 Why don't we start by introducing, having Nina Bacchus introduce you as the Director of Healthcare Reform, but welcome you to introduce yourself. And I believe this is the first you've been with our committee since we started, or am I? Yes. So, let's do again, I realize for members, new members, this is a repeated effort, but it's useful for, particularly for our new, for witnesses when they come to, before our committee for the first time. And some of us are, are, are known to the witnesses, but would represent black, would you introduce yourself and then pass it on the way we've done. It's worked very well. So, thank you. Hi, Alyssa Black, I live in Essex, and I represent Chittin' in 83, and I will pass to Representative Peterson. Yeah. Yes. I'm Mark Peterson. I live in the town of Clarendon, I represent Rutland District 2. I'll pass it on to Representative Burroughs. Good morning. I'm Elizabeth Burroughs. I live in West Windsor, and I represent Windsor 1, which is Heartland, West Windsor and Windsor. And I'll pass it to Representative Goldman. Hi, I'm Leslie Goldman. I live in Rockingham, and I represent Windsor. You, I think we heard most of that. You went on mute, Leslie, partway through your, oh, sorry, I represent Windham 3. Okay. Thank you. Well, again, welcome, Ina Bacchus, Director of Healthcare Reform. So I'm going to ask you to introduce yourself and perhaps share some of your own background as well. So glad to have you here. And Ina's going to give us a overview history of healthcare reform in Vermont, which I think helps set some context for much of what we're working on and thinking about. Thank you. Good morning. My name is Ina Bacchus. I'm the Director of Healthcare Reform in the Agency of Human Services. I've been in this role since June of 2018. The role is prescribed by statute as one that is responsible for coordinating healthcare reform activities across state agencies and with the Green Mountain Care Board. And of course, within the Agency of Human Services, which has six departments, there is a coordination function within the Agency as well when it comes to healthcare reform. Prior to my work in this role, I worked at the Green Mountain Care Board and so have familiarity with the Green Mountain Care Board and its regulatory role in the state of Vermont with respect to the healthcare system. I grew up in Bristol. I graduated from Mount Abraham Union High School. I will go ahead and share my screen now if it's okay with everyone. Everyone able to see? Yes. Wonderful. Thank you. As Chair Lippert described, my presentation is intended to provide some background on healthcare reform, history of healthcare reform in Vermont, and then to focus on, at a basic level, an overview of one of the active healthcare reforms that we have ongoing today that you may be familiar with, the Vermont All-Payer Accountable Care Organization Agreement. And so the materials here are certainly intended to give an overview, but they do not provide deep dive into any particular aspect, and I am happy to do that in the future. I'll defer to the Chair on questions, but it is okay with me if you want to interject questions certainly as I go along. So as I said, I'm going to give an overview and some history about healthcare reform initiatives in Vermont and thinking about healthcare reform and healthcare policy and the questions it raises for us in the state of Vermont and in the United States overall, and talk a little bit about or somewhat about the All-Payer Accountable Care Organization model agreement to give an introduction to it, and of course as it relates to prior and ongoing healthcare reform activity in our state. And I would just ask members to use the raise hand function if you have questions, and I will call on people as best I can throughout the presentation. I'd like to ground any conversation about health policy and healthcare reform initiatives in some key information about health in the United States as well as in our state of Vermont. We do live in a country that spends more money on healthcare than any other country in the world, and yet that spending is not necessarily delivering better outcomes and better health status for our populace. Unfortunately, the life expectancy, a key indicator of health in the United States, we trailed behind other developed nations, and we specifically see our life expectancy impacted in particular over recent years by deaths due to suicide and drug overdose and alcohol related deaths that do have very much medical healthcare components. In Vermont, we are not different in entirety, although we are different in some very good ways from the rest of the United States, but in Vermont, healthcare spending is also a considerable concern for us in that healthcare spending on the behalf of Vermont residents was $6.3 billion in 2018, which is the most recent year that we have data available, and our healthcare spending as a share of gross state products in that same year was more than 18%. And that is somewhat more than the healthcare spending as a share of the gross domestic product for our nation. I do think it's important to note that Vermont likely is providing for some healthcare spending on programs and services that are more generous than other states and maybe contributing to some better outcomes that we do see while we have room for improvement on health outcomes in Vermont, and we certainly have room for improvement in terms of curbing healthcare cost growth. We also consistently rank among the top of states for health, healthiest states in the nation, and I also want to celebrate that we have had a response to our public health emergency in the state of Vermont that has, I think, reflected some of the investments that we have made in our healthcare and public health infrastructure in the state of Vermont. When we talk about healthcare reform, we're talking, as I just described, about a large system. It's a complex system that's governed both by state policy as well as federal policy, and our healthcare system in the United States is one that is both public and private, which adds complexity to what we discuss. And so there are a number of key questions that I think are really important to frame any discussion about healthcare and healthcare reform initiatives, and those questions really center around what is the problem that you are trying to solve with any initiative. And there are problems regarding healthcare financing that are often healthcare reform initiatives. That means, how are we collecting the money that we use to pay for healthcare? How is that money being collected? And the financing of healthcare offered through different program designs. Healthcare coverage questions, do