UVMMC and Bi-State Primary Care Association detail COVID-19 response

The Senate Health and Welfare and House Health Care Committees received updates from University of Vermont Medical Center and Bi-State Primary Care Association this week on how hospitals and federally qualified health centers are responding to the COVID-19 crisis. UVMMC President Dr. Steve Leffler described the changes that the hospital has implemented including visitor policies, the cancellation of all elective surgeries, visits, and screening programs. Leffler said there is now onsite parking for providers (bus services have been halted), many individuals are working from home, and some personnel are waiting to be redeployed. “We are as ready as we can be for what is to come,” said Leffler.

Leffler said the hospital has two floors dedicated to the crisis and is currently treating 18 positive COVID-19 patients of which six are in intensive care. Three individuals have been able to be removed from ventilators and are recovering. Personal protective equipment and ventilators continue to be the most significant need for the hospital. Leffler said that the All Payer Model’s predictable fixed prospective payments have been very helpful in managing cash flow, and Medicare has told UVMMC that they could borrow from future payments. The hospital is in discussions to determine if OneCare Vermont can do the same.

Bi-State Primary Care Association reported that all of Vermont’s health centers currently have some telehealth capabilities (with a combination of telephone and video services). BSPCA Vice President of Policy and Programs Georgia Maheras said that FQHCs are bringing COVID-19 test sample collection online in Island Pond, the Champlain Islands, and Arlington. Three more sites are available, if necessary, in the Upper Valley, the northwestern part of the state, and the Springfield area. All dental practices are closed, but services are available in emergency situations.

Like UVMMC, Bi-State is concerned about the PPE supply, and are hopeful that more supplies are coming into the state. Financially, Maheras said that “the cash flow is not pretty.” These organizations have lean margins on an annual basis and not a lot of cash on hand. The addition of telehealth services is not balancing out the revenue reduction. They are still receiving care coordination payments through the All Payer Model, which is helpful, and the Department of Vermont Health Access has opened up some aid for Medicaid providers who need assistance with cash flow. Federally, Medicare is offering a cash advance and there are various aid options available for small businesses.

Committees receive updates from home health agencies and nursing homes

The House Human Services Committee received an update on the COVID-19 response efforts from the Department of Disabilities, Aging and Independent Living, the Vermont Health Care Association and the VNAs of Vermont on Thursday. DAIL Commissioner Monica Hutt provided the committee with an overview of the department’s response. The main goal is to keep people stable in the community and avoid the need for hospital placement. Hutt said DAIL is planning for what she called “Tier 2” – people who will need some level of support, can’t stay at home, but are not in need of hospital-level of care. Her team is looking at sites now under the authority of the State Emergency Operations Center. Hutt’s biggest concerns center around the workforce, the capacity of the state to provide financial stability and predictability to its provider community, the ability to reduce barriers for providers, and the need for additional personal protective equipment.  

Vermont Health Care Association representative Laura Pelosi thanked the committee for its quick action on H.742, a bill that provides regulatory and licensing flexibility for providers. Pelosi noted that the situation is fluid as we learn more every day about the virus and the best strategies to combat it. Her members are actively planning for medical surge. Her members play a unique role in taking care of patients that don’t require hospitalization, but are acute enough to need medical care. Pelosi also addressed challenges to include the workforce, the impact of the new unemployment insurance program, the national shortage of personal protective equipment, and the financial stress on all providers to expend resources to combat the virus.

VNAs of Vermont Executive Director Jill Mazza Olson reminded the committee that her members have both a medical and long term care role in the response. In the long term care realm she is particularly concerned about retaining staff. The long-term care workforce was in crisis before the outbreak. On the medical side, home health agencies will play an important role in reducing the pressure on hospitals by treating COVID-positive patients at home, especially with recent federal changes that expanded access to home health for COVID-positive patients and expanded access to oxygen at home. Like long-term care facilities and other providers, the biggest concerns for home health agencies are personal protective equipment and financial stability. She appreciates the Department of Vermont Health Access’ effort to develop a mechanism to provide short-term support for providers in financial distress. Congress also temporarily restored a two percent Medicare cut known as “sequestration.” Unfortunately so far Congress and CMS have refused to pay for any home health services provided via telehealth, although they acknowledge that it is appropriate in some cases.

