Working within the financial targets laid out last week by House Speaker Mitzi Johnson, D-South Hero, as well as the federal guidelines, the policy committees completed their Coronavirus Relief Fund proposals this week and presented them to the House Appropriations Committee. The proposals will be reviewed by the committee and likely combined into one or several bills.
The CRF money can only be used to cover: necessary expenditures incurred due to COVID-19, costs not accounted for in the budget most recently approved as of March 27, 2020 for the State or government; and costs that are incurred between March 1, 2020 and Dec. 30, 2020. The funds cannot be used for revenue replacement and must be expended – not just allocated or appropriated – by Dec. 30, 2020 or they will be returned to the U.S. Treasury.
House Health Care Committee Proposal:
The House Health Care committee designated a large majority of their CRF allocation to a $139 million Health Care Provider Stabilization grant program that would be administered by the Agency of Human Services. The program would be required to “meet eligible providers’ needs equitably, regardless of provider size, and based on demonstrated need and the ability to meet the criteria set forth by the program.” The applicants must demonstrate that they were fiscally responsible in responding to the COVID-19 public health emergency, both in delivering services and as it has affected the applicant’s organization. The applicant would also be required to use grant funds to supplement existing patient financial assistance programs in order to assist patients whose financial situations have been negatively affected the pandemic, and/or to enable the provider to continue providing services to Medicaid beneficiaries. Initial language setting an application due date was removed, and AHS is directed to disburse the funds to eligible health care provider applicants “as expeditiously as possible.” Although the proposal also designated any future available monies to the stabilization program, Chair Kitty Toll, D-Danville, said that language referring to Tier 2 or future available funding would be struck and addressed in future bills.
The House Health Care committee struck language to appropriate $30 million for access to health care for individuals after AHS said that they could not administer the program and Chair Bill Lippert, D-Hinesburg, conceded that the committee “cannot find a construct that works within the constraints of the CRF dollars.”
In an accompanying memo to the appropriations committee, the House Health Care committee urged the allocation of as much CRF funding as possible to health care providers to stabilize the system, adding that “Our health care providers rose to the challenge to save Vermonters from the worst ravages of the ongoing COVID-19 pandemic. They stood up and saved Vermonters lives. They did not let us down. We must not let them down.”
House Human Services Committee Proposal:
The House Human Services Committee proposal directs $8.5 million to supplement the House Committee on Health Care’s proposed Health Care Provider Stabilization Program for recovery centers, home health and hospice agencies, and designated and specialized services agency programs. An additional $5 million is designated to the Health Stabilization Program to support nursing homes.
The proposal also allocates the following funding:
The House Energy and Technology Committee recommended to the House Appropriations Committee that $800,000 of Coronavirus Relief Funds be used to support the COVID-19 response to the Telehealth and Connectivity Initiative.
The temporary COVID-Response Telehealth Connectivity Program will be administered by the Vermont Program for Quality in Health Care, an independent, non-regulatory, peer review committee established by the legislature in 1988. The purpose of the connectivity program is to support equitable access to telehealth services by providing outreach and educational opportunities that improve digital literacy skills of patients and providers and also by providing he equipment needed to support telehealth needs during the public health emergency, particularly in areas that are digitally and medically underserved, and distributed geographically across the state.
Department of Mental Health Commissioner Sarah Squirrel told several committees that “the impact of COVID-19 has significantly threatened the Brattleboro Retreat’s ability to provide mental health care to Vermonters, and its financial situation is tenuous due to client census running low.” The Brattleboro Retreat has 100 percent of Vermont’s children mental health inpatient capacity and over 50 percent of adult mental health inpatient capacity, Squirrell said that “if the most vulnerable cannot access care, we will see an increase in individuals waiting for care in Emergency Departments and lack of access to timely care.”
In mid-April, the Agency of Human Services and the Brattleboro Retreat agreed to a financial support package including a grant and advance Medicaid payments, and a requirement for AHS and the Brattleboro Retreat to enter into a collaborative process to develop an Action Plan for its continued viability and stability. The teams for AHS and the Brattleboro Retreat subsequently worked for five weeks developing a plan based on recommendations from a third-party consultant report required when the Retreat received rate increases and additional funding in January.
