 this morning and I'm going to ask for more flexibility throughout the morning. It's given everything that's on our plate between now and Friday, given crossover is approaching. In reviewing the agenda last night I've determined that we're going to get more done and more productively by doing some things differently than what's laid out on the agenda. So let me walk through that and let people know what we're doing this morning. So we will be hearing from Barbara. I don't know how to recognize people. We will be hearing from Barbara Prine about the about some high-tech nursing issue and then there may be someone else to comment on that as well. I'm going to have Lori take charge of that. Emily Brown is with us. Oh, there you are. Sorry, you're going to find David. David, we're going to see you. We'll hear from Emily and then, and I don't believe at this point, and then when we're finished with that, we'll be taking a break until 10 30. At 10 30 or at 10 o'clock, or when we take the break, Representative Donahue, we have an affordability work group that's been doing some work and is on the agenda, but what we've determined together is the next best thing is for that group to be able to do some further conversation amongst itself rather than trying to do something with the whole committee at this point, and so that group will be meeting during that period of time. At 10 30, we will come back to our agenda item on prior authorization, and we have a number of witnesses scheduled at 10 30, so we'll be hearing those witnesses at 10 30, and my understanding is that that should be fairly clear as to where we are with that, and like my hope is that we will finish that testimony roughly around 11, and that then at 11 we will again break from the whole committee, and we're going to divide into some other work groups. We have a number of other pieces that work and need to get work done with our legislative council who's going to be available to us. The workforce group has some continued work and you were working on some finalizing some language there, so there will be time this morning to do some more work on that, and Representative Donahue has offered to help assist with some of that, if that's helpful. And then in anticipation of tomorrow, numbers of us are going to be redeployed to other tasks to get ready for some other language around some prescription drug issues and some other remaining miscellaneous health care issues that remain on our agenda. I think we'll find everybody to board everything by the end of the day on Friday for crossover, but I think this will help us move things forward. So with that, I think we'll then start, and we will hear from Dr. Prime in the context of this is that we have, we came across a number of different issues in the course of our testimony since January. Issues that we believe either should be put into statute as a statute of change to put into session law to clarify some issues that we want more information on or where we're asking for something to take place. And we're going to be putting that together in a committee bill on miscellaneous health care, but I mentioned this real before. And this is an issue that actually hasn't come before the committee yet. It is something that I was approached on in the hallway, but it's also an issue that came up in appropriations when I was sitting in on some of the budget discussions early on. And so I agreed to say, let's put some language forth. Jen, this is language that Barbara will walk us through. Jen has not, you know, really looked at it or done anything with it. And I apologize because I did not get it to some of the other stakeholders in the band. So I apologize for that. So we'll take a couple minutes and have Barbara walk us through what this is. And then here from Jolson for a couple minutes, and then we can take it off at a later date, have a committee discussion about where we are. Hi, I'm Barbara Krine. I'm a staff attorney at the Disability Law Project at Vermont League of Lades. And I represent individuals with disabilities and severe medical conditions in the legal issues that arise out of their disabilities. I've been doing this work for about 23 years. For several years now, two or three years now, we've been hearing from families who have family members with very complex medical needs. And these are people who in 10 years ago, 15 years ago, would have been living their lives in hospitals, but they're now being served at home with the help of a lot of work by the families and home health nurses. So these are people with high medical needs and they're medically fragile people. They need nursing care often or for long periods of time. It's different than, you know, what we think of more as home health, more traditional home health, which is for shorter periods of time or for periods of recovery. Vermont has programs through the Department of Vermont Health Access through Dale and through the Department of Health, where a nurse assessor comes out, assesses the person's medical need and says, this person needs 40 hours a week of medical care. This person needs 80 hours a week of medical care in home. And so that's then awarded through the Medicaid program as medically necessary care. But what's been happening for years now is that only about a half of that care is actually being provided. And so that puts tremendous strains on families who can't sleep because they have to intubate their child in the middle of the night or can't go to work because they have to put the feeding tube in or have to use the compression chest or whatever it is that those families need. And so it and like we talked to one family where their doctor says if their child gets sick for more than two days in a row because they don't have overnight care, they have to put her in the hospital because it's unsafe if the parents fall asleep by accident because their child could die. So the repercussions of the shortage is more expensive hospital care. It's also people leaving the workforce and it's also tremendous stress on families. So we've been meeting with the Agency of Human Services for a year with the Department of Health. There are some Medicaid laws that say that all medically necessary care must be provided particularly for children. Like once something's been found to be medically necessary it has to be provided. And we've been meeting with the with reasonable promise like quickly not like two years later. And so we've been meeting with the Department of Health and the Department of Disabilities, Aging and Independent Living and Medicaid. Medicaid pays for it but it's sort of administered by Dale for adults and for Department of Health for children. We've been meeting with them and they admit that they are violating the law. And in other states there's been lawsuits about this and courts have found that the state has to has violated the law and has to fix it. So there's state permits not sugarcoating their failure to meet their responsibility. In this work they've done some things to improve things sort of like to like I don't want to say nibble around the edges because for the families that it's helped it's been very helpful. But we're still staying around 50 to 60 percent of the hours that are