Senate panel advances incentive pay for essential workers
The Senate unanimously passed S.346 on Friday, the Essential Employees Hazard Grant Program bill. The voluntary program is employer-based and would require essential employees who are at a greater risk of contracting COVID-19 to meet certain criteria to receive the grant funding.
Before passage, the Senate Committee on Appropriations shortened the program from a three-month to a two-month period to reduce the cost estimate from $89 million to $60 million. Committee Chair Jane Kitchel, D-Caledonia, said that there was concern that too much of the federal Coronavirus Relief Funds were being tapped while state needs were still being assessed. Eligible employees include frontline workers earning $25 an hour or less as a base wage. Excluded from the wage cap are covered employers (and its licensed professionals who are providing direct patient care) who receive reimbursement for services through the Agency of Human Services through a rate setting process, a grant, or as established by rule. Employees will need to work more than 108 hours a month to receive the full grant payment of $1000; employees under this threshold will receive a partial grant payment of $600 as long as they worked at least 34 hours.
The committee did not include privately compensated care-givers who may be difficult to track, with the understanding that the House may do further work on the bill. The bill also urges municipalities that may receive CRF to utilize a portion of the grant funding provided by the State to provide some kind of monetary benefit to municipal employees, such as firefighters, law enforcement officers, and ambulance workers, whose jobs place them at an increased risk of being exposed to or contracting COVID-19 during the pandemic.
Health committees review health care crisis standards of care
Members of the House and Senate health care committees met jointly on Thursday to review health care crisis standards of care, and the ventilator allocation plan specifically. Deputy Commissioner of Health Kelly Dougherty told the committee that crisis standards of care are implemented whenever there is a state of emergency, and are designed to provide guidelines and guard rails for allocation of resources in times of scarcity. They must allow for a careful balance of subjective decision-making and guidance so that there is consistency. Vermont Ethics Network Director Cindy Bruzzese added that in a public health crisis, the focus shifts from individual care to the utilitarian goal of saving the greatest number of lives possible. The infringement on personal autonomy needs to be commensurate with the severity of the crisis. The plans are a requirement for the hospital preparedness grants that the hospitals receive from the Center for Disease Control. The Vermont Department of Health and the University of Vermont Medical Center have been working on updating the language of their standards of care in response to the crisis.
The next iteration of the Health Department’s ventilator allocation plan will include the standard of care based on clinical presentation, not the presence or absence of an underlying factors such as age. Examples of factors that could be considered for a patient to receive a ventilator (in a time of scarcity) include validated metrics such as the modified sequential organ failure assessment score, prognosis likelihood of treatment response, co-existence of end stage failure of a major organ, and the institutional resources available to address the clinical needs of every patient. Factors that cannot be considered include sex, gender identity, race, ethnicity, disability or degree of disability, mental health diagnosis, chronic disease diagnosis, other infectious disease diagnosis, socio-economic status and insurance status. The decisions are to be made in an expedited manner, within 30 minutes if the ventilator is located at the facility that the patient is at, and the decision will be made by a team that is not involved in the direct care of the patient.
Currently, there is only one COVID-19 patient on a ventilator in Vermont, so scarcity is not requiring the implementation of the standards of care. It will hopefully remain unnecessary throughout the crisis.
Appropriations committees review budget process
The legislative appropriations committees received updates this week from the Joint Fiscal Office on the upcoming budget bill process and timeline. The JFO provided a document outlining the line item changes needed to adjust the budget and address the revenue shortfall.
In the House Appropriations Committee, Chief Fiscal Officer Steve Klein said it is likely that a combination of the increase in Federal Medical Assistance, reduced Medicaid spending, and Coronavirus Relief Funding may prevent the need to dip into reserves to balance the budget with the second FY 2020 Budget Adjustment Act (BAA2). Klein said the legislature only has six weeks to get BAA2 and a three-month “Skinny Start” budget passed and signed by the governor. House Appropriations Chair Kitty Toll, D-Danville, said her committee would start concurrently working on the bills next week.
