 Good morning. It is April 21st, and this is the Senate Health and Welfare Committee. So we're going to move on to hear testimony about S120. And I know that folks who are here with us this morning understand the time crunch that we are under. And I appreciate the comments that I've had back from you about that. So I look forward to your testimony and I know that many of you have testimony that Nellie is putting up on our web page that may extend further than your comments this morning. And we will certainly look at read all of the testimony that we get. That's our job. But please don't make it a thesis. Thank you. So, so 120 and then there are sections of 132. I think that people are commenting about, I have suggested streamlining 132 and adding some sections into 120 make some some changes. And I think that Jen had put put my suggestions together and I don't, I don't see them on the web page yet, but we'll, we'll get to that. Would you like them on the web page. I'm happy to have them there, you know, and I think it might help folks. All of us, because I feel responsible for 132 and if there are sections of 132 that are problematic or that people want to support that are not included in my triage. I think it's helpful to know that upfront. I will send it to Nellie. All right, so let's move along where I got first I have to have my agenda in front of me. Thank you. There we go. I'm going to go in the order of the agenda. And then I do know that there are a couple of other folks who have asked to testify, for example, Helen Laban of the FQHC's is asked to testify and so she would be also added on to our agenda. Looking forward to hearing everyone's comments. So thank you, Lynn Stanley is Lynn, are you here. Lynn, thank you. It's been terrific. So please introduce yourself for the record and then we look forward to hearing your thoughts. Well, thank you. Madam chair for the record my name is Lynn Stanley. I am the interim executive director for the National Association of social workers Vermont chapter. With your permission, I would like to turn it to Michelle to know who will be giving our testimony today. That's fine, but I am available to answer any questions. Terrific. Michelle welcome. Hi, thank you. Thanks very much. Good morning. Thank you for the opportunity to provide testimony as your committee moves forward on s 120 the joint legislation for healthcare affordability study. I'm Michelle Denal. I am an MSW candidate at the University of Vermont. I am here with when Stanley the interim director for the Vermont chapter of the National Association of social workers. We would like to bring to your attention the importance of mental health providers to both healthcare affordability and access per the findings of s 120 regarding the Biden administration's willingness to partner with states to pursue non traditional reforms. And the proposed reform to your consideration. Over the years this committee has acknowledged the value of loan repayment for nurses and primary care providers. We ask you now to look at the value of loan repayment for mental health providers. And that upon graduation these professionals must find high paying jobs so that they can earn enough money to pay for the loans, rather than work in the areas of the greatest need, which are far often than not lower paying jobs loan forgiveness would make it significantly easier to recruit retain mental health care providers, where the need is the greatest in Vermont, unlike New Hampshire, there are no state loan repayment programs for mental health providers. We have a federal program to the National Health Service Corps, but that program is very limited and does not provide widespread loan forgiveness. The New Hampshire state loan repayment program allows certain health care professions, including mental health providers who agree to work in the underserved areas in New Hampshire. Because the study and s 120 requires outreach to stakeholders and institutions we think this issue could have a place right here. We would request the following amendment, and then we have submitted the wording for it but I can go through it right here. It would just say section two joint legislation health care affordability study committee report. See power and duties, the committee shall consider the following. And it would be under number six, studying the viability of a state level state student loan forgiveness program for licensed mental health clinicians, including license. I see SW licensed psychologist licensed family therapist and licensed mental health counselors. Thank you very much for your consideration. Thank you. Very good. I would love to entertain questions but we're going to restrain ourselves. But we're, we are and just so folks know we are very familiar, I think with the areas that you all be talking about and we greatly appreciate your taking the time to share your thoughts with us. Thank you. And we're going to move on. So, both Lynn and Michelle thank you both for being here, and we can reach out as needed for clarification. So we're going to move on to Jesse Barnard of the Vermont Medical Society. Thank you for being here. Thank you very much. Good morning. Thank you for giving me the opportunity to testify I am Jesse Barnard the executive director of the Vermont Medical Society we represent physicians and physician from across the state in different specialties and employment settings. I wanted to start my testimony with a little bit of framing of how I see s 120 and s 132 and the different goals of the bills. I see the distinction between health care coverage and affordability issues which we see s 120 primarily addressing and then payment reform and delivery system reform which are all payer model and ACO are working on and we see 132 is working on largely elements of that with a couple coverage provisions and I think some people's frustrations and the testimony I've heard on on frustrations with the all payer model is that it's not really designed to change health coverage. That's not the purpose of an ACO or the all payer model. So we the medical society supports the intent of s 120 and looking at changes to coverage expanding coverage. But I think that's important to just keep in mind that we we really need different elements that we probably can't expand coverage in the way we would like if we can't if we're not also addressing payment reform and restraining growth in health care costs so we need both but there are different tools to work on those two elements of health reform. So on 120 specifically we do support looking at affordability of health care the Vermont medical society actually since 1992 has supported universal access to comprehensive and high quality health care with the the intent that it focus on investment in primary care reduced administrative burden and public health interventions. I would like to share the frustration that patients experience when they can't afford recommended plans of care or can't seek care in the first in place due to out of pocket costs. I would like to support what the healthcare advocate said regarding 120 and what I think you'll hear from boss later today which is that there is amazing opportunities right now for Vermont to make health care more affordable under ARPA. And while we support looking at health care affordability in other ways as well we really don't want to lose that the state has right now and making sure that Vermonters know that their health care may become more affordable already. That's actually one of the largest issues that we hear of as providers is the out of pocket costs for the cost of commercial care on the exchange and so we actually think there are tools happening right now that will really address a lot of that so we want to keep the focus on that. We do also have two recommendations if S120 moves forward again keeping these two separate buckets of payment reform and expanding coverage. We think including the language around the study of the all payer model is a little bit of a distraction from helping Vermonters afford their health care that could take over the entire work of this commission it is being extensively studied already you've heard testimony about that there's a federal analysis going on. So we don't want to lose sight of the the peace around affordability for Vermonters and so if there is going to be an element of payment reform that's incorporated in this work we suggest it's bigger picture to the point I made in the initial part of my testimony that it's a review of the role of payment and delivery system reform in minimizing health care cost growth and how that works together with coverage reform. Because again we think you need both that it's not a one or the other. You need payment reform if you're going to potentially be looking at expanding how many people were covering or how we're covering them. You've heard from a number of witnesses regarding 120 that simply having health