allocated on average getting provided. So we've met with Home Health. You know those folks are trying hard. There's no doubt they're trying hard. There's uh there's some administrative barriers. There's a pay gap between what the high tech nurses are getting and what the home health nurses are getting. High tech nurses are getting the same as the home health nurses but there's a pay gap between that in hospital and at the hospital's have a nursing shortage but their nursing shortage is about a nine percent vacancy rate. This is like 40 to 50 percent of the hours that are getting filled. It's not the same and it's because the pay gap is you know Jill and I were talking about how much the pay gap is. This is an eight dollar pay to all our eight dollar an hour pay gap, ten dollar an hour pay gap, six dollar an hour pay gap. It's a big pay gap when you're at the mouth. So we think there needs to be a pay increase. The state doesn't think there needs to be a pay increase. We think the state is not dealing with with the urgency because today they are violating law. Today they are not helping these families in the sufficient amount. So understanding that probably not going to get a pay increase, an enhanced pay rate this year even though we believe that's part of what's necessary. We at least need the state to be reporting to the legislature about what they're doing to fix the problem. They have an idea that they can fix the problem through payment reform that they have not yet defined or explained which we have high doubts that if there's not enough money that moving the money around is going to fill the gap. So the language that we're asking for is that you tell these parts of the state to report back to you in October what they've done to fix it and that they treat it with the urgency that it deserves. It's their responsibility to ensure that all medically necessary care is provided and we're asking you to have them tell you what to do. And I think some of you've been contacted by some of these families. I have a I mean so you guys have too much going on. I have a three and a half minute video from one family that explains their life and you can see the kid in the high tech care. I have testimony from two families that came to the budget testimony. I can forward this to you or you could also just say you know honestly that's just not going to be looked at right now or you could just believe me up that it's urgent and they are compelling in their disappointment. You know it's not it's not fair for us not to be it's not fair it's not safe. It's more expensive when they go to hospitals and it's also against Medicaid laws. So I'm asking you to ask for a report from the state on how they're trying to fix this problem. Thank you and I was actually going to acknowledge that you've already said such that you had asked if you could share a video. I view the video frankly it's compelling. I have family who are in virtually identical situation so it's very familiar and very you know the situation is one of complete exhaustion for the parents who are having to do the care for a great deal of the time and is a high level of care. It's not just a casual care but but I did ask not just not to do that this morning and I still feel comfortable with that but I'm happy to have you share that with committee members forwarded to committee members for people they can do it. Is it better for me to forward it? Yes I'll do that and the two pieces of the two pieces of testimony that people did and the appropriations budget here. We're demonstrating that. Yeah I'm happy to do that. Okay people have questions? Yes I have some questions for Barton. So is this primarily a staffing issue like there aren't enough people to do the work or is it an organizational problem that we're not getting people from the right spot? So I think that that's complex there's a big part of it is obviously the nursing shortage it's also hard if you're getting paid less than what you could do elsewhere. There's some administrative barriers I think that the administrative barriers aren't the biggest problem. I think that the pay rate is one of the that you need to fix both but if you don't fix the pay rate you're not going to get people to do it. I think you know Jill Olson might disagree with me on that but it the state has to fix it and they can figure out how to fix it but they we started talking to them about it in December of 2018 and we have had like this much improvement and for those families that improvement matters but what about the rest? At the very top of your document you have you said yep at the top of the document it says 20 Medicaid eligible children and 25 adults so that's the group of people that are in this category and it switches all the time yeah sometimes people die and new people come in but it's a fixable problem we can fix this problem I mean presumably we're not talking massive amounts of money as far as a pay increase okay and then so I think the pay increase is about would cost if all the hours were filled the pay increase would be about four hundred and sixty thousand dollars if it is a ten dollar gap if it's less as Jill says then it would be less than that and what you said it's high tech nursing is it the same license but yes the responsibilities are different it's sometimes called high tech nursing sometimes it's called medically complicated medically complex nursing it's typically people who like are doing intubation to feeding chest it's like if you see the video you see the amount of technology that these families are doing within the home but it's really medically complex care it's you know families are doing it and they don't have any you know nursing license level but most people are using RNs mostly not all of them are RNs but mostly what the home health agencies are sending us RNs which would be the same level for other home health care I think depending on what you're getting sometimes you get an LPN and sometimes you get an RN depending on what's going on for you in your other care so let me let me step in again we have as not just our committees but many people working with state are under enormous pressure to deal with other issues Jay Samuelson's here for the ABC Human Service I'm not going to ask you to comment at this time but I won't bite you too we will share this language Jenny needs to go be part of a COVID-19 planning meeting and we respect that and I appreciate your being here to listen and we will share the language we will bite your comments from the agency before Friday as well okay thank you okay a lot of yeah yeah a lot of moving I'm good I appreciate you guys got a lot going on and given me five months which I think I'm going to just stretch to ten is very much appreciated thank you thank you Jill you wish I do good morning I'm Jill Olson I'm the executive director of the VMAs at Vermont I representing home health and hospice this is also a service provided by by out of home health which we don't represent but we've been working closely with them on this issue so I just want to say first I don't have any objection to this language so if you want to have a report back that's fine with us we've been working really hard on this issue for a very long time it