The request would provide a weekly payment of $600,000 for 17 weeks until Sept. 30, 2020, for a total of $10.2 million. The funding would be tied to the Action Plan for Sustainability and Performance Metrics, with the Brattleboro Retreat required to meet conditions or the memorandum of understanding will be terminated.
The Senate Finance Committee took testimony Tuesday on telemedicine and broadband from members of the Health Care Coalition and the University of Vermont Health Network. Sen. Ann Cummings, D-Washington, said there are COVID relief funds available that can be used for broadband infrastructure for telemedicine, but any project will need to be up and running by the end of December. She asked presenters to provide the committee with information on small, achievable projects that the state can put forth as a proposal.
Bi-state Primary Care Association Director of Vermont Public Policy Helen Labun said telehealth has been an essential component of the COVID-19 response in health care, and will continue to be an essential component of serving Vermonters during recovery from this public health disaster. Overnight, health care practices went from having very little telehealth deployed to 80-90 percent of visits conducted remotely. Even as providers reopen, telehealth provides the majority of services for practices who are able to continue connecting remotely, and due to both risk and patient preference it will likely remain a significant part of care. Labun said broadband limitations clearly impact patients’ ability to access care. While Vermont moved quickly to make audio-only telemedicine available to help the state bridge this gap, there are many instances where a visual component is required. Labun, on behalf of a provider coalition, advocated for a 25/3 minimum access for all residential addresses for the purposes of utilizing telehealth during the COVID-19 crisis. Some larger health care facilities, including long term care facilities, in underserved areas may require higher capacity to deliver telehealth. The Coalition supports subsidizing those connections as needed.
Labun said the funding request is justifiable under the CRF allocation guidance to build the public’s capacity to allow for the delivery of telemedicine. Additionally, it would support the CRF allowable goals of permitting telework and remote education. The Coalition supports the state waiver of current restrictions on broadband development at capacity less than 100-symmetrical to allow the flexibility to facilitate the most rapid possible deployment of broadband for telehealth and to avoid the risk of the investment being later deemed ineligible for CRF support. Effective telehealth requires more than broadband infrastructure, it requires households to be able to afford broadband access, equipment for utilizing the broadband, digital literacy support, and a considerable investment in training and systems change for providers. The Coalition also supports directing broadband deployment funds to building infrastructure capacity and addressing the other elements (cost, equipment, workforce training) necessary to truly access telehealth.
VNAs of Vermont Executive Director Jill Mazza Olson said home health agency patients are unique in that patients can’t drive to ‘hotspots’ so the only way we can take care of them is at home. She said home health agencies have done what they call a ‘blended episode’ – where some care to individuals is done in person at a provider office because there is no other way, but when possible follow up appointments are done remotely. She noted that unlike most provider types, Medicare strongly penalizes the agencies for doing those blended episodes because they have not figured out how to pay for them.
Vermont Health Care Association Laura Pelosi said it is important for long term care facilities to have access to telehealth services for their residents in this COVID environment. Pelosi said typically, if you live in a nursing home, assisted living facility, or residential care facility, and a resident needs to see a primary care physician or a specialist, for the most part the resident is leaving the long term care facility. In the world of COVID, long term care facilities are the most susceptible to entry of this virus and anything that can be done to minimize the amount of exposure to residents is important including access to telehealth services.
On Thursday, Green Mountain Care Board Chair Kevin Mullin updated the Senate Health and Welfare committee on the current hospital financial situation and raised factors for the legislature to consider as it appropriates federal Coronavirus Relief Funds.
Mullin told the committee that even before the COVID-19 crisis, many of Vermont’s hospitals were in in difficult financial positions, with seven of 14 of hospitals experiencing operating losses in FY2019, several of which have experienced consecutive years of losses. For FY2020 year-to-date, the state-wide hospital system is experiencing a 6.7 percent drop in net patient revenue. All hospitals are experiencing negative operating margins.
Mullin urged the committee to consider how to use the funds to advance work on ensuring sustainability of the health care system, and to allocate the funds in a way that preserves the investments that we have already made in health care reform. He suggested that hospital funding could be contingent on the continuation of population health investments, and sustainability planning to ensure that hospitals are using the dollars efficiently and right sizing their operations for their communities and population trends. Funding should have a long-term return investment, and not only provide immediate financial support.