Policy committees directed to pivot work

In a hearing on Thursday, House Health Care committee chair Bill Lippert, D-Hinesburg, said that Speaker Mitzi Johnson, D-South Hero, has informed committee chairs to pivot from work on committee bills to work on the first quarter budget. Committees have been asked to provide recommendations to the House Appropriations committee by June 10.

Senate advances nurse licensure compact bill

The full Senate passed S.125, a bill that allows Vermont to join the Interstate Nurse Licensure Compact. The bill now moves to the Senate floor. The bill will enable a licensed practical nurse or a registered nurse to obtain a Compact license in a Compact state, allowing them to practice without obtaining an additional license to practice in that other state. The bill is now in the House Health Care committee.

Physician assistants bill advances  

On a vote of 10-1, the House Health Care committee advanced S.128, a bill that modernizes state law regarding the licensure of physician assistants. Rep. Lucy Rogers, D-Waterville, was the lone dissenting vote. The bill removes the requirement of a delegation agreement between supervisory physicians and PAs, and substitutes it with a practice agreement requirement. The committee approved an amendment before passing it out of committee that requires that the practice agreement include a plan to have a physician available for consultation at all times when the physician assistant is practicing medicine. The proposal brings the law into alignment with current practice, and would not change the scope of practice of PAs.

Panel advances miscellaneous health care bill

The House Health Care Committee advanced its miscellaneous health care bill on Thursday. The bill addresses several areas including mental health, hospital budget review, expansion of the VPharm prescription drug coverage for certain Medicare beneficiaries, and review and modification of prior authorization requirements. A summary of the bill can be found in the DRM update dated May 22.

The bill requires the Brattleboro Retreat to fall under the Green Mountain Care Board hospital budget review process gradually, requiring a full review by FY 2024. In developing the process for full review of the budget, the GMCB will collaborate with the Brattleboro Retreat and the Agency of Human Services to prevent duplication of efforts and reporting requirements. The GMCB and AHS will jointly determine which documents submitted by the Brattleboro Retreat are appropriate to share with the GMCB.

As a condition of further state funding, the bill requires quality oversight measures be implemented by the Brattleboro Retreat under the direction of the Department of Mental Health. It requires the Department of Mental Health and the Brattleboro Retreat to meet jointly each month with the mental health patient representative (an independent, peer-run organization contracted with DMH) and the mental health care ombudsman to review patient experiences of care, to discuss quality issues, and to review other patient care and safety topics.

Brattleboro Retreat President Dr. Louis Josephson accepts the language and appreciates the intent of the legislation.

Panel advances Older Vermonters legislation

Over several days this week, the House Appropriations Committee reviewed H.611, the Older Vermonters Act. The bill was referred to the committee due to language that compels the Director of Rate setting to create a mandatory Home- and Community-Based Service Provider inflationary rate increase.

Although the committee rejected the mandatory inflator last week, the committee discussed inserting language in the bill that would create an informational inflator. After an extended discussion, the committee agreed that it was a policy issue and should be handled by the Human Services Committee, agreeing to strike the inflator section before voting the bill out on a vote of 8-3. The House Human Services Committee will work on amendment language next week that will direct the Department of Disabilities, Aging and Independent Living, and the Department of Vermont Health Access to develop criteria and a process for calculating an annual inflation factor for potential application to the Medicaid rates for providers of home- and community-based services in future fiscal years. The departments will be required to submit a report on the criteria and process by April 15, 2021.

Panel works on continuation of DFR emergency rulemaking authority and telephone services

On Thursday, the Senate Health and Welfare committee reviewed a proposal that directs the Department of Financial Regulation to convene a working group to develop recommendations for commercial health insurance and Medicaid coverage of health care services delivered by telephone after the COVID-19 state of emergency ends. The proposal also extends DFR’s authority to adopt emergency rules to address COVID-19 related issues through June 30, 2021. The committee also stated their intention to leave DFR’s current emergency rules in place until June 30, 2021, either through this proposal, or through legislation extending provisions of Act 91 of 2020.

Providers stressed in previous testimony that telephone only delivered services are crucial to health care delivery during the crisis, and should be permitted until the working group recommendations can be implemented. The extension of DFR’s rulemaking authority is supported by the providers and DFR itself. Insurer BlueCross BlueShield of Vermont supports the extension of DFR’s rule-making authority, but not the extension of all of the current emergency rules in place. The proposals will be added to a bill that will move up the effective date for health insurance reimbursement for health care services delivered by store-and-forward means.

Chair Ginny Lyons, D-Chittenden, said the committee would also work with the House Health Care committee to add an amendment to the store-and-forward bill that would add language requiring the Vermont Program for Quality in Health Care to consult with its Statewide Telehealth Workgroup, the Department of Public Service, and organizations representing health care providers and health care consumers to conduct a patient connectivity needs assessment in the context of telehealth implementation, and cost estimates for providing connectivity services, network equipment, and end-user devices to patients who currently lack them. Rep. Bill Lippert, D-Hinesburg, had expressed concern that adding the language to the bill would bog the entirety of the bill down in appropriations if the money was needed to support the directives. Lyons confirmed that no billbacks or additional state funds would be needed, so the proposal will be added to the bill.