care coverage does not translate into access to health care coverage for example Patrick flood I really supported his statement that basically the coverage is no good if you can't get in to see your doctor or if there aren't enough primary care clinicians in the state. We know you've heard from a number of primary care providers already this session about how they're struggling under the current Medicaid program and the rates the program pays which is why we've actually been been talking to your committee and asking for increased primary care rates in Medicaid. We really think it's crucial if you're looking at expanding public options for health coverage, what those payment rates and program design options look like that would ensure fair and sustainable payments for health care providers and that provide patient access to care especially primary care. I don't think you can look at expanding access without looking at what that access would look like both for patients and providers to make sure that it's meaningful coverage and that we don't actually lose on it unintentionally lose healthcare providers and primary care providers based on what that program looks like or the rates in that program. So those are my comments on 120 I will shift to 132 I will say I have not looked at the new draft yet so I don't know which elements are carried forward I'll keep my comments on what high level there are more detailed comments in my written testimony which I submitted the two elements of 132 that we do support are the expanded hearing age aid coverage which was section 12 of the original bill and they eliminating of cost share for primary to primary care in 2019. There's a lot there was testimony last session in the Senate Finance Committee on expanding access to primary care I won't repeat all of it we have some comments in our testimony about the importance of access to primary care services. I've also submitted a letter I hope it's on your website from Dr Harrington and some other physicians and hearing providers at the UVM Medical Center in support of hearing aid coverage so hopefully you have that in front of you. We are concerned with unintended consequences of several other sections that were in the bill. I think I will again they're in front of you in writing. I will skip to just mention the piece about provider rate and contract review. We fully support fairness and equity and contracts between insurers and clinicians. We do have concern that the submitting every contract to the Green Mountain Care Board for review inadvertently gives even more power to insurance companies who would have more staff and capacity to shepherd those contracts through a Green Mountain Care Board review process. We've suggested if this is an issue the committee wants to continue to explore replacing a contract review regulatory process with the ability of services to more effectively work together and negotiating contracts and rates with insurers that would be an amendment to existing statute that allows health care provider bargaining groups currently only with public payers as opposed to private payers. So that's our one language suggestion and again I hope you have some time to look at our other testimony on other sections but not knowing which have been carried forward I will skip those details for the time being. And we do have you have very specific comments on 132 as well as 120 so that is very helpful. Thank you. Thank you. All right. So we'll move on to Heather. Is it Heather Riemer? Heather Breimer? I'm sorry Heather. No worries. No worries. So I'm Heather Riemer. I'm the director of AST Vermont. We represent 5,000 health care and higher education professionals in Vermont members in every county. And I just want to focus on, I guess, briefly two things. One, and I know you all know but I think it bears repeating, you know, our members who are health care workers see the personal costs of Vermont are delaying health care because of the costs and the tragedies that can come out of that. And I think that's something that we have to, I hope, I know you all are but I think it's worth repeating to keep that at the forefront of our mind and delayed care often is more expensive for everyone. And obviously there are some real personal tragedies from that. The other piece of testimony I would just like to say is that the sort of wasteful bloated health care system is a burden on employers. You know, one of the things we do is we bargain right we bargain with our employers and we have been representing members who only work in the public sector and for nonprofit hospitals. And, you know, it keeps wages down. It makes it the budgeting hard for employers and again especially for nonprofits and state and public employers. You know, and to be one thing if all of that money that we're all pushing into the system, we're going to provide the best care possible. But, you know, we know that we pay more and get less health care than most countries. And, you know, there's a lot of waste and bloat in the system, some of which we can control I think in Vermont and some of which we, we can't pharmaceutical companies is more of a federal level piece. But you know, I'm really hopeful with this new administration in DC that there may be opportunities for Vermont to move forward on that and really create. If employers are ratified, you know, we want the full thing we want nobody you pay through taxation for health care and you don't pay a penny when you go to the doctor. I know it's going to take some time to get there but we think that s 120 is an important step toward that and appreciate the work that you are doing on that. But again, we think there's opportunity here to move forward to advance the case. And I think we could be strategic and ready for it. So we support the bill and continue to look forward to working with you all to bring high quality health care to everyone. Thank you. Thank you. Well said. All right. Susan risen is here from So Susan. Good morning. Thank you. I will be brief because I know we have limited time but I will first off say that I have to agree with almost everything that just had to say. So I'll just put that out there. I'm starting s 120 Oh and for the record I'm Susan Ritzen from Vermont Health First Independent Practice Association representing physician to own practices across Vermont. We do support s 120 we think affordability is a critical issue. I think one of the things is the shortage of health care professionals. Well, just as point is very on point regarding the all payer model, having a different goal than affordability. We do think an evaluation of the all payer model is prudent. I know there's some evaluations going on. There are some concerns that the evaluations may be biased toward finding a positive outcome for the all payer model so we do have some concerns about that. So and we think that the state is uniquely positioned to look at all their alternatives, especially given the change in the federal administration, and we have the opportunity to be, you know, look at to be novel, try novel unique approaches. So moving on to s 132. I also have not seen what has been carried forward. I will say that we support many of the presumed tenants of s 132 such as transparency, fairness and increased access to primary care as well as hearing aid services. We do have some concerns about how the bill proposes that we get to some of those things. For example, really appreciate the fact that you're looking at, you know, the ACO administrative salaries, however we think linking the salaries to the primary care physician might miss the mark and make it difficult to recruit the skill set to make an impact. As far as the ACO as well as potentially limiting the attractiveness of Vermont by other ACOs or entities who want to do business in Vermont and we we think competition is needed. And it might we think it's more important that whatever model we have is able to show a clear and measurable positive return on investments for mantras can actually feel what the model is doing and that may, if we can see a positive effect that that's money well spent on the salaries. Regarding the contracting provisions of the bill we definitely appreciate the attention to this matter. We do support a system that distributes our finite health care dollars and a transparent and fair way that isn't dominated or ruled by market dominance. We think that the bills aimed to have the Green Mountain care board look at every contract might be trying to get to this. And while we applaud this presumed attempt, we have concerns that that's not practical and like just suggested we think provider bargaining groups. The ability to negotiate with payers might be a more practical way to get to that or even requiring basic contracting guardrails. On the issues of price transparency and market dominance. We believe that legislature and perhaps the joint fiscal office over the summer can take a look at the price transparency data that is now out there, mandated by CMS of the 300 shopable codes and the Green Mountain care board will be publishing a report based on VH cares data and discharge data and using those two data sets to help inform and direct health care efforts this this information has been long awaited so let's use it. Also support the provision related to inclusion of specialty care and health care reform that's been missing and important. And we also suggest that there's some language that directs the ACO or other health care reform effort to encourage the use of lower cost sites of care when appropriate. That doesn't seem to be happening now and you know Vermonters are paying for hospital prices for care that doesn't need to be delivered in a hospital. Lastly, we strongly support the provisions related to hearing aids as well as the cost share elimination for primary care visits. As you know we any the out of pocket costs can be a barrier to people accessing primary care which can lead to higher costs on the road. If they're delaying care. Like Jesse mentioned we do have concerns that our primary care network is already strained and needs to be bolstered before you know we can just assume that they can handle this. You know these, these visits. So, we would like to see, you know, in more investment in primary care and the terms in the way of, as we mentioned in previous testimony, increased Medicaid Medicaid payments loan reduction or debt reduction scholarships and decrease of administrative costs. In summary, we support the tenants in the bill and my written comments will have more details on some of the things that we suggest that you consider changing or adding. Thank you. Thank you. That was extremely helpful and appreciate your comments. We're going to move on to Betty Keller who is the president of Vermont leave women voters but Betty you sent me a little note in the chat or everyone that you have folks to representing different perspectives so why don't you go ahead and introduce yourself for the record and then introduce the folks who you have here who will be testifying. Thank you much. So I am actually not the president of the leave women voters I'm the president of the Vermont chapter of the positions for that for a national health program. I healthcare committee for the leave women voters my name was swapped in for Sue rack and Nelly the president to deferred to me to speak on this healthcare bill. Okay, thank you for that clarification. I have with me here on Marvin Malek. Dr Marvin Malek is a practicing primary care physicians. He's good. He's on the phone and trying to deal with patient care while he's getting ready to jump in here. And he'll be able to speak from a practicing physicians perspective so I very much think that that will be beneficial to you. And thank you for this opportunity to speak to you. Thank you. So thank you so much for inviting us and giving us the opportunity to speak on the healthcare bills 120 and s and s 132. Today I'm speaking on behalf of the League of Women Voters of Vermont, for whom I serve on the health care committee. Voters of Vermont has strongly advocated for Vermont to pursue a universal publicly help funded healthcare system for a long time, and recently have been active in raising concerns about the lack of accountability in our accountable care organization. We are also concerned about the failure of the Green Mountain Care Board to perform the work for which it was actually created. I absolutely recognize that good people can have different opinions about how to achieve a shared mission. And my good colleague, Dr Malek does not share all my opinions about s 120 but right now I'm representing the League of Women Voters. Some of you here have worked very hard for a very long time to try to reduce health care costs for her monsters and very much want to actively be working on something to make things better. Thank you for your passion. I would like to share with you a few of the sections of act 48 that are particularly relevant as we look at s 120 and s 132 from act 48 the healthcare system must be transparent in design efficient in operation and accountable to the people it serves. My comment our current healthcare system is not in any way transparent or efficient and it has become less transparent less efficient and less accountable, since one care has been inserted into our healthcare system as an additional totally unnecessary layer of administration. I'm not entirely convinced of this study committee is necessarily a good use of taxpayer money, however, if you're going to do another study by all means. In my opinion, this is the most important sentence in s 120 which must be retained section to see the committee shall consider the following the efficacy of Vermont's all pair accountable care organization model, and the changes to the model will be necessary to make healthcare more affordable for Vermonters or whether an alternative model may be more effective. It would be more efficient to cancel the ACO project or a minimum to not renew it. The legislature doesn't have the authority to do that but you could pass a resolution asking the agency of human services and Green Mountain care board to not renew it. You don't need to study to review these simple facts. ACO's are based on the idea that people use too much healthcare, but we don't in the US and we certainly don't in Vermont we can't afford to because we can't afford the deductibles and co pays. Integration of care and coordination of care are a couple of phrases that are used to speak of the purported benefits of an ACO, but you don't need an ACO to do those things in a rural area with only one hospital and not that many practitioners. Mostly, you need to allow time in their schedules to talk to each other. That doesn't require an ACO and an ACO may actually make it harder. What we want right now is affordability and access. This ACO has nothing to do with improving access. If you actually take money away from the services you reduce the access so that's why it does belong in 120 it does have to do with access as well. And there is no way they can improve affordability. The way to improve affordability is to reduce administrative costs and an ACO is added administrative costs. One care is monopoly. A single private ACO is a monopoly is dangerous. We need a single risk pool but it must be transparent and accountable which one care is proving it is not and it will fight several private ACOs with defined geographic borders and monopoly within the areas of each carry the same risk. Multiple risk bearing entities competing on the same turf cannot save costs because they will be spending money trying to compete. They will be lemon dropping and cherry picking if at all possible. They will be gaming the system for billing. They will be increasing administrative costs and reducing quality of care because of the nature of the beast. And in a rural area, this competition would only fracture care instead of coordinating it. So primary care must be preserved and enhanced so that vermonters have care available to them, preferably within their own communities, and that these health services be sustainable. When you talk about payment reform or value based payments, the payment reform that is really proven used in multiple countries that spend far less on health care is global hospital budgets. Global budgets could also be used for other entities like clinics and long term care facilities. But the green what the green mountain care board calls global budgets are actually imposters. I urge you to get a five or 10 minute lesson on what they really are and teach it to every rural hospital administrator and CFO in the state. And you will see a huge difference in the attitude of rural hospital administrators toward a system that actually use them. That could be a good use of time while the study committee is speaking with stakeholders. In March 48 again, Vermont's health care system must include mechanisms for containing all system costs and eliminating unnecessary expenditures. The mechanism mechanism to remove the most obvious unnecessary expenditure and source of excess excess cost growth would be to eliminate one care. I'm particularly alarmed at having heard that we won't be able to test the model because expenditures rating related to the pandemic will throw the data off or not just 2020, but for 21 and 22. I'm flabbergasted that this state of fiscally responsible citizens would commit to this project under this under the circumstances that we would sacrifice needed services like addiction services so that rural hospitals can pay their fee to the ACO is astounding to me. In March 48 the financing of health care in Vermont must be sufficient fair predictable transparent sustainable and shared it equitably. There will be train disruptions someday when we transition to a national health program. I was disappointed that on a federal little level so little was done to deal with the health care crisis while we were already moving money around to help companies families states and communities, whether the economic impact of the pandemic. It's a perfect time to take up the federal Medicare for all bill, but here we are in Vermont we are looking at how to use some of the money to help people pay for their health insurance. In s120 section to powers and duties, the committee shall explore opportunities to make health care more affordable for Vermont residents and employers, including identity, identifying potential opportunities to leverage federal flexibility. In section five you talk about opportunities made available by the Biden administration to expand access to affordable health care. I urge you to add, or through pursuing other programs with a state innovation waiver through section 1332 in the ACA. So here's where the public hearings come in. As long as you were traveling around the state, what are the most productive ways to use those hearings. Number one, teach what ACOs are most people can't even begin to understand what they're doing. What are their max, what is their maximum potential, what they can't possibly do, how much they cost and where the money goes. Have a doctor present to talk about coordination of care in that local area how well it works, and how one care makes or doesn't make a difference, and how it could be improved without one care. Then ask members of the public for their input and make their thoughts loudly and clearly known to the agency of human services, the governor and the Green Mountain care board, before the contract is considered. Before you go on this tour, decide what innovation waivers you want to pursue and be ready to gather the needed input for your application. There's a strong urge to do something. And there is this feeling that you have to pursue the ACO because you don't have anything else to try. First, do no harm. Sometimes a patient will get better from a useless intervention due to the placebo effect because you were nurturing them, but bloodletting for instance was doing harm. ACOs are not a harmless intervention. Even if you don't have a plan B, it is better to abandon this plan A. Thank you so much for your time. Thank you for your comments. So you also, we have with us. Marvin Malek. Marvin Malek, and you, is there anyone else who will be speaking from the League of Women Voters, but you're, I think you're, I'm the one speaking to the League of Women Voters. Finally got it. And Marvin has connection issues. So there he is, there he is. Okay. Marvin. Dr. Malek, thank you for being with us again. We greatly appreciate it. And if you're, if your audio starts to go, sometimes it helps just to turn off the video. So but we'll leave it to you. And please do go ahead, introduce yourself for the record and provide your testimony. Dr. Malek. Dr. Malek, can you hear me? Send him a note. I'm calling him. It looks like he's doing paperwork with this. It looks like he's doing some administrative work. Yeah, I'm calling him. We'll just wait one minute. There's a phone number in the waiting room ending with 271. Is that Dr. Malek by any chance? I'm not seeing it. It went straight to voicemail. So I didn't get him. So, hmm. I'm sending him a note. Did you say the number was in the waiting room because he often uses a, a, a phone at the same time that he's a computer and he's trying, he may be trying to hear me now. Yes, yes. Yeah, sorry for that. Technical problem on my work computer. Anyway, my name is Marvin Malek. I'm a long standing member of Physicians for National Health Program for 20 years, the Vermont chapter. I'm testifying today about, I'd like to talk both about cost control and also about the impact of one care and potential HCOs in general. And I guess I'll start out talking a little bit about cost control. And I think there are limits to what an individual state can do. We are unable to get rid of many of the external sources, external sources of funding, because they over 50% of the funding of our healthcare system comes from out of state sources. This adds to tremendous administrative complexity dealing with workers comp auto injuries Medicare federal workers, people in the Adirondacks who use our care people from Florida who are coming up for as tourists are coming up for as snowbirds. So it's very, it's very difficult for us to reduce administrative costs, unfortunately. However, there are some administrative costs that could be reduced. The one that makes my blood boil at a less than 212 degrees Fahrenheit boiling point is constantly listening to advertising for elective orthopedics by multiple hospitals. And I think that the state legislature should make it clear, both to the hospitals and to the Green Mountain care board that wasting money on advertising is not something that we're going to countenance. And that one of one of the more effective cost control strategies that we have and should continue is Green Mountain care board regulation of hospital budgets. And I think the amount of administrative expense, including advertising lobbying high CEO salaries should all be factored in in the in the in the percent increase or the hopefully decrease in hospital budgets each year. So I think the legislature should find ways to make its opinion known on those issues. There are a few issues that are also inter largely internal to the state that the state could work on and to achieve cost control. One is redo doing all it can to reduce spending on medical malpractice. That is basically an entry of money into the health care system that providers and hospitals have to cover that does not end up leading to any medical care. And that does not improve care. And the biggest single intervention that could both reduce errors and improve care is having high quality, a seamless high quality software system that we all share. That intervention I actually spoke nine years ago with people from the Green Mountain care board, but they didn't feel empowered or able to take that issue on to create a single seamless software that everyone in the state and ideally the country would be able to use. And I understand the reasons for that but I just want to point out that if you're looking to improve quality care and reduce costs that would be one of the most powerful interventions. If we had a national single payer system that would get this whole albatross off of our backs, and the, there is a resolution for state and local governments to support a single payer system nationally. This will not cost you any money to say that you supported and I will mail it to you. And so that you can see the resolution and I hope that you'll pass it to indicate to the federal go to federal legislators that we want a single payer national program pass, short of that. I think working on reducing administrative costs that the ones we have control over would be some of the more effective interventions. The final intervention that you could work on and I actually strongly recommend you do is the cost of recruiting. That is an internal cost within the state that we can control, and we are getting cream small hospitals across the state and really across the country are getting creamed on recruiting costs. And if you're aware that recruiting firms when they succeeded placing a doctor, they charge it say at a hospital practice, which is the usual situation these days. They charge $40,000 as a fee. I feel like if the state government could expand its a heck program, which is very limited and deals mostly with in with in state medical students, if they expanded that to a more general recruiting effort, create a website called Vermont, I think that would be an intervention. It wouldn't be as grandiose as what what you're looking for that you have the potential to control costs because these $40,000 outlays start to build up when there's enough of them. I think that reducing spending state spending on what is not working very well would also be another plan and Vermont information technology leaders is a program that's been going on for well over a decade. I've never used it and I don't know a doctor who has I've never gotten a single bit of clinical information using anything what they have developed. I don't know what they have developed. We get all of our information from Dartmouth and from and UVM and other facilities via fax machines, they're then optically scan into our record. So, whatever, whatever payments have been going on to that seem to have produced little utility. Similarly, the one care is an organization. And you will what how does one care impact your practice. And I said, I don't, I don't know that they've been any impact one way or the other I don't know of anything they've done. So, they're supposed to be helping with coordination of care, but for if I want to talk to a pulmonologist or rheumatologist or another primary care