 Good morning, everyone. This is Senate Health and Welfare Committee meeting. It is January 20th, and this morning we are looking at Medicaid a little bit with our experts in that area, Nolan-Winewell, and Ashley Berliner, and I'll let you each introduce yourself, and then we'll hear your testimony, your information. It's not really, it is testimony, but it's really critical. Great. For the record, Nolan-Winewell, do you want to go to the office? So I invited Ashley to do this with me for the third time for multiple reasons. One is she's the expert on a lot of what we're going to be talking about, but also like I think it's really good for folks to start seeing who the brilliant people are behind the mail. They're doing a lot of the work of things that make them up-tick. I'm going to share my screen, and I'll also say that, you know, I think after today, I think you'll be done with me for a little while in terms of bombarding you with information, and I'm sure you'll be thankful for that. But we'll have you back before everything we don't do. Yeah. The other thing I want to say is like I have a bunch of slides from the beginning. I'm going to go through them really, really quickly. A lot of it's repeat, and it's also me telling the story. But also what's also happened is the global commitment stuff is towards the end, and that's the stuff I really want you to hear about. Okay. So I want to kind of tell you a quick story to get you there, to make sure you have enough time, that there's enough time for Ashley to walk you through global commitment and for the big questions. So if you have questions, I would ask that we keep them clear. All right, we'll hold, unless it's a clarification of what's there, why don't we hold the questions and, you know, write right down here. So we really want to get the global commitment. Good. But I'm going to get there quickly. So if I go and write your question now, we can revisit it. There's time at the end. Sure. So again, this is meant to be a high-level overview of global commitment. So I start by just showing you again, here's our here's our chart that you've seen before. We're going to be talking about that 24% of Vermont things, the Medicaid piece. Again, I've told you the reason I threw this in here is I was telling you the story, if you remember, of how, you know, it used to be in 2008, 30% of Vermonters had some form of government coverage. And now in 2021, 45%. So we've seen a shift. You've seen the Medicaid numbers go from 16% of Vermonters to 24% of Vermonters between 2008 and 2021. This one you can ask, well, don't ask too much questions about this, but high-level, you know, Medicare and Medicaid, there's a difference between them. And they're easily confused because their names are both so close together and they cover a lot of the same stuff. So I've been doing this for this third time I've done it and every time someone has sent me some kind of like little trick like, oh, this is how we remember it. So my favorite though, I think it was Representative Goldman, she said, remember Medicare ends in E for elderly, but that's somehow a center. So I like that. Mostly elderly. That's some disaster. It's 55, I think you come on, quite elderly, but I'm not 55 yet, so I'm only 29. And so the difference is Medicaid is state and federal program. Medicare is federal only. So we do not have any influence, say, or whatever over Medicare. We only control Medicaid if we're staying under through the state budget. Medicaid is for low income, it's for children and adults, 65 older, blind or disabled. Medicare is all incomes, it's just 65 or older. Or any age with end state renal disease, or if you have certain disabilities and you're under 65, you could be out. But most importantly, the thing to remember, I think, is that Medicaid is a thing that we have some influence. The budget of Medicare is federal and that's out of our hands. So a real background, Medicaid started in 1965. It's a public health program for low income individuals with families and individuals with disabilities. Again, it's financed through a federal state partnership, but administered by the states. And I'll give you a little bit more details in a few slides here. Each state's designs operates its own program with broad federal guidelines. And there's this joke, and you heard me still as a joke, and I think that after you hear the global commitment talk, after actually this little line will make more sense and it will be funnier. But if you've seen one Medicaid program, well, then you've seen one Medicaid program. I think that's hilarious. You don't yet, but you will probably. And that doesn't work, I'll tell you what I'm actually saying, because this is our seventh time here in this country. Nationwide, there's 90 million folks who are on Medicaid in Vermont. The number 208,000 Vermont has received some form of Medicaid assistance. Again, I think I talked about this last time, there's some form of assistance versus those who are on Medicaid. One third of folks have assistance, but a quarter are on as a primary. So of that 208,000, 163,000 have as a primary. And the rest are some form of like pre-assistance or prescription drugs, et cetera. So eligibility, when I think about eligibility, I think about, or when I think of coverage, I think is who is covered and what is covered. So for the who, in order to qualify, you have to be a Vermont resident. You have to be US citizen, permanent resident or non-citizen with lawful presence. Your financial situation will be characterized as low income or very low income and be one of the following. Pregnant, responsible for a child, 18 years old or younger. Blind, have a disability or a family caretaker of someone with a disability. Or 65, eight years of age or older. And when we talk about benefits, I don't think I've put that chart in there. I have another chart that I did not put in this particular presentation. But it just shows what we have, mandatory benefits that we have to cover. And then there's optional, that comes from a manual, things that we don't have to cover what we do. In the previous presentation, I had that list. The one I gave you earlier, on the one side there was those that we have to cover and then there's those that we don't have to cover. I think we might have this conversation. I think, yeah, we have it on our side. That's right. So spending, again, no, this slide you've seen before, but again, like to tell the story, kind of repetition is good. So that 24% of Vermonters is 27% of our total spending. We spend about 6.3 billion dollars on healthcare. This is a 2020 number, we don't have a 2022 number yet. But 27% of that was for Medicaid spending. State budget, again, I think I've shared this slide with you in the bigger presentation, but Medicaid is a huge part of our budget after Pre-K. Pre-K is the biggest. But Medicaid is a close second. But then when you look at the state, from our federal, so the blue is state dollars, the orange is federal dollars. And so for federal, we get the most amount of our federal dollars from poor Medicaid. It's not Pre-K, it's K-12. No, I didn't make this slide. It says Pre-K through 12. Oh, it says P-K through 12. P-K 12. Yeah, yeah, sorry. Thank you very much. Overall Medicaid expenditure is 1.9 billion. It's funded through a combination of state and federal dollars. Overall, across the board, we get federal match for different pieces. I'll get into the mechanics of that, but roughly 70% of our Medicaid program are federal dollars. That's a huge amount. A lot of that is through matching dollars and this thing called FMAP. You're going to hear a lot about FMAP when you hear from the budget adjustment and the budget. And basically, it stands for Federal Medical Assistance Percentage. And there's multiple FMAPs for different programs and for different populations. But ultimately, it's the percentage that the federal government pays for a particular program or for a particular population. We do not determine FMAP. FMAP is determined by the federal government on an annual basis. It's calculated on a three-year average of state per capita personal income compared to the national average. And then there's limitations. No state can receive less than 50% or more than 83%. So for instance, states with high per capita income are all around 50%. They can't go below 50%. The federal government will always match at least 50 or more. California, Asia, Colorado, Asia, Connecticut. And then you have your states that have not as great of a state per capita income. Mississippi, you can see they have a very high app now, 77%. We have multiple FMAP, but the majority of our FMAP, our basic FMAP is around 56.75%. That's the federal share. Additionally, states are also receiving a 6.2% bump in FMAP as part of the Federal Families First Coronavirus Response Act. That is the recent, and Ashley can talk more to this, but the recent federal legislation began the unwinding of that. And we will start to see that FMAP decrease and eventually disappear. But tied to that is this thing called maintenance of effort or eligibility, MOE. And basically what this says is that during this time that we're getting this additional FMAP, we cannot change eligibility standards or take people off or do as known as redetermination. So redeterminations, and you're going to hear about this when you hear about budget adjustment. Basically redetermination is a process by which, maybe we talked about it here, I can't remember, but if you think about coming in and coming out of the program. So you have people, eligibility is determined for people to be in the program and then they're redetermined to see if they're still eligible for this program. So normally we have this thing called CHERP, where people come into the program and then each year of redetermining some stay, some leave, and our Medicaid populations continue to increase over time. That's because the amount of people coming in has been greater than the amount of people coming out. Well, because of this particular benefit right now, we also can't do redeterminations, which means that people are coming on in the program, but they're not coming out. So we're seeing a spike in enrollment, and you'll see that. And in budget adjustment, but the flip side is we're also getting federal match dollars to help pay for that as well. So, and I think when you hear the budget conversation, we won't get into the mechanics of the federal bill that's going to unwind that, but that'll be part of the conversation when you hear about the budget, when eventually the minister should come in and talk to you about what's in the budget and the numbers. But that's a big piece that's also driving our budget adjustment. So when you hear about redetermination, or churn, or why our Medicaid populations are so high right now, that's a big piece of it. We also have enhanced F-maps, and these are for our expansion populations. So we have multiple F-maps. We have our regular F-maps, which is the majority of our program. We have children's health insurance program, which is a subset of our, it's a federal program, but as we administer as part of our Dr. Dinosaur program, which is our Medicaid children's program, but we get a special F-map for that particular group, and that's 4,700 kids. And another F-map we have is for children, that was known as childless adults. And don't let the name fool you, or childless new adults. They're not new, but the title is kind of deceiving, but it's 47,000 childless