is a very complex problem and it's really hard to find nurses who actually want to do this work particularly the overnight shifts it's it's also stressful and tiring for them and there just aren't that many nurses who when there's so many nursing opportunities available want to choose that particular form of nursing so that's part of what we're we're struggling with we're trying to address the nursing workforce shortage in other matters I think exactly everyone through the rural services task force is fully aware that there is not a there's a shortage not an excessive yeah applicants for nursing positions yeah I wanted to just put a few things into context so all of home health it has a pay differential with all of hospital right so we are just a lower paid industry than hospitals the high tech and the home health nurses have similar pay in our agencies there is some differential based on a our last wage survey there's a lot of federal regulation about how we can compare wages there are legal ways to do it we do them every two years so we're waiting for another survey but the differential with hospitals is true across our entire industry we as an association put together a task force it's almost three years ago now we had families I've met with these families I've been to their homes we had all of the departments in we had Bayada so we did a lot of work and we identified a series of policy solutions that we actually thought would have an impact on families and as Barb mentioned they really have so we've really been trying to find all the policy levers that we can pull including more self-managed because families can actually pay more than we can because they don't have to they don't have an overhead structure and they don't have the regulatory obligations that agencies have we got that rate increased we have Diva has now implemented a policy allowing family members who are nurses to to be paid to provide care for their family members which has made a big difference for families who are not working so it's only four families across the system 10 percent of the families so small changes are actually significant and then the last thing I want to say just to put $500,000 in context to us that's a lot of money our 2% increase last year with global commitment match $750,000 wiped out by our provider jack's increase so it's a lot of money to us and it's really hard to get across the hall so I just need to put that in context because that's for our PCAs all of our nurses all of whom we need right now today as we're dealing with the prices that we're in so it's it's it does seem like a small amount of money I wish it was across the hall because we were getting our increases thank you David yeah so this is the problem it looks like based on the other testimony that didn't start in 2018 now and I'm wondering whether if there were a half million or some other amount of necessary to raise wages by X number of dollars would that even solve the problem so would there be people willing to do the work for that so my members think not is the issue so we've been asked the question by diva what's the number and when I ask that question of my members they say we don't know we're not sure we can't identify one there's no number that they feel like they could say would be the solution to the problem now does that mean that more isn't better more is always better but there isn't a particular sort of tipping point where we feel like we could say this problem could be solved nurses in a really tight nursing market would be willing to spend eight hours overnight in the homes of some really complicated family situations and the last increase we got which was a very significant one back in 2014 did not have much impact on the the availability of nurses in this field so it's it's a really complicated problem unfortunately yeah I'll just right obviously that's been going on for a while so wouldn't it have been better for this committee to have known about this situation in January rather than now I don't know I'm not sure that this committee has policy levers to do this work either we've been working really hard on it internally so I it's it's an ongoing problem for sure we had more discussion on this right I think it's a fair question Brian and I think that there are numbers of issues both from the heart efficacy around the budget as well as any other policy levers that are policy issues that we might have been able to bring to bear I know it has been brought to our to the attention of representative on behalf of our committee in the last several weeks but you're right you know we've we've not had the opportunity to look at this and it some people might question which committee's jurisdiction it falls under as well whether it's our committee or human services or certainly appropriations I would also just say because I because I having I'm not having viewed the video there's like like I said we have family who are virtually the same situation in another state and the level of exhaustion the level but the need for respite is quite profound family members are doing this I would just without the risk of becoming a witness I would just I would suggest that perhaps some of the nursing care that is in fact being done by families does not require nursing certification because in fact family members are in fact providing that in the absence of a nurse in the home and I think there's some there may be some things that need to be looked at in terms of reimbursing families for doing their what is in fact nursing care when a family member does it it's considered you can do it but when someone else does it has to be a trained nurse for in fact appropriately trained individuals within the family are providing a great deal in this care so that that's absolutely true and so I think it's a more complex issue than just saying we need to pay raise for nurses etc I don't begin to understand all the complexities but I appreciate you bringing attention I think can I just put that one comment you just made in context we are not allowed to hire non nurses to do that work well we've been asked that question the federal regulation does not allow I understand that but I think from what we've really come up on the ground yes one of you when you don't have nurses in the home the family absolutely ends up doing what would have been the nursing care that's absolutely right everything from everything that's required yeah absolutely requires 24 hour care can do nothing for themselves yes absolutely nothing assisted to everybody that is what's going on I think thank you we will we will look at the language we'll forward it to the other stakeholders we'll ask for feedback and we'll consider it as a piece of the miscellaneous healthcare bill that we're looking at thank you so much good let's then turn our attention to a different issue having to do with if we look at house bill I think it's 505 around supplemental Medicare policies I asked David to look at look at this a little bit further ourselves I've drawn to conclude that we're not going to be able to move that bill this year we've taken some testimony but we do want that many of us in the committee are very interested and I want to ask Emily Brown from the Department