OneCare Vermont reports on response to COVID-19 crisis

The House Health Care Committee received an update on Friday from OneCare Vermont CEO Vicki Loner on how the accountable care organization is responding to the COVID-19 crisis. Loner reported that hospitals and independent providers that are part of the OneCare network have expressed how valuable the All Payer Model fixed prospective payments have been in providing some financial predictability. OneCare is also looking at whether they can accelerate Medicare and Medicaid payments to hospitals and providers for the duration of the crisis and spread them out throughout each month to provide some certainty week by week.

OneCare is working with state and federal signers of Vermont’s All Payer Model agreement and the Green Mountain Care Board to ensure that that participants who are engaged in health reform efforts aren’t financially harmed due to the impact of the crisis. The scores and outcomes for the agreements quality measures will be impacted by the epidemic and OneCare is asking that the participants be held harmless financially for reductions in quality measures. This week the Green Mountain Care board waived the requirement that the ACO put aside .5 percent of Medicare incentive based payment for quality payments. The $250,000 collected so far this year will be returned to the hospitals, and the remaining $925,000 won’t be collected. OneCare Vermont hopes to shift outcome measures to reporting only and reach the same agreement with Medicare and it’s commercial payer. Additionally, because the pandemic’s impact on the total cost of care is unknown, OneCare is asking signers to hold them harmless for an overrun in spending. If there is no shared savings for TCOC, they will be accountable at the end of the year for the $8 million that has been used to fund the Blueprint for Health and Support and Services at Home program.

On an internal level, OneCare has reached out to innovation fund grantees to make sure that they want to continue work under their grants. They have the option of hitting pause on the grants without financial repercussions and can pick up grant activities at a later date. OneCare’s analytic team is also working on releasing a tool for care coordination that looks at all Medicaid and Medicare individuals that are a part of the ACO and to identify that those are at highest risk for COVID-19. It will allow providers to engage with those people who are identified, work to keep them healthy by managing chronic diseases, and help prevent further escalation of the disease.

Panel works to streamline support while waiting for further guidance from feds

The House Appropriations Committee heard from the Department of Finance and Management Commissioner Adam Greshin, Agency of Human Services Chief Financial Officer Sarah Clark, and Joint Fiscal Office Chief Legislative Fiscal Officer Steve Klein this week on the federal stimulus package. Greshin said between $15 to $20 million in purchase orders have been made in response to the COVID-19 crisis thus far. This has primarily been for health care supplies and emergency housing for people with health care needs. These dollars have been drawn from anticipated federal receipts and many are expected to be Federal Emergency Management Agency reimbursed. As the dollars coming from the federal bills become better understood, Greshin expects to do a separate FY 2021 budget adjustment and an abbreviated FY 2021 budget. Finally, Greshin said the money for primary and secondary education will go to the Agency of Education to distribute, but the money for higher education goes directly to those institutions.  

Clark explained that AHS and the Agency of Administration are working to stabilize and maintain the health care system through health care provider financial relief systems in three main tracks: nonhospital providers, hospital providers, and designated mental health agencies and support services agencies. Nonhospital providers, DAs, and SSAs will submit an application highlighting financial need. AHS is working with the hospitals and the Green Mountain Care Board to determine how they will respond to needs of hospital providers. Clark said AHS is working to provide supplemental pay to those still working as appropriate to offset what people would receive if unemployed. Clark also said that payments being made to providers are from Medicaid, but she hopes to switch to federal funding once that comes in because of the state’s duty to match Medicaid dollars.

Klein talked about the balance of acting quickly versus the risk of a claw back of federal funds. Klein noted that the Treasury will be issuing regulations sometime after April 12 that will provide more guidance on how this money can be used. He noted it may be more restrictive than desired, but at the same time it could be used to a restore any facility to their condition prior to the COVID-19 emergency. He recommended the creation of Czar to oversee all of the COVID-19 funds, like the state did with Tropical Storm Irene. He said the legislature may need to give spending authority to the executive branch during this time. He said some actions will require legislative action, like providing supplement pay to essential workers. Currently the major system in place is the Emergency Board with the powers to: cut up to 4 percent of the budget, transfer money of appropriations over $50,000, and appropriate money from the general fund. Neither a transfer or appropriation can exceed $32 million.

Health-related supports reviewed in House Health Care

The House Health Care Committee met on Wednesday and heard from Joint Fiscal Office Analyst Nolan Langweil on federal assistance for Vermont for the COVID-19 pandemic. Langweil said it is estimated that Vermont will receive approximately $1.4 billion in assistance for a variety of issues. He provided a brief overview of the three federal bills enacted to date. COVID -1 focused on the immediate public health response to the crisis; COVID-2 targeted relief for individuals; and COVID-3 provided a broader economic stimulus designed to help individuals as well as industry-specific relief. Langweil said it is not clear how the money will be distributed, when the state will get it, how much funding will be provided to each organization, and how will it be presented (through agency or direct pay). He said the bill also includes non-health and human services issues including unemployment insurance, education, transportation and other economic issues not captured in his summary document.

