DPS updates committee on COVID-19 medical surge preparation

Department of Public Safety Deputy Commissioner Christopher Herrick testified to the House Human Services Committee on Tuesday on the state’s work on additional hospital and medical capacity preparation. Herrick said the state operations center is working directly with hospitals, community providers, Dartmouth-Hitchcock Health, the Vermont Department of Health, and the Agency of Human Services to increase internal hospital bed and ventilator capabilities for patients who require medical care. The modeling data indicates that mitigation efforts are working in bending the curve. Even with this preparation, Herrick said the state could be very close to bed capacity.

Herrick said the state has partnered with the Vermont National Guard to create two additional high capacity care sites for surge. The Champlain Valley Exposition in Essex will provide 400 beds staffed primarily by guard personnel and the Spartan Arena in Castleton will provide 150 beds supported by staff from Rutland Regional Medical Center. The state also has sites at the Collins Perley Sports and Fitness Center in St. Albans, the Barre Civic Center in Barre, and the University of Vermont Patrick Gymnasium. Herrick said these sites will be operated in close coordination with health care providers and will only be used if hospitals exceed their capacity.

Herrick said the state is working to increase treatment and staffing capacity through partnerships with home health providers and federally qualified health centers. The state is also asking individuals with medical experience or retired health care professionals to sign up as a Medical Reserve Corp Volunteers through the state’s volunteer website.

Several committee members continued to express concern with personal protective equipment supply and whether the state is able to fulfill all requests. Herrick said he would defer to the Vermont Department of Health since requests are processed through the VDH command center. He said medical providers at all levels (hospitals, long term care facilities, home health and hospice agencies) are given priority. He added that personally he has not heard concerns from providers that they are not receiving supplies. 

Committee Chair Ann Pugh, D-South Burlington, asked how the state is communicating with providers, with community members, and to elected officials in terms of directives from the Scott administration. Herrick said the state has a joint public information officers group made up of all state agencies that work together on press releases and messaging; there are several conference calls every day with various working groups with hospitals and other provider organizations; and the majority of state agencies have a seat at the state emergency operations center and receive daily updates on ongoing progress.

OneCare Vermont reports on response to COVID-19 crisis

OneCare Vermont Chief Executive Officer Vicki Loner updated the Senate Health and Welfare Committee on Friday 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 working with state and federal signers of Vermont’s All Payer Model agreement and the Green Mountain Care Board to ensure 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. OneCare Vermont hopes to shift outcome measures to reporting only. 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.

OneCare’s analytic team released a tool for care coordination that looks at all Medicaid and Medicare individuals that are a part of the ACO to identify that those who are at the highest risk for contracting COVID-19. It allows 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.

Emergency medical services seek aid

Vermont’s emergency medical services are currently experiencing a major funding shortfall due to drastic drops in revenue because of the reduced number of patients transported by ambulance to hospitals during the COVID-19 crisis. Vermont EMS Advisory Committee Chair Drew Hazelton reported to the Senate Government Operations Committee that EMS has lost more than 50 percent of its transport volume in the last month, and as a result, are going to see a 50 percent or greater drop in cash flow cash flow over the next few weeks. Hazelton said, “as we look to increase staffing and payroll to prepare for what’s coming, we are in trouble.” In response, the committee will send a letter to the federal delegation, the Agency of Human Services, and the Governor to flag the issue.

On Friday, the full Senate unanimously advanced a S.182, a bill aimed at reducing the administrative burden on EMS infrastructure during the crisis. 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.

Department of Mental Health reports on response to PPE shortage, staffing concerns

Department of Mental Health Commissioner Sarah Squirrell reported to the Senate Health and Welfare committee this week on its action to sustain and support Vermont’s mental health system during the crisis and beyond. Squirrel told the committee the designated mental health agencies and specialized services agencies will receive a minimum of a two-day supply of personal protective equipment and supplies soon.

In addition to PPE shortages, the agency continues to be concerned with staffing shortages. This has been compounded by the potential impact of recent unemployment insurance changes, especially as it relates to home health, nursing homes, DAs, SSAs, and other direct care services. Squirrell said that it has been the department’s intention to give additional funding to DAs and SSAs so that they can implement pay increases to support staff retention. The department is still gathering data on need and funding avenues.

The Vermont Health Care Association – representing nursing homes, residential care homes, and assisted living facilities –said that they were in touch with the administration to find a funding source to support the additional significant labor related costs that facilities have to invest in order to retain staff. The substance use disorder treatment community also told the committee that they have the same staffing compensation issues.

Chair Ginny Lyons, D-Chittenden, said that she would like her committee to work on a legislative fix if it is necessary.