The FY2020 “Skinny Start” budget will appropriate funds for the first quarter of 2021.
The remaining budget will be completed in August and September after the official revenue forecast is released in August. JFO recommends tying the Skinny Start budget bill to the actual FY 2020 appropriations authorized through the BAA1.
JFO expects most line items will be up to 25 percent less than appropriations, but some line items will require a larger deviance: teacher pensions, Vermont Student Assistance Corporation, Vermont State Colleges, and several agencies. JFO also recommends including language establishing emergency appropriations that can be adjusted as needed by the Emergency Board in the first quarter. Finally, the Pay Act will need to be included in the first FY 2021 budget act because those payments need to be out by July 1.
Senate money committees receive revenue update
The Senate Committees on Finance and Appropriations held a joint meeting Thursday for a revenue update by Kavet, Rockler & Associates Legislative Economist Tom Kavet. He said the COVID-19 revenue risk forecast for FY 2020 is a consensus estimate, but FY 2021 is just his estimate. Kavet says they will be doing a deeper dive in the next few days with the April month end data. He also noted that they have been working on the forecast process since early March and that estimates can change within the day; they will be frequently updating the analysis with new information. The April unemployment rate is coming out soon, but noted that information only provides so much. People who say they are not actively looking for work that collect unemployment are not tallied as unemployed. Kavet did say that utilities are providing data on electricity usage by sector, and that has provided an understanding of what is happening. Residential use has increased, commercial use has decreased, and the peak begins about one to one and half hours later than before. Kavet believes this information will also allow them to see which areas are actually opening up versus simply being given the green light to do so as the spigot turns.
Kavet estimates that revenue loss will be about $144 million in FY 2020 and about $427 million in FY 2021. Concerning the $1 billion in Paycheck Protection Program funds that came to Vermont, Kavet said there is indication that the money is not going to the businesses that need it the most. He said that the leisure and hospitality sector only received about nine percent of the funding, but the sector is one of the most affected by the pandemic. Kavet said that about half of the money went to science and technical services, manufacturing, and health care and social assistance sectors. Kavet said income tax impacts will be felt in FY 2021. Kavet said while the corporate income tax March payment was strong—totaling around $35 million – due to merger and acquisition activity, he anticipates a steep decline will follow.
Panel reviews advance directives laws
The House Human Services Committee held a hearing on Tuesday on advance directives from the Legislative Council Deputy Chief Counsel Jennifer Carbee, Vermont Ethics Network Director Cindy Bruzzese, and Vermont Legal Aid Staff Attorney Olivia Graffeo-Cohen. Carbee provided the committee with an overview of the state law on advance directives. In order to execute an advance directive, the individual or principal must sign and date the advance directive in the presence of two or more witnesses. Bruzzese explained that the new social distancing orders have made it unsafe to fulfill that witness requirement, especially for at-risk individuals. VEN has provided guidance to principals to execute their advance directives over phone or video, to include contact information, and to note that it was witnessed remotely because of COVID-19.
Bruzzese asked that the committee validate any advance directives that have been created under VEN’s guidance so far and to create legislation that authorizes remote execution for a certain period after the stay home order is lifted. VEN’s initial proposal was for 90 days because some at-risk individuals may not be safe to leave even if the order is lifted. Vermont Legal Aid also supported this action, but Graffeo-Cohen did raise the question of equity—whether everyone could have access to the technology if needed. The committee has asked the interested parties to provide language recommendations to the committee. Under consideration is whether the document created with remote witnessing procedures would remain valid indefinitely or for a temporary time frame.