citizens have access to healthcare coverage? Are there barriers to healthcare coverage? Are there policies in place that impede healthcare coverage in any number of ways? There are also problems in our healthcare system related to cost, as we just discussed. We have a very expensive healthcare system. And so healthcare spending growth is a key area for health policy to be providing for reform initiatives. And the questions that we can think about in particular to healthcare spending growth are, what's contributing to that growth? How do we pay for healthcare? How are healthcare providers reimbursed? And how does that payment and reimbursement structure potentially contribute to healthcare spending growth? Another key contributor to healthcare spending growth is simply what is the price or the cost of these healthcare services? And is the combination of price and utilization that drives overall healthcare spending growth? And finally, there are many, many problems to confront in our healthcare system. And that also includes how care is delivered, how people experience the care available in our healthcare system, and the quality of the care that is provided through the healthcare system. And so with those questions in mind, I wanted to walk through some key healthcare reform initiatives that Vermont has undertaken going back all the way to 1989. This is not by any means an exhaustive list or a comprehensive list of Vermont healthcare reform initiatives. This list is meant to be illustrative of some different types of healthcare reform problems that we have confronted in the state with different policy initiatives and to give some context through time for where we are today in terms of implementing what is called the All-Payer Accountable Care Organization Model Agreement. And that agreement is certainly building on some of these key reforms that we've endeavored over time to implement here in the state of Vermont. And in this chart, I also paired the reform initiative with kind of a designation of the problem that that particular initiative was trying to confront in the healthcare system. And then the final column that's all the way on the right in this chart, and I know that there's a lot of information here and I am going to talk through it, that column indicates whether the initiative was later undertaken through the Affordable Care Act. The Affordable Care Act is still very much a turning point in federal healthcare policy that continues to inform and undergird our healthcare system in Vermont today. And that happened in 2010 that the Affordable Care Act was passed and we are still very active in implementation of that. And I think it's interesting to point out where Vermont was quite a bit ahead of the Affordable Care Act in some of the problems that it was looking to solve through health policy. So now I'll walk through the chart. In 1989, Vermont created the Dr. Dinosaur Program, which was a state funded program to increase coverage for pregnant women and children. And this program was both confronting a financing problem, how do you collect money and then provide for coverage for this particular group and then also a coverage problem was being addressed with this initiative? As I think you can appreciate, we all understand that prenatal care and early childhood care is extremely important for getting our children in our state off to a good start and to ensuring health and well-being through the lifespan. And so there's a seminal coverage program there in 1989. In 1992, the state of Vermont created marketplace reforms for persons who are purchasing insurance in the private insurance marketplace. And these reforms included guaranteed issue so that persons could access coverage even if they had had change in circumstance or other changes and that that coverage be community rated. Community rating meaning that the coverage cost, if you will, was consistent regardless of age or particular circumstance. And that is something that we see later on as reforms that come into play through the Affordable Care Act much later on at a national level in 2010. In 1992, also, Vermont developed a hospital budget oversight program and certificate of need law both to regulate spending by hospitals in our state as well as to provide for a process to review whether or not a healthcare facility was healthcare facilities coming into the state or looking to open in the state were necessary and appropriate in light of the care being offered in the state of Vermont already and the existing accessibility of care. I think the certificate of need law is a very fascinating process in that it both seeks to ensure that care that's being offered in the state is appropriate and the other side of that coin is, of course, that we want to have care be accessible to Vermonters and there are cases certainly very much so where need is demonstrated for additional healthcare facilities and services that they can provide. In 1995, that was a spending problem that those reforms were trying to address. How do we moderate healthcare spending in the state through budget oversight and regulation of healthcare entities looking to be active in 1995 through an 1115 waiver which is a Medicaid waiver because Medicaid is a federal and state program, a program that's offered in partnership between the federal government and states and when states want to customize how that program works in the state, it needs to secure a waiver and often times 1115 waivers are a key vehicle for states to customize how the Medicaid program works in their state and so Vermont through 1115 in 1995 looked to use its 1115 waiver to facilitate healthcare coverage for low income and child with adult, something that the federal Medicaid program did not allow for but later on again in the Affordable Care Act that that federal program was expanded to allow for the new adult group to receive coverage. In 2005, also through a Medicaid waiver, Vermont enshrined coverage for community-based long-term care services and supports as a part of its Medicaid program and here solving both a coverage and a delivery system problem or approaching both the coverage and delivery system issue meaning that Vermonters who qualified to receive supports and services in their homes rather than only in facilities and so the Medicaid coverage could be provided for Vermonters to receive these supports that enables them to stay home and to stay independent and to avoid more costly institutional-based care when they need ongoing support. In 2006, the global commitment waiver which is an 1115 waiver, it's a broad and sweeping 1115 waiver that encompasses multiple program waivers into one and is still active today in our state. It created