Vermont Health Care Update 02-03-2020 - An analysis from DRM's Health Law Team

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Minimum wage bill heads to the Governor

On a vote of 23-6, the Senate voted on Thursday to concur with the committee of conference report on minimum wage. The House passed the bill last week on a vote of 93-54. The bill now heads to the Governor. The bill will increase the minimum wage by $1.59 over two years, from $11.75 in 2021 to $12.55 in 2022. The Governor has expressed concerns about an increase in the minimum wage and the impact in rural areas of the state.

Governor vetoes Paid Family Leave bill

As expected, Gov. Phil Scott has vetoed a paid family leave bill that was passed by the legislature. In a veto statement that he issued on Friday afternoon, he reiterated that he would not support a mandatory paid family leave program that includes a payroll tax. While dismissing the efforts of the legislature, he is moving forward on a voluntary plan that begins with the implementation of a program for Vermont’s state employees.

The House and Senate will attempt to override the Governor’s veto. Needing two-thirds of those present in both the House and Senate will be a challenge. The Senate appears to have the votes for that effort but the House numbers are much closer. There were a number of liberal-leaning Democrats and Progressives who voted against the bill because they didn’t believe it was generous enough. Democrats and Progressives may feel pressure to override the veto in an effort to give Lt. Governor David Zuckerman an election issue in his upcoming challenge to Gov. Scott.

Workforce a priority for health care committee

The House Health Care Committee has identified workforce as a priority. This week, it heard from Rural Health Task Force member Laura Pelosi that Vermont’s health care workforce is aging, there is a decline in licensed professionals, and there are workforce vacancies in every sector. She said Vermont’s health care workforce crisis is driven by factors including student debt, education and credentialing challenges, licensing challenges, and provider burnout. Pelosi said the task force recommendations include occupational licensing reforms, higher education reforms, financial incentives, and maximizing of the workforce by removing telehealth barriers and reducing  administrative burdens. The report can be found here.   

The committee also heard from VNAs of Vermont Executive Director and task force member Jill Olson on care coordination. Olson thanked the committee for its support of the delivery system reform dollars to OneCare Vermont, which has allowed health care sectors to work as a system to provide care in the most appropriate setting. She described the UVM Health Network Home Health and Hospice Longitudinal Care Program, which is being expanded to other communities thanks to delivery system reform funding. It allows patients to receive nursing, community health worker visits and telemonitoring services at home beyond the point where Medicare requires discharge. In Chittenden County, the program has successfully reduced hospital admissions and emergency department visits, reducing costs and improving patient experience. 

Bi-state Primary Care Association holds legislative day

Members of the Bi-State Primary Care Association presented to the health care committees as part of its Legislative Day on Tuesday. BSPCA is a member organization made up of federally qualified health centers, rural health clinics, clinics for the uninsured, the area health education center network, and Planned Parenthood of Northern New England clinics. BSPCA Director of Vermont Policy Helen Labun said the health centers are committed to improving the health status of Vermonters and ensuring that all individuals have access to affordable and high-quality medical, mental health, substance abuse, and oral health care, regardless of insurance status or ability to pay.

Kim Anderson, Director of Development and Communications for Community Health Centers of Burlington, said CHCB addresses the needs of its community by providing an array of health services regardless of financial status or life circumstance – providing medical, dental, counseling and psychiatry services. Anderson said CHCB has played a critical role in combatting the opioid crisis with its robust medication assisted treatment program. She said its array of integrated services and collaborations with community partners isn’t limited to substance use. CHCB is the only federally granted Homeless Healthcare Program in the state and serves approximately 1,500 individuals experiencing homelessness each year.

Gifford Health Care Chief Medical Officer Dr. Josh White described strategies to address workforce issues. The hospital is hiring international nurses and is utilizing telemedicine with external agencies and internally between its clinics. This has been especially useful in psychiatry. He said the recent news about financial struggles at the Brattleboro Retreat is extremely frightening for all hospitals given the number of mental health patients that need treatment.

Senate advances Budget Adjustment Act

On a vote of 28-1, the Senate advanced the FY 2020 Budget Adjustment Act on Thursday. Sen. Corey Parent, R-Franklin, was the lone dissenting vote. Senate Appropriations Committee Chair Jane Kitchel, D-Caledonia, said the BAA is supported with an additional $18 million in revenue from July’s revenue upgrade. The most recent upgrade in January will be part of the FY2021 state appropriations bill.

Parent rose in opposition to the bill due to cuts to the OneCare Vemont RiseVT program. He said RiseVT started at his local hospital and has expanded to many rural communities in the state. The program helps children and families embrace healthier lifestyles and he opposes the budget reduction of $550,000. Kitchel responded that the Department of Vermont Health Access has made a commitment to OneCare and will honor that. She said the committee wanted to have a rigorous process between the Agency of Human Services and OneCare for the allocation of delivery system reform dollars to prevent duplication of state programs.

