Vermont Health Care Update 01-13-2020 - An analysis from DRM's Health Law Team

Downs Rachlin Martin PLLC

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DVHA presents budget adjustment proposal

The House Health Care Committee heard from Department of Vermont Health Access Commissioner Cory Gustafson on Tuesday on his department’s 2020 budget adjustment. The focus of his presentation was on the Brattleboro Retreat rate increase and the all payer model delivery system reform investments.

Gustafson said overall Medicaid enrollment is expected to continue to decline, but this is offset by increases to utilization in inpatient hospital services, hospice services, hepatitis C treatment, and primary care and preventative services.

Gustafson said everyone is aware that the Brattleboro Retreat is facing significant financial hardship. The Agency of Human Services has been working closely with the Brattleboro Retreat on potential proposals to mitigate that hardship. DVHA has budgeted a 10 percent increase for adult and children served at the Retreat effective Jan. 1, 2020.

Gustafson said the plan year 2020 delivery system reform investments total $3.9 million. These funds include continued investments in the Blueprint for Health and the Support and Services at Home programs. It also supports improving access to mental health services, reducing the number of suicides, reducing the number of persons requiring emergency mental health treatment, and implementing a home health pilot to reduce avoidable emergency department use and hospital admissions and readmissions.

Green Mountain Care Board approves rural health task force report

The Green Mountain Care Board approved the Rural Health Services Task Force Report on Wednesday. The report will now be submitted to the legislature. The Task Force focused their analyses on rural health delivery in three main areas: workforce, revenue stability, and care management. It was determined that telehealth, the use of electronic information and telecommunications technologies to support long-distance health care, has an impact on the three priority areas.

The Board heard from a panel made up of task force members and the GMCB. It included: Robin Lunge and Agatha Kessler from the GMCB, VNAs of Vermont Executive Director Jill Olson, and Vermont Health Care Association representative Laura Pelosi. Lunge reviewed the legislative requirements of the Task Force set forth in Act 26 of 2019. She explained the environment of health care in the state. This includes cost growth, an aging and less healthy population, the efforts of the Vermont All-Payer Accountable Care Organization Model, and national trends that have hit Vermont.

Workforce: Pelosi stated 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 several immediate factors including student debt, education and credentialing challenges, licensing challenges, and provider burnout. Pelosi reviewed the financial impact of vacancies, the actions taken to date, and recommendations to address these issues. The Workforce White Paper can be found here.

Revenue Stability: Lunge reviewed the issues with revenue stability. She stated operating expenses are growing faster than revenues, reimbursement rates do not cover inflation, and personnel costs continue to increase. Kessler explained the financial metrics selected and the data limitations. The metrics chosen were payer mix, days cash on hand, and operating and total margin. The health care sectors chosen for examination were home health and hospice, Federally Qualified Health Centers, designated and specialty service agencies, long term care facilities, independent providers, free clinics, and hospitals. Lunge also presented the impact of hospital closures on Vermont. She said Vermont is a resource constrained environment.

Care Management: Olson said a lot of work is currently being done to improve care coordination. Areas that still need work include: payer limitations to telehealth, data and technology tools, and integration of health records. Olson said recommendations for care coordination include: provide investment in delivery system reform efforts, maintain and build investment in existing care coordination functions in home and community-based services, and promote the coordination of data sharing.

Telehealth: Kessler addressed telehealth and the modalities used, which include Telemedicine, Store and Forward, and Remote Patient Monitoring. She reviewed the impact in rural communities, the regional impact and limitations, state and federal initiatives impacting Vermont, and reimbursement issues.

Lawmakers rally behind Brattleboro Retreat

News about severe financial difficulties at the Brattleboro Retreat quickly spread throughout the State House this week, and just as quickly, legislators rallied to throw their support behind the venerable institution. Low patient census, a high Medicaid payer mix, and a tight labor market requiring the use of expensive contract labor has exacerbated the Retreat’s financial challenges.

Brattleboro Retreat CEO Dr. Louis Josephson told the House Health Care Committee that like many other hospitals in the state, the Retreat has been working hard to address financial sustainability. Since Tropical Storm Irene forced the closure of the Vermont State Hospital, the Retreat has stepped up to back-fill needed services. He said Medicaid patients occupy more than 50 percent of the Retreat’s inpatient beds today and stressed that the Retreat cannot continue to function as an arm of the state mental health system without appropriate financial support.

Agency of Human Services Secretary Mike Smith told a number of committees that the state has invested significant dollars at the Retreat in the last two years. Smith said that after receiving a letter from the Retreat last week about its plans to explore closure or potential sale of the facility, it was prudent for the agency to begin contingency planning.

Additional meetings have taken place throughout the week and both sides agree that finding a path to make the Retreat financially stable is the goal. Gov. Phil Scott said in his State-of-the-State address, the Retreat “is simply too critical for us to let fail.”

Paid family leave heads to conference committee

The paid family leave bill, H.107, was pulled off the legislative calendar on the first day of the session and sent back to the House General, Housing, and Military Affairs Committee. After a fairly short conversation, the committee voted to move the bill to a conference committee where the House and Senate will likely agree to a compromise. H.107 will then move through the legislature and on to the Governor’s desk. A veto is expected. A detailed summary of the current version of H.107 can be found here.

Minimum wage moves to conference committee

Legislation to increase the state’s minimum wage, S.23, was taken off the House Calendar this week and moved back to the General, Housing, and Military Affairs Committee for further action. House and Senate versions of minimum wage proposals can be found here. This week the committee reviewed an issue brief on the cost of increasing minimum wages for healthcare workers that are paid through Medicaid. The financial impact, when considering compression costs, is anticipated to be about $4 million. Compression costs are the higher wages that employers may pay to those who are currently earning just above the higher minimum wage.