the Catamount for Health program that the Catamount for Health program no longer exists today but was created in part with the global commitment waiver which allowed the Catamount Health program to be created and to address a problem for individuals purchasing insurance and to help create a program of private insurance that could be accessible for Vermonters both looking to solve a financing and coverage issue. In 2006, the blueprint for Health patient-centered medical home model was created and also facilitated in part by the investments that the state was allowed to make because of our global commitment to health waiver that helped the blueprint to get off the ground. The blueprint again is a program that supports the patient-centered medical home model so that means it supports a model of high quality primary care for Vermonters. It invests with additional payment for those high quality providers. Those providers do need to meet national standards for quality of care and then the blueprint for health in addition invests in and funds in part community health teams that are connected to the primary care practices and provide for additional support and care coordination across a continuum of health care services allowing primary care providers a way to address concerns for their for their patients that may be beyond their immediate sphere of influence in the primary care practice alone and the community health team model really extends into social supports and services beyond simply the medical care model. The blueprint for health again very much active today and this emphasis that it has provided for a statewide model of high quality primary care really positions Vermont to be able to move into more to be able to advance in its health care reform approach particularly if and I'll and I'll and I'll talk more about this as I go through the presentation particularly if that approach is advancing to one that is really going to emphasize prevention and health promotion which those those things rely on a strong primary care system. In 2011 act 48 was passed in the state of Vermont and created it created a publicly financed universal health care program which was to be implemented only after the general assembly enacted further law to finance the program and as you are familiar the financing plan for that program was was not one that was viable given given the cost of a publicly financed health care system and so that that portion of act 48 did not move beyond a point in time where it was determined that the financing for the program was not feasible however act 48 also created the Green Mountain Care Board which is a regular regulatory entity and you'll hear from them I think you maybe already did this morning so I apologize for repetition they have a broad number of regulatory authorities that that are important for reducing the rate of growth in health care expenditures and improving quality and those authorities that the Green Mountain Care Board have do include and did include testing payment reform models that would influence and reduce the rate of growth in health care costs and those there was a emphasis on those models being all payer meaning all major payer categories and again in the United States we have we do have a complicated health care system in that we have a fully federal program which is our Medicare program that offers coverage for for individuals who are older than the age of 65 we have a state federal partnership which is the Medicaid program offering historically what has been coverage for low income individuals and then we have commercial health care insurance coverage which is offered by employers in in in our state and in the United States and it can also be purchased by individuals directly and that is where it historically in Vermont we have made policy changes such as cat amount health to make accessible coverage for individuals and then in with the Affordable Care Act the Affordable Care Act also created the healthcare marketplaces and in 2011 Vermont created the health benefit exchange to align with the Affordable Care Act to create a marketplace for the insurance for the purchase of insurance for individuals and small groups it's a regulated marketplace that complies with the federal program consumers can shop for and compare health care plans those health care plans that are offered on the marketplace are comparable in design and are all built on a essential health benefit or benchmark plan so they have consistent offerings across the plan types and through the Affordable Care Act considerable federal subsidies for the purchase of health insurance in the regulated marketplaces became available to Vermonters and that and so that obviated the need for the for the cat amount health program and we transitioned to operating the Vermont health benefit exchange as the health insurance marketplace and and those again so those subsidies coming to the state of Vermont were more than what the state on its own had been able to make available for the purchase of private insurance in 2013 the haven spoke model was created in partnership between the blueprint for health supporting spoke practices and those are our practices largely but not exclusively primary care providers that are able to offer medication assisted treatment to persons who are managing in their recovery from opioid use disorder and those folks work with hubs that are designated methadone distribution and treatment facilities in the state of Vermont so building on the building on the infrastructure of the blueprint for health which has the availability of the community health teams and a network of support for providers who are offering medication assisted treatment in their practice and that's that is a delivery system problem that this initiative in particular was looking to address in in that there there was not a clear there was not a a system of treatment readily available to persons who were who were seeking recovery from opioid use disorder use disorder so how and so it approached how can the health care delivery system change in design to meet the need of persons who are managing recovery from opioid use disorder I'm just going to try to move the bar here so I can read the next so I can read the next initiative 2016 act 113 was was provided for by the legislature and this legislation allowed the green mountain care board and the agency of administration to enter into an agreement with cms to implement an all-payer model I noted that the green mountain care board was um created by act 48 and did need to focus on cost containment um as a part of the health care reform the sweeping health care reform um that act 48 that act 48 put into motion