data types as described. And included a data integration strategy in the 23rd 2023 HID strategic plan to merge and consolidate claims data in the years with clinical data and health information exchange and then the appropriation would come out. Section five is the language that we looked at. A bit yesterday around the cures and taking out the prohibition on information being filed with the board in a manner that discloses the identity of the protected person patient. I did not make any changes there. Section 167 on the blueprint. Section six, I did not make any changes. This is reflecting the years of quality improvement facilitators in the blueprint. Section seven, it did make some changes based on some recommendations from there's a question from the Jessica Barnard at the medical society. This is where the director of health care reform is reporting we're recommending by September 1st, the amounts by which health insurers and Medicaid should increase the amount of the per person per month payments. They make sure to share cost operating blueprint to health teams and quality improvement facilitators. And then I changed your wording a little bit, but it would say to contribute to the goal of increasing each plan or payer spending on primary care over time. Until primary care and then we get away from this 12% concept until primary care reimbursement is sufficient to reflect the costs of providing comprehensive primary care services for monitors, and to sustain access to primary care services. And then we got a recommendation from American moment by state again this morning suggesting instead to change the language so that it would say recommend the amounts by which health insurers and Medicaid should increase the amount of the person from payments they made towards the share of cost of operating. The blueprint community health teams and quality improvement facilitators to contribute to the goal of increasing result consistent and increasing each plan or payers, spending on primary care over time to add additional resources for providing comprehensive primary care services to managers and to sustain access to primary care so she's instead of getting quite a specific about increasing the reinforcement amounts. She's talking about adding additional resources. It actually makes more sense considering what is being the purpose of the payments are not reimbursement for say they are adding resources to the primary care practices to provide the services the community health team and and quality improvement facilitators so they're not they're not really reimbursement in the kind of fee for service sense they are decreasing the resources. For me, it may be that this that the language we have allows the resources. Well, I think I think the language that is in the bill as I'm kind of thinking through Medicaid proposal here. I think the language is in the bill right now talks about increasing information payment. Payments that you're going to the goal of increasing spending on primary care over time until primary care reimbursement is sufficient to reflect the costs, but it's not really. It's not going to the rates. It's not going into reimbursement rates that these additional per person performance payments. So I think Mary Kate's idea of framing them as adding resources probably more reflective of reality then. So what do we think committee I mean that that does make sense but. I am on sort of jumping between 17 and 21. Just as far as a lot of a event well so. So she so Mary Kate's language would strike out after over time. So it would, it would take out until primary care and reimbursement is sufficient to reflect the costs of, and she would instead have it say, after over time to add additional resources necessary for providing comprehensive. I think it comes up. Yeah, yeah, exactly. I think that's a good way of saying it. Yes, it's adding up front. Yeah, to be able to provide services beyond just what they would ordinarily be going for. Okay, the care coordination. That makes sense. Okay. All right, good. Right. More things here section eight is the options for extending moderates supports. And most of this is as we have looked at it it's the working group, considering a number of things around. The working group supports and how whether and how to extend those Patrick had recommended and you were interested in the working group also looking at dual eligible and so I had it and because it doesn't necessarily flow out of the, the moderates I put it as its own subsection that the working group. She also made recommendations regarding changes to service delivery for persons who are duly eligible for Medicaid and Medicare in order to improve care, expand options and reduce unnecessary cost shifting and duplication. And for see I'm just going to run through all of these and see I specifically called out that's the part where the department collaborates with others in a chess to incorporate the working groups recommendations into the proposals and negotiations for that next next little commitment demonstration and so I clarified that that was specifically about the moderate needs group so that wasn't in Patrick had said and put those into the waiver and you had wanted to hear about them first. So, this is directing then just that they incorporate the working groups recommendations on extending access to long term home and community based services and supports into the proposals and negotiations for the next next demonstration. And then indeed, where they're recording, they would report on both. So they would report their working groups findings and recommendations, including its recommendations regarding service delivery for duly eligible individuals and an estimate of any funding that we needed to implement. And then it had said those because it was all about the moderate needs group, but now it's the working group recommendations. Okay. And that is it for changes. All right. Any, any of any of the changes that you were looking at that you wanted to address the committee first. I would like to remind you again, what changes have made to what is requested to what it's in front of you that I will put in the draft. Mike, did you want to comment. Jen may be about to cover this. I was looking for my Fisher healthcare advocate clarification about whether you're looking for language in this draft about the concept that I think Patrick puts forward that. That needs assessment be done process. This process include a recognition of the is our place to put that. I think there is I think when we are and I don't know if that's the community engagement process level or at a broader level. But I think it's a good question. I think it's a good question. What's happening with that in the community engagement process. I mean, it probably clearly pick up a lot of information about that. Right. This is really more of an administrative tasks that would happen. Prior to. Well, right. I mean, it's a, it sounds like at least as a, as a beginning step, you are interested in this process. So I think it's a good question. And I think that's a good question. I think it's a good question. I think it's a good question. I think they don't design a plan for something that is completely unworkable in our. Yes. Community provider system. Yes. And so. So reflect that. So a lot of this is focusing on the patient focused community inclusive. Plan. But I think maybe we could put in a. A loan. Subsection. It says. And doing this work. They need to be. Mindful of the capacity. I think that's a good question. I think that's a good question. And I think that's a good question. I think that's a good question. I think that's a good question. I think that's a good question. I think that's a good question. I agree. And then my father. My second clarification. Were we thinking there was a chair thinking that a definition. Value based along the. This bill where separate. Well, if we could, if we had something, we would put it in, but I'm not, you know, that's not something I would personally like to have my own. But. And, but it will, there will be time to put it into the bill as it goes forward. You know, I don't think we want to, we don't have to do that. Now. So. That works twice in two days. Are there other things you want to. Discuss about the changes before I go through and tell you what I think I have. I think I'm marching orders are. Yeah. I'll go ahead. Okay. So potentially looking for a definition of value based payments to add in section one. Section two. Adding what I think will be a new subsection C. About being mindful of the. Community based provider system and whatever we designed. Plan emerges. Taking out the standalone subsection on. On a report back on the funding necessary for the community based. Health care and social service providers to implement the plan. Then the next change would come on page. Okay. Okay. I'm just taking out the money. For the HIV work because that money is being used elsewhere. On page. 12 under the blueprint. Making the change that Mary. Moment had suggested. So reflect the impact of those increased. That was good. Perfect. Yeah. Hey, you. And. Just got a message. They were looking for a federal definition of value based care. I think it's value based care so much value based payments. So when they have to. They have to circle back with her. But hopefully we'll be able to find you. So. We are. We're pumpkin. I know you are. So I'm wondering. I see Katie is here. I'm wondering. Yeah. I'm getting ready. Right. I'm getting ready to have a bill. Yeah. You are $5 million. Pardon me. No, you're at $5 million. Five million of this one. So far. So I'm going to go. To the sent to the house floor and listen to my bill. And use my laptop to make these changes. And. Yeah. Yeah. Yeah. I'm not sure. You know, he is very. Like the roll call. Yeah. Aren't I? You don't have to give it to him. He keeps it in the official records. Okay. So if there's any question about the vote. That's the official back. Just making sure I wasn't supposed to go to the. Yeah. The reporter. Of the bill. You're just going to nervous. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah.