 The S-285 is a committee bill. We had gone through some consultant reports, one from the task force on affordable accessible health care. We also heard from Donna Kinzer, who was a consultant for health reform oversight committee. We also heard from the Green Mountain Care Board, and we also have looked at the financial sustainability report with regard to our hospitals. We had chosen as a committee to look at moderate needs group, and the blueprint, and some language there. As we discussed, I went forward and met with Jen Carby, Nolan Langwell, and Donna Kinzer in particular, and others to bring forward a recommendation in S-285 that we can go through today with Jen. I know there'll be questions, and so we'll go through it with Jen. We'll try to understand what's there. I hope that each of you has had an opportunity to read it. I think after reading it a couple or three times, it begins to join the meeting. It begins to gel. Good morning, Lorraine. I don't know how to do that on mine. That would be fun. Jen, thanks for being here. I know that your time limited and compressed because of where we are, but why don't we look at S-285, and go through that language. Great. For the record, Jennifer Carby, Office of Legislative Council, do you want me to put the language up on the screen? Yes. I think that helps. I do. Yes. Everybody's N is on the same page. I'm sharing the right document. Okay. Hopefully you can all now see this and strike all amendment draft 1.2. This was S-285, the underlying bill is the one that you had introduced as a committee bill, but really with placeholder language, just expressing some intent to address the blueprint and access to home and community-based services. That was the moderate needs group. This would be a strike all amendment, and it would put in a number of new provisions. The first group dealing with payment and delivery system reform, and so this is based in part on the Green Mountain Care Board proposal. This would appropriate 1.4 million to the board in FY23 to engage one or more consultants to assist the board to develop a process for establishing and distributing global payments from all payers to Vermont hospitals that would help move the hospitals away from fee for service and provide them with predictable, sustainable funding that is sufficient to enable the hospitals to deliver high quality affordable healthcare services to patients. That's the first thing is to develop the process for establishing and distributing global hospital payments. Second, determine how best to incorporate hospital global payments into the board's hospital budget review, ACO certification and budget review, and other regulatory processes, and build on the board's existing work on healthcare data collection and analysis through V-Cures and the healthcare expenditure analysis by performing per capita benchmarking analysis by hospital service area and by cost category, and providing meaningful comparisons to spending levels for the same services in other US states and regions. That also incorporates some of the recommendations from Donna Kinzer. That's the 1.4 million. Then it would also appropriate 600,000 to the board to support the board and the director of healthcare reform in the Agency of Human Services in the design and development of a proposed agreement with CMMI, the Federal Centers for Medicare and Medicaid Innovation to include Medicare in the hospital global payments described in subsection A. That's the 2 million then that the Green Mountain Care Board had requested, but including also some data collection and benchmarking work as part of that. This would have by September 1st, the Green Mountain Care Board provide an update on its use of the funds to the Health Reform Oversight Committee, and then by January 15th of 2023, the board would report on its use of the funds and the status of its efforts to obtain Medicare participation in hospital global payments to House Healthcare, this committee, and the Finance Committee. That was the payment and data collection, one of the data collection pieces in Section 1. Section 2 is looking at the delivery system transformation and additional data collection and analysis. This would appropriate $3 million to the Green Mountain Care Board in FY23 to engage one or more consultants to assist the board. First, in facilitating a patient-focused, community-inclusive redesign of Vermont's healthcare system to reduce inefficiencies, lower costs, improve population health outcomes, and increase access to essential services, including both providing the analytics to support delivery system transformation and leading the regional stakeholder community engagement process and supporting hospitals and communities with change management following the redesign. That comes from the Green Mountain Care Board's proposal. Then also using the funds to enhance the state's data collection and analysis by connecting clinical and claims data through an Enterprise Master Patient Index that collects data while preserving and protecting confidentiality of individually identifiable patient information, including determining how best to first optimize coordination and alignment of that Enterprise Master Patient Index with V-Cures and the Vermont Health Information Exchange. In using the data on patient care and outcomes to inform the work of the blueprint in collaboration with the director of the blueprint and the director of healthcare reform. So informing the work of the blueprint, the state health information plan that's adopted by the Agency of Human Services and the Interactive Price Transparency Dashboard developed by the board, Green Mountain Care Board. And finally to detect potentially avoidable healthcare utilization and low value care and identify additional opportunities to use the data for quality improvement and cost containment initiatives. These are some of the proposals from Donna Kinzer and others. Again, this would have by September 1st, the Green Mountain Care Board provide an update to the Health Reform Oversight Committee and then by January 15th of 2023, the board reporting on the use of its funds appropriated in this section, including the status of the delivery system transformation process and efforts to improve the state's healthcare data collection and analysis to the same committees as earlier, this committee, finance committee and house healthcare. So that was the payment and delivery system reform provisions. Then we move into a new group of sections on the blueprint for health. So the first one here would amend an existing blueprint statute to add to the blueprints initiatives, the use of quality improvement facilitators, which is something that blueprint already has but is not specified in statute, and other means to support quality improvement activities, including using clinical and claims data to evaluate patient outcomes. So tying back into that enterprise master patient index language in the previous section and promoting best practices regarding patient referrals and care distribution between primary and specialty care. And this is one of the recommendations that came out of the hospital wait times report that just came out last week. Section four would specify an increase, although it doesn't specify yet, puts in placeholder for you to determine the appropriate increase to the per person per month payments that go through the blueprint to medical practices for contributions to the shared costs of operating the blueprint for health community health teams, just currently reflected in the blueprint statute and quality improvement facilitators, which are not. The increase would also apply to Medicare to the extent permitted by CMS. And then this would appropriate a sum of some amount that goes along with that increase to the per person per month payment and global commitment dollars to diva and FY23 for the Vermont Medicaid portion of the increased blueprint payments. And if CMS does not allow federal financial participation for the increase, then it would be done with state dollars only and would direct the department to reconcile the difference in its FY23 budget adjustment proposal. Then we move into some options for extending moderate needs supports. And so this would create a working group but also infuse these concepts into the next global commitment waiver. This would direct the department of disabilities, aging and independent living, Dale, to convene a working group comprising representatives of older Vermonters, home and community-based service providers, the office of the long-term care ombudsman, the office of the healthcare advocate, the agency of human services and other interested stakeholders to consider issues related to and develop recommendations for extending access to long-term, home and community-based services and supports to a broader cohort of Vermonters who would benefit from assistance with one or more activities of daily living and their family caregivers. And so they would be looking at issues including the types of services such as those addressing activities of daily living, falls prevention, social isolation, medication management and case management that many older Vermonters need but for which many older Vermonters may not be financially eligible or that are not covered under many standard health insurance plans. The most promising opportunities to extend supports to additional Vermonters such as expanding the use of flexible funding options that enable beneficiaries and their families to manage their own services and caregivers within a defined budget and allowing case management to be provided to beneficiaries who do not require other services. How to set clinical and financial eligibility criteria for the extended supports including ways to avoid requiring applicants to spend down their assets in order to qualify. How to fund the extended supports including identifying the options with the greatest potential for federal financial participation. How to proactively identify Vermonters across all pairs who have the greatest need for extended supports and how best to support family caregivers such as through training, respite, home modifications, payments for services and other methods. You would direct Dale to collaborate with others in the agency of human services as needed in order to incorporate the working groups recommendations into the agency's proposals to and negotiations with CMS for the next iteration of the global commitment waiver so that the extended moderate needs supports can be available to Vermonters beginning on January 1st, 2023 just when the next global commitment demonstration should be in effect. An honor before January 15th of 2023, the department would report to number of committees including this committee, House Human Services, House Healthcare, House Appropriations and Senate Appropriations with the working groups findings and recommendations including the portions of the recommendations that were incorporated into the new global commitment demonstration and the amounts of any associated funding needs. Getting close to the end, next we have the summary, summaries of Green Mountain Care Board reports. So this would add to an existing provision in statute on the duties of the Green Mountain Care Board that the board summarize and synthesize the key findings and recommendations from all reports prepared both by and for the board including its expenditure analysis and focused studies. This had been a recommendation from Donna Kinzer and this would make all reports and those summaries prepared by the board available to the public and posted on their website. Finally, the act would take effect on passage though you could change that. And I just noted that you would likely want to update the title of the bill to reflect what is ultimately in it. Take that. Down in step. So questions committee. Go ahead, Senator Hardy, go ahead. I always try to hesitate, so I'm not the first one to ask the question. Good. Cheryl, Ann, anything? Sorry. Question about the blueprint part of the bill. Does that, the payments there are vague? So is it just for anything that they're doing or is it for a specific pro? I know they have a bunch of sub-programs. Right, so the language that is in existing statute talks about supporting, I believe supporting specifically the community health teams. So I expanded the language to include the quality improvement facilitators, but I don't know, I think there's also appropriations that come or funding that comes outside of the per person per month. Those are really the payments to the practices. Okay, I just want to wonder if it covers, and maybe Josh knows this, covers the stuff they do with both the MAT and, you know, the- Hub and spoke. Hub and spoke. It would be, yeah. The diabetes work that they're now doing. You know, all the many different programs they're doing or if it's for a specific one, that's, it's unclear to me. I think it's general, overall. So- Josh, do you have an answer? Do you know? So there, I'm not sure of the dollar flows from the state to the practice. So I'm not certain how the community health teams are paid. I believe they all get state checks. And so I'm not sure. You know, I don't know the answer to the question. We need to ask the department how those dollars actually flow. Okay. Yeah. I think it would be important to find out, yeah, from the department, from AHS likely, how they fund the individual initiatives within the blueprint for health. Okay. Is that really the question is, how does that, how do the per person per month payments to the practices relate to all of the various blueprint initiatives? Exactly. Exactly. And whether they're new stuff, because I know for example, they just, the diabetes work they're doing is relatively new. So I wouldn't want that to be left out. And one of the things that we're hearing obviously right now is that the hub and spoke work is even more important than ever. And so I wouldn't want that. Anyway, I just want to know what the money's for. And then in the section about the moderate needs supports, one thing that we heard pretty clearly from the people who came in and testified was the need to reorganize their wait list to make sure it was reflective of the highest needs, moderate needs, the highest moderate needs. And I didn't, maybe this is in here, Jen, but I didn't see that as part of it like reorganizing the... It's not specifically in here. I think that was reflected in the conversation about the existing choices for care program because this is looking to kind of expand the universe of people and services, people services and funding. I don't know what that would necessarily look like or whether there would be prioritization or wait lists in the future. We can certainly look at adding something reflective of that. I'm just not sure exactly how to... Yeah. How to reflect that. With that, it might go in that introductory statement in A somehow because they're currently doing that. We could just say in addition to looking at, because I think Senator Hardy is right that there's something that they're doing that we probably should reference. Yeah, I just, as we're expanding the number of things that they're doing, I don't want them to not serve the highest needs people with moderate needs. The highest moderate needs. The highest moderate needs. So that was just, and also just one more thing on this section is the timeline seems pretty tight given how overwhelmed they are. I mean, I know it's sort of in conjunction with the global commitment, but it's a lot for them to do in a short amount of time. But it's just an update. I think it was just in a matter of looking at how organized, what their organizational structure was. But at that point, I don't think there's any, I don't think we would expect any robust report. But just, yeah. And then I just assume we're gonna have the Green Mountain hair board in to comment on this. Oh yeah. Okay. I just want to make sure that the first part works for them as well, so. Yes, yeah. We should, we'll reach out. I think, Jen, if you can reach out to Diva about the initial question on the reimbursement or not on Diva, AHS, whomever. Yep, I think I'll start with Ina. Yes, I was thinking that. And then, and we did meet with Ina. I did