Senators Jim Leddy (Co-Chair), Ann Cummings, Jane Kitchel, Kevin Mullin; Representatives Steven Maier, Janet Ancel, Harry Chen, Francis “Topper” McFaun; Walter Freed, John Bloomer, Jr.

MEMBERS ABSENT:

None

Also Present:

Legislative and Joint Fiscal staff, members of the Administration, and the public.

Meeting Recorded:

CD HCRC 2/13/07, CD #1.

Documents Distributed:

Minutes of December 20, 2006 meeting

December 20, 2006

January 2, 2007

January 16, 2007

The meeting was convened by co-chairs Kitchel and Maier at 4:40 PM.

The co-chairs asked for a motion to accept the three sets of minutes. The motion passed unanimously.

2. Organization of Commission: Draft Framework for this Session

Jim Hester, incoming Director of Commission

Document distributed: Health Care Reform: A Framework for this Session

Jim Hester talked through his Draft Framework:

Health Care Reform

A Draft Framework for This Session

2/8/07

I. Three Tiered Approach: Long term strategy, annual operating plan, project management

a. Long term strategy

i. Existing:

1. Expansion of affordable health insurance coverage: focus on uninsured

2. Control medical costs/improve quality: focus on chronic illness prevention and care

3. Health Information Technology as a catalyst

a. New tools

b. Accelerate diffusion

4. Build capacity for change [systems can only absorb so much change at once]

a. Providers

b. Structural / state government

5. Common sense: do the little things we all agree upon

ii. Future: How should our strategy evolve? [this is a key task]

b. Annual Operating plan/budget

i. Oversight of execution for FY07

ii. Planning for FY08

c. Project management of legislatures’ key initiatives this session

d. Objectives for end of session

i. Long term strategy:

1. plan for how we will work on it 5/07 to 12/07

2. lay groundwork with other key stakeholders

ii. Technical amendments consistent with legislative intent and existing strategy

iii. Approved operating plan / budget for FY08 that is consistent with intent of health reform legislation

iv. Smooth coordination/execution of legislature's key initiatives

II. Structure: How to organize our work during the session?

a. Steering Group: Speaker, President pro Tem, Chairs of key standing committees

i. meet biweekly

ii. keep us in synch

b. Health Reform Commission:

i. meet monthly

ii. focus on oversight, identifying key issues

c. FY08 operating plan: how to divide this up?

i. Catamount - the numbers?

ii. Blueprint/chronic illness

1. FY08 - lots of issues

2. Review of strategic plan

iii. Health IT - lots of ideas, state health IT plan

iv. Capacity for change: de-emphasize this session, work over summer?

d. FY08 budget: ‘money’ committees, input from other re operating plan, numbers

Senator Kitchel asked about inventorying all the thoughts and discussions regarding next steps—key issues and concerns.

Jim Hester will have this within a couple of weeks. He is now having conversations with key legislators and staff—and will compile this list.

Question re steering group (Memo, above, II.a.): at the moment, the members of the steering group listed in item II.a in Jim Hester’s memo, above (Speaker, President pro Tem, Chairs of key standing committees), are all members of one political party. The Commission may want to consider and review this.

Sen. Kitchel said it is important to state clearly that the legislation we passed was just a beginning; and to remain focused on the long term.

Discussion: there may be other major themes we have not addressed yet.

3. Technical Corrections and Policy Issues CD 1, Tr. 3

Robin Lunge and Cassandra Edson, Legislative Council

Document distributed: H.229 Act 191 Technical Amendments: Section-by-Section Summary

Discussion: the 12-month waiting period and employer assessment. R. Lunge noted that it is important to understand that the employer contribution is not linked to eligibility.

Overview: this legislation started with a list of proposals from the Administration, re technical corrections. The committee has made some changes; the bill is currently in the H. Ways and Means Committee. It was voted out of H. Health Care 11-0.

Q: Does the Administration agree with all of this?

Besio: Yes.

4. General Implementation Update CD 1, Tr. 4

Susan Besio, Director of Health Care Reform Implementation

Document distributed: Health Care Implementation Status Update for the Joint Commission on Health Care Reform, 2/13/07

Health Care Reform Implementation Status Update

for the Joint Commission on Health Care Reform

February 13, 2007

Susan W. Besio, Ph.D.