those cost contained that cost containment work was um was emphasized as being necessary to focus on all payers so that as much alignment and consistency as possible could be um put into play for the health care provider system that would be potentially receiving payment differently and changing delivery system and to do that most successfully um having those incentives aligned across the payer types as much as possible is very important so that and while this is it it still remains the case today there are different rules uh from different coverage um offerings that the health care providers need to adapt to and they need to be able to maintain a fairly complex business model to be responsive to the different payer types that we have in our system the focus of all payer reforms is to try acknowledging that we have multiple payers in the system and multiple payer types to try to align rules requirements um and incentives as much as possible across those different payer types and with that to um reduce administrative burden of course uh is is a purpose in that alignment but also again to um strengthen any incentive from a payment change um or or delivery system model uh so the the ACO uh the all payer ACO model agreement again emphasizing all payers but also emphasizing that accountable care organizations where providers are working together uh in a network to share accountability um for the quality and outcomes and the cost of a group of patients that those accountable care organizations in the state of Vermont uh would be the entities um for for a focus on a change in payment and also would be regulated by the Green Mountain Care Board would have standards that those accountable care organizations would need to meet in order to uh work in the state of Vermont as well as um the subject to the budget review uh by the Green Mountain Care Board and you've probably heard some of this from them today already or you will hear more um and and this act also required that the agency of human services establish a process for integrating Medicaid providers and services into payment and delivery system reform and this is a large body of work that the department of Vermont health access um has undertaken and can also do a deep dive with you on if you're interested in learning more about that and finally in 2019 um I wanted to highlight that Act 63 established um protections for Vermont consumers that are consistently those protections um many protections afforded by the by the Affordable Care Act um and and and those those protections are preserved um here in the state of Vermont due to this legislation um so that if the Affordable Care Act were to uh were to be significantly changed certain key provisions associated with health care coverage would remain um such as being able to remain on your parents insurance if you're up to 26 years of age I will I will take a a breath there or or I can continue on well let me say that I I appreciate your your outline of these uh reform efforts and the uh effort and the aligning it with what were the problems of being solved and how things prior to the Affordable Care Act uh were already being put in place uh in Vermont uh and it's notable that that at the 2010 it's it's hard to remember that it was 2010 when the Affordable Care Act uh was first put in place um I should I I'm pulled to I'm just gonna make one further comment uh number of people have said to me I've asked about what the work of this committee has been and uh the Act 113 and Act 63 uh certainly have been the recent work of this committee uh at least during the tenure of some of us who are continuing on the committee and I've you know I've I've said I've been quoted as saying that uh it's uh this committee worked very hard to defend to protect for monitors from what were active in my view they weren't I think it's fair to characterize the attempts to get rid of the Affordable Care Act through either repeal of the act or through the courts and Act 63 as you've outlined in 2019 was a very uh deliberate and determined effort on the part of the Vermont Legislature and then with the Governor's support and with the Administration's support to move into Vermont law as you said a number of the provisions of the Affordable Care Act in the event that during that period when it was actively being um sought to be overturned at the federal level so but they continue to be I think important in Vermont law there's a lot of there's a lot of information here and some of it's historical but but a great deal of what is outlined here is very useful in understanding how we've gotten from where we have been to where we are currently and what currently exists. Now I'll take a little bit of a deeper dive into Act 48 as it was the legislation that put some of the key the key components of our system that we have today into place and also prompted through that legislation certain approaches to health care health care reform and health care policy as I said the Act 48 created the Green Mountain Care Board and provided for it some key some key pieces of work including cost containment as I said all payer payment reform also oversight of workforce development and many aspects of health policy were were provided for in Act 48 in terms of the Green Mountain Care Board and as I also detailed Act 48 created the Vermont health benefit exchange which then today provides for the state to meet with the requirements of the Affordable Care Act and so that we can take advantage of the federal subsidies for Vermonters in individuals that are purchasing health care coverage and finally as I said Act 48 did create the detailed planning process for Green Mountain Care and provided for the steps that needed to be achieved in order for that to be implemented and as I described it was with the financing plan for Green Mountain Care that it was determined it was not feasible to continue moving forward with what was known as single payer but I think the Act actually described it as a universal and unified health care payment system. I also wanted to just mention that in 2013 we received the state of Vermont received a state innovation model grant that's that model grant was available to the state of Vermont through the Center for Medicare and Medicaid Innovation that's the same entity that we now have our all payer accountable care organization agreement with and it was created by the Affordable Care Act very specifically to promote new payment models to promote multi-payer payment models and to allow Medicare they often call you know their special the special sauce of the of the Center for Medicare and Medicaid Innovation is that it can bring Medicare to the table as an innovative payer in a