doctor, or a doctor in Florida was taking care of the patient. You know, last week if the where they were down there a patient was down there, none of that happens. And they, there isn't there is. So I asked other people who might be impacted by one care. I asked the care coordination team at our hospital. And they are funded to some extent by one care. If they enter things. They enter their data elements into the software that one care provides. So the software that one care provides has the advantage that actually connects with all the other people involved with mental health patients who need a lot of services, which is an important population. So that's good. And so that might make you think that this is a great intervention and it's fine I certainly no objection to all that. I can say, however, that we had the same care coordination teams really the same people doing the same work before there was one care. It was when back when there's the blueprint for health was primarily involved, and that's when it got going. So it was continued but now funded through through one care. So whether all of the administrative costs through one care are needed to get us to care coordination team is another question I think it is not. And the other issue is that I have no access to any of the information that there is that's in their software. So people who do care coordination have to make two entries one is into the software that I could see in our primary care practice, and the other is the whatever this software that one care has developed. So you can start to see the issues with wasting time and software incompatibility. So, that's sort of coordination of care I see them as fine I don't think it's greatly innovative but you know to the extent that coordination of care for mental health patients who need a lot of services to the sense that that's happening that's certainly a good thing. How much we should credit one care for that is another question. I, in terms of whether one cares likely to save money through perspective payment or abandoning fee for service. That's very problematic, because the patients are attributed through primary care. While there's the money that you're spending is primarily in specialty care. And we don't really have that much control over what the specialist do. And, and also an individual specialist. There's a strong motivation to do more, even with one cares, negative incentives, because if they're going to get paid $16,000 to do a procedure, and they get penalized for every procedure they do they might lose $20 at the end of the year that you can see where the incentives lie. And so I think it's going to be very problematic the fact that our main referral hospital for Southern Vermont is in another state makes it more difficult. And then it one care has high administrative costs inherently it's not particular to one care it's what an ACL has to do. So I'd be fairly pessimistic and want to, it's hard going to be also very difficult to evaluate the efficacy of one care, comparing Vermont spending rate of cost inflation health cost inflation to other states would be one way because most other states are very far along either for all these same reasons. So, I think you may want to not expend money where it's not likely to help, and maybe little projects that are in state that can actually save some money, especially recruiting might be useful thing. And I do hope you'll support the national single payer resolution. You will be the, we haven't put it very, we haven't done very much to get state governments to do it, but I think if Vermont leads the way on that it would be fantastic. Thank you very much for all your work and I know how hard you're trying to improve care for Vermonters. Thank you Dr Malik and I know how hard you, we know how hard you were have been working on this for many years and appreciate your comments. Thank you. You're welcome. So, we're going to move on to Vicki loner of one care Vermont. Are you where are you. Here you are. Okay. Yeah, I am. Thank you for being here and there was someone in the waiting room, calling by telephone. So I don't know that it may have been Dr Malik I don't know but now they've hung up so we won't. I won't ask again for folks who are here if you know who that was so Nellie's put a message up on chat. So, okay. Thank you for being here, Vicki and we look forward to your testimony. Thank you so much so for the record picking loner CEO one care Vermont. And I want to thank the committee for the opportunity to testify on behalf of one care and it's partnering participating providers, who as Jessica pointed out so eloquently really are committed to helping to change both payment and delivery system reform. And that's the primary goals of the co that were set out under the all payer model. In regards to s 120 I do believe that that has to do more with financing and less about the delivery system and payment reform efforts. I'll say about the additional evaluation of the all payer model is in the terms of the agreement between CMS and the state of Vermont. There was a very good evaluation framework set up that looked at cost quality. There was a model being performed by independent evaluator which is nor out of the University of Chicago, who has fairly extensive experience in both qualitative and quantitative analysis of such models. And understanding that their evaluation of years one in years to will be out later on this fall, that there was a delay because of the pandemic and that work, because it does require them to do interviews with providers throughout the state of Vermont to get perspective on the model. And so knowing that providers have been really busy, caring for patients during the pandemic. There had to be a pause in that. So I would say that adding additional layer of evaluation is unnecessary in terms of s 120. Also note that the all payer model improvement plan that was put out earlier this year by the agency of human services has a lot of nice steps in it that can be taken to provide some continuous evaluation and improvements to the model as we move forward so as not have to wait for the framework evaluation I think there's a lot of good work that could be done in between. In terms of s 130. I would of course say that we are in support of hearing aids primary care support and moving the innovation oversight to the director of payment reform. There is a tension between having the three mountain care board be both the innovator and the regulator. So I think that just makes good sense to have that transition to the director of payment reform. In terms of the other aspects of the bill as it relates to the CEO. We generally oppose all other aspects of the bill. What it really sets up is a system where it is diminished capability of provider led payment reform and that's what this was set up to do that's what the CEO was set up to do was to really be provider led payment reform and it transfers. Essentially all management operations and decision making to a very small regulatory body that is not set up with the right expertise to do the work. So I would say if the goal was to increase engagement in the model. So I would say that this bill as written and madam chair I have not seen the updates. So maybe many of this has been addressed but it does not support provider led reform and I feel that what will happen is that providers will not engage anymore. It would be particularly unfortunate given that even during a pandemic. We had an additional community Rutland joined because they are so committed to this model into the work that the state is trying to do. So I would hate to see engagement go down which would further put us in. So I would say that there is a lot of action with the federal government as a result of this. I would also say that there's a lot of additional administrative burden and oversight put in this bill that's unnecessary. The ACO has fairly rigorous oversight by the Green Mountain care board by all of its payers. As an entity we have an independent financial audit every year from PwC. We have a compliance audit every year independent auditor. So there's lots of structures set up in place within the ACO. I'm not sure what the auditor's office would be able to do in terms of adding value, aside from adding additional administrative cost and burden to the ACO and the system. So and I would also say that opening up access to all participants that are part of the ACO to the auditor's office is going to make further engagement with provider participants particularly hard. So as we look to how we move forward with this, I would say that again the state has put forward a really nice framework under the all-payer model improvement plan. We have recommendations in there in terms of really moving insurers to true payment reform such as the federal government, which is a big player in this, would be well worth the effort of this committee to look at how steps