Vermont Health Care Update 02-21-20
An analysis from DRM's Health Law Team
Health Care Legislative Update Quick Links
Panel poised to pass insulin bill
Panel advances insanity defense bill
VNAs of Vermont director educates panel on home health provider tax
Panel struggles with medical surprise billing issues
Panel continues discussions on telehealth reimbursement
Green Mountain Care Board offers recommendations to health reform bill
Tools in the health care work force toolbox
Panel looks to mandate Transportation Demand Management
Grants for emergency medical personnel training
Planning for the care and treatment of patients with cognitive impairments
House committees finalizing budget memos for Appropriations Committee
Green Mountain Care Board
On Friday, the Senate Finance Committee was poised to pass S.296, a bill that limits a beneficiary’s total out-of-pocket expenses for insulin drugs to not more than $100 per 30-day supply, regardless of the amount or type of insulin needed. It was noted that it would initially reduce costs to consumers, but would put pressure on the cost of insurance plans. A proposal to require hospitals to sell 340B-eligible insulin to their patients was rejected by the committee.
On a unanimous vote of 5-0, the Senate Judiciary Committee advanced S.183 on Tuesday. The bill addresses competency to stand trial and insanity as a defense.
- Separates the competency to stand trial evaluation and the person’s sanity at the time of the alleged offense evaluation;
- Requires the court to appoint counsel from legal aid to represent the person in court proceedings and allows the Department of Mental Health to appear and call witnesses in proceedings and be represented by the Office of Attorney General;
- 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.
A provision that would have established a three-year initial commitment period for a person adjudicated not guilty by reason of insanity for a homicide or attempted homicide was removed from the bill.
The Senate Health and Welfare Committee did a cursory review of the bill on Friday and offered its support of the bill.
VNAs of Vermont Executive Director Jill Mazza Olson appeared before the House Ways and Means Committee on Tuesday to share her concern on the provider tax currently assessed on home health and hospice agencies. Olson said the SFY 2020 budget assumed that home health agencies would be billed $4.8 million, the actual bill totals $5.5 million. The increased cost of the tax wiped out the benefit of nearly the entire Medicaid increase for SFY 2020. The tax bills came in at just under $750,000 more than budgeted and more than the previous year. The entire Medicaid increase budgeted for home health and hospice agencies was $750,000. She said with the federal match, the state will collect nearly $1.6 more than budget and twice what agencies will receive in rate increases.
Olson said the home health and hospice agencies will have audited financials by mid-April. Given the timing she will advocate in the Senate for a rate that generates a tax to not exceed $4.8 million.
The Senate Finance Committee continued to take testimony on S.309, a bill that prohibits health insurers from shifting liability for out-of-pocket expenses to referring providers when they refer a patient out of network. The bill is in response to a policy Blue Cross Blue Shield of Vermont put into place that would allow Blue Cross Blue Shield to fine providers when they refer out of network. The bill also proposes to eliminate patients’ out-of-pocket exposure for nonemergency services delivered by out-of-network providers at in-network facilities, ensuring protection to patients for an issue that is happening in other areas of the country.
Southwestern Vermont Medical Center Chief Medical Officer Trey Dobson described the distressing effect this policy has on the provider-patient relationship. It also causes financial hardship to both patients who cannot afford care and medical providers whose resources are limited by insurance companies lack of reimbursements.
Chief Health Care Advocate Mike Fisher presented an amendment to the committee would require insurers to pay out-of-network providers up to a certain amount and would prohibit a nonparticipating provider to bill the patient for the difference between what the patient's health insurance chooses to reimburse and what the provider chooses to charge.
On Thursday, the health insurance companies testified in opposition of the Fisher amendment pertaining to nonemergency services delivered by an out-of-network provider. MVP Government Relations Specialist Susan Gretkowski said insurers have a process for providers to be considered an in-network provider. In-network providers go through a credentialing and licensing process that ensure protections for patients and payers and keeps total cost of care down.
Committee Chair Ann Cummings, D-Washington, asked that the stakeholders try to work on a solution outside of the room.
The House Health Care Committee took testimony on H.723, a bill that requires health insurance reimbursement for expanded telehealth services. The store-and-forward and telemedicine portions of the bill received wide support from all that testified, with the main recommendation to keep the extended effective date to allow for time to make the necessary changes. Legislative counsel Jen Carbee recommended clarifying that Store-and-Forward does not include the use of audio-only telephone, e-mail, or facsimile.
On Wednesday, the Vermont Medical Society proposed an amendment to include a prior authorization provision. Department of Vermont Health Access Director of Policy Nissa James said DVHA has a program in place that already waives certain prior authorizations. DVHA does not support the amendment, but hopes to find a solution with VMS. Commercial insurers were caught off guard by the proposal and do not support the amendment. Rep. Bill Lippert, D-Hinesburg, said this is an issue brought up every year and that it was time to address. Rep. Lori Houghton, D-Essex, asked that that health insurers and VMS work on a compromise and return to the committee next week.
Blue Cross Blue Shield of Vermont Director of Government Affairs Sara Teachout said prior authorizations helps protect patients from unnecessary costs. BCBS launched the Provider Passport Program, which will provide a simplified prior authorization process for advanced imaging, with the plan of reviewing the program’s success at the end of two years. Teachout also told the committee that prior authorizations for out-of-network services cannot be eliminated because if a person seeks out-of-network service, but no prior authorization is sought, the outstanding balance becomes the responsibility of the patient. Houghton suggested that if the prior authorization conversation continues, the committee should consider separating in-network and out-of-network services.
Green Mountain Care Board Exeuctive Director Susan Barrett presented the Board’s recommendations to S.290, a bill that expands the Green Mountain Care Board’s regulatory authority. Barrett began by saying that many of the provisions in the bill related to the accountable care organization already exist under Rule 5. She said the Board does not support going to a two-year budget cycle saying the ACO has not reached scale yet and that it may be premature to move to a multi-year budget.
Barrett offered alternative language on the section related to hospital rate and reimbursement information including commercial rates, charges, fee schedules, reimbursement methodologies, and proposed reimbursement increases or decreases. She also recommended health insurers disclose to the Board provider reimbursement information including fee schedules, payment methodologies, and other information as requested.
Barrett said given the board’s lack of regulatory levers over the designated mental health agencies, the board recommends a review for solvency and transparency. This will provide the board with insight into the DA’s role in rural health care. Barrett said this will require an additional staff position.
Barrett recommended a study to understand what it would take to implement fee-for-service rate setting for providers and to consider additional methodologies as the state transitions away from fee-for-service to valued based payments or global budgets. Barrett said funding for actuarial support and analysis is needed.
HealthFirst Executive Director Susan Ridzon supports many provisions of the bill that are aimed at addressing inequities in the health care system. She said her organization supports payments to healthcare professionals in a manner that is equitable, site neutral, and sufficient enough to support the availability of services without the need to cost shift.
The committee plans to add provisions from S.246, a bill that directs the GMCB to evaluate the costs of certain high-cost prescription drugs and setting limits on what Vermonters would be expected to pay for some high-cost drugs.
The House Committee on Health Care heard testimony this week on the health care work force issues plaguing Vermont. Representatives from University of Vermont and Vermont State Colleges testified that the shortage of clinical nursing educators is a burden on the State’s capacity to provide nursing program. Castleton University receives fewer applications for nursing instructors than for any other profession. The shortage is due to the cut in pay educators receive in comparison to practicing nurses and the education requirement that clinical educators must have a master’s degree. This is why there is much support for the Office of Professional Responsibility’s bill that would remove that requirement among other obstacles.
Work force solution also include scholarships, loan repayment programs, loan refinancing, and finding ways to make it easier to receive the necessary education. The committee heard of multiple scholarship opportunities that are already in place or proposed to be from the Vermont Medical Society, the Vermont Student Assistance Corporation, and the Vermont Area Health Education Centers Program. Many of the programs incentivize or require students to work in Vermont if they accept the scholarship, or the scholarship will revert to a loan if the student would decide to work elsewhere after graduation. AHEC Program Director Elizabeth Cote testified and stated that repayment programs are now considered baseline offers that most states provide and that Vermont “would be wise to do more.”
Health care work force shortages raised other concerns. Traveling nurses were brought up several times, with many committee members questioning whether they are the right investment, despite the apparent need for them to address the workforce shortages. University of Vermont Professor Mary Val Palumbo asked the committee to consider recommending the creation of a Vermont Blue Ribbon Commission for 2022 and another Governor’s Commission on Healthcare Workforce. The committee is likely to make the recommendations.
Rep. Annmarie Christensen, Democrat-Weathersfield, and Rep. Peter Reed, Independent-Randolph, discussed the workforce subcommittee’s recommendations. The recommendations include creating a scholarship program for primary care doctors that choose to do their residency in Vermont, a VSAC scholarship for nurses, a proposal to lower the education requirement for clinical educators, and a proposal to lower the age requirement for licensed practical nurses to 17 in order to allow high school students to take advantage of free dual enrollment nursing courses.
Representatives of the VNAs of Vermont, the Vermont Association of Hospitals and Health Systems, and the Vermont Health Care Association appeared before the House Transportation Committee on Thursday to oppose a proposal that would require all employers with 50 or more employees to design, adopt, and implement a transportation demand management plan. They said health care is not an industry that lends itself easily to telecommuting with 24/7/365 days a year operations. With limited transportation options in rural communities where most health care providers are located, public transit is not necessarily available beyond normal working and business hours.
They appreciate the committee’s goal of addressing a primary driver of Vermont’s carbon emissions and providers are building in efforts to address carbon emissions where it makes sense including working with Efficiency VT on weatherization and efficiency initiatives. The concern with this bill is the increased burden on an already overly burdened health care system that is under pressure to reduce costs and increase access.