way that wasn't possible prior to the ACA as and so the Innovation Center provided states with grants for testing innovative payment and delivery system reform models Vermont was a recipient of the first of the first wave of grants and received 45 million dollars over three years beginning in 2013 those those dollars were used in a in a whole host of ways as you might imagine but included investments in planning stakeholder engagement contractual expertise and significant analysis to determine to determine the best course in terms of an approach to healthcare cost growth containment through payment and delivery system change so it's definitely informative for some some key policy some key policy models that that we are still implementing today this this slide here is actually a slide that was created in 2013 and is still incredibly relevant and descriptive of what we are endeavoring to do in the state of Vermont in terms of healthcare reform to impact both cost growth in our state as well as quality quality of care going back to that slide that I talked about at the very what problem are we trying to solve we are very active in our in our current policy in trying to solve and address the growth of healthcare costs as well as the quality and patient experience of care in in Vermont so I want to emphasize that again that our current current healthcare reform initiative that is called the all-payer accountable care organization model is a cost containment and delivery system redesign effort it's not a coverage model it's not an insurance product it is not it is not a healthcare coverage vehicle and so it is not trying to solve that problem of who is accessing healthcare coverage specifically in our state and again this slide from 2013 really emphasizes emphasizes a path that that was set out on and that we are still working on today to move our system away from fee-for-service reimbursement which I'll talk about a little bit more in just in just the next slide to build on the strong infrastructure that was put in place by the statewide blueprint for health primary care medical home model supported by community health teams emphasizing primary prevention and health promotion and that this model include all payers again for it to to have the strongest possible incentive for change because the incentives are aligned across all payers all payers are saying these are our priorities there aren't competing priorities among payers we have we have more work to do on that front we certainly and we have identified where we can improve on that front but we are but we are working with all payers at the table all major payer types and finally that any any move away from fee-for-service and delivery system redesign should absolutely incorporate performance measures for cost quality and patient experience of care which our model today does in fact do so in terms of addressing healthcare spending growth and the the moderating healthcare cost growth in our state and we need to change how we pay for and deliver care healthcare in the united states and in vermouth has predominantly been paid for through a fee-for-service reimbursement model that means that every service that is deemed to be a covered service so it is typically a healthcare service that is performed such as a test an image an exam an assessment those types of services are reimbursed and paid for regardless of the quantity of those services delivered regardless of the outcomes from those services regardless of whether or not that is the most appropriate service um for a person's need uh other other healthcare services um that may not have been or may not historically be considered healthcare services such as time spent coordinating care making phone calls um follow up uh follow up between providers uh providers seeking consultation from one another um providers communicating to the care team those sorts of activities that very much influence health and outcomes are not typically reimbursed by the fee-for-service system or if they are reimbursed they're not reimbursed in a way um that emphasizes that sort of care coordination activity over um a more uh high high yield service such as an image or um such as a such as an image or visit um and because of this model of reimbursement which again is the predominant model for our healthcare system um we we see that uh healthcare outcomes aren't aren't not necessarily um as good as they should be um we see a system that uh where there is a lot of utilization of healthcare services um without necessarily that utilization being clearly linked uh to the best possible outcomes so the the theory is that providing a budget for the healthcare system um paying the healthcare system prospectively um based on what is uh expected to be a reasonable a reasonable cost to deliver services allows the system to operate with more flexibility allows the system to invest in services and supports that may like I said not otherwise be uh reimbursed and provides predictability for the system um and uh predictability for for the system within the budget if the system manages more efficiently while still delivering high quality healthcare outcomes then the system can keep can keep those savings so to speak so there is an incentive um to perform in the most efficient possible way to provide the best possible health outcomes rather than uh simply being reimbursed for each additional service regardless of the health outcome and that is really the premise of the payment model that we are implementing through the all-payer accountable care organization model agreement which is an agreement between the state of Vermont and the Center for Medicare and Medicaid Innovation that I talked about just a few minutes ago and this is the logic model that describes um what I just what I what I just reviewed with you that we will test um paying for healthcare differently that that dip change and payment will allow for transformation in care delivery because of the flexibility to invest in care coordination and social determinants of health and then um from there we uh we emphasize the importance of seeing improved population health outcomes and focusing on improving access to primary care reducing deaths due to suicide and drug overdose and reducing the prevalence and morbidity of chronic disease in in our state which should should I pause or should I keep on going I think it might be good to pause and see if there are particular questions and you we've had you going on stop now for a good hour uh or not quite an hour but um let's see if there are particular questions and I see there's at least one from Representative Cordes and then uh and then we'll we'll come back and finish up and know