President and Governor declare national and state of emergency

President Donald Trump officially declared a national emergency on Friday that give states access to up to $50 billion in federal funds to combat the spreading Coronavirus epidemic. The declaration allows the Department of Health and Human Services to waive certain regulatory requirements for healthcare facilities in response to the pandemic. It will allow healthcare organizations to submit waivers to establish alternate care sites, to modify patient triage protocols, patient transfer procedures, allow for the use of telehealth, and the authority to waive rules that restrict hospitals from being able to adequately care for patients.

Late Friday afternoon, Gov. Phil Scott held a press conference and also declared a state of an emergency. Scott has restricted access to long-term care facilities and prohibited gatherings of more than 250 people. He will be suspending some medical regulations to bolster health care capacity. Schools are not being closed yet.

Lawmakers consider COVID-19 measures

House Speaker Mitzi Johnson convened committee chairs on Thursday morning to brainstorm on the global Coronavirus pandemic (COVID-19) and to pull together a package of legislative actions to address the potential spread of the COVID-19. At the request of the House Health Care committee, a coalition of health and human services providers provided the committee with a list of temporary emergency statutory measures that could be put in place in this emergency. Coalition member Jill Mazza Olson began by stating that the coalition supports and would encourage a declaration of a state of emergency by the Scott administration. This would waive interstate licensure requirements and would trigger federal telehealth flexibility.   

Olson presented the proposals which fall under four major categories:

  • Preserve cash flow for all health care facilities;
  • Enhance the workforce by passing the interstate nurse compact and easing clinical nurse educator requirements, flex the childcare regulations in order to set up emergency childcare, and allow providers to be paid for telephonic and video visits;
  • Ease compliance by allowing the Agency of Human Services the authority to release providers from state obligations that they may not be able to meet in a crisis; and
  • Waive some private insurance and Medicaid cost-sharing for visits associated with a COVID-19 diagnosis and allow coverage of early refills of chronic maintenance medication so people can always have a 30-day supply on hand.

The committee drafted language based upon the coalition’s proposals, and introduced it on the floor as an amendment to H. 742. The proposal includes expanded professional health care licensing, temporary waiver or suspension of the provider tax, and a directive to health insurers not to impose any co-payment, coinsurance, deductible, or other cost-sharing requirement for health care services directly related to COVID-19 treatment or prevention. The proposal directs health insurance plans to suspend deductible requirements for all prescription drugs and impose only the applicable co-payment or coinsurance requirement under the plan. An enhanced version of the telehealth bill already passed by the house is also included.

Senate advances insanity defense legislation

The full Senate approved S.183 on Tuesday, a bill that addresses competency to stand trial and insanity as a defense. The Senate approved a floor amendment offered by Sen. Chris Pearson, D/P- Chittenden, that clarifies that a defendant is entitled to have counsel appointed from Vermont Legal Aid, but may also have their own counsel. 

The bill:

  • Separates the competency to stand trial evaluation and the person’s sanity at the time of the alleged offense evaluation;
  • Requires the Departments of Corrections and Mental Health to submit an inventory and evaluation of the mental health services provided by the DOC contractor for health care services to include type, frequency, and timeliness of mental health services provided in a correctional setting differ from services available in the community;
  • Creates a Forensic Care Working Group to identify gaps in the current mental health and criminal justice system to improve public safety and coordination of treatment for individuals incompetent to stand trial or who are adjudicated not guilty by reason of insanity; and
  • Requires DMH to notify state’s attorneys and crime victims before a person is released in the community.

Senates passes insulin bill

The Senate passed S.296, a bill that limits a beneficiary’s total out-of-pocket expenses for insulin medications to not more than $100 per 30-day supply, regardless of the amount or type of insulin needed. The $100 out-of-pocket spending will be applied to the individuals yearly deductible.

The bill now moves to the House.

House passes board of medical practice licensing bill

The House approved H.438, a bill that clarifies board procedures around disciplinary investigations and hospital disciplinary reporting. It clarifies that providers being investigated by the board of medical practice have a right to view their investigation file and have the opportunity to depose witnesses. The bill also creates a framework at ensuring hospital reporting of a disciplinary action even if the provider has voluntarily left the hospital.  

House panel releases prescription drug technical advisory group

The House Health Care Committee revealed its prescription drug proposal on Thursday. The bill creates a Prescription Drug Technical Advisory Group that will provide input and recommendations on the following:

  • Models that enhance the Board’s ability to analyze, monitor, or report the pricing of prescription drug products or the relationship between prescription drug pricing and consumer prescription drug costs;
  • The effectiveness of prescription drug initiatives on prescription drug costs; or
  • Other mechanisms for increasing prescription drug price transparency at one or more levels of the prescription drug supply chain.

