Rural Health Task Force presents report to health committee 

The Rural Health Services Task Force presented its report to the House Health Care Committee on Tuesday. Green Mountain Care Board member and Task Force Chair Robin Lunge said the task force focused its analysis on rural health delivery in three main areas: workforce, revenue stability, and care management. It was determined that telehealth, the use of electronic information and telecommunications technologies to support long-distance health care, cuts across all three priority areas.

Vermont Health Care Association representative Laura Pelosi stated that Vermont’s health care workforce is aging, there is a decline in licensed professionals, and there are workforce vacancies in every sector. She said Vermont’s health care workforce crisis is driven by several immediate factors including student debt, education and credentialing challenges, licensing challenges, and provider burnout. Pelosi reviewed the financial impact of vacancies, the actions taken to date, and recommendations to address these issues. The Workforce White Paper can be found here.

Lunge reviewed the issues related to revenue stability. She said that operating expenses are growing faster than revenues, reimbursement rates do not cover inflation, and personnel costs continue to increase. Lunge also presented the impact of hospital closures on Vermont.

VNAs of Vermont Executive Director Jill Olson said a lot of work is currently being done to improve care coordination and the task force fully supports the delivery system reform dollars currently being discussed in the 2020 Budget Adjustment Act for OneCare Vermont, the state’s accountable care organization. She said these funds are critical to maintain and build investment in existing care coordination functions in home and community-based services, and promote the coordination of data sharing.

OneCare Vermont details operations and programming

The House Health Care and Senate Health and Welfare Committees held hearings over two days on OneCare Vermont, Vermont’s accountable care organization. OneCare CEO Vicki Loner and Senior Director of Finance and Payment Reform Tom Borys detailed the structure and budget of its organization. In 2021, $43 million will be paid to Vermont providers to invest in care coordination, primary care enhancement, data, and value-based payments. In response to questions raised recently regarding transparency, Loner told legislators that OneCare is committed to transparency and all board meetings are open to the public. It is also developing dashboards that will be posted on OneCare’s website showing quality and financial program data.

RiseVT Executive Director Marissa Parisi highlighted the RiseVT and Developmental Understanding and Legal Collaboration for Everyone initiatives that are part of the accountable care organization. RiseVT looks to amplify wellness efforts in communities. There are 16 program managers employed by Vermont hospitals. The 2020 goal is to have RiseVT in all 14 counties. DULCE is an intervention that takes place within a pediatric care office to address social determinants of health in infants, zero to six months, and provides support for their parents. As of December 2019, OneCare was able to exceed its goal of having three new DULCE locations and funded four models at pediatric practices statewide.

Several legislative committees have indicated that they will continue to review OneCare Vermont in hearings this session.

Brattleboro Retreat provides bed expansion update

The House Corrections and Institutions Committee heard from the Agency of Human Services, Buildings and General Services, and the Brattleboro Retreat on Wednesday on the status of the Brattleboro Retreat’s 12-bed expansion for the most acute mental health patients. The beds are scheduled to open in late June. AHS Secretary Mike Smith told the committee there continues to be a desperate need for this level of inpatient beds. The state currently has 45 beds for this level of care and has been at capacity for several years.

Smith provided an update on the events that have transpired over the last week. He said the tone of discussions has changed and there is a path forward for AHS and the Retreat to work together.

Brattleboro Retreat Chief Executive Officer Louis Josephson said that there will be a shortfall of $1.7 million for the expansion. There are enough funds for the construction project, but not enough for fit up costs that will be needed before opening. He said after years of balancing its budget by using surplus funds, there is not enough money left to cover the cost overruns for the project. Josephson acknowledged that the Retreat underestimated the cost of the project after AHS asked the hospital to consider the expansion and that in better times the hospital probably could have found the money to finish the work.

BGS Commissioner Chris Cole said there is an additional request of $250,000 in the FY21 capital bill to help the Retreat.

Primary care workforce challenges and solutions discussed at GMCB

The Green Mountain Care Board hosted a Primary Care Workforce panel this week, focusing on the challenges in workforce recruitment and retention. Currently, over 40 percent of the primary care workforce in Vermont is over 60 years old and there are over 70 primary care positions that need to be filled. All panel members agreed that there is a workforce shortage that is likely to worsen.