adults for which we get this 90-10 match. So, and I'll walk through these again, but basically, in short, you know, F-map is, you know, essentially for every dollar we spend, 56.52 cents, our federal and 43 cents are state, or roughly every dollar we spend on Medicaid or state dollar, we're getting $2.30 worth of program. So we're going to put a dollar and the federal matching is $1.30, and we're getting $2.30 worth of program. The flip side is, in the not so, in the years where we've had less, more economic difficulties, and your predecessors had to look at cutting services or finding money, when you cut a dollar, a state dollar in the Medicaid program, you lose $2.30 in services. So it's a double-edged sword. Again, we get this, we have this roughly 70-30 for the Children's Health Insurance program, and this 90-10, it was part of the Affordable Care Act. And when it first came out, we were at 80-20, and then you have states that were, I think they called them the do-gooder states, that were already doing expansions. They were getting 80-20 in this population, and the states that were not doing anything like Mississippi were getting 100% federal match on these votes. And then over a period of five or six years, everybody worked down to 90-10, or at 90-10 for this particular population now, or in perpetuity. But it's been helpful because there's a lot of people in this population. And this does not include the 6.2. This is the base, and then you would add the 6.2. The 6.2 is additive to the regular math maps. You would add a 6.2 to the 56.52. We don't get the 6.2 on the childless adults. And then for the children, it's kind of embedded in the formula. So you wouldn't add 6.2. It's more like embedded into the population, so it's a little different. But not to get too much in the weeds. FMAP is an important part of how we fund our Medicaid program. This slide I like because it shows you the cyclical cycle. So there is a correlation between economic well-being of the state and FMAP, because it's tied to, it's a more complicated format, but ultimately it is the three-year average of per capita relative to the other states. So when our per capita, when our FMAP goes up, we're like, right, we're getting all this extra federal dollars. You know, our FMAP goes up by, you know, 6%. That's $22 million a quarter. It's $80 million a year. It usually goes up by .01 or .02, but that can translate to $3 or $4.5 million. The flip side is when our FMAP goes down, it might cost, you know, three or four, ten million dollars extra to maintain the same level of service for the same population. But the flip side is what I would think about is if our FMAP is going down, which is a bad thing for our state budget, it's one of many sides that means that our per capita income has increased a little bit. So there's that sort of thing to think about. It's a bellwether, but not necessarily a complete sign. So you can see that there's like a trend. So the gray years where our FMAP decreased, and the way it's more increased, so you can see it's kind of done this through the years. And I tried to look at like the relationship between those and recessions, and there is a correlation, not a very strong correlation, but there is a correlation. All right, we've glued through that quickly, but now I'm going to pass the mic over to Ashley Berliner to talk to you about global commitment. Oh, good. That is terrific. And you know, a lot of, we already have a lot of this on your other slides, but it's so good to hear it again. Yeah, and you probably won't have a lot of questions about it, so I want to make sure there's time. I have too. Thank you. It looks like it's on. So the global commitment to health is what our mom called in 2015. Oh, wait. Ashley. Yes. Is there a way that you could improve your sound? It's a little bit garbled. Is this better? It is a little bit is better. Sorry about that. Let me know if you're losing me again. So the global commitment to health is what Vermont has called it's 1115 demonstration waiver, which is an agreement between a state and CMS. Ashley. Yes. The sound is deteriorates when you start to talk. Okay, let me try something else. Okay. Yeah, I think the closer you are to your microphone, the better it will be. Try again. Is this okay? Still not. Worse. Okay. How about this? I guess if you talk really loudly at work. Yeah, talk loudly and slowly and then we'll be okay. Okay. Can you hear me? Yeah. Is that good? Go. All right. If you start, if you start going too fast or it gets worse, we'll stop again. But you'll please go ahead. Let me try one more thing. I'll try corded headphones. Some for Medicare and medical services. Can you hear me? Yes. We can hear you. Is this better? Yes. All right. Okay. So take five. Global commitment to health. That is what Vermont has called its 1115 demonstration waiver, which is an agreement between a state and the centers for Medicare and Medicaid services CMS to administer. Parts of a Medicaid program. So back to Nolan's hilarious joke about if you've seen one, one state Medicaid program, you've seen one state Medicaid program. Every, I would say, I think it's a 47 or 48, it fluctuates, have an 1115 demonstration waiver. They're all called different things in Vermont. It's global commitment. Most states have a very tiny portion of their Medicaid program under their 1115 waiver. In Vermont, our entire Medicaid program, every six months, with the exception of dish payments, funny enough, is under our 1115 waiver. And so what that means is, A, Vermont's extremely unique. And B, we are able to waive certain provisions of federal law related to Medicaid and how it's administered to give Vermont additional flexibility. And carrying out and operationalizing the Medicaid program without the global commitment waiver, we would be limited to what CMS approves in a state plan. And we would have to be in strictly in compliance with Medicaid regulations, either fee for service or managed care. And so we would be able to waive certain provisions of federal law related to Medicaid and how it's administered to give Vermont additional flexibility and. Carrying out and operationalizing the Medicaid program. And we would be able to waive certain provisions of federal law related to fee for service or managed care. So one of the key aspects of any 1115 waiver in any state is that it must be budget control for the federal government. So you can't spend more with a waiver than you would have spent without a waiver. In Vermont, an 1115 waiver or global commitment waiver has existed since 2005. Since that time, it has existed since 2005. It has existed since 2005. It has existed since 2005. So we used to have two 1115s. Now we have one. And it really does two big things for the states. It gives us additional money. Federal dollars that we wouldn't otherwise have. And it gives us additional flexibility to administer the Medicaid program in a way we otherwise couldn't. So on the money side, we get federal funds, and here's a not exhaustive list, but the marketplace subsidy in Vermont premium assistance for individuals buying qualified health plans on the exchange. The community rehabilitation and treatment program, which is a supplemental insurance product for individuals with severe mental illness, providing that above Medicaid limits. V farm pharmacy assistance for elderly Vermonters who are on Medicare, which is a full prescription wraparound service. It provides the same prescription coverage as individuals on Medicaid for those at higher income on Medicare. Choices for care, moderate needs, global commitment, investment, institution for mental disease payments in Vermont. That is for, we have three specific psychiatric institutions, the Brattleboro retreat, Vermont psychiatric care hospital in London home. And then we have several other substance use disorder residential treatments that qualifies institutions of mental disease that we wouldn't be able to pay for without our waiver. And in Vermont, there's a real error. Sorry. And in federal law, there's a really obscure regulation from the 60s that prohibits Medicaid from paying for any institution over 16 beds that focuses on the treatment of mental illness or substance use disorder. And so I'm, I'm sure some of you have been here for a long time have heard about the IMD phase down and IZ IMD exclusion. And so our waiver is what allows us to pay for, for those facilities. We also have cost effective alternative authority to be able to pay for services that aren't typically Medicaid covered by our cost effective. So an example I always use is something like acupuncture in, which is potentially cost effective over something like back surgery. When we can think about more innovative lower cost interventions for people where Medicaid wouldn't traditionally cover it. We have the flexibility to, if it's been proven effective. We also pay for palliative care services for children above income who are at end of life substance use disorder coverage above Medicaid limits and permanent supportive housing services. Those last two with the asterisks are newly authorized under the amendment that was approved in July of 2022. And so we're in the middle of plan design and thinking through how to turn those benefits on and operationalize them. They're not currently available to any of our mentors, but we're, we're working really diligently to stand those up and make sure that they're available by 2025. So I'll stop there. I know that's a lot on just the money. Do you have any questions before I move on to the flexibility or do you want to hold questions to the end? That's up to you, Ashley, whichever you prefer. I'm happy to hear questions about the, the financial participation from the feds. If you have any on those top bullets. Okay. We're good. Okay. Oh, wait, sorry. Go back. On the flexibility side. We are able to administer Medicaid using a really unique model, which is in Vermont, what we call a public managed care model. We're the only state in the country that does this. Most states. Contract with an etna or a Kaiser to administer their Medicaid program. Some states have 30 different managed care products and services. Some states have 30 different plans and Vermont, instead of contracting with a for profit managed care or non-profit managed care. Organization, we actually contract as a chess. We contract with the department of Vermont health access to be our public managed care plan. That allows us to take advantage of federal managed care flexibilities. It allows us to make payments outside of what CMS would do. We are able to operate our designated agency system and home health agency system because of a state wideness waiver. We're allowed to have wait lists on the moderate needs population for choices for care. And we're allowed to limit amount duration and scope to only be provided to certain populations. So things like respite or case management services, you must meet a certain clinical threshold to receive those services. We're also able to waive the upper payment limit, which is a federal provision that says, for certain categories of service, Medicaid can never pay more than Medicare can pay. This has been particularly useful in Vermont over the past couple of years as we're paying significantly more than Medicare pays for inpatient hospitals, which is a broad category of service. If you're looking at any individual code, it might be higher for Medicare than Medicaid, but as an aggregate, that's what the upper payment limit looks at. And we're paying significantly higher for inpatient hospitals than Medicare pays as a program. And that's largely due to the significant amount of funding being provided to Brattleboro Retreat. So if I could just interject really quick. This is a lot of information we just threw at you. And the way that I helped get my head around it when I first understood it, and granted it's changed since then, but as you know, a managed care organization, a traditional managed care organization would be an operator where someone would hire you, hire them and manage care. The idea is that if they can manage the population and keep the costs down, doubt savings is profitable. What we're doing is we are paying ourselves AHS is higher diva as a managed care entity. That's the logistics of how it works. But ultimately those savings that would be achieved instead are being able to use for all of these other things that we'll be able to reinvest in the population and do these other things. And that's where the flexibility comes in. And the federal government just says as long as you don't spend more than you would have in the absence of the waiver, you can do these other things without mission within these guidelines and under these terms and conditions. And that's what the big negotiations are about. And that's what cash is. So that's, I don't know if that helps, but that helped me understand it when I first. Thanks, Naline. Move to the next slide. So this is kind of a different visualization of the top bullets on the previous slide, which just shows you our Medicaid populations, how they are eligible. So the first teal box at the top are folks that would be eligible for Medicaid with or without our waiver. Some of these are optional groups. Some of them are mandatory, but most states cover these categories up to some federal poverty limit in Vermont. We have a particularly high federal poverty limit for children under 19 and pregnant women. But these are pretty basic Medicaid categories. Then in the purple, we have our home and community-based services for certain populations. So these are choices for care, developmental disabilities, children with severe emotional disturbance and people with traumatic brain injury. Again, these individuals would be eligible with or without our waiver. They're eligible for comprehensive health coverage. So everything that the folks above have, the full state plan benefit, and then they're also eligible for an additional array of home and community-based services. So things like supportive employment, respite, case management, to help them be out in the community and in their homes rather than in an institution. And everything that the feds have done around this purple group, this home and community-based services, is about taking away the institutional bias and figuring out how to keep people out of nursing homes, out of institutions and in their home and in their community. And then the last two boxes, or categories of boxes, the with waiver only, these are things that we are only able to pay for because of our 1115 waiver. And again, it's the VFARM program, the marketplace subsidies, moderate needs, community rehabilitation treatment, and then our investments, our IMD payments, cost-effective alternatives, and palliative care under 21. Next slide, Norm. So the goals of our global commitment waiver are really about advancing the state towards population-wide comprehensive coverage, implementing innovative care models across the continuum, engaging Vermonters in their own health care, strengthening care coordination and accelerating payment reform. So we're really trying to make sure that every action we're taking at the agency around the Medicaid program has those goals in mind and are working towards moving the needles on those specific objectives. Next slide. The investments, as Nolan talked about a little bit previously, these are a broad list of individual projects and programs that have been slowly accruing over time since 2005. And that link there has a list of 67 investments from 2022 that are anything from funding 211 to paying for a portion of the public health lab to providing emergency services for uninsured to mosquito repellent on a population level, like the spraying that happens. So it's a really random list of investments. These have a lot of them were generated as a way to leverage federal funding for programs that previously were general fund only. Over the next five years, which is this next demonstration period through 2027, we're going to be really digging into this list and seeing what measures are being collected, whether they're actually achieving the goals that they were set to achieve in the cases where they are. We're going to be asking if they're scalable, if we can put more money in them to make a bigger impact, or if they're not doing anything or being as successful as we had hoped, can we pivot, can we invest in a different investment or program or intervention to help meet our objectives. So this is a real focus of the next five years where currently working with our procurement team to find some really big players in the evaluation space and are looking to have a really comprehensive evaluation and partnership so that we can dig into the investments and also to the more inherent parts of our Medicaid program to make sure that we're using data to see that we're doing what we want to do, which is improving access, improving quality and decreasing cost. So as you're talking through this and Nolan gave a really good comment about how the savings are invested going forward, there seems to be somewhat of an analogy here with the prospective savings, prospective payments that we see in the ACO and the savings there that then are distributed into the provider community. So it's like an investment into the system only in a different way. So can we think of it? I guess I shouldn't bring that up right now, but I think as you look at the ACO and look at, or the, let's not even call it, let's call it the all payer model, for value-based payments, for overall payments to providers there, theoretically makes the use of the funds efficient and so savings approved and then can be reinvested in some way to the providers in the system. That's kind of the thinking, I think, that's parallel with what we're doing in Medicaid. Yeah, I think that's right. The kind of motivation in both the investments and the way that we are paying, as a Medicaid program at least, we're paying one care at the ACO is really about, can we do this differently? Can we do it better? And if you are able to change the way you deliver care, can we reinvest in things or invest more upstream so that we can divert costs from the really high acuity interventions like hospitalizations and surgery? So I think the investments are really state-driven and the idea around the all payer models that it's provider-driven, but there's definitely a similar motivation there. This is actually a great moment for me to plug an issue brief that I wrote over the summer. It's called, it's basically Medicaid's global commitment, a primer 101, and I actually just asked Alex to post it to the website and I have a paragraph here called the relationship with the all payer model and I'm going to read a quick sentence in there and I have to quote myself, but... We love that. To quote myself. Well, global commitment and the all payer model are two separate agreements authorized by CMS. They are required by CMS to be in sync. This goes to the centerline point. According to AHS, Medicaid is the anchor payer for the APM, all payer models, sorry, with over 80% of Medicaid beneficiaries attributed to the ACO. So we attribute lives to the ACO. Further, Medicaid and global commitment play a crucial role in the state's value-based payment initiatives that are central to the success of the all payer model. That's good. That's a great sentence. Thank you. I wrote it. Yeah, I know. Actually, I wrote it. Ashley probably edited it. Well, both of you together. I mean, this is really helpful because what it does is it begins to help us synchronize all the things that we're hearing from different places. Thank you. So next slide. Sure. This is what our delivery model looks like in the state of Vermont. I don't know how interesting this particular slide is, but I think it's worth just noting the organizational structure of our waiver, which says that the agency of human services is the single state Medicaid agency who contracts with a public managed care entity. In this case, it's the department of remote health access. Diva then subcontracts through an intergovernmental agreement and IGA with all of these departments and agencies listed on the side. So Diva is the payer, but it is certainly not the program lead of all of the Medicaid program. So it subcontracts mental health. It subcontracts substance use. It subcontracts special education, aging, developmental disabilities, and then children's services. So I think it's important to just note that while Diva pays for these services, a lot of the Medicaid program is administered across the agency and in the agency of education as well. Yes, the global commitment has tentacles where it plays a piece in almost across almost every agency or department within the agency. And I think that's where you can go last slide. Okay, yeah. So this is the acronym for average use. Wow. We've never seen that before. I think this is on everything. We're good. But I think this is a good time to answer any questions that you may have. And again, I will just plug. I highly recommend that everybody takes a moment. It's two pages. It's a very high level of Medicaid. And the global commitment 101. Great. Thank you. Yeah, this is very good. But I put it on the website. Yeah. No, it's great. Yeah, that, that, that. Yes, that will be good. And we have that now. Alex, thank you for putting that out on our webpage. You bet it. Questions from the committee. I think I have weed questions. But I didn't want to emphasize. God, this has done the holiday. So, you know, I'm in the wetlands. But, um, so I might go there a little bit. The one, one I think might be helpful. And that is, there, everyone hears from time to time about a cap on global commitment. Or what is the cap? What is that cap? Can you just talk a little bit about that? I'm looking at both of you. So. So it's actually changed quite drastically as a result of our 2022 negotiations. So you're right. Previously, we were really concerned about a budget neutrality cap, which is that, that conversation about, we can never spend more than we would have spent without a web, without a waiver. And that really tied our hands in terms of thinking about new investments. And so for a really long time, there was a moratorium on investments. We weren't adding new investments. It was just like, stay the course. And we were very, you saw those thermometers where we were talking about how close we were to the budget neutrality cap. And we were quite close. As a result of our July waiver negotiation, we negotiated a really good waiver and we actually were the first state to really push CMS and changing their federal policy related to budget neutrality. And what it looks like now is we can make changes to that cap based on increases in payment rates to providers. So we're essentially held harmless for any infusion of money that we put into provider rates. Whereas previously, if we increased provider rates, that would get