of Financial Regulation to join us and I think some of my request as a chair of the committee to ask the Department of Financial Regulation which has oversight of all insurance policies in the state whether the FR would be in the physician to help us assess the complexities of implementing what in fact is the proposal in each 505 which I believe I quickly see it I'll try to summarize it and then help me if I don't have it which is to create an additional open enrollment period for supplemental Medicare policies and that raises if a person has not signed up for the supplemental policy upon enrollment in Medicare and some questions about what happens if you're in Medicare advantage policy and that's about that but what what my hope would be is that the FR might be assist this committee in looking at that issue in the interim period in the period between when we leave and when we come back our successor committee is formed next January because I think there's some we love interest and I don't think we're going to be able to address fully right in the future so we'll be happy to do that it is the market as it's currently structured has one open enrollment period that's available to individuals so this would be changing it to expand that to an annual enrollment so I think what we could do is look at what effect that would have on the current enrollment premiums potentially and how that would also interact with other products available at Medicare advantage is there anything that you would need from us in order to have that move forward so that we could have some confidence that we would actually we know that we'd question whether you do it but would it be helpful would it be helpful to have this committee either include some language or to maybe have some communication officially with the FAR asking to assist us yes and that would help whether it's in a formal you know something in the bill or a letter though that would definitely help to give us guidance on what you'd like us to look at is it possible for you to implement it without us being in session and well so if we were to have that implemented as it as is written in 505 our regulation would need to be changed we have a Medicare supplement regulation that would have to be amended I'm not it could potentially have an impact on statutory language as well right now the requirement for community rating is in title eight so we have to look at that as well so there are a few pieces that I think we would have to look at to figure out okay what changes need to be made and so in that sense it would probably have to go through the legislation I believe it would have yeah well let me let me and we appreciate your question because I know again there's some real real interest on the part of some of us on this we're of course trying we're thinking initially in terms of coming up against our crossover deadline of Friday but assuming we don't leave the building for other reasons early is it realistic or would it be realistic for DFR to provide us with some preliminary analysis of this before we adjourn each year so that in fact should there be should that analysis suggest that maybe with some work between the senate and the house even post crossover that there might be if there's a if the analysis suggests that we move forward maybe there's a way for us to do something or at least review that possibility before the end of the session I would ask if that could be done then that would allow us the option of potentially finding a way with bills that are moving or other avenues to whether we can do something in this period okay help us understand what the pros and cons and what the statutory changes would be required okay we can do that thank you that would be very helpful so I want to do a letter to that okay so timeline let's talk offline okay about that okay that would about what's realistic for your office's work and what what would be required for us to actually have time to look at something okay that's great okay thank you thank you very much okay with that as I said I think we're going to then take a break and we're going to work the affordability workbook is going to convene I think the workforce group can convene to have some conversation with Jen I think that's the best part of the immediate use of that I know Laurie has some other things that you're suspicious of tomorrow that she's going to be working on um I have some requests for some other committee members to work on a couple items help us move forward so with that let's take a break and uh we'll reconvene at 10 30 start at 10 30 and look at the prior authorization language to hear those things before we can before we drop will we stop or any other questions for committee members clear what we're we're going to come back 10 to 30 to start the prior authorization testimony okay well and Brian uh just I didn't think that Brian is out today I spoke to okay I think we're going to convene the committee and I think a lot it's got down during the break so I think that was a good choice um and we're going to turn our attention to the issue of prior authorization and we're going to jump to representative to walk us through this part of the agenda great Jen yes um so we left this uh I don't know when a week or two ago um asking the stakeholders to come back with some language so we have that one now it's everyone's efforts as well as Jen so Jen's going to walk us through it and then we can um great target legislative council um so this is prior authorization language it is not going to edit it so I want to just flag that um so this has a number of provisions relating to prior authorization the first one and they're just lettered A through E because I don't know where they'll end um first section would amend an existing statute on prior authorization that would direct a health plan to review the list of medical procedures and medical tests for which it requires prior authorization at least annually and shall eliminate the prior authorization requirements for those procedures and tests for which such a requirement is no longer justified or for which requests are routinely approved with such frequency as to demonstrate that the prior authorization requirement does not promote health care quality or reduce health care spending to a degree sufficient to justify the administrative cost to the plan and then the whole plan must attest to DFR and the Green Mountain Care Board annually by September 15th that it has completed the review and appropriate elimination of prior authorization requirements as required I'm going to stop for any question but not a health a health plan would include it so it's a defining term earlier in the statute but it's basically that's health insurance plans and to be clear there's no report to our committee or any other committee this is this is data right the second section is a prior authorization report this would say that by January 15th DFR in consultation with health insurers and health care provider associations would report to this committee senate health and welfare incentive finance and the green mountain care board opportunities to increase the use of real-time decision support tools embedded in electronic health records to complete prior authorization requests for imaging and pharmacy services including options that minimize costs for both health care providers and health insurance section C is a report on prior authorization in the context of the health care model this would direct the green mountain care board in consultation with diva the acos payers participating in the all-payer model health care providers and other interested stakeholders to evaluate opportunities for and obstacles to aligning and reducing prior authorization requirements under the all-payer model as an incentive to increase scale as well as potential opportunities to waive additional medicare administrative requirements in the future and that report the results of the evaluation would be submitted to this committee and the senate committees by January 15th section D also by January 15th each health insurer with more than 1,000 covered lives in this state for major medical health insurance must implement a pilot program that automatically exempts from or streamlines certain prior authorization requirements for a subset of health care participating health care providers some of whom shall be primary care providers this exemption or streamlining is is sometimes called gold cardings i'll put that in the section heading but not actually in the language each insurer must make available electronically including on a publicly available website details about its prior authorization exemption or streamlining program including the medical procedures or tests that are exempt from or have streamlined prior authorization requirements for providers to qualify for the program the criteria for health care provider qualified for the program the number of health care providers who are eligible for the program including their specialties and the percentage to our primary care providers and whom to contact for questions about the program or about determining a provider's eligibility for the program and then by January 15th 2022 each health insurer who was required to implement the program of pilot would report to this committee the senate committees and the green mountain care board the results of the pilot program including an analysis of the costs and savings prospects for the insurer continuing or expanding the program feedback the insurer received about the program from the health care provider community and an assessment of the administrative costs to the health insurer of administering and implementing prior authorization requirements and finally whoops and i codified this that i shouldn't have this would just be another report this would say that on or before september 30th of this year the department of access would provide findings and recommendations to the committee the senate committees and the green mountain care board regarding prior authorization requirements in the vermont medicaid program including a description and evaluation of the outcomes of the prior authorization waiver pilot program for medicaid beneficiaries attributed to the vermont medicaid next generation aco model for each service for which vermont medicaid requires prior authorization the denial rate for prior authorization requests and the potential for harm in the absence of a prior authorization should say requirement be based on information provided under subdivision a the services for which the department would consider waiving the prior authorization requirement the results of the department's current efforts to engage with health care providers and medicaid beneficiaries to determine the burdens and consequences of the medicaid prior authorization requirements and the providers and beneficiaries recommendations for modifications to those requirements the potential to implement systems that would streamline prior authorization processes for the services for which it would be appropriate for the focus on reducing the burdens on providers patients and the department which state and federal approvals would be needed in order to make proposed changes to the medicaid prior authorization requirements opportunities to expand the pilot program created pursuant to 33 vsa section 1999 to exempt prescribers from the prior authorization requirement of the preferred drug list program if the provider meets certain compliance standards and the potential for aligning prior authorization requirements the cross payers any questions for them is there any mechanism in this process for adding new things to prior authorization i don't know that there's anything in this process but i think that's something that i think that's been the providers subject to our existing laws already have the authority to do much jesse barnard with the vermont medical society and thank you to the committee for giving us a couple weeks to work on this i think um it's really come together it's to me this work has highlighted that administrative burden is multifaceted and we can't solve it with one approach so while in some ways this is a little the gold card piece of what we started with a couple weeks ago has been a little bit narrowed in scope in general i think actually it's a lot broader in scope and it's looking at a number of ways in which we can reduce administrative burden on providers which is what i really like about where this has landed because gold carding may solve the issue or reduce the issue for some providers it doesn't address other issues like alignment between payers or opportunities to expand programs under all payer model or increase alignment under all payers so i think i feel really positive and encouraged about where this is going and the the collaborative work with all the folks involved on this so we are very supportive gen really walked through the details so i don't know that i need to repeat much of what she said i'll just say that one of the pieces that is sort of new is the the piece about is section b under the electronic health records and what that that is so those are electronic tools that basically embed the prior authorization process in the provider's electronic health record so that while you're documenting the diagnosis or what you're ordering it sort of automatically can also process whether our PA is needed or give you that approval so embedded within your EHR and what i think is so promising about that is there are areas where we may have less opportunity fewer opportunities either all under all payer or the gold cards to waive prior authorization for example around pharmacy i think at least for the foreseeable future we're probably going to have pharmacy prior authorization and this is a way that it streamlines that administrative burden on the provider for doing it we know there are costs associated with that to providers they may have to update their EHR so that may be something that's only able to be rolled out over time but hopefully this will give us some more information about what those opportunities and costs may be under section b the gold card pilot we're also excited about so the intent is to basically capture for example what Blue Cross is already doing they just told you about a couple weeks ago their new programs so that would for example count as one of these pilots and then asking other payers to do that as well and report back what they're learning from that and if that gives them opportunities to expand gold card further and then i'm really i really appreciate the work with diva on the report they're doing because that's going to look at their all the waiver they're doing and i think you can hear more from them under the all payer model and taking what they learn from that to both see whether they can expand that waiver or expand their existing gold card program so you may they have a pretty small gold card program now but as they learn kind of where the costs and benefits of prior authorization are they are open to taking that information to inform expansions of their gold card program so again from the provider perspective it's you know it's definitely a number of steps in the right direction to get us the information we need and and try to start reducing some of the events you're so thank you i'm happy to answer any questions um i guess i was curious if you could talk a little more i know the original proposal one of the reasons why it was appealing to providers was that they wouldn't have to be dealing with a different system for each insurer the original original proposal of the 90 percent approval rating you know one of the like i my impression was that one of the reasons it was appealing was that providers would know whether or not they were gold carded without having potentially a different answer for each insurer is that i just i don't think that's necessarily the case which is one of the limitations of a gold card program at least the way we've been thinking about it or talking about it with this committee before is that we always intended that each payer could come up with their own gold card program so then you could still end up with three four or five gold card programs and so you may qualify under one but not another or certain types of providers or procedures may be exempt under one but not another so that's actually where some of these elements came in around alignment is that that's only that only goes so far to help if you're exempt for one payer but not the other three or four that you work with regularly it actually does not help reduce your overall working that's very hard to integrate into your workflow because then each time you need to figure out which insurer the patient has and if you are exempt or not and so that's kind of actually one of the things that i think diva has been learning over time and one care has been learning with their pilot waiver is that depending how you structure it if it's just as hard to verify whether you qualify for the waiver it's not really reducing your administrative burden so how can we really try to get the payers as aligned as possible i'm going to take a gold card program maybe more limited in that regard than looking at which directions can we go under the all-payer waiver which already and you can hear from the green mountain care board but already requires or cms already wants the state to be looking at alignment and reporting on opportunities for alignment under the program so you know again it's not a it's not a one-size-fits-all solution there are a number of different components of this kind of getting at the issue from different angles so just just because this language is i think somewhat new to all of us can you point can you help me see where in the language it's talking about alignment and they're just going to help point me to sure yeah so there are a couple places under section c that's asking the green mountain care board to consult with the aco payers health care providers and other stakeholders and evaluate opportunities for aligning and reducing prior authorization requirements under the all-payer model as well as potential opportunities to have additional medicare administrative requirements so you again you can hear more from the board but they are already my understanding is they already do some alignment assessment and this would kind of be building off of that specifically around prior authorization and whether we look to divas waiver as a model or other models of how can we um either wave or streamline prior authorization requirements um and then the other it's also mentioned actually under divas report a little bit too is looking at um so that's section e looking at their current waiver under um so it's asking them to provide a description evaluation of the outcomes of their prior authorization waiver pilot program under the next gen aco model and then at the towards the end they reference potential for aligning prior authorization requirements across the payers under seven yeah so i mean so this this gold card pilot program in this language is no it's not a step is it true that it's not a step backwards from the original 90% gold card proposal as far as the alignment specifically is concerned i think that yes i mean i guess i would say it would if it had truly been a 90% that and at least what the payers testified is that that's a large number of their providers so truly if you exempt most providers from all prior authorization from all payers then that would be consistent but i think we heard that that's really not feasible at this time so if you're looking at small what most gold cards are a much smaller percent exempt um you know really gold carding is to get at the highest performing you could call it providers who are approved at a very you know what whatever it may be 98% um rate so maybe you're you're getting it five ten you know percent of your providers who qualify so if it's a small percent or sort of the top performing only and then plans are developing their kind of own pilots their own programs to look at it you could get a different five or ten percent and under each of those programs and then you don't have an alignment that's really helpful to understand yeah yeah for any other questions for jesson great thank you sure thank you so now that we want to cut anyone short but there is another meeting happening at 11 30 so we'll need to be done a couple minutes before that um so just be aware of that with the number of people that we have good morning lisha cooper director of payment reform reimbursement and rate setting for the department of remote health access diva is supportive of the language as just reviewed and we wanted to use our testimony this morning to provide a little bit more context for the reporting that was described for diva in section e of the legislation has been drafted in 2017 diva executed a contract with one care vermont for the vermont medicaid next generation aco program we've had the opportunity to talk a bit about that program with this committee in the today i'll speak specifically about the labor prior authorization within that program because our contract with one care stipulated that diva would pay one care and agreed upon price for the cost of medical care for attributed medicaid members and because the network of aco providers was assuming financial risk for services in a way that providers had not assumed risk previously diva and one care agreed at that point in time to begin testing a waiver of prior authorization for those services for attributed members the goals of doing so were to reduce administrative burden for providers and practices and to empower providers to follow best clinical practice and to determine appropriate care for their patients without that additional layer of payer review as a result we began our waiver of prior authorizations in 2017 which was the first year of our aco contract as it was constructed in this first year three criteria had to be in place in order for the waiver of prior authorization to be in effect the first was that a provider had to be participating in one care's network the second was that the medicaid member had to be attributed to the aco and the third was that the service was one for which the aco was assuming that financial accountability as we were implementing this in 2017 we learned from the aco and their network of providers that this approach had a number of limitations and the most pronounced limitation at that time was that having the waiver of prior authorization only available to providers that were participating in the aco's network meant that there were implications for referral patterns as you may recall in 2017 the medicaid program had four provider communities participating and so to the extent a provider for instance in burlington wanted to do some sort of referral to a provider that was outside one of those four communities they would still have to go through the prior authorization process in conjunction with the provider that would ultimately be performing that service and so there wasn't necessarily that reduction in administrative burden comprehensively it was very specific to the providers that would be performing the service so with that feedback we made some adjustments to our prior authorization waiver for the 2018 performance here and we brought into the criteria so at that point in time the only criteria that were in place were that the member had to be attributed to the aco and that the service was part of the aco's financial accountability this therefore extended the waiver of prior authorization to every medicaid enrolled provider regardless of their participation in the aco's network part of our interesting learning from going into this stage of our waiver was that when the waiver was specific to the aco network with providers we could work with the aco on communication about what the waiver of prior authorization was and when it was in effect as soon as it was available to all of our medicaid providers we had a lot of very skeptical providers who were hearing that a prior authorization wasn't necessary for a particular member and service and they said we don't believe you can you send us a letter that says that we don't need it so that if your claim doesn't pay we can come back to you with this and so we had to do some more focused work in 2018 on broader provider education i think that was ultimately successful but but it took a while for for the whole scope of medicaid providers to understand how to interact with the waiver of prior authorization another thing that we looked at in 2018 was making a more clear distinction between prior authorizations for the purpose of traditional utilization management as payers will employ and the use of prior authorization to ensure that there's clinical review of requests that relate specifically to patient care and safety the reason we wanted to have that conversation at that point in time as we were evolving our waiver of prior authorization is because at the end of the day even though we're contracting with one care diva continues to have responsibility for the care and safety of all of our medicaid enrolled members regardless of their aco attribution status and so at this point in time we made a few adjustments to our waiver prior authorization whereby diva continued to perform clinical review for things that could result in adverse consequences for a member if that clinical review did not occur and good examples of these are often in the area of complex durable medical equipment so for instance medicaid requires prior authorizations when a medicaid member needs a complex wheelchair for example if there isn't that level of clinical review in identifying which wheelchair is appropriate for the member and making sure that it's appropriately fitted to that specific member there's the potential for someone to get an item or piece of equipment that's not suited to them that could result in harm down the road and so we do have at this point in time a few exceptions to our waiver of prior authorization that relate to these patient care and safety considerations so we've continued to operationalize the waiver of prior authorization from 2018 through the present with those modifications that were made in 2018 but we recognize that that's not the end of the road we've continued to hear feedback from providers that I think this was just mentioned in justice testimony that while there is some benefit in having a waiver of prior authorization for an increasing number of medicaid members that doesn't help when a particular provider has some members in their panel who are attributed to the aco and others who are not because then their workflow has to contemplate consulting a list to know which member is attributed they also have to know which services are eligible for the waiver of prior authorization which aren't and so as a result of that diva is actively exploring payer level modifications to prior authorization requirements based on our learnings from the waiver of prior authorization through the aco program the goal would be we would move away from an aco program specific waiver of prior authorization and toward a broader set of rules that are less restrictive than those that medicaid has had in the past and so that's the work that would be described in the report that is contemplated by section b and then on my last slide I just have a quick summary so in 2017 we had our more narrow definition we've moved to a slightly broader definition for 2018 through 2020 and we're doing this analysis about how we could change operations going forward the graph on the bottom of the slide shows I think this is helpful as well the number of unique medicaid beneficiaries for whom the waiver of prior authorization applies over time so we are going from 2016 when we did not have a waiver in place to 2020 where approximately 114 000 medicaid beneficiaries have the waiver in place for them so we do still have this waiver active through our aco program and it's affecting a pretty significant number of our medicaid members but in the meantime we are looking to make some of those broader changes going forward thank you can you just remind us of the total number of medicare beneficiaries i'm sorry medicaid thank you certainly i believe our total number i want to tell you a number that's not right but i believe so 114 000 who are attributed represent approximately 85 percent of our full medicaid benefits membership anyone else thank you very much sarah i think um sarah teach out with the cross and boost shield of brahman um and i worked i testified a several weeks ago on our provider passport program and i worked with bms and the others in this group to come up with this language and we support what you have now okay any questions i know you're trying to know yes susan gertowski mvp health care um mvp can live with the language