The Board will provide an interim report to the General Assembly on Jan. 15, 2021 and a final report on Jan. 15, 2022.

House passes telehealth legislation  

The House advanced H.723, a bill to require health insurance reimbursement for expanded telehealth services. The bill would require reimbursement for a category of telehealth services, store-and-forward, which is commonly used for provider-to-provider consultations, also known as eConsults. Although health care systems regularly use eConsult technology for a wide range of specialties, Vermont statutes allow reimbursement only for dermatology and ophthalmology services.  

On Tuesday, the House Health Care committee approved an amendment that was introduced in response to Coronavirus concerns. It expands the Department of Financial Regulation’s authority to expand store and forward reimbursement by emergency rule. The amendment also changes the effective date of H.723 upon passage. The exception to this is the store and forward section, which is effective Jan. 1, 2021.

House Appropriations will approve grants to EMS providers

The House Appropriations Committee heard testimony from Rep. Mari Cordes, D-Lincoln, and Rep. Jim Harrison, R-Mendon, on H.742, a bill that would provide grants to allow emergency medical service districts to provide low or no cost training to EMS personnel. Cordes explained the bill aims to centralize training, to remove barriers with the application process, and to allow the EMS Advisory Committee and the Vermont Department of Health to work on making access to funding easier for the EMS districts. Harrison said that the House Ways and Means Committee will review the bill in reference to the insurance rate increase.

Joint Fiscal Office Analyst Nolan Langweil provided an overview of how the EMS Fund operates. He said the total appropriation is $450,000. The committee is prepared to support the funding.

Senate delays vote on health care reform bill

Health care provider groups and commercial insurers continued to voice concern on many of the provisions in S.290, a bill that expands the Green Mountain Care Board’s regulatory authority. The GMCB provided additional changes to the bill this week, which still had many areas of concern to the entities the Board regulates.

The committee delayed vote on Friday and may have continued discussion remotely next week while the legislature is on recess due to concerns regarding COVID-19.

House health panel passes health care workforce bill

The House Health Care Committee passed a health care workforce bill on Friday. The proposal includes a requirement for the Director of Health Care Reform to maintain a current health care workforce development strategic plan, with the help of an advisory group. The plan must continue efforts to ensure that Vermont has the health care workforce necessary to provide care to all Vermont residents. A draft of the plan must be submitted for review and approval to the Green Mountain Care Board by December 1, 2020, and after approval, the plan will be provided to the legislature.  

The bill also proposes expanded health care scholarships aimed at supporting and increasing primary care providers and nurses in Vermont. If funds are appropriated, the Area Health Education Centers Program at the University of Vermont College of Medicine would establish a rural primary care physician scholarship program. The scholarships would cover the medical school tuition for up to five third-year and up to five fourth-year medical students annually who commit to practicing primary care in a rural, health professional shortage or medically underserved area of this State. For each academic year of tuition covered by the scholarship, the recipient would incur an obligation of two years of full-time service or four years of half-time service. The bill also expands the existing Educational Incentives for Nurses program of the Department of Health, administered by VSAC.

Because the bill includes appropriations, the bill will now be referred to the House Committee on Appropriations.

Older Vermonter’s Act approved by committee

On Wednesday, the House Human Services Committee approved H. 611, the Older Vermonter’s Act. The legislation aims to help aging Vermonters live independently, and is intended to work in tandem with the federal Older Americans Act, the Vermont State Plan on Aging, and the Choices for Care program. The bill was referred to the House Committee on Appropriations.

Committee passes buprenorphrine decriminalization

The House Human Services Committee passed H.162, a bill that proposes to remove buprenorphrine from the misdemeanor crime of possession of a narcotic. Buprenorphrine is an opioid used to treat opioid use disorder, acute pain, and chronic pain.

The language approved by the committee is a strike-all amendment to the language passed by the House Judiciary Committee last session and decriminalizes possession of 224 milligrams or less of buprenorphine. Persons under 21 years of age in possession of 224 milligrams or less of buprenorphine would be referred to the Court Diversion Program for the purpose of enrollment in the Youth Substance Abuse Safety Program. Knowing and unlawful possession of more than 224 milligrams of buprenorphine would continue to be criminal and penalized in the same manner as other narcotics.