The committee voted to send the bill to a conference committee. A group of liberal Democrats is aligning with Progressives to vote against any changes that would have a lesser impact on businesses. This could make a compromise more challenging. Should the liberal Democrats, Progressives and Republicans vote against this bill, there may not be enough votes for passage. S.23 is headed down a bumpy road.

Older Vermonters Act

Legislation to help aging Vermonters live independently was introduced this week based on recommendations contained in the Older Vermonters Act Working Group Report. H.611 is drafted to work in tandem with the federal Older Americans Act, the Vermont State Plan on Aging, and the Choices for Care program. It calls for regular funding increases for health care and long-term care providers who serve older Vermonters. Vermont’s population is growing older, and that shift in demographics is expected to continue. This will have implications for the state’s workforce, economy, and community system of supports and services.

Members of the House Committee on Human Services, who reviewed the report this week, said that it is their desire to make Vermont a good place to age. The committee will continue to work on aging issues this session.

Senate Committee considers Nurse Interstate Licensure Compact

The Senate Committee on Health and Welfare is considering legislation that would authorize Vermont to adopt the Interstate Nurse Licensure Compact. Participation in the Compact would allow registered nurses and licensed practical nurses to practice in other Compact states without having to obtain individual state licenses. There are currently 34 states that have adopted the licensure compact.

Lauren Hibbert, Director, Office of Professional Regulation, told the committee on Wednesday that the Secretary of State’s office, Office of Professional Regulation, and the Board of Nursing support the bill. Hibbert said that the Compact may make it easier for Vermont to recruit needed nurses, especially for sub-specialties. Board of Nursing Chair Ellen Watson agreed and said that the Compact would increase access to nursing care by removing a practice barrier. Nurses licensed in states that are part of the Compact would also be able to provide telehealth services and provide online education in other Compact states.

Concerns about the impact on nurses currently practicing in the state led Chair Sen. Ginny Lyons, D-Chittenden, to suggest an amendment to the bill that would extend the effective date of the bill to allow OPR time to analyze and report on the potential impact of the Compact on Vermont. OPR would also examine the difference in salaries between Vermont-based nurses and traveling nurses, and determine the Vermont nurse salary level that would reduce Vermont’s reliance on traveling nurses. The committee will continue consideration of the bill in the next few weeks.

Physician Assistants seek licensing changes

Stakeholders worked on a bill to modernize state law regarding the licensure of physician assistants over the summer, and reviewed the bill with Senate Committee on Health and Welfare this past week. S.128 would simplify documentation and administrative requirements in the current PA-physician relationship.

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 well physician liability for PA practice solely based on being the participating physician who completes a practice agreement.

Chair Sen. Ginny Lyons, D-Chittenden, said that her committee will continue to review the proposal and will hear from additional stakeholders, including private payers and the administration.

Committees review insurance report

The Agency of Human Services presented its Health Insurance and Merged Markets report to the House Health Care and Senate Finance committees last week, which recommends focusing on and prioritizing the Vermont All-Payer Accountable Care Organization Model Agreement as a system-wide cost containment strategy rather than creating a partially merged market configuration. The report also recommends not pursuing a regional health care program due to current federal policies and potential policy changes, differences in state policies, and financing problems. The report does suggest engaging in additional research and analysis to evaluate the necessity and reasonableness of subsidizing health insurance for Vermonters who earn over 400 percent of the federal poverty level.

Both MVP Health Care and Blue Cross and Blue Shield of Vermont told the committees that they would prefer that the market was fully unmerged, but BCBS emphasized that an additional mitigating proposal (such as suggested in the report) would be required to reduce insurance premium costs for Vermonters.

Chief Health Care Advocate Mike Fisher responded that he was concerned that unmerging the health insurance market would stress the individual market to a dangerous degree and that the rationale behind the decision to merge markets in 2012 still holds despite no longer striving for universal health care. Fisher also pointed out that Vermonters were being impacted by a $11,000 benefit cliff at the 400 percent poverty level. House Health Care committee chair Rep. Bill Lippert, D-Hinesburg, asked Fisher to work with the Joint Fiscal Office and other stakeholders to develop proposals of how to make the “benefit cliff more of a slope.”

Legislative Reports

As part of overviews in the House Health Care and Senate Health and Welfare committees this week, Legislative Counsel Jennifer Carbee presented lists of reports that were submitted to the committees at the end of 2019 and the beginning of 2020. Those reports can be found here.

Health Care Bills

H.571  An act relating to testing for bloodborne pathogens on behalf of persons assisting in emergency situations

H.572  An act relating to the Maternal Mortality Review Panel     

H.607  An act relating to increasing the supply of primary care providers in Vermont

H.611  An act relating to the Older Vermonters Act

H.612  An act relating to creating a State-operated family and medical leave insurance program

H.613  An act relating to warning labels on opioid prescription containers

H.620  An act relating to the powers and duties of the Board of Pharmacy

H.621  An act relating to involuntary commitment of persons with substance use disorder to an addiction treatment center

H.622  An act relating to suspending the religious exemption to immunization

H.625  An act relating to health insurance and Medicaid coverage for chromosomal microarray analysis

H.626  An act relating to administering stem cell products not approved by the U.S. Food and Drug Administration

H.650  An act relating to boards and commissions

H.663  An act relating to expanding access to contraceptives 

H.684  An act relating to consent by minors to preventative services for sexually transmitted diseases

H.685  An act relating to the definition and performance of surgery

S.183  An act relating to competency to stand trial and insanity as a defense

S.187  An act relating to transient occupancy for health care treatment and recovery 

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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