The BAA:

  • Transfers funds to address deficits in the Workers’ Compensation and State Liability Insurance funds;
  • Provides funding to the Department of Corrections for out-of-state beds, medication assisted treatment, and Hepatitis C treatment;
  • Addresses the gap in the Vermont Technical College National Guard tuition program;
  • Provides for a rate increase at the Brattleboro Retreat;
  • Funds increased costs in Judiciary; and
  • Provides funds to the Department of Aging and Independent Living for increased costs of serving higher acute needs patients at nursing homes.

Department of Mental Health presents 10-year plan

The Department of Mental Health appeared before the House Health Care Committee on Wednesday to present its report on the 10-Year Plan for an Integrated and Holistic System of Care. DMH Commissioner Sarah Squirrell said the plan is informed by input from community members and stakeholders to include individuals with lived experience.

Squirrell said the plan promotes a population health approach to build a holistic and integrated system that includes all aspects of health. She said the goal is a model to present a whole-person approach in all aspects of wellness promotion, prevention and treatment of illness, health equity, social justice, and person-led care, with stigma elimination as a priority.

Squirrell said community members and stakeholders reviewed data describing the current state of the system as well as demographic trends to inform strategies and steps for implementation. Data show overall high rates of health and access when compared nationally, while other trends reviewed include high rates of suicide deaths, and an aging population.

Squirrell said the plan is organized into eight action areas supported by short-, mid- and long-term strategies for implementation. These include:

  • Promoting health and wellness to improve the health of populations;
  • Influencing social contributors to health to ensure individuals meet their most basic needs;
  • Eliminating stigma and discrimination;
  • Improving client experience by expanding access to community-based care;
  • Enhancing intervention and discharge planning services for Vermonters in crisis;
  • Embedding peer services in all levels of care;
  • Ensuring service delivery is person-led; and
  • Committing to workforce development and payment parity.

DMH also recommends creating a council or board with the authority to oversee and guide strategies in the plan.

Testimony continues on bill to fan flavored tobacco

The Senate Health and Welfare Committee heard more testimony this week on a bill, S.288, that would ban the sale of flavored tobacco products, including menthol cigarettes. The committee heard from a health expert from the University of Vermont and a UVM Medical Center researcher who presented compelling evidence that menthol cigarettes and flavored products are resulting in high levels of addition by young people. 

The committee is expected to vote on the bill next week.

Senate finance panel considers eliminating primary care cost sharing

The Senate Finance Committee took testimony Tuesday on S.245, a bill that proposes to eliminate cost-sharing requirements for primary care. Blue Cross Blue Shield of Vermont Director of Government Affairs Sara Teachout told the committee that there is already no cost share for preventative care, and this proposal would only affect 25 percent of Vermont’s population. Teachout testified that although “spending money on primary care is the right thing to do … , it doesn’t produce cost savings,” as people will live longer and require longer and eventually require more expensive care. Sen. Chris Pearson, P/D-Burlington, sponsor of the bill, pushed back, saying, “Everyone has said that if we can treat people up front, we can save money. It is the basis of our health reform efforts.”

Both Teachout and Susan Gretkowski of MVP said that the requirements of the federal Affordable Care Act would make it difficult to meet the proposal’s requirements. Each plan must fall within a range of cost share percentage between insurer and insured. Locking in the amount for the copay for primary care (of zero) will put pressure on other line items. Both said that this proposal would increase premium costs.

Chief Health Care Advocate Michael Fisher is supportive of the idea, but he told the committee that the proposal may need to be revised to reach the right balance so as not to increase insurance costs.

The committee will return to the bill in the next few weeks.

Scott administration proposes Woodside as secure residential site

The commissioners of the departments of Mental Health and Building and General Services have recommended the closure of the Middlesex Therapeutic Community Residence, and the construction of a new facility at the site of the Woodside Juvenile Detention center. On Friday, BGS Commissioner Chris Cole told the House Health Care Committee that the Scott administration is proposing that the Woodside facility be demolished and replaced with a 16-bed, state-run, physically secure residential program with increased clinical capacity. Cole said funds to support the planning and development of a larger, permanent facility are included in the proposed FY 2020 Capital Bill. Cole told the committee that it is not possible to retrofit the existing space into a therapeutic environment. 