Senate Judiciary committee advances bill without involuntary medication changes

The Senate Judiciary Committee met remotely this week and unanimously voted in favor of a S.114, a bill that addresses statutory time frames for some judicial hearings, rent in escrow and the waiver of defendant in person appearances. Prior to its passage in the judiciary committee, a provision to extend the statutory time frames for involuntary treatment and medication hearings was removed from the bill due to lack of consensus among Senators.

The extension for involuntary treatment and medication hearings had the support of Superior Court Judge Brian Grearson, who told the committee that courts struggle to meet the time frames currently, but the Department of Mental Health and the Vermont Association of Hospitals and Health Systems expressed concern that hearing delays could result in patients staying longer in a hospital setting than is preferred right now. Chair Sen. Dick Sears, D-Bennington, said that the issue will be dealt with in a separate bill and that the committee “is not giving up on it.”

On Friday, the full Senate unanimously advanced the bill.

Update on Woodside

The Department of Children and Families and the Department of Mental Health reported to several legislative committees this week on the current statuses of the Middlesex Therapeutic Community Residence and the Woodside Juvenile Rehabilitation Center. Residents of Middlesex have been moved temporarily to the Vermont Psychiatric Care Hospital for space and staffing efficiency.

Department of Children and Family Services Commissioner Ken Schatz said three youth under the care of the Department of Corrections or DCF have been moved from Suite 12 in St. Albans to the Middlesex site. The facility will be used for male youth, and female youth will continue to go to Bennington Vermont School for Girls in Southern Vermont. Woodside will be used for psychiatric patients requiring isolation due to mild COVID-19 symptoms, but DMH Commissioner Sarah Squirrell said that facility preparations are “in a bit of a holding pattern” because they have not adequately identified personnel for staffing. Schatz added they are still exploring ways to shut down Woodside in the future.

Senate panel awaits federal funding guidance

The Senate Health and Welfare Committee continued to take testimony this week on COVID-19 related issues in their purview to aid in the development of a funding priority list for the Senate Appropriations Committee. As are other committees, the committee is waiting for details on how Vermont’s $1.3 billion in federal funding will be distributed, as well as what the legislature’s role will be in the decision-making process.

Joint Fiscal Office’s Nolan Langweil reviewed the federal funding from federal grants and the three COVID-19 response bills, noting that the $1.25 billion from the most recent Coronavirus Aid, Relief, and Economic Security Act must be used for new state government funding in response to COVID-19. New spending is defined as spending that was not approved by the state as of the federal bill’s enactment, and can be used for spending incurred between 3/1/2020 and 12/30/2020. The money from the federal bill will be overseen by the federal Pandemic Response Accountability Committee that will have the ability to claw back funding spent inappropriately, and grant money will have guardrails on allowable spending.

Senate Panel reviews medication assisted treatment needs

Vermonters for Criminal Justice Reform Executive Director Tom Dalton testified in the Senate Health and Welfare Committee on Thursday on the impact that the COVID-19 crisis is having on medication assisted treatment for substance use disorder. In order to reduce the number of people who need to travel and access MAT at Hub treatment locations, the federal government has relaxed guidelines to allow stable patients receiving MAT to take home up to 28 days of medication. The Hub and Spoke model is Vermont’s system of Medication Assisted Treatment, supporting people in recovery from opioid use disorder. Nine regional hubs offer daily support for patients with complex addictions Although a positive step, Dalton said that “hundreds of hub patients are still required to risk exposure by traveling to a hub to get medication that they rely on to survive. Many people do not own cars and rely on shared rides or travel by public transportation, bicycle or on foot” and have underlying conditions that put them at risk for COVID-19. Masks and gloves aren’t provided to patients upon arrival at the hubs, and because some facilities are operating at reduced hours, many are arriving at the same time.

Dalton asked the committee to act to expand the number of people who are eligible for take home MAT by making it the default determination. People would only be denied take homes if there was a documented specific clinical reason as to why their supply has to be limited below the federally allowed baseline. In order to prevent misuse and diversion of medications, hubs could require the use of tools to help people manage medications at home such as call-backs, random drug testing, and virtual medication checks. Hubs could re-assess eligibility for take home each week. Chair Sen. Ginny Lyons, D-Chittenden, responded that they will explore this issue along with liability concerns due to diversion risks.

Administration decisions driven by science and data

Gov. Phil Scott is deliberate when he refers to “science and data” when he addresses the public. So it was with intention that Department of Financial Regulation Commissioner Mike Pieciak spent the week reviewing COVID-19 Modeling Data for the public. All evidence suggests that social distancing sacrifices are making a difference in saving lives and reducing hospital resource needs.

The modeling considers worst, best and likely outcomes, and is continually updated with new data and assumptions that is used to forecast available hospital beds, intensive care unit beds, ventilators and personal protection equipment.