High tech nursing proposal discussed

The House Health Care committee took testimony this week on Vermont Legal Aid’s legislative proposal to direct the Department of Disabilities, Aging and Independent Living, and the Department of Vermont Health Access to report to the legislature on efforts to fully staff the Medically Complex Nursing Program.

Vermont Legal Aid attorney Barbara Prine told the committee that only half of the required care hours have been administered recently, in violation of law requiring that medically necessary care be provided. She said that the ability to fully staff the program is hindered by administrative barriers, the difficulty and stress of the position, and the pay gap between high tech and hospital nurses, preventing nurses from choosing the lower paying high tech nurse positions.

VNAs of Vermont Executive Director Jill Mazza Olson underscored the complexity of the staffing issue, and reiterated that the tiring and difficult work required by the positions, including overnight shifts, compounds the difficulty in recruiting and retaining high tech nurses. Any amount of appropriated pay increase is beneficial, but the VNAs of Vermont members do not think there is a magic number that’s a solution to the problem. Last year’s pay increase was completely consumed by the provider tax levied on the agencies.

The committee is considering adding the proposal to their miscellaneous health care bill.

House passes hospital price transparency bill

The House passed H.795, a bill that proposes to require hospitals to report to the Green Mountain Care Board its actual charges for health care services delivered to patients without health insurance or other health coverag. The GMCB will take that information along with VHCURES data and make public the average charge for each health care service at each Vermont hospital for insured patients and for private-pay patients.

The bill also directs the board to develop an interactive price transparency dashboard in order for the public to have easy access to the required information. The dashboard must be available for public use as soon as it is operational, but no later than Feb. 15, 2022. At the time that the dashboard goes online, the board must also make recommendations on how the dashboard may be expanded to provide information on health care quality. The GMCB, the Vermont Association of Hospitals and Health Systems, and the Health Care Advocate all support the bill as amended.

Senate committees recommend AHS reorganization study

The Senate Health and Welfare and Government Operations committees advanced S.297, a bill that creates a working group to develop proposals for reorganizing the Agency of Human Services. The working group will consider options for reorganizing, restructuring, or reconfiguring the AHS to best serve Vermonters. The workgroup will report its findings to the General Assembly by Jan. 15, 2021.

Panel advances stem cell products legislation

On Friday, the Senate Health and Welfare advanced S.252, a bill that proposes to require health care providers who administer stem cell products that are not approved by the U.S. Food and Drug Administration to provide notice of this fact to their patients and in their advertisements, and to obtain specific informed consent prior to performing an unapproved therapy.

Panel advances climate change response plan

The Senate Health and Welfare Committee advanced S.185, a bill that adopts a climate change response plan and requires regional planning commission involvement in identifying health care-related needs. It directs the Vermont Department of Health to develop a climate change response plan for the state and to develop a communication plans that establishes responses to climate change related health risks with the regional planning commissions. It directs regional planning commissions to identify health care related needs in each region.

The bill requires hospitals, in consultation with regional planning commissions, to have a protocol for meaningful public participation in its strategic planning process for identifying and addressing health care needs that the hospital provides or could provide in its service area. Hospitals will be required to post on its website a description of its identified needs, strategic initiatives developed to address the identified needs, annual progress on implementation of the proposed initiatives, opportunities for public participation, and the ways in which the hospital ensures access to appropriate mental health care that meets standards of quality, access, and affordability equivalent to other components of health care.

Mental health integration council

The Senate Health and Welfare advanced S.218, a bill that creates a Mental Health Integration Council. The council will address the integration of mental health in the health care system by:

  • Identifying obstacles to the full integration of mental health into a holistic health care system and identifying means of overcoming thosebarriers;
  • Helping to ensure the implementation of existing law to establish full integration within each member of the Council’s area of expertise;
  • Establishing commitments from non-state entities to adopt practices and implementation tools that further integration;
  • Proposing legislation where current statute is either inadequate to achieve full integration or where it creates barriers to achieving the principles of integration; and
  • Fulfilling any other duties the Council deems necessary to achieve objectives.

The council will provide a progress report on Dec. 15, 2021 and a final report on Jan. 15, 2023 with its findings and any recommendations for legislative action.

Panel hears from AHS on the Brattleboro Retreat  

Agency of Human Services Secretary Michael Smith recommended to the House Corrections and Institutions Committee that $1.5 million be allocated to the Brattleboro Retreat through the FY 2021 Capital Budget Adjustment Act in order to finalize construction of 12 new inpatient beds for the most high acuity patients.