that we're going to be coming back to the all-payer model uh issues uh in significantly more um depth uh tomorrow so Representative Cordes you have a question yeah thank you um and thank you Ina it's good to see you and hear from you again um I have a comment and then um one possibly two questions about act 48 I just wanted to highlight that um I know you were talking specifically about technical policy within act 48 but I wanted to mention as well that we are still striving um to manifest or make real the the human rights principles that were also embedded in in act 48 of universality equity participation transparency and accountability um so just wanted to put a a plug in there for those five human rights principles which um I think were a really important part of act 48 um as far as the all-payer model um you know what would you say is are some of the biggest obstacles um in that program including um is one of them getting providers um to participate how are we doing with that in November um and I'll and I will I will touch on this but I'm happy to to talk about it now as well but in November of 2020 the agency of human services um given that we are in now performance year four we're beginning performance year four of a five-year performance period in the all-payer model agreement we we put forth um what's called implementation improvement plan or reboot it's also been described as a reboot for our model agreement because at this time we can see where there are areas for improvement in our performance um we do know that uh more payer participation is necessary um to to test the theory of the case if you will that if we align incentives across as many payers as as is feasible that the um providers who are uh transforming care delivery um and and are working under this changed payment model will um both have a have uh have it easier time doing that because there are consistent um there's a consistent emphasis across the payers that are covering Vermonters um uh but also that the incentive and and the need to change the business model from one that drives um utilization and I mean that for the system I don't mean any one provider but I mean that the system drives utilization in this way um that we know that there's more of work to do um to really test that and so we put forth uh recommendations which I think I would like if you're interested to come back and do a deep dive into those recommendations even tomorrow it's and and really uh highlight uh where we think um we need to make some improvement in order to perform better in this agreement one one thing to highlight is that the state employees um were not attributed to this model um as as a group um the state employees are self-funded um with Blue Cross Blue Shield as the administrator of the state employee health plan um but the state employees will be and are being attributed now for 2021 so that's just one example of a large group of commercially ensured that we're not participating in the model and now we'll be participating in the model and it's improvements like that uh that we need uh to continue working working towards thank you Ina and I have another question that I can say for tomorrow because I think it might relate to your presentation tomorrow thank you yeah yeah I think I think that's let's let's um if we can try to save all-payer model in-depth questions for tomorrow we've asked I've asked the I've asked for us to be given an update on the reboot uh as part of it the presentation tomorrow so we'll hear more about that uh than as well uh I'm gonna just I see Representative Goldman has a question I want to just pick up on something that you just touched on Ina and I was thinking about earlier and that is uh who can we in fact affect in our health care reform efforts uh in Vermont and both as the Green Mountain Care Board was presenting earlier this morning I I found myself wanting to ask and to say that um there are certain it gets complicated or it seems complex as in terms of uh self-funded plans uh being uh in or not available being outside of the uh purview of the state of Vermont's uh a lot of our legislative efforts and uh could you talk a little bit about that and how that relates to health care reform who who were able to influence and where we're where we have limitations because of the uh what's called a RISA plans or and if that's technically right but the self-funded lawyer plans yeah those those self-funded plans are governed by uh by federal by federal law and that federal law basically says that those those plans um uh because they could cross state lines and be offered in multiple states are not subject to um state state regulation because that would be too burdensome to be subject to multiple states uh regulation um I believe is the premise of that of that federal law and so those plans are not subject to um the the state regulation of insurance um in the same way that the insurance um the the fully insured um are our subject and so that would be um large group plans in Vermont that are fully insured uh are subject to regulation as well as those plans that are offered on the exchange where someone is you're you're purchasing full insurance um from from a plan on the exchange um you are not paying your own insurance claims so you're you're purchasing an insurance product um those are subject to state insurance regulation and so there is different purview over those types of insurance offering than those offering um where a large group such as the state employees in Vermont the state and in many other places but the state employees paid their own claims they are their own insurer um rather than purchasing insurance from uh the cross-blueture for instance becomes important for us over time to understand what those limitations are and are not um representative Goldman you have question still no representative court has asked my question thank you okay representative black um regarding blueprint is blueprint for health still working and I mean it seems as though blueprint is sort of overlapping a little bit now with um the AC are the um ACO or are are they working in collaboration with each other good question yeah that's a that is a great question um the the blueprint for health and the and the um care coordination model with um the with the accountable care organization and they they are working in alignment um and and so the patient center medical home model is is still supported through the blueprint for health program likewise the community health team supported through the blueprint for health program but they are working in close coordination and alignment with the accountable care organization one care of Vermont and its care coordination program and