meet with Ina and others on this, but it's, this is the first framework. So it's important to get some of the details. This is good. Yeah, and I would just like to hear from Green Mountain care board. I got a note from Jessica Holmes this morning. So I just want to make sure they get a chance to come in about the language. Yes, absolutely. We'll do that. Thanks. And everything they asked for, we've modified some of the things I've asked for, understanding that we also looked at Donna Kinzer's report. So we're, it's hard to be, have two masters, but that's what we're trying to do, maybe three or four, five or six hundred. Senator Cummings. Yeah, I would like to hear from the home health agencies. Okay. I've gotten an email from my local one and they're losing money hand over fist at this point. So have some real concerns about expanding the responsibility. Well, I think the, but the bill does is to ask for analysis of what is possible, which is why we didn't put in an expansion, but we can bring those folks in. That's a perfectly good idea. Would be helpful. All right. All right. Anything else? That would be Jill Olson probably and maybe Laura Pelosi. That's a nursing home. So I'm thinking visit home health. You want home health? Yeah. That's hitting, that's where this is going to land. Yeah. Do you have a suggestion of someone you'd like to hear from? You could try Centralmont Home Health and Hospice, Sandy Rouse. Okay. But I don't know if they haven't... They may not have, they might not have the global, but... They may, I think they have, I think they have a lobbyist, the whole organization. Yes, Jill Olson is the... Jill. Yeah. That's why I thought. That's why I mentioned her. You could... We'll bring Jill in and she may suggest some additional testimony. All right. Any other questions, comments? Okay. Wow. Okay. So my Josh Slain is here. Do you have any questions for Josh or Josh? Do you want to make any specific comments in the blueprint, moderate needs area? We tried to use at least some of the information that you provided to us. And last time we went through, you may have had some concerns. So I'm just asking for your thoughts here. No, I appreciate that. And I'm happy to be constructive in this conversation here. With the reservation that I would like to read through this a second time, because we went through it quite quickly and there's a lot in there. And it's all connected as we know, right? So each piece is connected. And so, but what I would say is that Senator Hardy's comment regarding the moderate needs group and the prioritization exercise that the department has said they are going through now, my administrative experience would say that it is helpful to have some language that recognizes that it's a priority to have a prioritization and then let the department come back and do that. So I would support that. I think that's a good thing to do. And because once you start doing that prioritization, actually it's good to have legislative language behind you that says you have to do it because it gets thorny when you actually start prioritizing, right? So that's why I say it that way. And then I would say for the blueprint that really that fund flow is important but recognize that any dollars that get given to a primary care entity are fungible once they hit that entity. So there's a substitution that can occur. So that's just We're just saying don't get too specific but we don't wanna be too unspecific. But it's got Well, I think we go in two different directions here, right? One is to say you can only use this money for this very specific thing. And that's pigeon holes it and requires lots of reporting. And the other is just here's dollars for the primary care facility. I think actually given where we are in workforce and given where the blueprint is that that discussion about how to target it is one that should be had after the fund flow is discussed with the blueprint about how to best put this money to use so it doesn't just be absorbed without going specifically where you want it to go. And with the least amount of administrative burden on the providers. So I think everyone can support that generally but it's good to have that explicit conversation so that we don't pump money into the primary care practice and it goes somewhere you didn't intend it to. So that's one other comment. And then I am very interested and look forward to hearing the Jill's comments on the home health agencies and how that rolls out. And then finally my last comment that may be helpful is for the moment is that the question about timing and how fast the department of aging independent living could move forward and do some of the moderate needs changes. I think that regardless of the amount of effort necessary the conversation with our federal partners happening. And so that has to proceed the implementation could be pushed out but the actual global commitment submission this has to go in that whenever it goes in. So I guess my point would be we should be clear if we can in the legislative language that it needs to be in this version of the global commitment not miss that train. And then after that the actual administrative thing could be delayed by a quarter or something. The actual implementation might be delayed because we get backed up but the submission needs to happen and this should be in it. So I think we could be a little more, we could point at that issue in