Joint Fiscal Committee approves conditions of acceptance of grant funds
The Scott administration told the Joint Fiscal Committee on Monday that the committee’s plan to allocate $60 million of discretionary spending to the Administration from the federal Coronavirus Relief Fund “gave us pause.” Commissioner of Finance and Management Adam Greshin asked for $200 million from the CRF for health and safety and other emergency response needs, stating concern that the legislature would not move fast enough to react to the state’s immediate needs. Sen. Tim Ashe, D/P – Chittenden, responded that “that’s the concern that we have, in the name of wanting to move quickly, it’s boxing out the intuition that the legislative branch brings in meeting people’s needs – and in (the case of UI benefits) we apparently had a difference of opinion in how quickly to act to move dollars to support the people who were suffering the inability to get into UI programs … it highlights the need for JFO to have a role in spending the funds because the administrative branch doesn’t have sole custody of knowledge about the best way to meet people’s needs during this time. And while you had the best information during this time, we had the best intuition about unemployment, and our intuition was not met with action.” Additional committee members expressed frustration at the lack of detailed accounting of the money already spent, and asked to have clear numbers at the committee’s meeting on May 4. Greshin said that the administration will have the numbers ready as well as the administration’s FY2020 budget adjustment proposal.
Despite the Scott administration’s request, the committee approved the Conditions for the Acceptance of the CRF Grant to Vermont, which allocates the $1.25 billion federal grant into three levels of expenditures. The administration would be authorized to spend up to $60 million for health and safety and other emergency response needs. Subject to review and pre-approval of JFC, the Scott administration would also be authorized to spend up to an additional $150 million for time-sensitive critical needs that cannot wait for the appropriations process. The remainder of the funds would go through the legislative appropriations process. After the vote to approve the conditions, Committee Chair Sen. Ann Cummings, D-Washington, and Sen. Jane Kitchel, D-Caledonia, commented that the numbers could be altered if the administration provided compelling information to the committee at the next meeting.
The committee also approved a $2 million grant from the Substance Abuse and Mental Health Services Administration to the Vermont Department of Health. Funds will be used to provide crisis intervention and mental health support for individuals impacted by the COVID-19 pandemic.
The Joint Fiscal Committee will continue to meet weekly on Mondays at 8:30 am.
House panel continues work on COVID-19 concerns with long term care
The House Human Services took testimony Thursday on the impact of COVID-19 on long term care providers and older Vermonters. Presenters said older Vermonters are struggling with social isolation, the fear of illness and death, and food security.
Long-Term Care Ombudsman Sean Londergan said his organization provides an independent voice to promote the rights of people receiving long term care services and advocates for changes that lead to better care and better quality of life. Londergan said COVID-19 has specifically been problematic for long term care facilities and he is trying to adjust to the fact that he cannot go into facilities to help residents. Londergan said Vermont has done a good job with containment with only a few outbreaks and people need to continue to be vigilant. Long term care facilities and its residents face a number of issues including visitation restrictions, evictions, lack of information on outbreaks, and staff shortages. His presentation can be found here.
In response to a question raised by Rep. Topper McFaun, R-Barre Town, Vermont Health Care Association representative Laura Pelosi said facilities have paid aggressive attention to infection prevention and control, and state agencies have been reaching out to facilities to check on prevention control processes and procedures. Pelosi said even before the Governor’s Executive Order and the issuance of th Centers for Medicare and Medicaid Services guidance, facilities had already begun screening of essential staff before entry into the buildings and had prohibited visitations. Pelosi said, “It is one of the reasons that we have had such good success. It has been tragic; there is no question.” Pelosi said communication has been very important with the long term care ombudsman and how to transition over time. She said the opening of facilities will probably be one of the last things to open and there is tremendous concern among her members on how to do that in a safe way.
Pelosi said personal protective equipment continues to be an ongoing issue for long term facilities since they are not considered a priority and purchasing through regular supply chains is cost prohibitive. Pelosi said the state has done an excellent job of helping long term care facilities and home health and hospice agencies to access PPE, but the bottom line is that there is not enough to go around. Facilities have implemented conservation guidelines. Pelosi said some facilities have had to restrict admission of residents because facilities do not have an adequate supply of PPE. This has had a financial impact on these facilities, as well as a ripple effect on the entire health care system.