resources which provides for risk stratification of their members so that they can identify um where those members needs with respect to care coordination and services and also um where one care of Vermont and I'm sure that um you might appreciate the opportunity for them to talk more about what what they offer but it um it is it is an alignment with the blueprint for health it's important that we keep alignment as as a central principle of the reform initiative and that as we continue to move forward and perhaps expand um in care coordination services that we remain aligned um with one care of Vermont in those in those efforts but there has been really good collaborative work done uh to align but just to clarify something you just said did you say that blueprint is actually who calculates the risk of of no you know and attributed people no no one care one care of Vermont um okay yes okay sorry I thought I missed her I thought I heard you say that and you know can I pick up on that and just am I correct in understanding that the blueprint for health was uh in part funded under an earlier 1115 waiver and was not going to be able to be continued uh but was able to be continued as a part of the all payer model is that do I misunderstand that or help me under help us clarify that I can help clarify that and um in in a later slide I'll touch I touch on it but I think I can expand on it even more so now the blueprint for health is a multi payer program and so another reason why it's a really important foundation for moving more aggressively away from fee per service the blueprint for health program um has participation um from commercial payers in the state of Vermont as well as Vermont's Medicaid program and previously Medicare um they ran what was called um uh Medicare advanced um primary care primary care program primary care practice uh initiative and that was what that predated the affordable care act and what was called a Medicare demonstration project um and so it was through that Medicare demonstration project that the blueprint really became an all payer uh program and that Medicare demonstration project however was going to be discontinued um at the end of 2016 and so when we negotiated with our federal partners in the center for Medicare and Medicaid innovation they agreed that a strong primary care system that a system that was supported with community health scheme uh and care coordination supports was very important for a statewide health care system that was shifting towards risk for health care providers meaning paying providers up front uh with a set budget for care it's the most basic kind of explanation of um where we want to go with the all payer model agreement and where we are in our Medicaid program now um if you pay providers up front a fixed amount then they are at risk for how they perform within that fixed amount and the providers um and the care delivery system ultimately needs to uh perform and be designed to provide for the most efficient care in the most efficient settings uh to to to ensure the best quality outcomes for Vermonters so our partners in the federal government said it is worth Medicare investing in that foundation um and we will continue to we will continue to provide that investment the way that we're going to provide it is through the accountable care organization um and so that's how um what we consider to be Medicare money flows into Vermont because of this agreement and it is um it is on the order of eight million dollars a year uh that that that that we receive that funding um for what we consider to be the Medicare portion of the of the blueprint for health program okay so I'm looking at our time uh and I I'm not quite sure you know what further you were going to present about the all payer accountable care organization model agreement uh I would you like to walk through the rest of what your presentation is today uh briefly and then we can we'll be coming back to hearing from you again tomorrow and yeah we can recap some things then and how about what I'll do is I'll just I think I'll move a I'll move ahead to this slide here because I think it builds on what I was just talking about um and and helps to um kind of lead off to the areas for improvement um but basically in Vermont we with federal partnership um have designed a model to pay differently for healthcare and we do that by paying an accountable care organization differently um it is the accountable care organization only uh that can receive an alternative payment through the Medicare program and Medicare is participating in this model by paying providers what's it called up all inclusive population based payments so they're paying providers at the beginning of every month they're still reconciling that to fee for service so we have work to do to further evolve the Medicare payment model um the Medicare is participating in Vermont and it is indeed paying providers differently in Vermont than it pays anywhere else around uh the entire country so it is significant uh that Medicare pays Vermont providers differently than traditional fee for service um so we have Medicare, Medicaid and commercial partners that are all participating in paying an accountable care organization differently in Vermont we have a statewide accountable care organization which you will hear from and they have a broad network and diverse network of provider participants which does distinguish it from other ACOs at least those um that I've seen nationally which tend to be more hospital based or primary care based or hospital and physician based but our um in Vermont the ACO network is more diverse and includes designated um agencies it includes home health agencies as an example um and so our agreement um is looking to change how we pay for and deliver care and it also does some other important things um for health care in the state um again I'll emphasize that this is an an agreement that is um seeking to improve health outcomes and to and to moderate health health cost growth but it is not a health care coverage plan through this agreement again Medicare offers some things through an ACO that they otherwise wouldn't offer and so that really distinguishes um Vermont and and we have this uh federal partner that's offering um in Vermont through an ACO um these these benefits that Medicare beneficiaries otherwise wouldn't have access to including uh even if they are not considered homebound getting a post um hospital discharge home visit easier access to skilled nursing care what this really means is that if you need skilled nursing care and that's the most appropriate care then um Medicare will pay for that uh direct directly rather than requiring that you uh