could be taken to improve and move that forward more quickly for both the federal government and for commercial insurers. Currently Medicaid is the only payer in the state of Vermont that is offering true fixed payment reform under this model. So I think others could really learn from the work that they've done. I also want to appreciate the work of this committee and house healthcare and appropriations and the agency of human services for making those investments and programs like Dulce, the home health longitudinal care and care coordination programs that support providers on the ground. The ACO has not set up an internal centralized structure to do that. That's really helping the delivery system to make those changes and reforms that will be necessary to be able to be paid under a different structure. I think that would conclude my comments. I have submitted written testimony as well to the committee. Thank you. All right, thank you very much. Yes, we do have your written testimony on our web page and we'll go through it completely. Thank you very much. Thank you. We have Devin Green of Vermont Hospital and Health Systems. Oh, you're sitting right there. I'm looking for my screen for you and you're right there. This is the problem with Zoom, you know, in the committee room, Vicki would get up and walk over to her seat or her standing area and you take her place. But so thank you for being here, Devin, and we look forward to your testimony. So Devin Green, Vermont Association of Hospitals and Health Systems, thanks for having me in today. I am going to quickly go through S-132 and our response to that S-120 and then I have a little proposal that I'm going to throw out there because it's really important to our hospitals and I apologize for it being last minute but it's important and it's come up recently and so I'm putting it out there. To start with S-132, I saw that these provisions were no longer in the proposed bill but I want to address them anyway because the overall concept of the bill goes towards health care provider delivery and it creates a lot of instability and unpredictability in the health care system. So one thing that the bill was proposing was changing health care delivery system reform from provider-led and evidence-based to shifting funding, having the Green Mountain Care Board shift funding around so to a state-based regulatory exercise by a small panel without clinical expertise. And this creates a lot of unpredictability in our health care system, these proposals. We saw the unintended consequences of shifting health care dollars when the legislature cut a dish funding to hospitals in fiscal year 2018 and redistributed it to the designated agencies in an effort to reduce times in emergency departments for individuals in mental health crisis. Today, ED wait times are longer than they were a few years ago and in the meantime that dish cut directly contributed to Springfield hospitals bankruptcy. So the idea of taking health care dollars and moving them from one place to another is deeply concerning to our fragile hospital system and it comes up every year. And so they are in this complete state of instability. I talked to a head of a premier care organization who said that he is trying to decide between investing in EMR and investing in population and health and he's leaning towards investing in EMR because it's a safer bet. Why should he invest in population health when the stands keep shifting in health care reform. So I just want to put that out there in terms of the instability that the proposals in S-132 create. I also want to say that I saw that the audit of the ACO is in the new draft and Vas does not support the audit of the ACO. The auditor's office already did a report through the Green Mountain Care Board's oversight of the ACO and so this would be redundant. And we also can't support auditing non-government organizations. It really opens the door there and creates a new precedent that we cannot support. That being said, there are pieces that we do support in S-132 including the hearing aids, the two primary care visits and the DMR reform and also moving the reform pieces of the Green Mountain Care Board over to the director of health care reform. So those are my thoughts on S-132. Moving on to S-120. This bill I see is really supporting immediate affordability for Vermonters. What we've been hearing in the testimony time and time again is Vermonters have high premiums. They have high out-of-pocket costs. It prevents them from accessing care. They need immediate relief now and we support efforts for affordability for Vermonters. We've seen an uptick in uncompensated care which indicates a clear problem and it leads to bad health outcomes for Vermonters and makes our rural hospital system more fragile. So we support affordability for Vermonters. We want to see S-120 done in a really direct and focused way so those Vermonters will see relief immediately. And I think the best way to do that is to build off of the previous work on affordability that this body and previous administrations have done. So we have the single payer report. We have five reports on the universal primary care. We have, I was dismayed to see that this new group would look at expanding Dr. Dinosaur because we did a 2017 report on expanding Dr. Dinosaur and we found out that it would increase adult premiums by $1,000 a year. And so it really looks like this is a group that's starting from scratch and not building off of previous efforts and in that I think that will just increase the amount of time of making headway on this and not give Vermonters the affordable care they need. So please work off of previous efforts and not do redundant efforts. That being said, if we're looking at affordability, the all payer model and the ACO is not about immediate affordability. It's provider delivery system reform. It's designed to reduce the cost of the health care system over the long term by employing preventive services today to create better health outcomes for tomorrow. So while it is making measurable differences for the child and mental health crisis who can now go to the psychiatric urgent care for kids instead of the emergency department. While it's making a noticeable difference for the food insecure diabetic who benefits from greater coordination of care. It's not going to change people's premiums or out of pocket costs overnight. So, in terms of focusing your efforts, I think it makes the most sense to get regular reporting on the progress of the implementation improvement plan. AHS is done. So there's oversight by the green man care board. There's oversight by the federal government and AHS has this implementation improvement program. So if you're looking for accountability for the ACO have them have AHS come in and report on the progress that's happening through the implementation improvement plan. Don't restart from scratch on some separate, you know, study, looking at the ACO when really you could focus on other things that will make remonters lives and health care more affordable going forward. I think the main thing there are all the incredible opportunities under ARPA. The American Rescue Plan Act. So that act is going to significantly bring in a lot of subsidies for remonters. It takes the former benefit cliff where people got subsidies up to 400% federal poverty level and it totally smooths it out. People are getting subsidies up to $76,000 for a single individual. So if you're an individual making $76,000 you'll get subsidies through the exchange. If you're a family of four, you'll get subsidies up to $157,000. No one's going to pay more than 8.5% of their income with these new subsidies. There's going to be a bunch of questions. So, if you have a lot of subsidies going into the exchange, should people drop their health care coverage or not. Sorry, people should not drop their health care coverage. But do we want to look at it that was a test we were. Do we want to look at having small employers drop health care and health care coverage because people will have affordable health care in the exchange. This leads to other important questions. This is particularly important for health care reform moving forward because when you apply for a 1332 waiver to do single payer or to increase the age limit for Medicare or to do any of these options. So what they look at is how much you're receiving in federal dollars through the exchange and they take that money and they love it to you and they give it to you. So you want to have a strategy where you are maximizing your federal dollars through the exchange and maximizing your federal subsidies. So these are all really important things to look at. One of the things to look at is, we have a premium assistance program. That's $5 million. That's additional to what the federal government provides. What do we want to do with that $5 million. Do you want to subsidize other income levels do we