DMH Commissioner Sarah Squirrell said six of seven beds at MTCR are filled and potential referrals are being reviewed for the seventh bed. At any given time, there are 10-15 people who could be referred to a secure residential program that has the capacity to perform occasional Emergency Involuntary Procedures. EIPs include restraint, seclusion or emergency involuntary medication. Squirrell said this cohort of individuals occupy significant inpatient hospital bed days and cannot be appropriately served at the Middlesex secure residential program due to current regulations for Therapeutic Community Residences, the facility’s design, and the staffing pattern. She said the new facility will continue to serve individuals who no longer require acute inpatient care, but who remain in need of treatment within a secure setting for an extended period.

The committee plans to take additional testimony on the proposal.

Physician Assistants seek licensing changes

The Senate Health and Welfare Committee continued on Wednesday to take testimony on a proposal to modernize state law regarding the licensure of physician assistants. S.128 would simplify documentation and administrative requirements in the current PA and physician relationship.

Last week, Vermont Medical Society Executive Director Jessa Barnard told the committee that the changes in the statute governing PA practice was necessary to reduce barriers to licensure and healthcare workforce employment in Vermont. The proposed changes would bring the law into alignment with current practice, and would not change the scope of practice of PAs. The need for delegation agreements with primary and secondary supervisory physicians would be removed, as would physician liability for PA practice solely based on being a participating physician who completes a practice agreement.

The bill would mandate a practice agreement between a physician assistant and a physician. A practice agreement would not be submitted to the Board of Medical Practice for approval or filing, but would maintained by the physician assistant and provided to the board upon request. The Physician Assistant Academy of Vermont supports this language and testified that the board has rejected delegation agreements for minor reasons such as word choice, although the board is tasked with only accepting the agreements, not reviewing them. Other states in the region do not require the agreements to be filed with a regulatory board.

David Herlihy, the Executive Director for the Vermont Board of Medical Practice, urged the committee to consider requiring the filing of agreements with the board, saying that they are part of the authoritative public record on licensing, and with the shift in liability from physicians to physicians assistants, it would be beneficial to have them on file with the board. It would be difficult for the public to access the agreements if they were filed at hospitals.

Committee Chair Ginny Lyons, D-Chittenden, said that her committee will review an updated proposal next week.

The Agency of Human Services and half of its departments present budgets changes

The House Appropriations Committee heard testimony this week on the proposed FY 2021 State Appropriations for the Agency of Human Services, the Department of Disabilities, Aging and Independent Living, and the Vermont Department of Health. On Tuesday, AHS Secretary Michael Smith provided a general overview of the entire agency budget, noting AHS saw an overall budget increase of $15.1 million. Smith also revealed that meetings with Brattleboro Retreat’s Board of Directors “have been cordial and very productive,” and that he expects “to get an ask soon.” Additional departments will be presenting their budgets to committees during the next few weeks.

Department of Disabilities, Aging, and Independent Living: DAIL Commissioner Monica Hutt reviewed her department’s FY 2021 Budget in the House Appropriations and Human Services Committee. Hutt said it is the goal of her department to make Vermont the best state in which to grow old or to live with a disability. She said DAIL has embraced Results Based Accountability and continues to focus on program performance measures and performance improvement.

Hutt presented the Choices for Care Savings Report. Appropriations Chair Kitty Toll, D-Danville, asked why DAIL is proposing to raise the case management services cap from twelve to twenty-four hours annually. Hutt replied that many providers are already giving more than twelve hours service, so the change aligns the cap with current practice.

Rep. Dave Yacovone, D-Morrisville, asked Hutt whether DAIL had “any way of knowing the financial fragility any of the entities within your system and programs. Hutt responded that DAIL does collect that information for some programs like home health agencies, but does not for others like residential care. Wood expressed concern that residential homes aren’t getting increased reimbursement, while also being burdened by added requirements and regulations. Hutt pointed out that the Medicaid Vermont Assistive Community Care Services funding was increased by $5 per day last year. Human Services Chair Ann Pugh, D-S. Burlington, told Hutt that she would like budget dollars directed at oversight and training in nursing homes that are “having issues.”.  

In the Human Services Committee, Rep. Theresa Wood, D-Waterbury, questioned Hutt on the moderate needs wait-list. Hutt stated that the majority of the wait-list is under the homemaker services program, and that it is difficult to find people to hire to provide services. Wood also noted that there is no cost of living increase for Medicaid provider reimbursements. She has asked the Department of Vermont Health Access to determine what a one, two, or three percent COLA would cost.

The Human Services Committee will take additional testimony and will provide recommendations to the Appropriations Committee.

Vermont Department of Health: On Wednesday, the committee heard from the Vermont Department of Health Commissioner Dr. Mark Levine on his FY 2021 budget request. Levine said his department focuses on public health and prevention programs to keep communities healthy. The FY 2021 budget will continue to sustain the following:

  • Providing access to reproductive health services;
  • Working to prevent disease by ensuring high vaccination rates;
  • Reducing exposure to toxins, especially among children;
  • Enhancing the Universal Afterschool Network; and
  • Building Resilience and Primary Prevention of adverse childhood experiences.