go through a hospital uh encounter in order to be able to consider eligible for for skilled nursing care and finally telemedicine services um Medicare has been paying for telemedicine telemedicine services in rural areas and I think this is a a a true testament to how quickly things change we all appreciate telemedicine as a much different and essential services when we are in a remote environment and that is a a key way to maintain um to maintain a certain level of health care um however as you you might not expect because Vermont is largely a rural state uh telemedicine services were not available to Medicare beneficiaries in uh the metropolitan regions of Vermont and I know hard to believe that we have a metropolitan region but in Chittenden County for instance Medicare would not reimburse for telemedicine services but it does do so through the accountable care organization model agreement so I think it's important to highlight where we have um where we have uh access uh to services different and and because of this of this state federal agreement that we have um and as I've described the agreement we think encourages better coordination of care can lead to more meaningful time spent with your provider because there is the flexibility within a different payment model to take that time and to really look at um look at what the needs are of the patient panel um even if those needs were not historically ones that would be covered through a fee for service model linking health care outcomes um for the population with the health care delivery system we want to reduce deaths due to suicide and drug overdose we know that that is not um exclusively in the hands of the health care system but the health care system is a partner in that work very much and this agreement does it does uh formalize that partnership because it holds accountable um the state of Vermont as well as the health care participants in in in our state for those outcomes um the like I I described the agreement provides funding for blueprint and support and services at home through the ACO that otherwise would not be available to the state um more than eight million dollars each year and um uh finally we are moving away from fee for service in Vermont through this agreement on our own terms or at least on more of our own terms um the federal government is very much moving away from fee for service it is doing incremental it's doing so incrementally um Vermont is certainly leading in this regard um however we have seen now two administrations the two previous administrations beginning with the Obama administration and sustained through the Trump administration and even uh enhanced um in the Trump administration a real focus on the federal government's part on moving away from fee for service um for really uh many of the you know many many many of the same reasons um that we're focusing on it here in Vermont which is that um we need to we need to address health care cost growth and moderate it so that we have a sustainable system and we need to we need to look at ways to improve the health outcomes of our population and so finally this agreement was signed in 2016 performance year zero of the agreement was 2017 and performance year one was 2018 we're now beginning the fourth performance year out of five and we can see clearly that there are areas where we need to do work um make adjustments uh modifications to best understand whether this new payment model and um and uh our work is is um effective in in improving outcomes and um in moderating cost growth and so we've identified four key areas where we think um we need to uh do more work which include um in our state and federal partnership like I mentioned Medicare isn't uh as far along in paying differently for health care services as our Medicaid program is and we would like to see them move even further along um reorganizing and prioritizing health care reform activities in the agency of human services the blueprint for health this uh our strong foundation for primary care is now sitting uh with health care reform uh health reform in the secretary's office um and we uh have a reporting structure um so that we can be sure to align um the activities of health care reform uh certainly with the blueprint evolving the regulatory framework for value-based payments the green mountain care board um is the is the health care system regulator largely speaking the dfr does have a component of uh insurance regulation but um that regulatory model really was built on a fee for service reimbursement system and so it does need to evolve uh in to to appropriately regulate in a value-based payment system which is you know the fee for service alternative system and strengthening the aco's leadership strategy uh so that the aco um we have just one aco in the state of vermont this model does not require a single aco um the model is agnostic to the number of acos in the state we do have one aco in the state and so um that that leadership and the strategy of the the aco really needs to be as strong as it possibly can be to appreciate the different dynamics um and provide for the for the most attractive um the most attractive model to to uh garner participation from both payers and providers in our health care system and so we can talk more about all of these areas tomorrow right wow we've covered a lot of a lot of territory here this morning uh but i think it's again it's in in the interest of putting together some of the essential building blocks and understanding the current health care landscape in vermont uh where we've been um what we're what were some of the issues we're wrestling with now and and frankly positioning us to be able to think more fully as we have a new administration in washington as well which will be undoubtedly advancing some additional health care reform initiatives in various areas um i'm gonna thank you inna for taking the time with us uh and spending spending this time and again in anticipation of more time tomorrow uh i realized there's i mean for myself there's numbers of questions and and i can imagine for people who are newer to the committee uh and others who are returning there's other questions as well so we'll we'll turn more to that tomorrow um and i think with that again thank you inna thank you members and i'm going to suggest at this point that we adjourn for the morning and we are reminded to committee members we're on the floor at 115 today so please plan to join the speaker at 115 on the floor where i believe our agenda is the budget adjustment act so with that and we're back here tomorrow as a committee at uh i believe 9 a.m am i correct Colleen and remembering that we're we convene again at 9 a.m yes