Vermont Association of Area Agencies on Agencies Executive Director Janet Hunt said each of the AAAs have been able to respond to their communities in a seamless transition. The agencies moved swiftly to help in flattening the curve and in social distancing by closing offices and moving all of the services remotely. She did address high-level areas of concerns including: needing to connect with people who they serve by phone as broadband continues to be an issue in rural communities, increasing anxiety and mental health needs, finding caregivers to do respite work, putting off needed medical care, making sure that older adults nutritional needs are met, and staffing. Hunt also said as the state begins to reopen older adults will be advised to continue to shelter themselves and there is concern that elders become invisible or forgotten.
Community of Vermont Elders Executive Director Ruby Baker said Vermont has made a commitment to aging in place. COVE strongly believes in self-determination and the right of people to participate in decisions made about their own lives. When people think of the impact of COVID-19 on elder supports, thoughts immediately go to hospitals and nursing homes. Flying under the radar are many of the supports and services that make it possible for adults to age in place. Baker said adult days have all shut down, but are reimbursed on a fee-for-service model, which means that without clients coming in for services they do not get paid. Her presentation can be found here.
Health panels hear cost impacts on health insurance premiums and reserves
The House and Senate Health Care Committees held a joint meeting on Wednesday on the cost impacts of COVID-19 on health insurance premiums and reserves. Department of Financial Regulation Commissioner Mike Pieciak reviewed the actions his department has taken in response to the COVID-19 crisis and reported that the department issued bulletins and emergency rules that require insurers to eliminate cost-sharing for testing, treatment and prevention of COVID-19; to cover health care services delivered through telehealth, telephone, or store and forward means; to institute grace period for payments; and to allow for early prescription refills.
Pieciak said the state’s major insurers had good reserves and were in strong financial positions as Vermont entered the crisis, but will feel the impact of poor investment portfolio performance and emergency regulations eliminating cost sharing. As preventative treatments, such as vaccines, becomes available, the insurers will incur additional costs.
The insurers all reported that they have instituted policies in compliance with DFR’s rules and bulletins, and the majority of their self-funded plans have as well. BlueCross BlueShield of Vermont has established advanced payment programs to help stabilize cash for providers and MVP reported that they have relaxed grace period rules and increased outreach to groups who are delinquent to work on payment plans. American Health Insurance Plans, a national association of health insurers, commissioned a report through Wakely that concludes that COVID-19 health care costs could reach $556 billion nationally over the next two years. The group will issue another report mid-May based on new data on claims experience, populations impacted, testing costs and treatment costs. Vermont has already implemented many of the policy changes touted by AHIP, but they are also requesting that states extend rate filings to July 22, or allow flexibility and supplemental filings.
Independent health care providers share COVID-19 cost impacts
The House and Senate Health Care Committees held a joint meeting on Wednesday to hear testimony on the cost impacts of COVID-19 on independent health care providers. Richmond Family Medicine Provider Dr. Hannah Rabin discussed how 95 percent of all patient visits are now through telemedicine services. Rabin said this is helping with cash flow along with receiving the Paycheck Protection Program Loan, the Economic Injury Disaster Loan, the Department of House and Human Services Provider Stimulus Payment, and the Medicaid retainer process for providers – one of several provider financial relief mechanism that the Agency of Human Services is pursuing as part of a multi-phased plan with tracks for different types of provider organizations. Rabin also said that prospective payment would “allow for steady income and a more surefooted financial approach.”