Department of Children and Family Services: DCF Commissioner Ken Schatz presented his department’s FY 2021 budget to the House Appropriations Committee on Thursday. Schatz said his department fosters the development, safety, and well-being of Vermonters. The goal of his department is to reduce poverty and homelessness, improve the safety and well-being of children and families, create permanent connections for children and youth, and provide timely and accurate financial supports for families. The FY 2021 budget supports these goals.

Schatz discussed the elimination of the Specialized Childcare Transportation and Emergency Housing Motel Voucher Program. Committee Chair Kitty Toll, D-Danville, and Rep. Mary Hooper, D-Montpelier, questioned if the allocations to these programs were bridge funding for new plans that have yet to be developed. Schatz explained that while that is the case for Specialized Childcare Transportation, DCF has a plan to replace the voucher program. Schatz relayed that the Children Integrated Bundled Services will be seeing rate increases in some districts but not all. He said that an independent consultant felt the same rate should be applied to all districts, but that DCF would need an additional $2 million in funding to be able to accommodate that.

Hooper raised concerns about seeing a huge loss in child care facilities in the state, Schatz expressed that DCF’s partnership with Let’s Grow Kids is very helpful in addressing this issue. He said Let’s Grow Kids help fund child care facilities that are financially unsustainable or they would help families transition to a new facility if the facility had to close. Concerning the proposed federal rule changes for Supplemental Nutrition Assistance Program, DCF would rather expand that program and not reduce it, and the committee agreed.

Woodside closing: a reflection of “good things going on” in the communities of Vermont

The House Human Services Committee heard testimony regarding the Woodside Juvenile Detention Center from the Department for Children and Families Commissioner Ken Schatz. Schatz said  there is a reduction in the need for restrictive centers like Woodside, and that this must be a reflection of good things going on in  communities. Concerns expressed in the committee revolved around making sure there are beds that provide stabilization services and that can be locked. Schatz said “our system of care is built on short and long-term placement. The Scott administration does not believe there is a need a 30-bed facility at Woodside to fulfill this service. There are several places that can offer stabilization services.” A request for proposal has been issued.

Panel reviews health care price transparency tools

Rep. Lucy Rogers, D-Waterville, gave a presentation on Thursday to the House Health Care Committee on health care price transparency as part of the committees review of issues to focus on for the rest of the session. Rogers reviewed Vermont’s insurance claims database, Vermont Health Care Uniform Reporting and Evaluation System and detailed the steps to access information from the database. By law, the data must be available as a resource for insurers, employers, providers, purchasers of health care, and State agencies to continuously review health care utilization, expenditures, and performance in Vermont.

After a brief overview of other states’ All Payer Claims databases Rogers suggested supporting H.795, a proposal that would increase hospital price transparency, or supporting the Green Mountain Care Board’s current price transparency work. The Board was required as of Act 53 of 2019 to research and review price transparency tools, and all five board members have named price transparency as a high priority. Christina McLaughlin, Health Care Analyst for the GMCB, reported that Board staff and stakeholders have completed a tool survey and are implementing the next steps in developing a health care transparency tool website.

Committee review of bills.

Committees heard from legislative sponsors on the following bills:

H.607:  Introduced by Rep. Chip Conquest, D-Newbury, the bill proposes to establish a rural primary care physician scholarship program funded evenly by the state of Vermont, the University of Vermont College of Medicine, and OneCare Vermont. It establishes a primary care access tax credit for individuals who practice in a rural and underserved area. It requires any graduate medical education payments to the University of Vermont Health Network made by Agency of Human Services be contingent on the hospital maintaing at least 30 family physician residency positions by 2026.

S.202: Introduced by Senate Health and Welfare Committee Chair Ginny Lyons, D-Willison, the bill proposes to limit the co-payment amount for chiropractic services in silver- and bronze-level qualified and reflective health benefit plans to not more than 125 percent of the amount of the co-payment applicable to care and services provided by a primary care provider under the same plan. Because plans are designed almost two years ahead, insurers expressed concern that the limit would apply to 2021 plans that are already designed.

Green Mountain Care Board

The Green Mountain Care Board met briefly on Wednesday to review staff recommendations for the Non-Standard Qualified Health Plan Approval Process and 2021 Evaluation Criteria. Non-standard plans are approved to promote plan innovation and are required to add value to the Vermont individual and small business health insurance market. These plans often fill a product gap identified by consumers. There was little discussion on the topic, and the Board will be voting on the process and criteria on February 5th at the close of public comment.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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