the language a little bit. Okay, that's helpful. May as well be specific. All right, any other questions for Josh? Joshua. Okay. Jen, are you still there? And Nolan. So in terms of the quadruple Xs that we have in the blueprint section then we'll have to sort out what exactly goes in there. I'm trying to think through what goes there what might better be there and maybe Nolan or as, but as we hear from AHS that may help clarify. Okay, so we'll hold that thought until that time. Right, I think you need to identify what the additional funding need is. So you can back into the amount of the per person for a month payment and then that will inform the amount that needs to be appropriated as well. So I think until we have a better sense for what the need is. Okay. We won't know how much to increase it. And for the record Nolan will join this class. So I also think that it would be important to hear from Ina particularly because blueprint is an integral part of the global commitment waiver negotiations. And so our ability to increase payments may be tied to whether we even can use their blueprints always a part of a negotiation. So that's going to play into that piece as well. Right. Well, you know, this is the hard piece because we've always advocated for primary care as prevention and trying to, you know, we don't want to rearrange deck chairs necessarily. What we would like to do is to invest more fully in primary care as prevention and then get savings at the other end. And those are the savings that we'd like to invest but initially you need to have a resource investment to make it happen so it gets catch 22-ish. Go ahead, Senator Hardy. Thank you. Just in going through the language a little bit more this section on page two paragraph B the $600,000 to Green Mountain Care Board in the design and development of the agreement with CMS does what do they do versus AHS in that agreement renegotiations? Do you know, Jen or Nolan or Jen? I mean, I think it's definitely a partnership. They were both signatories on the original version. I think there is my understanding that it's important to the federal government that they're both signatories going forward. So the funding is appropriated to the board but it's to support the board and AHS. I think they would need to tell you what their specific roles have been in the past and what they see going forward. Okay. Oh, I see it says the board and the director of healthcare reform in AHS in the design. Right. Okay, so it's for both of them because I thought it was a partnership so I didn't want to make, I wanted to make sure AHS was not left out but I see that it's there. The second question or comment on page three this is the stuff about the, you know, community engagement. I guess I would really like to double down on making sure that we have a really good community engagement process as we're talking about how to redesign or, you know, alter things in our hospitals because so it says community inclusive redesign but I think it would be important to have in their language specific about community engagement with actual people or... Senator, Senator, let's go through it together because that's a whole section that begins on number one and then you're going through with the communities that B, A and B and then two or that so that's, Jen walk us through that because this is a really important point that's being made about making sure that people are fully engaged and it isn't just the, we're not just talking about hospital administrators here. Exactly. We're talking about everybody who's in this healthcare world. So how can we make, how can we put language in that really suggests a robust, you're talking about having a really robust community engagement process. Yeah, I mean, just having been through the Act 46 process I just know that this is not exactly the same but it's kind of similar in some ways and we want to make sure that people know what's happening and it's not just the hospital administrators who know what's happening it's actual people in the community. And I guess I would also include the healthcare advocate in this process too so that there's really somebody at the table who's paying attention to how this will impact patients or consumers as some people like to call them but the people who are using the healthcare. This is, yeah, so that's a good point to be made. So let's think about how best to do that. I see Jen is taking notes on this, this is important. And I think this is a real key part of any transformation that's gonna take place because if people can't work together it isn't gonna happen. So, and when we have the Green Mountain Care Board in we'll have to follow up as we're looking perhaps at some new language that modifies this we'll have to have them in and follow up. Okay, anything else? Committee folks at this time. Do you want to go quickly through the bill one more time? Not at the two foot level but maybe let's go a little bit at a slightly higher level that will help reinforce what's here and then it may raise some questions for Jen as we're going through. So why don't we do that? I think that's repetition is not a bad thing. Okay. Yeah, let's do it. Put it back up. All right, so the first section then is the 1.4 million to the board to engage consultants around hospital, global budgets incorporating them into the board's regulatory processes and building on the board's existing healthcare data