Health First Executive Director Susan Ridzon represents 69 independent health care practices. Ridzon said some rural primary care and specialty practices have seen up to 95 percent reductions in revenue. Those providers who are able to do telemedicine are able to recover some losses, and she recommends the legislature make telemedicine a permanent component of the state health care system. Ridzon also said that 95 percent of the Health First practices are receiving PPP loans, that a smaller percentage are doing the EIDL, and that many have received provider relief funds from the Vermont Department of Health and AHS. Ridzon said that the practices that have received the prospective payments from the insurers have greatly benefited and supports prospective payments where possible.
Panel considers tax credit for families who paid to retain child are slots
The Senate Education Committee reviewed this week family payments to their currently-closed child care centers and considered creating a program that would partially reimburse them for their payments as a way to acknowledge their role in saving the sector. Under the state’s $4.3 million Child Care Stabilization Program, parents are required to pay one-half of the cost of child care while facilities are closed in order to retain their child’s slot. The state pays the other half.
Let’s Grow Kids and other child care proponents have lauded this program to shore up child care businesses during the COVID-19 emergency response. Aly Richards, CEO of Let’s Grow Kids, told the committee that without the stabilization program, Vermont could face a similar situation as other states where half of child care establishments have gone out of business. She said that COVID-19 has revealed the fragility of a private-pay system that already asks families to pay more than they can afford.
Providers testified that guidance they have received from the Department of Children and Families regarding families’ contributions was fastâ€‘moving and difficult to parse. The result has been that some providers have asked parents to pay 100 percent of tuition if they could afford to in order to stay enrolled while others advised families that the state would cover 50 percent or more of their tuition. Some families made difficult decisions to unenroll their child based on that advice.
Senator Phil Baruth, D-Chittenden, said he could think of no other instance where the state has asked individuals to contribute so much so that a business sector could survive the pandemic. Parents were being asked to shoulder a disproportionate burden. He suggested a $500 flat tax credit to symbolically say thank you to those parents and acknowledge their contribution.
The committee will review draft language for the credit, including cost estimates, next week.
GMCB reports on COVID-19 response to legislators
Green Mountain Care Board Chair Kevin Mullin appeared before a joint meeting of the House and Senate Health Care Committees on Friday to present an update on the board’s response to the COVID-19 crisis. Mullin first assured the committee that “the Green Mountain Care Board has in no way put health care reform on pause.” He said that the board is looking forward to working with the legislature to increase All Payer Model scale participation, to increase the flow of fixed payments to providers, and to enhance the overall financial stability of the health care system. Under the authority of Act 91 of 2020, the board waived or granted variances for hospital budget review, the certificate of need process, and accountable care organization certification and budget review. Board staff has paused hospital sustainability planning, but is closely monitoring hospital financial health through weekly reporting. The board recently sent a letter to the Center for Medicare and Medicaid Innovation Center requesting flexibility and additional funding to ensure that providers participating in the accountable care organization initiative can access all available resources now, and not be harmed financially. The letter included a request to waive penalties for not meeting quality metrics.
Mullin emphasized the importance that fixed prospective payments have in providing some revenue predictability for providers during the crisis, and acknowledged increased interests in global budgeting. The board will be looking at how to tie global budgeting and OneCare Vermont’s efforts together to increase fixed prospective payments in our health care system in the future.
As news broke during the meeting that the University of Vermont Health Network is anticipating a $152 million loss in revenue this fiscal year due to the impacts of the coronavirus pandemic, legislators questioned Mullin about hospital solvency throughout the rest of the state. Hospital Chief Financial Officers are transmitting weekly data that measures the hospital’s solvency at this point int time. Mullin said that they have been very reluctant to post any of the information “because they don’t want anyone to get scared that a hospital might close.” There are a few hospitals in the red-zone who would be in serious trouble after a month and a half, the biggest one being Springfield Hospital. For the system as a whole, Mullin said that hospitals need to be able to start performing elective surgeries and other currently halted services by the beginning of June or it’s going to be “problematic.”