Langweil said the bill provides for the following health and human services supports:  

  • A temporary increase in the Federal Medical Assistance Percentage of 6.2 percent. The FMAP are the percentage rates used to determine the matching funds rate allocated to certain medical and social service programs;
  • An increase in the Supplemental Nutritional Program for Woman, Infants, and Children;
  • Additional funding to the community health centers; and
  • An increase to the Low-Income Home Energy Assistance Program.

Committee chair Bill Lippert, D-Hinesburg, said it is not clear what the spending authority requirement will be from the federal government. It is also unclear what role the legislature will play on how the money is dispersed within the state as well as review, oversight or participation in distribution of the funds.

Panel finishes work on Capital Bill

The House Corrections and Institutions Committee did a straw vote (10-0-1) on version 1.8 of the capital bill. The bill includes the $1.5 million to finish the construction of the new 12 Level I beds at the Brattleboro Retreat. It also includes language for the Brattleboro Retreat to provide detailed financial reporting to the Agency of Human Services.

The committee will hold the bill until floor procedures have been established and in case there are more COVID-19 related measures that need to be added to the bill. Building and General Services Commissioner Chris Cole said he would like to have a conversation about allow BGS to begin design work for projects in the FY2021 capital bill.

The bill can be found here. The spreadsheet can be found here.

DCF looking for new temporary Woodside replacement after two youth escape

Department of Children and Family Services Commissioner Schatz reported to several legislative committees this week that DCF is looking for a new facility to house justice involved youth after two youth escaped from a temporary staff-secure facility in St. Albans. These youth were previously housed at the Woodside Juvenile Detention Center. Woodside will now be used for adult psychiatric patients that are COVID-19 positive. Although DCF reported last week that they would be adding locks on the front door and windows to make the building more secure, the landlord would not grant permission for the changes.

The Department of Mental Health said an isolation facility is needed for patients who require appropriate psychiatric care and COVID-19 symptoms. The department is currently recruiting staffing, ideally state employees. The facility will likely be up and running in ten days, and until then, there is current capacity in the health system to handle the patients.

Panel continues work on child care system

The House Human Services Committee received a COVID-19 response update on the child care system. Department for Children and Families Child Development Division Policy Director Melissa Riegel-Garrett explained that for those using the child care system this week, families that are able to pay will be paying 100 percent of their child care tuition to reserve their spots. Starting next week, those families that are able to pay will be paying 50 percent of their child care tuition. If a family is unable to pay, they will not lose their spot and the full tuition cost will be covered.

Essential workers child care providers will receive a daily $125 stipend for each child. But those that were already in the child care system may have to pay their normal tuition. Providers receive $200 a week to care for children in grades kindergarten through eighth grade. DCF Commissioner Ken Schatz said currently there are a little over 2,000 spots available for essential workers and there are approximately 1,180 requests for those spots. However, Schatz said that there are pockets that are a little uneven around the state that needing more help such as Addison and Essex counties.

Riegel-Garrett said private-public partnerships have been vital to the success. Let’s Grow Kids quickly set up a mechanism for collecting information on who needs child care. LGK Chief Executive Officer Aly Richards said that LGK is collecting feedback and triaging concerns to the state as well as updating information for early childhood educators, families, and employers. LGK is also providing support to those child care facilities that have closed. Vermont After School has been feeding the referral specialists information about schools able to provide support.

However, Lamoille Parent Child Center Executive Director Floyd Nease said allowing child care in congregate settings went against all other health protocols that are being issues, placing the providers and children at risk. He recommended finding a new solution, such as placing an individual in the child’s home. Richards said they have considered this, but noted that there is low risk of spreading the infection with good hand washing, as seen around the world. Richards said that there are many medical students that have completed background checks that could help provide care in homes.  