collection analysis work through V-Cures and the expenditure analysis by doing per capita benchmarking analysis so that there can be comparisons to other states and regions in the US. That's the 1.4 million and then 600,000 for the board and AHS to design and develop a proposed agreement with CMS or CMMI in this case to include Medicare and the global hospital payments. And then reports to September 1st, 2022 and January 15th, 2023. And just to reiterate that early 2022 is just to let us know that things have started. That, so. Right, it's really an update. It's an update. Section two is the $3 million for the, to the Green Mountain Care Board for consultants for facilitating the patient-focused community inclusive redesign of the delivery system and supporting hospitals and communities with change management and also to enhance the state's data collection and analysis by using this Enterprise Master Patient Index and figuring out how to coordinate and align that with V-Cures, the Vermont Health Information Exchange, the work of the blueprint, the state health improvement plan, the interactive price transparency dashboard and use the data to look for ways to identify potentially avoidable healthcare utilization and low-value care and other ways to use that data. And again, reports due September 1st and January 15th. Sections three and four are on the blueprint. The first one about using kind of codifying this idea of the quality improvement facilitators and other ways to support quality improvement activities and section four being an increased, some increase to the per person per month payments to medical practices, both for community health teams and quality improvement facilitators. I'm looking to get federal participation and also appropriating some amount as needed and for the Medicaid portion of that. I don't mean to interrupt the flow here, but I just like to make a comment that every time we hear about the blueprint, regardless of whether it's from someone locally or someone at more at a national level, including our consultants, we hear that the blueprint is an outstanding nationally known program. And so that it might not receive a blessing from CMMI would be, I couldn't understand why it wouldn't. So anyway, keep going. Any? Yes. Just, I'm looking at all the millions that we're appropriating. Yep. Is this in the house budget? I don't know. Okay, does appropriations know it's coming? Yeah, I've talked with Senator Kitchell and I'm going to talk with her again and we don't know what will happen to it in appropriations, but I do know there is some interest in having this go forward. So we'll continue it. I just wanted to make sure because I have to get out some tax bills because all the money is spent. Yes, I'm sure it is. So I just check it. I do know that the BAA had money in it for some of this. Okay. Okay, section five is looking at options for extending moderate needs support. So having Dale convene a working group to look at issues and come up with recommendations to extend access to home and community-based services and supports for more Vermonters. Having them look at the types of services, most promising opportunities to extend supports including things like expanding use of flexible funding and allowing case management only, setting criteria for the supports, how to fund them, identifying Vermonters who have the greatest need and supporting family caregivers. And this would have Dale collaborating with others in AHS to incorporate the recommendations into the next global commitment demonstration so that these supports would be available beginning on January 1st, 2023, which is when the next demonstration should be taking effect as we're in a one-year extension right now. And having a report back on January 15th of 2023 on that. Then we have the requirements that the Greenland Care Board summarize and synthesize the key findings and recommendations from its reports, the effective date and the placeholder for a title change. Oh, we forgot the title. Okay. Well, I think once you have decided what's in the bill we can make the title reflect what's in the bill. Okay, we're good. Good idea. Okay, that's it for now, I guess. Thank you. Any questions, committee? At this point. So we have some folks we'd like to have in on this, not the least of which are Green Mountain Care Board, the Healthcare Reform Director and Home Health. Those are the ones we've been looking at most specifically that will have them come in. Let's see what we can do about getting them in sooner than later. Maybe also the healthcare advocate to see where. Yeah, I got him on the list too, thanks. Yeah. Thanks. Thank you, Jen and Josh. I will say, let me just say there are a lot of interested parties who will want to comment on the bill. We've already taken a lot of testimony from a lot of different interested parties, whether it's Dale or whether it's individuals with concerns about access. I think our goal here is to listen to the folks that we've identified and then try to move the bill before crossover. So that it's gonna be hard to have miles and miles and hours and hours of testimony at this point. We've already heard a great deal from many people, whether it's been in the task force process, a truck process, the healthcare, healthcare committee, health and welfare committee, appropriations, everyone's been taking testimony on this and listening. That's it. Okay. So it is 949.