VNAs of Vermont Executive Director Jill Mazza Olson said this bill is nonsensical for the work her members provide, which is delivering care to people at home. Olson said massive workforce shortages are impacting every aspect of healthcare. The staff in these facilities wear many hats and this would be another program that someone would have to be responsible for designing and overseeing. Olson said there are efforts underway to address this including telehealth technology being implemented across our health care system, which is critical in addressing our workforce shortage and has the added benefit of positively impacting carbon emissions goals. Telehealth is the delivery and facilitation of health care services via telecommunications and digital technology.
The House Health Care Committee heard testimony from Rescue, Inc. Chief of Operations Drew Hazelton on H.742, a bill that appropriates related to grants for emergency medical personnel training. The three components of the bill include: removing cost barriers by granting funds to areas that have EMS needs, reducing the travel burdens by offering online training, and reducing competition with other states by providing incentives to remain in state.
Hazelton said that the main challenges for emergency medical services are access to education and workforce development; every year the state is losing EMS providers. Hazelton noted the success Rescue Inc. had when they offered the training program for free, highlighting that finding volunteers is not the issue but paying for their training is. Chair Rep. Bill Lippert, D-Hinesburg, said that of the “committee bills that were brought into our committee, this was the number one bill that emerged. This is clearly a timely and important issue.” Hazelton said paramedics are being pulled into the hospitals to address the nursing shortages. Rep. Brian Smith, R-Derby, said currently, the VDH distributes the funds for tuition, but Smith hopes that the process for distributing funding would be altered to make it easier. Lippert agreed that easing access to grants is important.
On Friday, the Senate Health and Welfare Committee took testimony on S.300, a bill that plans for the care and treatment of patients with cognitive impairments. Provider organizations said as Vermont’s population ages, they want Vermonters suffering from dementia to get the highest quality, appropriate care that will reduce patient risks related to cognitive impairments and relieve burdens on families providing care. Vermont is engaged in a number of interventions and activities to support patients, their families and providers caring for those with dementia and Alzheimer’s that go beyond the scope of this legislation and question whether S.300 is entirely necessary.
The Alzheimer’s Association - Vermont Chapter Executive Director Grace Gilbert Davis supports the bill. She said there is no overcoming this disease. She said an integrated state plan will accelerate the development of treatments that would prevent, halt, or reverse the course of Alzheimer’s disease. She said efforts to coordinate the health care and treatment of individuals with cognitive impairments is imperative and to implement a strategy to increase the diagnostic rate of Alzheimer’s disease in the state.
A provision in the bill requires hospitals to implement an operational plan for the recognition and management of patients with dementia or delirium in acute care settings. The operational plan needs to be completed on or before January 1, 2022. Vermont Association of Hospitals and Health Systems Vice President of Government Relations Devon Green described current efforts on early diagnosis and primary care integration. The state’s Dementia Hub and Spoke Alzheimer’s Group are developing a SmartPhrase tool for use with any electronic medical record and includes diagnostics that can be drawn in from the chart, dropdown menus for history taking, medication choices, referral choices and resources for patient and family. Several hospitals are currently using this tool. The hub and spoke group is working to integrate this tool in primary care practices across the state through a half-day continuing medical education program rollout.
Green said the report proposed is both a comprehensive inventory as well as a strategic plan. This sort of long-term planning is important and requires significant resources. Because the hub and spoke group is currently implementing a tool for early diagnosis and resource referral and other training and coordination efforts, the assessment and state plan should have the assistance of a consultant or dedicated state staff to work on this proposed assessment and state plan.
The House Health Care and Human Services Committees are poised to finalize their recommendations to the House Appropriations Committee. A detailed report will be available in the DRM Health Care Update next week.
The Green Mountain Care Board heard from representatives from the University of Vermont Health Network Central Vermont Medical Center on the proposed 25-bed psychiatric care facility. CVMC President and Chief Operating Officer Anna Noonan said the expected $150 million price tag is far in excess of what either UVMHN or the state expected and will delay the project.
Noonan said UVMHN has begun the process to identify alternative options to evaluate the necessary project parameters and scope. She said they will prioritize the programming and design work completed to date. She said because the analysis was originally completed in September 2018, an update is needed and will take into consideration the new 12 Level One beds (most highly acute mental health patients) scheduled to open at the Brattleboro Retreat in Spring 2020, as well as the proposed new16-bed secure residential facility.
Noonan said the UVMHN is committed to engaging in the necessary steps to reconsider the scope of this project to present a more affordable option to improving access to adult inpatient psychiatric care that will best serve our patients, families, community and staff. “No one was trying to design something that was exorbitant or frivolous… It was thoughtfully done and it was a very iterative process,” said Noonan.
GMCB Chair Kevin Mullin and board member Tom Pelham expressed their frustration with the situation. “Here we are two years out and everyone’s overwhelmed at a cost that’s way beyond what anybody had envisioned,” said Mullin. He asked for better reporting of how that money has been spent for planning and a clear accounting for psychiatric beds versus the rest of the project. The $21 million was specifically designated for inpatient mental health beds and not for planning for other hospital projects such as a new emergency room or additional parking, he said. The network has spent $1.2 million on the planning process.