Jessa Barnard, Executive Director of the Vermont Medical Society, said that burnout due to system dysfunction is affecting the retention rate. Interventions that improve the practice environment, including better electronic health records management, a streamline of quality measures, and a reduction of prior authorizations would improve work and life quality for providers.

Bi-State Primary Care Association Director of Public Policy Helen Labun noted that current provider-led health care reform efforts in Vermont help providers feel connected and invested in the health care system and should be used as a recruitment tool. All members of the panel support financial incentives for providers, including tax incentives and loan repayment.

Dartmouth-Hitchcock Medical Center and Geisel School of Medicine Dr. Cathleen Morrow told the Board that the placement of medical students in rural communities with providers is critical. The power of individual relationships with mentors and students early in training cannot be overstated. Morrow also pointed out that Vermont only has 1.5 family residency programs, and since the majority of residents stay in the state where they train as a resident, expanding residency programs would increase the number of family physicians practicing in Vermont.

Competency to stand trial debated

The Senate Judiciary Committee took testimony on Tuesday on S.183, a bill that would extend the time a person remains in state custody if the person is adjudicated not guilty by reason of insanity for a homicide or attempted homicide. Under current law, those that are found not guilty due to insanity at the time of the crime can be released as soon as 90 days later. The bill as drafted would extend that time to three years.

The bill:

  • Establishes a three-year initial commitment period for a person adjudicated not guilty by reason of insanity for a homicide or attempted homicide; 
  • Requires the Criminal Division of the Superior Court to hold a public safety hearing before the Department of Mental Health can discharge or discontinue treatment for a person who is in the department’s custody after being adjudicated not guilty by reason of insanity for a homicide or attempted homicide;
  • Requires the Department of Mental Health to notify state’s attorneys and crime victims before a person is released and allows them to speak at the court hearing that determines whether the person can be released to the public;
  • Requires reporting on availability of psychiatric support services during the criminal process, mental health services available in a correctional setting, and forensic models used in other states; and
  • Implements a public education campaign regarding the operation of the forensic care system.

Assistant Attorney General David Scherr said Vermont hospitals could be at risk of losing their federal funding if the state establishes a three-year commitment period because hospitalizations need to be based on treatment. He said the only way to address this issue is to have a secure forensic unit for individuals who are mentally ill and a danger to themselves or the community but who are not eligible for psychiatric hospital level of care. He also said any legislation needs to take into account due process and constitutional rights.

The committee will take up the bill next week.

All-payer model 101 provided to Appropriations Committee

The House Appropriations received an overview of the Vermont All-Payer Model Accountable Care Agreement and delivery system reform investment requirements on Wednesday. Agency of Human Services Director of Health Care Reform Ena Backus provided the history behind the program and the attempt by the state to address health care spending growth. She said the goal is to change how we pay and deliver health care by having a set budget for the health care system instead of paying for each service. Backus explained that the contract is between the state and federal government and is a cost containment and quality improvement model, not a coverage expansion model.

Backus provided information on the delivery system reform investment guardrails for 2020. There is a federal review and approval process, regular reporting to the federal government, and an evaluation plan to assess the project and determine if it should be scaled or sunset. The appropriations committee has been reviewing DSR investments as part of their Budget Adjustment deliberations.

OneCare Vermont Chief Executive Officer Vicki Loner said that the OneCare budget grows every year because there are more lives attributed to the model and more accountability. The APM contract requires that scale is increased. The federal government and the state, through OneCare, are moving away from fee-for-service payments because it is not predictable or sustainable. She also stressed that delivery system reform dollars go into communities, not administrative costs. Loner answered several questions regarding administrative costs, economies of scale, and the provider network. Her presentation can be found here.

Secure residential facility update

The Senate Institutions Committee received an update on Friday from Department of Building and General Services Commissioner Chris Cole and Department of Mental Health Commissioner Sarah Squirrell on the Middlesex Secure Residential facility and plans for the future.

Squirrell said DMH was asked to do a review of the number of secure beds needed in Vermont. The preliminary analysis indicates the need to expand by 16 the number of secure beds. Squirrell said the goal is to move people through the levels of care, because at any one time there are up to 15 people in level one beds who could be transferred to secure beds.

