Regulatory and Reform Duties of the Green Mountain Care Board (S.211) - Jan 24, 2024

Chairwoman Lyons opened Wednesday's meeting of the Senate Health & Welfare Committee by introducing Dr. Elliott Fisher (Professor of Medicine and Health Policy, Dartmouth Institute). He introduced some Framing Questions. The first being that Vermont had established an aspirational set of goals for health system reform (Act 48) and created an independent agency (the Green Mountain Care Board) with the responsibility to evaluate and improve health system performance. He claimed that the Green Mountain Care Board (GMCB) is effective, transparent and accountable, “the envy of many states.” He questioned whether the Legislature wants to build on this foundation. 

Fisher continued on to cite issues to consider, including if the current reform discussions are guided by a clear understanding of the cost drivers. He also asked who will "look out for the little guy," if private interests are well-represented. He noted that the public lacks voice. His final question was how reform can be sustained over the long haul.

One of the problems Dr. Fischer addressed was life-expectancy has increased and spending has followed. The problem in Vermont is affordability, he noted, citing that the state recently had a much higher cost growth, which has been reported by GMCB. Combined regional investments (like the ACO model) could substantially enhance health system performance and be financially affordable. He noted that drivers of spending are poor health, as poor health is expensive, and that 27% of US health care spending can be attributed to modifiable risks that are addressable via clinical and public health interventions.

A second driver of spending, he noted, is poor quality "supply-sensitive care." He referred to a national study of 1 million Medicare beneficiaries with heart attacks, colon cancer, and hip fractures. He concluded that Vermont is low overall on Medicare utilization (price adjusted spending), primarily due to low utilization of physician services. However the state is relatively high in hospital utilization compared to some states, but lower than the US average. Vermont patients spend more time in the hospital than some states, but less than the US average. Fisher pointed out that under fee for service there is no attention to quality. He also discussed examples of the variations of survival and spending for heart attacks, as well as how high US health care spending is compared to Europe. He concluded that prices in the US are higher, but vary among hospitals.

NOTE: The claim that fee-for-service dis-incentivizes quality may be dubious. Quality is often degraded with the Medicaid system because only certain tests or procedures will be covered. Any system replacing fee-for-service will need a vary carefully-calibrated incentive structure.

He continued giving examples ways to address the situation. He started with discussing Accountable Care Organizations (ACOs), and stated the underlying problem being fragmentation because no one is accountable for integration, improvement or supply. He specifically noted that fee-for-service is inherently uncoordinated and drives spending growth. He also recommended Global payments to ACOs to increase savings, concluding that capitation would be necessary to motivate change. Fisher referred to a prior study performed in 2020 that opined that ACOs would replace Health Insurance Companies, as groups of doctors, hospitals and other health care providers would come together to provide the full range of medical care for patients. However, he shared evidence that spending growth has not slowed at all.

He described one of the primary reasons as the "Balloon Problem," in that it is easier to shift costs to others than to improve value. This is the result of the failure to cap and control spending growth. He recommended establishing state level spending growth targets, monitor progress, use “bully pulpit”, and intervene (where possible). This has been accomplished in five other states. He also recommended enabling innovation and team-based care, with examples of capitation. He acknowledged that policy change is hard and slow, but that there is need for a system that can continually evaluate, learn and adapt, as sporadic reform can’t work. He viewed current barriers to this change was profound lack of data to support improvement, as well as lack of sufficient capacity to evaluative and identify all sources of waste, cost growth and harm. Improvement requires understanding the causes of poor performance and approaches that could help.

He believes that Health Care has become an extractive industry that involves greed, or our failure to build systems that protect the public interest. He advised strengthening data systems (clinical and claims), as well as further investment to enable the GMCB to oversee and evaluate health system performance, and help develop approaches to improvement. He recommended maintaining the GMCB as an independent agency representing the public good for the long haul.