Health committees review health care financial assistance for undocumented farmworkers
The House and Senate Health Care Committees met jointly on Thursday to review health care financial assistance available for undocumented farmworkers in Vermont. Vermont Association of Hospitals and Health Systems Vice President of Government Relations Devon Green detailed the new federal plan that is funding COVID-19 treatment for individuals without health care coverage, which will cover undocumented farmworkers. The program is funded from the $174 billion Public Health and Social Emergency Fund for health care providers and will cost $14 billion to $42 billion. Providers will be accessing a portal to submit patient information, and then will receive a Medicare level payment. Free clinics without claims systems may have difficulty accessing payment. Guidance has not been issued yet on the information that uninsured patients will need to present for coverage at time of treatment.
Green also explained how hospital financial assistance policies are developed and implemented, noting that in the case of uninsured patients during the crisis, the hospital assistance will be accessed after the federal program. There is no cap to the federal program spending, but if the fund runs out of money, extra pressure will be placed on the hospitals to provide uncompensated care. Referencing testimony from last week, Rep. Bill Lippert, D-Hinesburg, asked Green to report back on how hospital financial assistance programs consider undocumented immigrant income when they are financially supporting family outside of the country.
Green Mountain Care Board
The Green Mountain Care Board met on Wednesday and received a presentation in the morning from the Northwestern Medical Center on its 2020 budget adjustment rate increase of 14.9 percent effective May 1, 2020 . The GMCB delayed its vote on the budget request until Monday, May 4. Public comment will remain open until 8 a.m. In the afternoon, the board received COVID-19 response updates from the Department of Financial Regulation and health insurers.
NMC Chief Financial Officer Robyn Alvis and Director of Finance Stephanie Breault said that FY 2020 has been a challenging year, primarily driven by a net revenue variance resulting from the transition to a new Electronic Health Record and by significant overages in temporary patient care staffing costs. The greatest impact of the new EMR is the longer than anticipated ability to reach productivity levels, which has resulted in lost revenue that cannot be recaptured. There is no quick fix to bring volumes back up to previous levels. The use of temporary patient care staff (travelers) was higher than budgeted. The budgeted cost for these services in FY2020 was $300,000 and is projecting to spend over $2.3 million. The hospital is also reviewing service lines, administrative structure, and community partnership opportunities to ensure that vital services can continue to be available in our community, even if not provided by NMC.
On a positive note, NMC will soon be starting a tele-Intensive Care Unit program in partnership with Dartmouth Hitchcock Health. Alvis said will allow DH critical care clinicians to work in tandem with the care team at NMC reducing the number of patients requiring transfers to high acuity hospitals, such as the University of Vermont Medical Center. The tele-ICU programs allows even the most critically ill patients to receive care close to home and will allow critical care nurses to maintain their skill set.
GMCB Board Chair Kevin Mullin and several board members expressed concern about the level of the rate increase saying this situation could be temporary and yet the rate increase will be permanent. Mullin also is concerned that the board could approve the rate increase and yet the commercial insurer contracts do not require approval of the rate.
In the afternoon, the board received COVID-19 response updates from the Department of Financial Regulation and health insurers. The presentations were a repeat of information reported to the legislative health care committees in the morning (see update above). Mullin asked DFR Commissioner Mike Pieciak if the current reduction in elective care utilization would result in a windfall for insurers, and asked if refunds (similar to the auto insurance refunds issued) would be appropriate. Pieciak responded that health insurance is different, because there is pent up demand for care and it is unclear what it will look like in a few months.
BlueCross BlueShield of VT, MVP Healthcare and CIGNA all reported that they have implemented the procedures and cost-sharing rules issued by DFR. Many of the policies were already in place, and some will be permanent, including some telehealth provisions. The insurers testifying said that they are not seeing a marked decline in membership. Responding to the posited possibility of insurers receiving a windfall due to the current reduction of claims, BCBSVT President and CEO Don George said that “In the end, if BCBS receives a windfall, it will be used to mitigate future rate increases.”