Senate committees seek relief for parents of high need students

The Senate Health and Welfare and Education Committees met jointly to investigate the issue of relief in the form of payments for parents of high needs students with complex learning, emotional or physical disabilities at home during the COVID-19 crisis. Parents have found themselves performing several roles for their high needs child/ren while interventionists and providers cannot safely enter the home or the remote options have become inadequate or impossible. Education Chair Sen. Philip Baruth, D-Chittenden, said his greatest sense of urgency during this crisis is around parents who are home with children with special needs, who are having to perform many different special education and health care roles for their children, some while still working full time jobs. Sen. Ann Cummings, D-Washington, fears a family tragedy given the tremendous amount of pressure some families are under. Some of the children are medically complex, but having health care providers in the home at established levels, is now inadequate due to the increased needs of the families now that all children are home.

Baruth asked Brad James, Education Finance Director for the Agency of Education if there was flexible money that could be allocated to these parents. James said their hands were tied for now because the Individuals with Disabilities Education Act is federal law and is constrained. He said that the approximately $35 million in direct grants to schools from the Coronavirus Aid, Relief, and Economic Security Act might also not be flexible enough to address direct reimbursement to parents for their increased roles in serving their children’s needs with at-home learning and specialized educational support services.

The committees discussed successful technological interventions that districts were providing directly to families where they could. Districts are supplying burner phones, Chromebooks, iPads and Wifi hot spots, sometimes at the same time they deliver food in order to facilitate remote and distance learning. The Internet availability divide is a well-discussed issue statewide, and Sen. Ruth Hardy, D-Addison, said that districts now know who does and does not have Internet and when federal money becomes available to run new lines, the AOE can aggregate the information on location.

Laurel Olmland Director of Child, Adolescent, and Family Unit, Department of Mental Health presented  Success Beyond Six – School Mental Health. She said their goals are to maintain services to the greatest extent possible for students and families. All SB6 services may be provided through telehealth (video + audio) or phone (audio only) with the student and family in their home. They are coordinating with the AOE on the role of school mental health in the development and implementation of continuity of learning plans for remote learning. They will eventually focus on coordination of SB6 services with educational compensatory services such as summer programming. 

Senate panel considers EMS changes

The Senate Committee on Government Operations is poised to propose several provisions next week that are aimed at reducing the administrative burden on Vermont’s emergency medical services infrastructure during the COVID-19 crisis. The provisions were lifted from S.124, a miscellaneous law enforcement bill pending in the Senate Appropriations Committee. The approved provisions eliminates the requirement for EMS personnel to be credentialed by their affiliated agencies, extends ambulance license terms from one to three years, and requires the Department of Financial Regulation to enforce the current law provision that health insurers are to directly reimburse ambulance service providers. The provisions will likely be attached to an existing bill when the Senate begins voting remotely next week.

Green Mountain Care Board adjusts OneCare Vermont’s budget orders in response to crisis

The Green Mountain Care Board met on Wednesday to discuss and act upon OneCare Vermont’s request for operational relief and adjustments to OneCare’s FY2020 budget orders in response to the ongoing COVID-19 crisis. The board approved requests to:

  • Waive the withhold for Medicare portion of the Value Based Incentive Fund (approximately $1.175 million). These funds can be immediately released back to hospitals to provide financial relief during this pandemic and the Medicare agreement does not require a withhold.
  • Request weekly claims files from the Center for Medicare and Medicaid Innovation Center (CMMI)/Lewin to OneCare to support more proactive monitoring and adjustments to Medicare fixed payments (currently they flow about six weeks in arrears). Center for Medicare and Medicaid Innovation (CMMI)
  • Extend the deadlines for Budget Order items # 17 and 19 to September 30, 2020. Those items require OCV to report on population health investments and design and propose a plan to implement a performance dashboard. OCV staff who would otherwise work on this project are responding to changing budgets and contractual obligations. GMCB staff, also prioritizing contingency planning work, and experiencing staffing constraints, have not been able to complete the guidance necessary for OCV to initiate this work.   
  • Extend the deadlines for Budget Order items # 8, 9 and 13 to May 30, 2020, and delegate authority to GMCB Chair Kevin Mullin to further extend the deadline if needed due to COVID-19 related issues. Those items require OCV to report on 2020 attribution and payer contracts and present a revised budget with supporting documentation if population health management programs are not fully funded as detailed in OneCare’s 2020 budget proposal. Much of the attribution data and projections are up in the air due to the current crisis.  

The board also approved a motion that requires OneCare Vermont to present to the board on April 22 on how OneCare Vermont sees its role in the state’s response to COVID-19 and what programs might need to change as a result.

Under authority granted by H.742, the board agreed not to have a physical meeting location designated while they meet remotely. Next week, the board will review a list of COVID-19 related projects types that the board will consider waiving certificate of need applications such as medical surge sites.