Administration proposes support to health care system as financial losses are reported

In a joint meeting of the House and Senate Health Care committees on Wednesday, Agency of Human Services Secretary Mike Smith announced that the Scott administration will be proposing a $300 million health care system support program with funding from the federal Coronavirus Relief Fund. Money granted under the program would be available to many providers in the health care system, including hospitals, home health agencies, independent providers, dentists and mental health care providers, and could be used to cover COVID-19 related lost revenues and expenses incurred. The program would have verification and accountability, and would be auditable. The administration hopes to have the proposed program approved by the legislature by mid-June, and the administration will be ready to set up the application process as soon as possible.

Smith listed five additional programs that AHS has already implemented with the goal of keeping the health care system financially viable during the epidemic and stabilizing the system to weather future impacts. Smith reported that the agency has obligated $7.2 million in support funding to the Brattleboro Retreat and $1.3 million to Springfield Hospital. The Brattleboro Retreat funding was tied to an agreement to submit a report detailing the Brattleboro Retreats future operational and financial viability of the facility. AHS has also stood up a $4 million non-hospital retainer program, a $7 million enhanced pay program for the designated mental health agencies and specialized services agencies, a $4.6 million nursing home retainer program, and $24 million in the prospective Medicaid payment program for Medicaid eligible health care providers. The prospective payment program covered Medicaid payment shortfalls for May and June. Smith reported that the program was underutilized, with advocates adding that it may have been due to the confusing and onerous application process.

Although AHS’s relief programs infused some funding into the health care sector, the hospitals and provider organizations testified that additional relief, like the administration’s proposal, is needed. VNAs of Vermont Executive Director Jill Mazza Olson said that reduced revenue from home health agencies’ largest payer, Medicare, is contributing to their already difficult financial position. Because full Medicare payment for each patient depends on meeting a threshold for in-person visits, the agencies are receiving reduced payments because of patient fear of in-person contact as well the use of tele-visits that don’t count as visits to meet the threshold.

Olson said the agencies have received some Coronavirus Aid, Relief, and Economic Security Act funding from the federal government, but it is only equal to six percent of the Medicare revenue, and when balanced with the 4.02 percent provider tax that the agencies will still pay, there is little money to cover the revenue loss (a15-20 percent revenue loss is being reported nationally). Olson reminded the committee that the home health agencies rely on Medicare revenue to cover the 25 percent loss ratio in the Choices for Care Medicaid program. She said that with proposed additional funding coming into the system, “this is the moment to shore up our long term care system and deal with some of its underlying fragility and not merely try to restore the dollars to the normal level.” Olson added that because the home health agencies did not receive the same staff payment increase as the designated mental health agencies, it was crucial that S.346, the Essential Employees Hazard Grant Program, pass to increase the home health workers who have cared and are caring for more COVID-19 positive patients than all of Vermont’s hospitals combined.

Vermont Association of Hospitals and Health Systems Vice President of Government Relations Devon Green told the legislators that before the crisis, Vermont’s hospitals were already in a fragile financial condition, with 50 percent not reaching their financial margins. The hospitals have ramped up many services in response to the crisis, including partnering with National Guard on alternative care sites, assisting state with supply chain for PPE and testing materials, and setting up drive-up testing sites. But as they dedicate time and resources to serve in the crisis, they are suffering approximately $100 million in lost revenues monthly. Most hospitals have received Medicare Advance payments, but the funding is a loan and will be recouped by Medicare at a dollar-for-dollar rate on future payments starting 120 days after receipt of money with a 10.2 percent interest rate.

The Vermont Health Care Association reported that nursing homes are also seeing a greater than 50 percent reduction in revenue due to census and admission declines and Medicare losses for post-acute short stay rehab and skilled nursing services.

Green Mountain Care Board

The Green Mountain Care Board met Wednesday and received an update from Agency of Human Services Secretary Mike Smith on its response to the COVID-19 crisis and to vote to approve the FY2021 hospital budget guidance. Smith discussed the administration’s proposed $300 million health care system support program as well as the five programs that the agency has already implemented in response to the crisis. (Smith gave the same presentation earlier in the morning to legislative health committees – see above for details.)

The board reviewed and approved the FY2021 hospital budget guidance with minor changes. In response to the current health crisis, the budget submission deadline has been pushed back to July 21, and the process has been streamlined under the authority of Act 91 of 2020. The guidance includes a two part change in charge: the first part reflecting standard price growth and the second part a time-limited charge request to offset FY 2020 commercial revenue losses due to COVID-19. At their March 18 meeting, the board approved a Net Patient Revenue/Fixed Prospective Payment of 3.5 percent for FY 2021, and agreed at this meeting to consider an additional, temporary NPR/FPP adjustment to compensate for FY 2020 utilization that was not realized due to COVID-19. Due to the Center for Medicare & Medicaid Innovation Center delays, hospitals will have until Sept. 1 to submit data related to OneCare Vermont. The board also voted to waive any FY 2020 budget enforcement action.