want to subsidize cost sharing. What do we want to do with that. And then in terms of the primary care visits one thing that we keep running into when we look at covering primary care is the HSA so the health savings accounts and how they do not allow for coverage until you meet your deductible. And so that's always a barrier and that should be looked at too. So, I would say for us 120 instead of going broad. Go big, but go effective. You know, we know that we know that Vermonters need affordability relief and so make it happen line yourself up so that it can really happen this time, instead of starting from scratch. The other thing I would do is work with diva on these on these public hearings that you're going to have Vermonters need to know there are people in the 400 to 600 federal poverty level who don't know that they're eligible for these subsidies go to them and educate them about that make sure that they know the opportunities that are available to them through our but so I would just ask this committee to make this, I think this study is important, but ask this committee to make it really useful and really focus on health care coverage affordability. The other opportunity, if I may, sorry, is I think in the delivery system reform piece there is an opportunity to look at care coordination so the one care has care coordination insurance companies have have care coordination. So I would like to overlap working that still be streamlined, but give you the efficacy of care coordination and good health outcomes that would be another opportunity to sort of reduce the costs. So that's what I have on as 120. Quick pitch. Totally shifting gears to pharmacy benefit managers. FQHCs and hospitals have been dealing with attacks on the 340 b pharmaceutical program which provides subsidies for hospitals and FQHCs to keep their doors open and do programs. And we've seen express scripts recently required this burdensome reporting requirement, and we are asking for some protective language that can also be found in Utah that would prohibit pharmacy benefit managers basically from creating additional requirements or restrictions on the 340 b program. And that's what I have. I know that Utah had done had done that. But I know that when I've met with folks from Utah they're very active in pharmaceutical covered costs so thank you for that. That's new. Okay, and do is that's in your. Yes, at the very bottom, at the very end. So, okay, thank you. And we're going to keep moving along. We have other folks added on after Steve Howard. Steve, I hope you are here. Yes, he is. Thank you for being here. Introduce yourself for the record and we'll listen to your testimony. Thank you for being here. Thank you for members of the committee feel well represented in this committee because I have my actual senator senator Cummings and my two honorary centers. The Rutland delegation who are here in full, full regalia here for this testimony. I'm going to start with a strategy that has worked pretty much throughout my life because you've been hearing from some very smart and well versed folks on the issue of health care. And so I want to just lower expectations for what I'm, what I'm going to say, and just let you know that I am the spokesperson for the BS for the members of the benefits advisory committee. And I'm going to go back to the CA who are much more immersed and well versed on these issues than I am, but I did consult them about this bill and they did have some points that they wanted to make. The first thing I wanted to say is that the state employees health care plan is perhaps a model. We are the plan is negotiated as part of collective bargaining and is managed. It's a shared plan, and it is really managed the practical everyday management of the plan is through blue cross blue shield but the decisions about the plan or are really made at the bargaining table where the workers in the management have equal power. So it's overseen by a collaborative effort of labor and participants, you know, the administration, the members of the VSE a and the members of the retirement community work together throughout the year to make advisory decisions and to consult on the operation of the plan. The best plan is one of the best plans in the country it has some of the lowest costs in the country. And in fact this year, we are in the budget going to have premium holidays because of the massive amount of surplus in the plan so I just want to make that point because when you have a collaborative effort like that, you are able to to manage the plan in the way that the state employees plan is managed so it is a it is a good example, maybe for health care cost containment throughout the state. Our members wanted you know we are now as this fall our members lives have been attributed to the accountable care organization one care was not the choice of the members of the VSE a to be attributed to one care. It was out of our control and unilaterally decided by the administration. It's not it was not a decision that we supported our members. I think would stress what some folks have said is that the ACO is not health care reform it's payment reform. Our members feel that there's not enough data around the ACO AC, ACO to know whether it's being effective and transparency really needs to be improved and increased. And our folks really believe that this real model should be scrapped and that we should be looking at a model that will cost something less than $20 million in administrative costs. They think basically this is the wrong approach. And that really if you want to contain costs and the state employees plan as an example of this. It's all about access and making acts increasing access, making it less costly, making it more available, which really means lowering out of pocket costs, increasing costs of coverage and using using tax revenues to do that, tax revenues to do that rather than limiting services that are provided to folks. The other important part that our members wanted to discuss and it's, you know, it's clear, it's clear in places like Rotland and other rural communities and throughout the state that we don't have enough health care infrastructure and not enough primary care access to nurse practitioners or specialists that would reduce, would get people the right care at the right time and reduce their dependence on more expensive care. Another point I think a couple of points folks wanted to make was that it's really important that the consumers that organize labor be included in any study committees that you have that, you know, it's both in terms of just their experience, which is with our health care plan, vast but also in our ability to Devin's point to get the word out about about what's out there in the broader marketplace beyond the state employees health insurance plan there's a lot of infrastructure there. And the only last thing I just want to put it I know put it just a quick plug in and I know this is part of s 132 is that our members are strongly supportive of the coverage for hearing aids that is included in that bill. So those those are just the brief points that our members asked that I make. So if you have any questions I'm happy to try to answer them. I probably will defer to people who actually know more about what they're talking about than I do. Thank you very much Steve this is very helpful. I don't see any written testimony from you on our web page so if you have that it would be really helpful to send it into Nellie. Thank you. Alright, thank you very much. All right, we're going to keep going. We have two more people who are here with us. Helen Laban of VP of VP QHC FQHCs the queue always gets me. Thank you for being here Helen. Thank you. So I am Helen Laban I am the Vermont Public Policy Director for by state primary care association. You do have written testimony from me on s 120 it is succinct for me is shorter than my average email. And I won't restate that here it does speak broadly to our perspective on payment reform healthcare delivery form and payer reform. You know to follow up on points that have been made. I think you've heard it clearly that the idea that direct and immediate reduction of insurance costs and affordability for consumers is not a goal of the all payer model. And nor should it be it's those are sort of they're connected but they are in many ways apples and oranges. We agree that there should be focused legislation and policy efforts to directly reduce those insurance costs for Vermonters. We do not believe that s 120 necessarily achieves that as currently presented. I did not do a close line by line and suggestion for other options in the way that boss has done. However, I'd be more than happy to crib off of their work and review that testimony and provide additional line by line ideas on behalf of I say if that's something that would be helpful to you. So kudos to Devin for being very constructive in that way and