us closer to the cap. Now the cap just goes up at the same rate that the provider rate goes up. So that's really great. We also were able to take a lot of services that were paid for from investments into, we're now able to say that we're paying them through program and created just a lot more room generally in investments. And so now our investment cap has a lot more room. And it's why for the first time since I've worked for the Medicaid program, we're really able to think critically about those investments and think about whether there are new investments that we want to make as a state. If I can just add really quick, cap's important to pay attention to because if we go over the cap, which Ashley mentioned is the maximum amount we can spend over a time period for this program, if we go over that, we have to use pure state dollars. So we don't ever want to go over that cap. So that was very restrictive. So Ashley was just saying we have more flexibility because there's things we want to do under previous waivers like increase reimbursement rates for providers, but we couldn't do it because we were always like, oh, we're getting too close to the cap. The other thing I want to just sort of throw out there is we've been, the first global commit waiver was in 2005. And now we're in 2022 negotiating through 23, and it is just through 27. You know, and it's supposed to be budget neutral. We don't know what we would have spent in the absence of the waiver. It's been going on for almost 20 years. So it's a negotiated amount based on, you know, calculations done by CMS and AHS. And so, you know, the state pushing, you know, to make sure that we have the most generous cap is really an art versus a science at this point. So Kudos to, I would say a lot. Kudos to AHS and Ashley and the team for getting what they got in this waiver. Like, if you don't understand what we got, it's like, great, but when they got this recent one, we were all like, wow. So we were so... Yeah, I... They deserve a pat on the back. I do, and I do want to pat Ashley in particular on the back for the work that she's done. Thank you. It would be fascinating to know the process of how one gets the waiver. It's an art form. Well, every state, I think the last time I looked at it, 40 states have some form of waiver. And as Ashley mentioned, we used to have two. We're the only state that has a home Medicaid program. So, for instance, other states, they might just have the small population, and we're going to do a waiver just for that population. We had one for Choices for Care, which is mostly, you know, older folks with different needs. And a lot of states still just target specific population. We're the only state that said, we're going to put the whole kit in the booth into one waiver. Go ahead. I would just add to what the chair and Nolan said. I was at a national conference, the Medicaid Leadership Conference, and I gave a little brief presentation on our Medicaid waiver and the rest of the states there. And this was national. 26 states, I think, were there. Everybody was blown away by what we're able to do with our Medicaid program. And our waiver. And some of the states who wanted to do more came up to me. And how do you do that in Vermont? And could we do this, maybe, with a region of our state? So, I agree kudos to Ashley and whoever else was involved, the secretary and others, because it's a really great waiver that we're able to do a lot. If you look at that list of investments that we're able to reinvest in, if we could figure out a way to do this with our entire healthcare system, it would be amazing. Well, yeah, you're right. And as we were talking about earlier, moving in that direction, if we can get private insurance in synchrony with what we're doing, as well as through the value-based payment programs, we'll be light years ahead. But right now, the rest of the country, every time we talk with people, including CMS, Vermont is way ahead. It's neat. And here we have Nolan and Ashley. And there are, so it's great. Thank you. I think one of the reasons we get away with we're able to do that is because we are a small state, so the federal government sees this as a very little financial risk. Yeah, other states were like, oh, we could have a county or two doing this. A town. I also just say that we are way ahead. We were really big thinkers, and we have been for decades in the state around healthcare. But one of the areas we're really not ahead in is our systems, our data systems, and our data collection and analysis. And so that's something that I think you're going to be hearing a lot from the agency over the next little bit. You've already heard a lot about it, but we need to get better at our analytics and evaluation and really making sure that those investments are doing the things that we want. Senator Hardy, if they're not, can we pivot it to a different part of a healthcare system? We haven't done a good enough job over the past 17 years in that space, and I think this new waiver is really going to be a time for us to dig in to the data and make sure that we're data informed. Yeah, you're absolutely right, Ashley. Thank you for saying that. So that is exactly the direction we're hoping that Exit 167 in some ways will take us as well as looking at quality metric analysis in a broader view and integrating data sets that haven't been fully integrated. We don't want to put them all together. That's not the goal, but to at least make the clinical data accessible for outcomes, improvement of outcomes. Yeah, we're all getting there. This is good. Senator Weeks has a question. Just a question. You mentioned the 60-some-odd investments. Can you give a couple examples just to kind of get a little pull the sheet out? Yeah, so 211, the statewide hotline, we pay for we pay for dental for people who have met their dental cap, their $1,000 dental cap, who are at extremely low income. We pay for things like the designated agency's ability to provide emergency services to uninsured, underinsured. The public health lab gets a lot of funding from Medicaid. The statistics team at the health department gets a lot of funding from Medicaid. It really runs a broad spectrum, but those are some examples. That's all good. Thank you. If you go on the link and try to get it to work, if you go on the link on the prep, go on the link. It's a long list and it's in, like, one part. But we have a hundred and something million dollars in investments. You can find that at the JFO site. I will send Alex the link to the post. We'll get that on our webpage. That's great. Any other questions? Senator Buick. No, actually. Senator Williams. Whoa. This is good. See how clarity brings. Thank you. I have some questions, but I'm just going to throw them out there and then we can talk about them sometime as needed. I'm always interested in what Medicaid support we have for those in our correctional facilities. That's an issue in particular support for MAT. That's one. And I know there's some of that. The other one is is there a regular Don't laugh at this question. Is there a regular increase in the federal percentage? Can we ever expect something beyond a negotiated increase in federal support? Federal dollars, we're not on a CPI for any of this. It's all negotiated state to state every other day. The F-NOT is not negotiated at all. So that's what Nolan was referring to at the beginning of his deck, where it's based on health and state economy. It is not negotiable, unfortunately. And so we cannot move the needle at all out there. On the DOC thing, just quickly, the corrections and procedures. There is a federal prohibition on using Medicaid dollars for inmates of an institution. And so we're largely tied from being able to use any Medicaid dollars in a correctional setting. CMS under the current administration has started to think about loosening that restriction a little bit. And so we're having conversations with CMS currently in inmates in pre-release. So like 60 or 90 days ahead of their transition back to the community, what can we do to get them into care and make sure that care is seamless. CMS hasn't greenlit anything yet, but that's something that we hope to be able to come back to this committee within the year and say that we're able to put some money into investments. I know that I had the room filled with all the DOC and agency folks about four years ago, maybe five years ago, where we talked about this and now to have it move forward is, I mean, it does take time to get all of this organized. So, you know, thank you for that work. It's really important. Yeah. And I know that Senator Sears on Justice Oversight is very sensitive to it as well. And just, Judiciary Committee, that's good. Okay. Anything else? Actually, sorry. I just want to say, I think Nolan touched a little bit on the unwind and the fact that Medicaid's rosters are a bit inflated right now because we haven't been able to redetermine anyone over the past three years. That's going to be changing in May. We're going to start renewing folks. And so I want to just give you a sneak peek of testimony that we want to make sure we get in front of your committee, which is what we're going to be talking about. We're going to be talking about what we're going to be talking about in the next few months. People for the first time in Vermont are going to, in three years are going to be receiving notices saying that they have to reapply for Medicaid or that they might be losing their Medicaid coverage. And so we're definitely going to be coming back with what that plan looks like, what the communication looks like to Vermonters so that you are educated. Thank you for that. And so make sure that you connect with Alex so that we can get you in on an agenda in a timely way. Because I know we all know we're going to hear from everybody in our districts about this. We're good to know what the communication process will be for you and what the plan is. So thanks. It's good. Thank you. Go ahead. The question to Ashley. Ashley, has there been any conversations at the federal level of increasing the percent of poverty for eligibility for Medicaid? I know there is in some limited programs goes up to a higher level of poverty. But for the overall Medicaid program, it's still quite low. And like I said earlier, the Medicaid program we have is so good and if we could get more Vermonters eligible for it, it would be helpful. Is there any talk of that happening? Not that I'm aware of. That would have to be a congressional law. And as we know, they're not going to be doing that in the next two years at least. We are we are able to kind of work around the fringes there, though, with our premium assistance up to 300%. So it's not as good as Medicaid coverage, but we're providing premium payments for individuals up to 300%. We go up to 317% for children under 19, which is huge. And we're able to pay for bits and pieces of services regardless of income through our investments. So I would say like all Vermonters benefit from those investments and some of them were targeted than others, but a lot of those kind of indirectly affect everyone regardless of income, but no short of Congress at the federal level passing a law expanding Medicaid, which feels pretty unrealistic right now. We can't do anything. I know that the new waiver has the increase in eligibility for substance use disorder treatment. What is the timeline on that? Do you think that's going to be a final approval soon? Because I know it was still an asterisk in your list. So it was approved. And we're really excited about that. So we're the only state in the country that has a federal approval to pay for substance use disorder treatment for folks above Medicaid income thresholds. This is a brand new benefit though. And so we are in this early stages. It just got approved in July. We're in the early stages of working through what are the services that we're going to cover? How are we going to enroll them and identify the providers? How are we going to identify the providers? So it's an enormous amount of work not to mention our really old IT system that takes a long time to program. And so I just say all that because the 2025 date feels far out, which is what we're slating for. 1-1 of 2025. But there's just a lot involved and our IT system is not January 1st of 2025 is when you think that's going to be available. Oh wow. I'm just thinking in context of the opioid settlement advisory committee and whether we would be able to count on any. But it sounds like no, not for two years. Not for two years. I will say we're currently paying about $10 million a year in investments and we're going to be paying about $10 million in investments. So we're going to be paying about $10 million in investments. But it's not an efficient version of the same benefit. So through the division of substance use at the health department, they are doing a lot of work to get services to this higher income population. But it's not quite the same. It's not a streamlined or accessible as what we'll be turning on in 2025. I think we'll be taking the Medicaid treatment. Yeah. Medical. MAT. MAT. It would, but there really shouldn't be anyone other than folks who are uninsured in Vermont, which we have very few of who don't have MAT coverage now. But the Medicaid coverage does include coverage for that investment. Good, okay, that's good. I mean, that's helpful. But yeah, if it's 2025, remember that the advisory committee is going to come up with something and maybe next year, maybe this year, there'll be something that goes into place through appropriation. So it might actually be very close. Yeah. Yeah, so go ahead, Senator. Just to get us mentally prepared, what do you have a sense of how many folks are going to be redetermined? We do. That's the percentage one has. Everyone will be redetermined. One hundred percent of the people are mentally will be redetermined. Our kind of preliminary data, which is not sufficient is that we think about 29,000 people will fall off, but we don't have a complete picture of the data. We only know, you know, the limited amount of information that we know. So I think that's why Deputy Commissioner Schromelow will need to come in and really talk to you about the plan around it. But 100 percent of Medicaid will be redetermined. I was looking for the 29,000, I mean, the 29,000, which is what percentage approximately? We'll end from that. That was 208,000. Okay. 168 is primary, so. Okay. 15 or 60 percent. Yeah, 15 percent. All right, thank you. Okay. Are we good? I think Alex, we could go off line. We'll take a little. Okay, thank you. It is, this is the Senate Health and Welfare Committee back January 20th, and we're moving on to hear from Dr. John Sororian from the blueprint for health. And so Dr. Sororian, welcome. We'll go around and introduce ourselves, and then have you introduce yourself for the record. So, okay. Although I'm from Iraq, you live, I live in Burlington, and I search it in central. Thank you. Good morning, Dave Weeks, Weldon County, and I come from Brock. Terry Williams from Weldon County, I'm from Portland. Ruth Hardy will be in in just a minute for Madison, and she's not in Madison right now, but she'll be back in. And Ginny Lyons, who, and we have met. John Sororian, Executive Director for Blueprint for Health. Okay, so you're going to give us the blueprint 101, and we'll look forward to it. Are you going to share your screen? Good. Thank you, Madam Chair, for inviting me to present to the committee this morning. I have been looking forward to reviewing the blueprint with you all. The statutory framework for the Blueprint for Health was established in 2010 through Act 128. The blueprint has 15 years of experience as to how healthcare is distributed statewide. Through research, design, and implementation of innovative healthcare delivery and payments models, the blueprint remains a multi-payer, whole population program that can develop and test healthcare reform initiatives. As an innovation engine, it has implemented concrete and durable changes to treatment delivery, payment models, and healthcare information systems, particularly related to integrated primary and community care. The blueprint for health is ambitious in its goal for Vermontra's primary care providers to be supportive in taking a long-term, whole-person approach to care, one that addresses medical, social, and mental health needs, and provides access to a range of supportive services in an integrated fashion. For primary care providers, the blueprint for health can encourage and expand the focus on the needs of the entire population they serve. The program has offered support through delivery system reform and payment models that give primary care the ability to invest time and resources in team-based, data-driven, quality-focused care. In accompaniment to this slide, you all should have an additional document entitled Blueprint for Health, Internal and External Return on Investment. This is a topic I plan to return to in the future, Senator Lyons, but did wanna let you all know that the external and internal evaluations that have been done for blueprint for health are been done robustly and showed positive return on investment. And I will leave this for maybe a future discussion if that's okay with you. Absolutely, yeah, good. And you all, of course, are welcome to... Great. The Blueprint Executive Committee is defined and statute by the members representing departments at the agencies of human services, including the Department of Health, Department of Mental Health, and the Department of Vermont Health Access, as well as a representative from the Green Mountain Care Board. Two private health insurers are represented, healthcare professionals who provide health services are represented, as well as healthcare associations and consumers. Representative Lori Houghton is an individual appointed jointly by the President and Pro Tem of the Senate and Speaker of the House of Representatives and she joined our community last year. Health service areas represent the areas in which patients receive their healthcare, and historically have been defined by which hospital they have been discharged from. This is a term among many that I included in a glossary for you all that's quite particular to the Blueprint. Blueprint utilizes health service areas to help ensure that resources are distributed across the state in a way that is accessible to most people. Also shown here are our current program managers, and I'll talk to you all about program managers and define their duties as well. Are each of these folks at the hospital or... Two of them are at federally qualified health centers, Madam Chair, and the rest are at hospitals. Thank you. Of course. Each administrative entity hires a Blueprint program manager to oversee Blueprint activities in their health service area. The program manager is the primary contact locally responsible for management of all programmatic and administrative components of the agreement. They provide support and help in the development of effective strategies in alignment with grant and program deliverables. They establish key relationships with patient-centered medical homes, a term that I'll be defining more completely soon, community partners, regulators, and governmental agencies. The Blueprint program manager is also the key liaison for Blueprint trainings, strategic direction, coordination, and support in developing and spreading best practices. Next, I will be reviewing Blueprint programs, including the patient-centered medical home model and quality improvement facilitation, community health teams and defining them as well as payment systems for both, the hub and spoke system for opioid use disorder treatment, and also the pregnancy intention initiative. And if I haven't said it before, I'd say it now. I'm happy to pause and entertain questions whenever you feel is appropriate. It's up to you. Okay, I'll keep going. You're in charge. The Blueprint was founded on the establishment of patient-centered medical home recognition by the National Committee for Quality Assurance. Practices that meet their standards have been shown to help better manage chronic conditions, improve quality, and are associated with lower healthcare costs. The Blueprint supports practices that become recognized as patient-centered medical homes through supplemental or additional payments to support their work. They still bill the way they would normally bill, and these are supplemental payments, and I have a very detailed slide about all those amounts in that background. These payments are made by public and private health insurers directly to the practice. The practice and practitioners know their patients, they understand their health history and needs, their preferences, and those are taken into consideration as prevention strategies new and long-standing healthcare needs are met in context with their goals. There's also expanded access to the provider and care team through electronic communication, extended hours, after-hours coverage, and screening procedures are done regularly based on the patient's age and gender. There is assistance with managing various specialist referrals, referral follow-up, care planning, as well as coordination of that care. All together it's an approach that emphasizes and supports informed decision-making, motivational interviewing, the patient-centered goal-setting, and self-management of chronic conditions. The Blueprint also supports the patient-centered medical home practices with a quality improvement facilitator. This is a professional who uses evidence-based tools to help the practice meet key healthcare quality metrics and make sure that they are maintaining their recognition as a medical home. Just to interrupt you here, but to let folks know that your script is also on our webpage. So you have the slides and then you talk about the script, which is very helpful. Sure, sure, and the glossary of key terms. And the glossary. Which I refer to briefly. Yes. I love the glossary. We love it. It's also very carefully referenced. Thank you to my team. So shout out to them. Okay, payments, patient-centered medical. The patient-centered medical home payments that the committee sees on the left side of the screen represent the current per member, per month amount paid by commercial, Medicare, and Medicaid payers. The commercial and Medicaid payments have not been increased since 2016. The Medicaid payment is higher than the commercial payment because it incorporates a pre-existing payment for managed care services. The Medicare amount is based on available shared savings amounts that are determined from the all-payer agreement. Half of the performance payment, so this is the middle text that you see, patient healthcare utilization, is based on healthcare utilization of the patient population of individual practices up to 25 cents per member per month. So that number's multiplied by everybody in their clinic that falls under these categories. And the other half is based on hospital service area population, healthcare quality measures, also up to 25 centered cents per member per month. To give the committee an idea of how these payments might accrue for a small practice of providers, for example, I took this from an example of maybe two physicians, one nurse practitioner, just on the smaller side. I present you with an example of the dollar amounts per insurer as well as the total per month that would be paid. And again, this is an example, this is not a natural practice. This funding is used at the discretion of the practice, that medical clinic, the doctor's office in more commonly used terms, related to maintaining that high level of recognition as a patient-centered medical home and activities therein. I started with the darker green circle, which is where people receive their care. I'm moving now to a slightly lighter green circle that I'll go through with you all to show you the next layer of funding that's directed by the Blueprint for Health, which is the community health team. The community health team supplements the services available in the medical home and links patients with social and economic services that make healthy living possible for all remanters. The community health team staff are intended to provide supports and services that are not generally covered by insurance at no cost to the patient and without regard to insurance status. These staff may include social workers, coordinators of their care, mental health counselors, dietitians, community health workers, and other types of professionals who provide and support whole person care. The community health staff are intended to provide supports and services that are not generally covered by insurance. So these individuals working for the community health team do not fail for their services when they're in their role for the Blueprint. And there's no money extracted. There's no bill for that service that the person would get. And it's provided without regard to insurance status. I have a question, and you have a question. My question is, how is the care management facilitated from the service to the outside ring? And then Senator White, go ahead and ask your question. We'll try and get it. My question was, so the slide that you showed, how the payments work. Should I go back to it? Sure. Is this all the 2,300 people at the bottom? Is that all the patients in the practice, regardless of income and regardless of how often they're seen by the clinic, et cetera? It is not all the patients in the practice and the second part of the question was how often they're seen, say, that part of your question. So who are they? If they're not all the patients, how do you know? So the total of number of patients who receive the majority of their primary care services at a specific practice within the past 24 months, the Blueprint has a methodology that the insurers, the payers, follow to combine the individual with their payer. So there are payers, for example, for some patients who are exempt from the statutory inclusion of being a Blueprint provider, payer, and those payers do not pay in. So we have a very specific formula that's followed. It's a look back of 24 months for a primary care visit that qualifies. And if a person is insured by a certain type of insurance offered by the cross-bueshield, MVP, SIGNA, all of Medicaid, all of Medicare, then that individual is included in this attribution model. So it's only the patients who are covered by these types of insurance. And this is in my glossary of terms as well. Individuals for whom there is, and this part's always drilled down on, so thank you for pointing it out, that it's for individuals who are wholly insured. So this is not inclusive of individuals for whom their employer, let's say, is in an administrative services only or claims-based way of paying. This is individuals who have health insurance that are. Do you mind if I show you in the glossary where it is? It's hard for me to explain that extemporaneously sometimes. It's just, it's hard for me. I'm not understanding who the patients are that are covered. The blueprint-attributed patient population is the total number of patients who receive the majority of their primary care services from the providers in the past 24 months. And that number is used by participating insurers to determine the practices caseload. Excluded from that would be things like a third-party administrator. So a company that contracted a health insurance provider to perform just the administrative duties of payment. So because my health insurance is from a self-insured employer, I wouldn't be an attributed patient for the primary care practice that I go to. Because my insurance is not through one of those. So the presence of your visits during a two-year look back, that out of one would not occur in an arrangement of self-insured payers. So I would not be included. I'm trying to get you to say this in simple language. You keep saying it in complicated language. So because my insurance is through a self-insured insurance plan, I wouldn't be countered as one of the patients. In the attribution model. If I were on Medicare or Medicaid or had my primary insurance through SIGNA Blue Cross or MVP, I would be countered. Regardless of income, whether I made $20,000 a year or $250,000 a year. To my knowledge, yes. OK. And you still receive services. And what if I don't go every year? What if it's only every other year? Is it any patients who's technically an enrolled patient at a practice, or is it you have to actually have had a visit during that? It's a two-year look back. It's a 24-month look back. It's a two-year look back to have had any kind of visit to this super, super long list of different types of visits. Yeah, they fall into the rubric. And actually, we even include, yes, we include a wide variety of codes for what counts as a primary care visit. OK. So yeah, this is very good. This is helpful. If her self-insured coverage includes blueprint coverage, then it does that happen? I don't know of a self-insured program that is a payer, because they're zen from contributing. If they wanted to, welcome to the call. Let's talk, yeah. OK, that's all. I mean, I don't know that we direct payments for many. I look at all of them and I don't remember seeing them. So the state health insurance plan, are state employees? Or is it NEA? That's a third-party administrator arrangement. And to my knowledge, that's not a blueprint. To my knowledge, it's not. And the same with the teachers. And yeah, there are a lot of people that love you included. Yeah, OK. Community health teams? Or do we have a question? I'm sorry. Yeah, no, it was just about care management. I was staying up at this level. So how it's paid for a coordinator. And you've got a health care, a health team there. So whether it's SASH or the hub and spoke, let's not go over there, someone. You have a nurse care coordinator. Is that the person that helps to connect each patient with the external care that they need? How does that work? Sure, there are care coordinators that are in the clinic. If that's a priority to how the clinic is expending its resources, there are also care coordinators on the community health team. And those individuals would make sure that they're not overlapping or doing duplicative services. But they would work in concert and decide who has the expertise to manage that person's issues. You may not know I visited every site except two last year and learned in quite a bit of detail the implementation of these programs specific to care coordination, other services, and how practices work with community health teams. And I saw both models of care coordination. I saw models of care coordination, which is fine. I saw models of care coordination where the individual was in the practice. And I saw models where the practice would reach out to a care coordinator in the community, but external to their physical location for assistance with figuring out referrals, following up on labs, helping with transportation, et cetera. I just thought of a question you could ask somebody else because you opted in my mind. All right. Community health teams supplement the services available in the patient-centered medical homes and link patients with social and economic services that make healthy living possible for Vermonters. The community health team staff are intended to provide support and services that are not generally covered. And I'm realizing I've read this already. I think I will go to slide 14. One of the key functions of the community health team is to serve as an access point to specialty supports and services already existing where the patients live. So despite it being blue, the outer circle does not represent agencies or groups that receive funding directed from the blueprint. But this is the community supports and specialty supports that our community health teams link individuals with. And these may include food, housing, transportation services, specialty and disease management, and the other aspects of this slide. There is the self-management program, which is an exception to what I just said, that actually is a link between the Blueprint for Health and the Department of Health. The Department of Health implements local programming for the blueprint about self-management at myhealthyvermont.org is where signups for all the different hypertension, diabetes, and other self-management and education programs are, which are evidence-based and led by facilitators. So the payments, the blueprint support staff of the community health team by directing public and private health insurers to make payments to the administrative entity, a term which I haven't defined yet, but I will, in each region of the state. Usually the local hospital, but not always. Sometimes the Federally Qualified Health Center is considered that entity in a health service area. Blueprint-funded program managers oversee the outflow of funds to local practices to make sure that the needs of the community are being met, and that practices have the appropriate level of support. Medicare funding availability has not kept up with the past payment increases of both commercial and Medicaid. So in the middle slide and the dollar amounts, one can see $2.77 for commercial insurers, and $2.77 for Medicaid, and $2.51 for Medicare. And I'm going to show you a next similar type of slide as I did before, it's an example. On the left of your screen, on the right side of your screen, I share with you three different ways by which staff can be employed. One is the actual entity receiving the money directly hires the staff member and deploys them. The second is that the entity contracts with a local provider, such as a designated agency in what we call a pass-through of those dollars. And then the other is that the clinic or the practice itself receives funding to hire staff that it chooses and hires. How are the administrative entities at the local level chosen, the hospitals versus the FQHCs? And how do practices become a part of the blueprint? And how do you ensure equity across the practices that are part of the blueprint? This is a concern I've heard in my community, that not all the practices that are part of blueprint feel like they get as much support and attention and resources as others. And there's concerns about who is controlling it at the local level. The first question regarding how administrative entities are chosen historically, I don't know. In my year of being the executive director and in my visits to all of the, except for one, administrative entities, it's a lot of administrative work. It's a lot of administrative entity takes on a great deal to manage the funds that are directed. And what I heard is I went around the state was to do all of this work, John, we need more. We're investing our own dollars in administrating the funds you give us. And historically, it would be something maybe you could bring back to us at some point. It could be. It could be. And I can certainly ask. I don't know how that came up. I can certainly ask and bring up. And I have to, with my team and with my own work, make those assessments to see how well are they following our guidelines? How well are they participating? How equitably are they distributing things? How responsive are they to corrections or changes that we might suggest? But I certainly can ask my team and bring it back to you. I don't know the origins of the beginnings. How do practices become a part of the blueprint? The program managers are tasked with the responsibility of reaching out to all non-participating practices on an annual basis. They're also charged in their quarterly reports with giving some mention of that, though it's really an annual reach out that they're expected to do. And I'll just give you an example of a practice that was interested. The discussion usually begins with the program manager. This person wanted to speak to me, so they came to Waterbury and met with me for an hour to review the blueprint program similar to the presentation I'm giving you all. And that's where the discussion begins. And then the assistance comes in a person on the team that I haven't spent a lot of time speaking about, but is known as the Quality Improvement Facilitator. The Quality Improvement Facilitator really works intensively, especially in the beginning, but also over time, so that the practice can meet the high standards in its own practices and policies and procedures of becoming a patient-centered So that's the process on that side. The equity across practices question in terms of how dollars are distributed by the community health team is an area that I've taken a lot of interest in myself and asked those questions of both the administrative entity and, in some cases, trying to listen to practices themselves, either to reach out to me or that I've heard don't feel like they get their due. And those are tricky one-by-one situations that, as an executive director, I need to make a judgment myself about how far I go in, how far I coach, how far we support the program managers and the practices with what the rules are to make sure the rules are well understood and well implemented. And that's an ongoing part of my responsibility to continuously, with the team, evaluate when those concerns come up, encourage people to bring them to me because they do. This is precious resource. People can, practices can feel on either end. And I'm not sure, Senator Hardy, if I'm answering your question, but it's an ongoing oversight of funds where, as executive director and as a team, we have to remind people of the rules of the state and we also have to work with the administrative entity and program manager to remember that it's all blueprint practices in their area. I feel like, for the most part, I've been very fortunate that that hasn't come up too, too much, but it definitely does arise. And do you have some kind of evaluation process for the local administrative entities and the practices themselves? So this, so an evaluation process for the administrative entities, I do not have an evaluation process that I know of. This year I am planning on, and I haven't but got it yet, meeting with the CEOs and the CFOs of every administrative entity to review the rules of engagement with the blueprint. I found that last year, there were so many new people in leadership positions and that pandemic and the few years before the pandemic that that frequent contact with the executive director and why things should be spent on what they are and what the rules are that these are state directed dollars have been followed. I will share with you the next time I come a distribution, I don't know how that slides today but I hope the next time I come, share with you how the community health team dollars are spent by different positions. That's something I think you'll be interested in. Obviously, I was very interested in last year and we spent much of the year collecting that information so that we know how are these dollars being spent on what, where, so. And the outcomes. So yeah, I think this is a great introduction to that conversation that we will have. So why didn't you just, you know. Okay, so similar to the example I presented to the committee for the medical home payments, this slide depicts, and again, this is, this is to some extent, I made this up based on a number of different areas. What one administrative entity could receive based on their attributed population. So not their entire population but the attributed lives that need the formula for blueprint. So on a monthly basis for the outer ring of kind of darker green for them to hire or pass through or pass along dollars. They might be receiving as much as $107,000 monthly and those payments are sometimes put quarterly or monthly, this dollar amount is what it would be on a monthly basis. This is a 12,000 attributed patient population. I would, that's still on a small to medium size. So I kind of waited my slides more towards health service areas that were not geographically smaller but the numbers are smaller. If we move to a different county, I might have an attributed patient population of well over 100,000. So those are the dollars. In addition to the community health teams, there are two additional key programs sponsored by the blueprint that patients may interact with in their medical homes. The hub and spoke is Vermont system of treatment for opioid use disorder with nine regional hubs under the direction of the Department of Health as well as daily support for patients with complex addictions. At over 75 locals spoke. So either office-based treatment of opioid use disorder, doctors, nurses and counselors offer ongoing opioid use disorder treatment that is integrated into their healthcare. This really reduces stigmatization and contributes to their whole wellness and normalizes the treatment of opioid use disorders as opposed to separating it out from what people may feel is regular in quotes of medical care. So it normalizes the inclusion of that service into a medical home. This framework utilizes medications for opioid use disorder for treatment and deploys expertise. In addition to that, counseling and care coordination into the community and links them to the specialty centers, the so-called hubs. As you can see in the right hand column here, there's been quite a growth of patients that have participated in the spoke program since its inception in 2013. You know, while we're talking about this, I know that Senator Hart is very much involved in the use of the dollars we're getting from our, the first pharmaceutical settlement. Oh, are the opioids settlement agreement? Yeah, so, and one of the questions that I asked at a meeting with, it was Diva folks and Ian Bacchus, was there anything, is are those dollars able to be matched, Medicaid matched? And the answer is yes. So that will have an important, that's important for us to know and it's particularly here where we're looking at help and spoke. Anyway, just an aside. The pregnancy intention initiative helps ensure that women's health providers, medical homes and community partners have the resources they need to help women be well, avoid unintended pregnancies and build driving families. In 2017, what was then called the women's health initiative, what we're moving the name to something that's more inclusive. I'm calling it the pregnancy intention initiative today was begun in an effort to increase the intended pregnancy rate. As of 2020, the intended pregnancy rate in Vermont was 57.1% and increased from 55.9 in 2018. And on this slide, there are multiple components that you can see of the program that include family counseling, psychosocial screening, intervention and then referral and assistance to other services that might be needed. Central to the data that is collected and the counseling that goes on, excuse me, the assessment is the would you like to become pregnant in the next year which is known as the part of the pregnancy risk assessment and monitoring system. Yes. Just to make sure I understand that you're saying that intended pregnancies are not even 60%, over 40% of pregnancies in Vermont are unintended? That's correct. As I compare with other states, do we know, can we get that data? Sure. Yeah, that seems pretty good. And I'll just make sure I have that and then I'll come back and if it's a link I'll send it to Alex. Perfect. The, as of 2022, attributed patients numbered 22,000 and payment schemes include $1.25 per member per month which is just goes to those practices. There's also support for staffing through the community health teams for the women's health initiative when it's in a medical home. Alternatively, some OBGYN practices in the state participate and they actually receive funding directed by the blueprint to hire a mental health clinician. There's also a one-time per month, excuse me, one-time per member payment to support those practices in keeping in their inventory effective contraception as well as long-acting reversible contraceptive devices. Thank you. So maybe you could just talk briefly about the hub and scope and we will be looking in here if that bill ever gets hung on. The expansion of hub and scope to include the OBGYN opioid system and that's my bill, my intent and I know it's maybe synchronous with yours but could you just talk a little bit about how the hub and scope works on the ground? Sure, so the hub and scope model was considered a novel approach to the services of evidence-based medication-assisted treatment for opioid use disorder so that's where it started. So opioids and that might be a little jargony. Morphine heroin, over the prescription, oxycodone, oxycontin, medications certainly in my practice when I was practicing that I saw people develop use disorders from. So the treatment of that type of use disorder has a medication known as buprenorphine in addition to other medications that in my physician brain is quite elegant. It's a medication that prevents withdrawal and also can have a very, not for everybody but for many people a very quick effect of being able to stem their addictions, their use disorder. So the hub and scope program was developed to increase the number of buprenorphine prescribers in Vermont but also to provide individuals who were struggling with these use disorders, the option of counseling and also the option of care coordination because there are frequently not just a use disorder that's going on but perhaps mental health needs, other medical conditions like hepatitis to really coordinate their care. The hub is the specialty area and those are distributed around the state for individuals who need daily monitoring and daily medications. And that would be, for example, someone who's mixture of different medications reached such a high dose, perhaps that they really weren't fit to be seen every week. They needed to be