A report with a comprehensive analysis of bed needs, including group homes and other residential programs, was delivered to the legislature on January 15. The report concludes that there are significant needs for secure residential with capacity to do involuntary procedures and long term intensive recovery residences. Squirrell emphasized the need to expand group home capacity. Group homes are at 100 percent occupancy and people are not moving out of those beds.

GMCB presents financial analysis on the Brattleboro Retreat

The Green Mountain Care Board presented its analysis of the Brattleboro Retreat audited financial statements to the House Health Care committee on Wednesday as required by Act 53 of 2019. The analysis confirms that the Brattleboro Retreat is facing significant financial challenges, including operating revenues outpacing losses, increases in uncollectable receivables and an aging plant. The Board is optimistic that the Retreat and the Agency of Human Services will be able to work out a path forward.

Paid Family Leave bill heading to a showdown

The Senate approved the conference committee report on the paid family and medical leave bill on Friday, with a vote of 20-9. H.107 will now head to the House for a vote. This new benefit would be funded with an employee-paid 0.2 percent payroll tax. The committee agreed to keep an option by which employers can cover that cost in whole or part. Upon approval by the Commissioner of Financial Regulation, an employee can be exempt from the tax if their employer complies with the requirements in the bill through their own benefit plan.

The tax will support the following benefits:

  • A qualified employee shall be permitted to receive a total of not more than 12 weeks of Family and Medical Leave Insurance benefits in a calendar year which may include:
    • Up to 12 weeks of benefits for parental bonding leave taken by the employee;
    • Up to eight weeks of benefits to care for a family member; and
    • Family members include:
      • child or foster child;
      • a stepchild or ward who lives with employee;
      • spouse, domestic partner or civil union partner;
      • parent or parent of the spouse, domestic partner or civil union partner;
      • sibling; and
      • grandparent or grandchild.

If an employee opts into temporary medical leave coverage for themselves, they are also eligible for up to six weeks of medical leave for themselves. The additional cost to them is a 0.38 percent payroll tax. Employees can use this benefit once each calendar year.

Determination of reimbursement:

  • The portion of the employees average weekly wage that is less than or equal to 55 percent of Vermont’s average weekly wage shall be replaced at a rate of 90 percent.
  • The portion of the employees average weekly wage that is greater than 55 percent of Vermont’s average weekly wage will be replaced at a 55 percent rate.

This is a mandatory payroll tax that must be paid by all workers. Progressives and a group of liberal Democrats believe that without mandatory temporary disability benefits, too many will be left out of the program, and therefore this group will not support the bill. On the other side, the Republicans are joined by a group of moderate Democrats who also do not support the bill. The Governor has promised to veto anything that includes a payroll tax, so passage of H.107 is looking highly unlikely.

Health Care Bills

H.734  An act relating to prohibiting certain provisions in dental insurance contracts with dentists

H.768  An act relating to augmenting the insanity defense with a disposition of guilty but mentally ill

H.776  An act relating to the involuntary commitment of persons misusing substances

H.778  An act relating to home visiting services

H.779  An act relating to allowing pharmacists to dispense injectable naltrexone

H.785  An act relating to Green Mountain Care Board authority over prescription drug costs

H.786  An act relating to eliminating cost-sharing requirements for primary care

H.787  An act relating to hospital use of savings from 340B drug pricing

H.795  An act relating to increasing hospital price transparency

H.796 An act relating to recommendations regarding ownership of medical data in electronic health records

H.816  An act relating to establishing a mental health mobile response unit pilot program in the city of Rutland

H.822  An act relating to limiting out-of-pocket expenses for prescription insulin drugs

H.823  An act relating to banning flavored tobacco products and e-liquids

H.824 An act relating to required medical personnel for dental procedures using sedation or anesthesia

H.825  An act relating to limitations on health care contract provisions and surprise medical bills

H.826  An act relating to authorized professional use of regulated drugs

S.264  An act relating to paid vacation leave 

S.288  An act relating to banning flavored tobacco products and e-liquids

S.290  An act relating to health care reform implementation

S.300  An act relating to planning for the care and treatment of patients with cognitive impairments

S.302  An act relating to establishing a mental health mobile response unit pilot program in the city of Rutland

S.305  An act relating to making State-formed nonprofits subject to the Public Records Act

S.309  An act relating to limitations on health care contract provisions and surprise medical bills

S.314 An act relating to consent by minors to preventative services for sexually transmitted diseases