The slides in the modeling document show that Vermont is trending far closer to the best than the worst case projections, and peak caseload is expected within the next two to four weeks.

Vermont has 622 hospital beds and may need 521. The state has 135 ICU beds available and at peak is anticipated to need 211. The state has 93 ventilators available and it is possible that at the highpoint, 114 ventilators may be needed.

These numbers are important as the state prepares for the next month and remains resolute in its adherence to social distancing. The Stay Home Stay Safe Order will remain in place until these trendlines start to decline.

Green Mountain Care Board

The Green Mountain Care Board voted on Wednesday to finalize a letter to Center for Medicare and Medicaid Innovation Center/Centers for Medicare and Medicaid Services to request federal support in the distribution of resources to support hospital solvency during the COVID 19 pandemic and to adjust the evaluation of the Vermont All-Payer Accountable Care Organization Model. Included in the draft letter are OneCare Vermont’s requests for operational relief and adjustments to OneCare’s FY2020 budget orders that the board approved last week.

The board is requesting that CMMI/CMS:

  • Invoke the exogenous factors clause under Section XII of the Medicare contract with OneCare to allow the 2020 benchmarks to be reevaluated as appropriate.
  • Eliminate downside risk and adjust the initiative to be shared savings only for 2020.
  • Make 2020 a “reporting only” year for purposes of quality measurement given the impact that responding to COVID will likely have on providers’ ability to meet quality targets.
  • Allow the 2020 all-inclusive population based payments to be a true capitated payment should the fee-for-service equivalent be less than all-inclusive population based payments at reconciliation.
  • Provide an extension for the submission of the final Medicare provider participation roster for 2021.
  • Allow OneCare to keep funds due to CMS for duplicate payments made to hospitals in 2019 and exclude these payments from the year-end reconciliation of the all-inclusive population based payments.
  • Forgive repayment by Vermont hospitals of any unearned advanced shared savings for 2019, should Vermont’s earned shared savings in the Vermont Medicare ACO Initiative in 2019 be insufficient to cover the advanced shared savings that supports the continuation of Blueprint for Health, Support and Services at Home, and community health teams, programs which curb health care cost growth and improve quality of care for Vermonters.
  • Open additional funding opportunities for participating providers.

GMCB staff also reviewed the All Payer Model Annual Health Outcomes and Quality of Care Report for performance year one (2018). The report outlines baselines, targets, and progress made for quality metrics as required in the All-Payer Accountable Care Organization Agreement. The agreement sets five year goals in place for population-level health outcomes, healthcare delivery system targets, and process milestone targets. The report “demonstrates that Vermont is currently meeting three of the six population-level health outcomes targets, seven of the nine healthcare delivery system quality targets, and is making progress toward six of the seven process milestones.” The report points out “encouraging signs of delivery system reform: hospitals are increasing their investments in primary prevention and the social determinants of health; traditionally siloed providers are finding new ways to coordinate care and reduce duplication of services across the care continuum; and advances in data analytics are helping to identify high risk patients who would benefit most from early intervention and complex care coordination.” For details, please see report here.

The board also approved Certificate of Need Bulletin 003 to temporarily waive the requirement for health care facilities to obtain a certificate of need from the GMCB for certain types of new health care projects related to COVID-19. The waiver applies to any new health care project which enhances or supports the state’s ability to respond to the COVID-19 public health emergency, and:

  • the health care facility has received a 1135 waiver; or
  • the project is permitted under CMS’ COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers; or
  • the project is part of the State’s coordinated response to the COVID-19 pandemic and is directed by the Vermont Department of Public Safety or the Vermont Agency of Human Services; or
  • the project is for the development of a hospital constructed or operated by the U.S. government or a duly authorized agent thereof in response to the COVID-19 pandemic.

Working remotely, Senate passes four bills

In an historic session, the Senate convened remotely Friday morning to unanimously pass four COVID-19 related bills.

S.182 reduces administrative burdens on Emergency Medical Services during the crisis. The bill also extends licenses for plumbers and electricians and allows sheriffs to access emergency funds for COVID-19 needs. (See EMS article above).

S.114 addresses several emergency judicial measures. The bill provides judges with discretion over the payment of rent in rent escrow hearings, allows powers of attorney and deeds to be executed remotely, extends statutory time frames for some court proceedings, and suspends statutes of limitations for civil actions that would expire during the state of emergency until 60 days after the emergency declaration is lifted.

S.333 creates a moratorium on ejectment and foreclosure actions for the duration of the emergency.

H.741 gives the Department of Buildings and General Services the authority to obtain criminal records for contractors working in state owned or leased facilities.

The Senators conducted their business across the now-familiar sight of Zoom tiles. They were dressed in their usual suits and professional attire although their bookshelves and potted plants were visible in the background.