seen every day and monitored closely. Jenny, hub and scope isn't unique to Vermont. Is it, if you want to talk about it. Yes, yes. How it helps to go on with that in this country. It's been hard to keep up. Multiple states nationwide have replicated Vermont's model and other conditions have utilized the terminology hub and spokes beyond use disorder, both in the state. And I saw the term hub and spokes used in California's wellness for aging report. So it's not trademarked. No, it's not trademarked. Vermont really is a leader in this area and that's why I wanted to emphasize it a little bit. And we're learning the need for mental health counseling as well so that we maybe see that in the legislature. I didn't emphasize it in my slides and I probably should have though. It's very much in the glossary, the pregnancy intention initiative or the self initiative and also the spokes are funded only by one payer, Medicaid. So similar to what I probably didn't speak to as directly as I could have around medical homes. Every person who comes into that clinic setting receives services only individuals with Medicaid and draw that additional piece of funding. So if someone has coverage from MVP and they go in to the hub and spoke system then they're only covered as much as their insurance. So that gets very much into the particulars which are hard for me to speak to. MVP has, if my memory serves me correctly, MVP has more than just fee for service building, I believe another commercial insurer in the state says to, but in the field, do they have something? I see Rebecca over here. I think so, I think he's MVP. But it's not every single patient that's served in Scopes. I think it's more limited to certain areas but certainly they still bill for fee for service, they still get billed for medication. It's this additional support staff that's primarily in terms of blueprint directed funds and those models are outside my Scopes of Knowledge or Medicaid. Okay, yeah, good, thank you. I know historically, I think back to the origins of this and we used to sit here and listen to people who had to travel two hours a day to get their methadone treatment. They had lived up in the Northeast Kingdom and the other place they could get methadones in Burlington or they had to travel down South or from the South. So it was really inappropriate for the care that they needed. And so then gradually the hub and spoke evolved and then the type of treatment, drug treatment would also evolve from there. And then we've changed who can do what when within the hub and within the spoke that's been an evolution but all the whole time your office, you and others who have been in that office have really demonstrated significant leadership for us and then across the country. So I think very, yes. Sure, yes, okay. Can you give me an example of a patient started in America again? Sure. Um, should I start with a place or should I just start generally? So any place involved? Oh, well the Federally Qualified Health Center is a patient-centered medical home, the Hogan camps. I've spoken to a number of times and when I was listening, when I did my site visits around then in October I told both of them they speak more eloquently about patient-centered medical homes than me. I followed up with them since. I was in touch with Dr. Bolick as well. We spoke in I think in December that's a patient-centered medical home as well. So those are just some examples in Rutland. I did warn the Hogan camps that they spoke so eloquently that I may recommend they speak. And certainly that would be, but they're just, I probably spoke to 30 or 40 or 50 clinicians over time and I think the two of them put it in more concrete terms than I ever could because that's what, they've seen it change their practice. They've seen it help them rise to a higher level of delivering whole person care than their training and all their very good work as physicians could do along. What might be helpful is to get their contact information to Alex, so rather than, we have. Yeah, I might warn them first. Please, oh no, if it's appropriate. Yeah, yeah. But to probably come, it could be on screen, but. Oh, sure, I'm happy to do that, I'm happy to do that. And because we've got field terms planned but that one might be another one. We could do it next year, but it would be, I think, more appropriate to get a man a little bit earlier. The pediatricians that I've spoken to around the state, too, I'm thinking of, should I say people's name on the testimony, I don't want to put them on the spot, but I've spoken to. As their professionals and they're part of your system, it's probably okay. Oh, okay. I don't have to say them that. I'm thinking of Dr. Hay in Unisburg and similar to, I forget the Hogan camp's first names, but the doctor's Hogan camp, I have been lucky enough to meet both community health team members and providers who speak about these programs and are able to share professionally, personally, the impact that they've made on individuals in their practice. That was definitely the, in addition to scout camp, that was the best part of my year last year was making health service area visits, community health team visits, the stories that people tell and my shock at listening to how much support they gave individuals in their communities. In a couple of cases, they actually, I'm just sharing this set in the lines. No, that's perfect. So my beginnings were in pediatric palliative care, children who were terminally ill and had serious pain, and that's what I did. That was my work. I worked in hospice for similarly about eight or nine years going into people's homes. For me to be astonished at the coordination that teams are giving individuals around us, I've seen a lot and there's a lot of things I wish I could unsee. So to hear stories about how far they were going to keep, for example, someone home until they had placement in long-term care and to do it regardless of the person's payer type, their insurance, to measure that impact is close to impossible in terms of sort of dollar objective terms. To hear the stories is, again, for me being not callous, but rather seasoned as a clinician having seen a lot. They sometimes wondered why I was having such a astonished reaction because their response was, Dr. Swarman, we do this every day. We do this every day. We help people achieve their goals every day. That's our work. So we did take a field trip as a community a few years ago to Gifford and there's a wonderful... Yes. Oh, yes. Yes, yes, I can, Gifford, they call it the community help team. I think she and their... She was talking to the same person you did. I bet I did. She was taking orders for the entire... And she's unbelievable and the gift that she gets to her community and to her patients. So it's been a very rewarding transition for me stepping away from, which is hard to do, 20 years of direct service and supervision. It's hard to step away from that clinical work. The stories and the individuals I, we get to support certainly make up for it. And I think Senator Hardy, back to your point, knowing that their executive director, their leader, their team centrally is energized, is paying attention, is going out and visiting them and helping the problem solve when things come up that are good and sometimes more points of disagreement. I think that that's been a very energizing component for our blueprint funded staff. And it's enjoyable, it's good work. Sorry. Two more. One more. And they're flexible, the plan is flexible enough so that they're making it work sometimes by themselves. Yeah, and I think that I'm not sure where this is going with your question, but for me having served in pediatrics and then also in adult hospice, one needs to look out for one's colleagues so that they are not setting boundaries, that's probably too strong of a term, but sharing the work with their team, speaking up when they're needing more help because the inclination is to help that person until they've been helped, which is amazing. But can also, I talked to more people who said they've been on the community health teams for more than 10 years. I mean, if the person you're talking about is different, I'm thinking of Bennington, I mean, I can start picturing multiple people and they're like, no, this is the work I do, this is where I am now. Well, it's a powerful statement about who we have in our medical community and in our community services. It's so committed to people. I think that mental health came up and in the broadest of senses, not just individuals with a diagnosis or a certain something, but just support, someone to talk to, someone to connect. There was one individual who calls a member of the community every day to check in. Now, is that as a physician? Is that a, I mean, it doesn't matter with it, I don't. There doesn't even have to be a diagnosis, but for her to call and checking with that individual every day, five, 10 minutes, that's what that person needs, that's what that member of the community health team does. And then there's other people that might spend hundreds of hours supporting individuals. It gets to the point where sometimes it's hard to, to, even for me to believe, but that's what our community health teams do. I'm sorry, you had other questions too. I was just wondering if you could give me an example of a couple examples of the homes in the Burlington area. I did a, and pardon me for not remembering practice names as well as I should. There was a pediatric practice, I believe, in Essex that reached out to me in my first month. And I don't want to make up the name under testimony. And what they do with community health team dollars to really individualize care for children and families is above and beyond what they get. And they certainly were making the point of saying, you should be doing more. The practice that I visited, Dr. Stein, is on the opioid resettlement, is that? The Resettlement Advisory Committee. So I visited where Dr. Stein works, the Federally Qualified Health Center, so that's community health centers of Burlington. Yes, I was wondering. And we spent a few hours there, and, wow. Yeah, it's fun. It's inspiring to see what individual teams and practices, and I think I could go on with other ones too. Those were the ones that I reached out to most, or they reached out to me in one case, I reached out to the other with the Federally Qualified Health Center. Here's what we'll do. This is really, this is sparking a lot of interest, so if you can get some names of folks who could come in and share their experiences within the, and define for us very practically a community health team, that'd be great. I don't know how much time we'll devote to it, but we'll do that. It'll be like our field trip into the blueprint community health center. It sounds like I should recommend a couple of people to speak just to the Patient Center Medical Home, or we should rather go to both. Yeah, and then a little bit of the other, but we'll always do triage here and figure out what we can. Sure, I can give that to you probably Monday, I'd say. Send it right to Alex. I'll send it to you, Alex, sure. All right, so this is great, and I greatly appreciate the time, again, you're coming in, and it's been quite an evolution since last year. Glad you're here, and thank you. And enjoy your work. Sorry? You obviously enjoy your work. Oh, well, thank you. So Alex, we're good to go offline, and thank you all. This has been a good morning. Great morning.