I can I can replicate. We want to make a quick point that I think has come up a little bit but not been as strongly stated as FQHC's feel it so we are federally qualified health centers the federal part of that is is key. We do provide health care primary care and preventive care access to about a third of Vermonters through our membership. And we also provide access for about 45% of Medicare beneficiaries. We strive to be highly responsive to our local communities to be innovative to do a range of services and to reach the most vulnerable Vermonters. That being said we are both funded and regulated by the federal government. So we don't have an option to move forward on health care reform that is not in alignment with the federal government. And that's really what the all pair model allows us to do it brings in our federal partners into Vermont's health care reform initiatives and let's us all move forward together. We don't, we don't want to be in a point where we have to choose between what Vermont wants to do and what the federal government wants to do that as an impossible choice for us, we would be unable to do anything in that situation. And for that reason it's critically important to us that the all pair model exist and provide that alignment because I, I literally don't know what we will do if we don't have that alignment. And so that's really a key and critical point in, and we have heard clearly from the federal government and are told, you know, on a monthly basis that value based payment reform is what we need to be doing, and we are contracted with to support that. And that will be forever strongly in favor of value based payment reform, and that alignment so that's really the point that I want to bring home I believe that one of my members is also on the line and I would not take up additional time that could be spent hearing from how this is playing out on the ground so thank you for listening to my testimony. So thank you for your written testimony. I think if you concur with other things that you mentioned, Devin greens testimony, if you concur with some other testimony, whether it's Devin or others, you know, please do let us know that it's nice to have some triangulation along the way. We've certainly heard that from different folks. Thank you. We also have Michael Costa here. Thank you for being here Michael and I don't know if we have anything in writing from you. Yes, Senator, I submitted something in writing and I'm happy to speak to it. Thank you. Why don't you introduce yourself for the record and then we'll hear your testimony. Good morning. Thank you to the committee for having me here I knew you were quite busy. My name is Michael Costa and thank you for the opportunity to testify regarding as 120 and related topics and health care reform. Presently I serve as Chief Executive Officer of Northern counties health care in St. Johnsbury, which is a health system consisting of a fairly qualified health center with five primary care sites, three dental sites, and an express care clinic. And we're also a Medicare certified home care and hospice agency. We also serve on the board of directors for the by state primary care association, the V&As of Vermont, Vermont Association of hospitals and health centers and one care Vermont ACO. Prior to that as many of you on the committee know, I served as Deputy Commissioner of Diva during the present administration and part of my duties was to bring to life, Diva's health care reform efforts, particularly regarding payment reform. In that role I served as Deputy Director of health care reform for Governor Shumlin, which included being on the negotiating team for the all pair model and working on Green Mountain care and the universal primary care studies among others. So, you know, I left Diva, even though it was the best job I'd ever had my life to suffer a summer at Carville ice cream for the following reason, you know, after years of working on Vermont's vision for health care reform and time implementing that vision at Medicaid. I wanted to be involved at the point of care. That pivot from focusing on health care reform vision to execution has been really illuminating, particularly during COVID. And for me it's instilled an extraordinary amount of humility. I think of the term delivery system reform really differently now, because I have a responsibility for our team which cares for people 365 days a year. And I watch our clinicians and our nurses and our personal care attendants care for people who are frail and elderly and sometimes really scared. And you know that experience hasn't dimmed my belief in the need for reform but it has made me appropriately respectful of the scope of the project. So the transition to value based care which I know the community has taken a lot of testimony about and value based payments that allow us to focus on how to make communities physically healthy mentally healthy well housed well nourished and financially secure. It requires time and trust and effective risk management. So each day as CEO I have to decide how aggressive or conservative I want to be about transitioning northern counties to value based care. So I have to decide what portion of our time money and talent and my own credibility as a leader is allocated to that project. And the healthcare reform bills this session and particularly recent comments made by the state's state's chief healthcare regulator, have a chilling effect on our reform efforts at the provider organization level. I'm left to wonder whether the president approach will continue or whether Vermont will find a new vision for healthcare reform, which would be our third in the last 10 years. And uncertainty creates real dilemmas. So do I work with one care on a capitated payment model for FQHCs for 2022, or do I wait until a new agreement is signed with the federal government. Do I invest in population health management, or do I take on an electronic health record project which would take a year and quite a bit of money. Do I add more wraparound services because so many of our people come into our clinics and their problem primarily is not a healthcare problem. There are other issues that we need to help them with, or do I do I be more cautious about that because I may lose the substantial support we get from one care. Do I add a clinical pharmacist because more and more the problems that our patients have are complex pharmacology, right, how all their drug interactions work together. Now that'd be great for my patients and it would reduce visit volume, which is great in a value based world. But do I take on that it spends now and potentially be stuck in fee for service for a long time, and then have to wait to see what the state's next commitments are in healthcare reform. And so this is just a few of the many trade offs that healthcare leaders have to make when thinking about the operational imperative of the present, and then the transition to future innovation. And so, you know Vermont in my view is rightly viewed as a leader in thinking about creating more just and equitable healthcare system. Yet, you know what I found in the transition from state government to the provider community with that policy vision is only as good as the execution by those healthcare organizations. So I just asked the committee to consider the effect on healthcare leaders and organizations of potentially diverting attention away from the all pair model, and considering a new way forward. So that's all I wanted to say. Thank you very much for all you do for Vermont and Vermonters. And thank you for what has been a really probably the best zoom meeting I've had this week you are all getting really really good at this. So, I can't we were almost good. I didn't unmute myself, but I just want to say thank you. We've had a lot of practice at zoom, you know, ever since last March. The day that this committee started was March 13 or 16 after we got off the telephone. And we've been doing it through the summer of the fall and continuing so. But thank you very much, Michael for your, for your comments it's good to see you again and we very much appreciate your, your testimony. Thank you very much. Terrific. So I don't think there is anyone else with us this morning, who has asked to testify and, and frankly, committee, I think that it's time for us to close the testimony loop on this one on the bills and then for us to dive into some exploration of what we have heard and some recommendations perhaps for amending one or both bills. So, before we begin that conversation. My suggestion is that we take a little break. It's been a very intense morning we've heard a lot of good testimony, and we have, I think we deserve a little time to stretch. Our minds and our bodies so let's looking at the time and what we have before us we also have the budget memo we want to firm up. So let's take. Oh, I hate to say 15. Let's come back at 1045 that's a 14.