Smith asked the committee to include language that set requirements that the Brattleboro Retreat must comply with. The language requires:  

  • Compels monthly reporting on financial performance;
  • Requires the Retreat to follow best practices outlined in the March 2020 Best Practices Memorandum to ensure compliance with Medicaid billing practices and provider enrollment;
  • Compels the Retreat to keep the agency advised of any event or occurrence that materially impacts its financial stability, performance, staffing service delivery capacity, or viability;
  • Requires the Retreat shall provide information to the Department of Mental Health necessary for its statutory oversight responsibilities;
  • Requires the Retreat shall work with the Department of Mental Health to develop an initial strategic plan for the long-term reuse of the renovated facilities to meet future system of care needs;
  • Expects the Retreat to provide access to the additional 12 beds to the State for a period determined by the Secretary of Human Services to be in the best interest of the State;
  • Requires the development of a long-term strategic plan that analyzes current and future needs of the service delivery priorities and role of the Retreat in Vermont’s mental health system of care, and
  • Update on the strategic plan for the long-term reuse of the renovated facility to meet future system of care needs.

Surprise medical billing legislation stripped to study

After several weeks of testimony, the Senate Finance Committee did a straw vote on Wednesday on a stripped down version of S.309, a bill related to surprise medical billing. The bill in its current version now requires the Department of Financial Regulation to report by Jan. 15, 2021 regarding the scope of unanticipated out-of-network costs for health care services borne by Vermonters with Vermont-issued health insurance and Vermont based group health plans and possible solutions to reduce the impact on consumers and employers of such costs.

A provision that would have prohibited health insurers from shifting liability for out-of-pocket expenses to referring providers when they refer a patient out of network was removed from the bill.

Prior authorization bill delayed

The House Health Care Committee conducted a straw poll and approved an amended draft of prior authorization language drafted by a subgroup of the committee. The language will be added to the miscellaneous health care bill that the committee will likely be voting on at some point when they return from break

The amended language lists the following requirements:

  • Health plans must review procedures and tests for which it requires prior authorization at least annually and eliminate the prior authorization requirements for those procedures and tests for which the requirement is no longer justified or for which requests are routinely approved;
  • requires opportunities to increase the use of realtime decision support tools embedded in electronic health records to complete prior authorization requests for imaging and pharmacy services;
  • the GMCB, in consultation with DVHA and stakeholders, must evaluate opportunities for and obstacles to aligning and reducing prior authorization requirements under the All-Payer ACO Model as an incentive to increase scale, as well as potential opportunities to waive additional Medicare administrative requirements in the future;
  • large insurers must implement a pilot program by January 2021 that automatically exempts from or streamlines certain prior authorization requirements for a subset of participating health care providers, some of whom must be primary care providers and report on results of pilot program in 2022; and
  • DVHA must report this year on prior authorization requirements in Vermont Medicaid program.

The proposal is the result of collaboration between stakeholders, and as a result, has the support of Blue Cross Blue Shield of Vermont, MVP Healthcare, the Green Mountain Care Board, and the Department of Vermont Health Access.

Green Mountain Care Board meeting

The Green Mountain Care Board met on Wednesday to discuss updates to the Hospital Budget Guidance, with a plan to review changes again on March 18 and vote on March 25. One common theme is to have hospitals provide only new information and not to burden them with filling out the same information from years past. Additionally, appendices were created to streamline the process of gathering the information, removing some questions formally located within the narrative of the Guidance. The narrative and the presentation will now align for easier board review. Board member Robin Lunge recommended including any prepopulated fields where possible to help with the streamlining goals. The presentation can be found here.

Board Chair Kevin Mullin plans to schedule a vote on March18 for the decision on the growth limit target for the net patient revenue and fixed prospective payments and for those hospitals that don’t reach their target amounts. Board member Jessica Holmes said that the first priority is that the hospitals can meet the needs of the communities, referencing the potential impact they could see from the Coronavirus outbreak. Holmes would like to know more about unique patients, those patients that are from out-of-state or Vermont patients going out-of-state, and whether some of the proxies around the average commercial to Medicare ration can be used as a proxy for where the hospital’s starting point is. Board member Maureen Usifer is supportive of putting in the 3.5 percent. Usifer would also like to include the structure of the hospital boards for the non-financial part of the guidance, including who the members are, the length of tenure, and any qualifications of the members.

A representative from the UVM health network said that “as we think about growth, it is about the actual to actual changes between period to period, not budget to budget. That is what the true rate of growth is. If you want to understand the actual change that is what you need.” Usifer agreed that it is very important to look at actual to actual and that is one of the reasons the bridge goes to projections versus budget to budget. Usifer said, “What we need to really look at is how good are those projections.”