i would like to thank representative houghton for working with all the stakeholders to get us to this point so thank you very much thank you thank you okay see you next all right you make it shorter susan barrett executive director of greenham care board i also support the language in the higher authorization what is it bill proposal um and i just want to say that back in 2018 the board sent a letter to the legislature regarding administrative burden on providers and particularly focused on prior authorization so um we at the board want to thank you for taking up my request to look at this and for making some proposals on this important issue and so my board will be very happy to hear that this is being done thank you thank you any questions okay thank you discussion and i just want to say how absolutely ecstatic i am at the word you're able to glory this has been such a high priority well and everybody else i mean it it has been such a high priority for me for so long in terms of admit all of the reasons and i was at the point where i was quite discouraged because of the you know the conflict between us trying to say do this and other people doing other things and you know never the twain shall meet and you make them meet everyone working together so it's just um thrilled lucy um yeah i wanted to echo that i'm very very happy for all the work that's i'm very appreciative of all the work that's been done um by representative houghton and the stakeholders and excited to hopefully move forward on something this year i also i think i just i also want to express frustration that we're unable to move forward on something more complete and i just wanted to share a reflection with the committee which is um we representative houghton and i were forward a met forwarded a membo that the university of vermont health network had sent the green mountain care board in uh last summer where they tried to just capture let's get a sense of the scale of how much time it's causing us to go through prior authorization and they came up with a number just for the university of vermont health network not including other hospitals not including physicians or providers who aren't with hospitals that they've retained 44 full-time equivalent employees for prior authorization work and that's on the that's on the hospital side of it that's you can imagine maybe a reflection of a similar amount of time on the other side of it and so i just did some very very rough not accurate just very rough like what's the order of magnitude of money we're talking about making a guess at salaries and came up that we're in the range of just from the uvm health network side of it who are in the range of a few million i got four and a half million dollars and just i just wanted to put that number into context with the testimony we heard from blue cross blue shield that they think they save about seven to eight million dollars a year so if we if we double it and we say if that's on the uvm side if that's on the uvm side you know if we double it and we say okay there's a person on both end just through the uvm health network we're talking the same order of magnitude as the money we're saving and it just is deeply frustrating to me given our workforce issues that we have 44 full-time equivalents working on something that potentially is costing us more money and not saving us money so i'm very appreciative of the step forward and also feel the need to express frustration that is not a bigger step okay so let me just speak to our own process from the forward it sounds like there's a support for the language of this proposal i think what i might might do at this point is simply ask for a strong hold of the committee for support of this and then we will come back to each each element this would be one of the elements in what currently calling miscellaneous health care bill from our committee to take to the floor so uh folks prepare the comfortable we're doing a strong goal just to kind of be able to put that forward so i would ask uh for those who committee members present in the room who are uh want to prepare to support this language as one element of the miscellaneous health care bill by show hands they let the record show that all 10 members present support the inclusion of this in uh my hand is up he can vote straw fault straw fault so as you name it all 11 members the voice from the center okay and again let me also express my appreciation uh glory for helping to move this forward to all the stakeholders and i think the blue blue look forward to achieving the longer-range role which represent rogers is particularly particularly as well i think there's a high level this i would just reiterate from i think from the first day practically of becoming the chair of this committee this has been a repeated uh drum beat of uh from providers and when we talked about supporting primary care physicians uh there's the repeated and ongoing uh plea to reduce administrative burden instead actually part of your burden yes yes so so we we do uh simultaneously acknowledge the pressure uh on the health care system and the need to move forward in a manner that moves the whole system forward so hopefully this this will uh make a significant move forward so with that i'm going to uh let me just see we have scheduled at 11 30 we need to take some next steps as the work group on the workforce so i think uh i think there's anything else that we need to do before we adjourn over the morning uh we're on the floor this afternoon David will be doing 30 oh i know a couple of knowledge that's uh there were at least one of our colleagues i've reached out with some questions about the uh medical practice board bill lucy thank you for doing some research i want David to work against something else and we're going to give feedback to that member hopefully that will not require some interrogation on the floor that's a lot of necessary interrogation on the floor uh podiatrists asking if it was about the podiatrists we were considering interrogating David to understand why it's the board of medical practice and podiatry we might let it go but you might want to consider letting it go the chair has spoken and lori has been on uh on the hotel health bill uh so just a two second report that we um the affordability group has made significant progress on the proposal to present uh there's language that's being redrafted and whenever we can fit it in our schedule we can present that okay and uh let me again say looking ahead to tomorrow's schedule in the same way that we have to modify today's schedule i don't know that we'll post a revised agenda but you just need to understand that we are going to be putting both the affordability issue back on the agenda we're going to be uh looking at other elements of the health care miscellaneous bill uh we will be talking about some language on the description for our data and um we'll just do our best to folks who are stakeholders of a particular group will try to keep you advised but you i encourage you to stay in communication with us as well we do our best to let you know what we're doing now but we have a lot to cover a lot of ground to cover and i think we'll cover it the next day okay so let's adjourn