He suggested S.211 should include total cost of care spending growth targets that the GMCB should establish and oversee them. Additional recommendations included ACO Reform, as the current ACO lacks public accountability (inherent conflict between its public purpose and private interest of its parent organization). He also recommended social services that reduce costs; increasing investments in the Vital Conditions

The Committee expressed their appreciation for Dr. Fisher’s testimony. One member shared his concern about the lack of facilities for patient to be transferred to following acute care hospitalization, which results in longer hospital stays. There was agreement that the setting of hospital budgets should remain with the GMCB.

Jessa Barnard (Executive Director, Vermont Medical Society (VMS)) testified next, stating that the membership includes approximately 2900 physicians and PAs around the state, representing various health care settings. Many health care professionals find Vermont’s health care regulatory structure confusing and difficult to navigate. She struggles to understand why the GMCB doesn’t have, or use, regulatory levers to do more to reduce prior authorization, address a shortage of primary care clinicians, or increase primary care reimbursement. She opined those are items that would make a difference in their day-to-day practice. She continued to comment on various issues that would assist with health care reform in the state, as well as functions of the GMCB and the health care professionals. She also expressed concern about mergers of private practices with health care facilities (aka large hospital networks).

The next to testify was Sarah Teachout (Director Of Government and Public Media Relations, Blue Cross & Blue Shield of Vermont). She started by saying that the GMCB needs to remain independent and have full oversight over both health care policy and regulatory issues. She made reference to the Medicaid Program being a government payer, and has inherent conflict with commercial payers, and should not be given authority over decisions such as global hospital budgets. She opined that it would it would lead to conflict with parts BC/BS supports, i.e. regulating health insurance participation in the AHEAD model (multi payer total cost of care model to improve health and health equity). Stability of the system is a problem, it seems that as global spending has pushed premiums up, BCBS is losing members (presumably to uninsured?). They also have concerns regarding privacy of health care information regarding data breaches and cyber security risks.

Abe Burnam (Interim CEO, OneCare Vermont) was next to testify. He shared that it is difficult for patients to navigate the health care system in Vermont, as well as across the country. He shared examples of some situations he was personally aware of with patients having difficulty acquiring adequate care. He claimed that the All Payer model can reduce spending and improve outcomes. He reiterated that care givers were losing payments from Medicaid and that he has concerns about the AHEAD model. He believes that OneCare has "accomplished a lot," and argued that ACOs should continue. He opined that GMCB is too big, with “too many cooks in the kitchen.”

Michael Fisher (Chief Health Care Advocate, Vermont Legal Aid) was up next. He opened referring to his prior position on the House Health Care Committee when the GMCB was formed and designed to initiate the single-payer model along with the Affordable Care Act. He thinks that this S.211 will "confuse the process and serve the government," but that it still has some possibilities. He is concerned about it being time consuming and that regulations may become onerous.

The final testimony was from Kristin McClure (Health Data Officer, Department of Vermont Health Access). Her agenda included goals of Unified Health Data Space (UHDS), Unified Data Space Strategy, benefits, stakeholder engagement and interaction with S.211. Goals of Unified Health Data Space includes a health record for every person, better health outcomes, improved health care operations and use of data to enable investment and policy decisions. She continued to discuss ways to accomplish those items, concluding that it would enable value-based care in in the state. The infrastructure for this service would be housing with Agency of Human Services (AHS) and Vermont Health Information Exchange (VHIE), which would maintain it.

Included in the bill, there would be a Steering Committee of 18 representatives, with her as Chair and include others from health care groups. She discussed the stakeholder engagement and the governance process, including that the GMCB would be required to approve, reject, or modify the strategic plan annually. Transparency would be important as well. She concluded that this new system would be a single source of trusted data and would not only produce the best clinical outcomes but is the most economical way to store data. As for privacy and security, a centralized data warehouse stores the most uniform and consistent procedures to keep Vermonters in “the driver’s seat" of their own health data.

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