Director, Health Care Reform Implementation

• Legislative Reports Submitted since December 20, 2006:
• Seasonal Employees Report (Department of Labor, Agency of Administration)
• Non-group Market Reform Report (BISHCA)
• Hospital Standards for Bad Debt/ Uncompensated Care (BISHCA)
• Common Claims Report (VAHHS)
• Blueprint 5-Year Strategic Plan (VDH, Blueprint Executive Committee)
• AHS Chronic Care Implementation Plan (Part 4 of Blueprint Plan)
• CHAMPPS Inventory (VDH)
• CHAMPPS Report (VDH)
• VITL Progress Report (VITL)
• Draft Health Information Technology Plan (VITL)
• Immunizations Report (VDH)

• Governor’s Proposed Budgets
• Medicaid Provider Rate Increases ($4 million FY08 – additional increase over FY07)
• Non-group Market Security Trust ($3.75 million FY08 )
• Blueprint ( $4.8 million FY08 )
• Immunization Program ($4 million FY08)
• Outreach and Enrollment ($3.034 million FY07; $1.316 million FY08 )

• Technical Corrections Bill (H. 229)

• Other Activities
• State Employees Health Plan
• CIGNA Assistant Medical Director for Vermont
• Responses Received for OVHA CCMP RFP (N=8)
• Outreach and Enrollment Efforts:
• Proposal Submitted to RWJ Foundation
• Steering Committee
• Marketing RFP
• Coordinator Interviews
• AHS – DII Meeting to discuss Web-based Options

• New Web-site Implemented, Updated Weekly : http://hcr.vt.gov/

• Besio noted the substantial number of reports submitted since the Dec. 20 HCRC meeting.
• She is working with the Governor on proposed budgets—both the Budget Adjustment and the FY08 Budget. The Medicaid provider rate has been increased.

Q: Re the rate of inflation in medical spending—are Medicaid rates keeping up?

Besio: She and Joshua Slen will need to bring back an answer to the Commission.

• Brief discussion of the non-group market security trust.

Q re the grant through BISHCA—the high-risk pool?

A: It is only planning and implementation money—it can’t be used to bring down costs.

Q: Please get us background information on this: Joint Fiscal Committee re $1 million.

• Besio gave a brief update on the Blueprint, and on the immunization program.
• Again, the Administration’s Health Care Reform web site is a handy resource for all these reports.
• Re the Technical Corrections bill, she supports the way it came out of committee.
• There are also, of course, many other HC reform activities under way, related to each of the listed reports. A few key points:
• State employees’ health plan. CIGNA will hire a Vermont medical director. This person will sit on the Blueprint Executive Committee.
• OVHA has received responses from vendors to its RFP.
• Outreach and enrollment efforts. A proposal to Robert Wood Johnson Foundation. If they get the grant, may be able to use some state budgeted funds elsewhere.

Q from Sen. Kitchel: There’s an issue: students, 18 or older, living at home—currently, their income must be counted towards their parents’ income. We need to re-look at some of these rules. Please add this to the list [directed to Jim Hester].

Q: Are there any specific bottlenecks in the implementation timeline?

A: The Chronic Care management program may start later than July 1.

And as Ken and Hans have noted, there are concerns re the Blueprint. Some of these relate to major cultural changes.

ESI; Premium assistance: they are implementing the Rules, but they may not be automated by October 1; although the rules will be available.

Q from Rep. Larson: source of funds for some Catamount proposals—will need to be monitored, and considered. There is some switching of funding. We will need to discuss this further. He also mentioned the non-group market security trust.

5. General Discussion

Ken Thorpe, Consultant to the Commission CD 1 Tr. 5

Thorpe gave an inventory of ideas and suggestions in two areas:

1. Reforms dealing with infrastructure changes
2. Financing—especially re people who are uninsured

FIRST AREA:

It is essential to make sure that we can make the changes for primary care physicians. Re their getting engaged: the centerpiece must be changes in the way we pay physicians. Perhaps accelerated pilots in areas. Maybe increase the IT demonstrations.

We must recognize the additional costs of managing care. Perhaps move some funding, to support chronic care costs. The new management model requires more services and more time from physicians.

The other piece that was promised to physicians was administrative simplification.

1. Uniform reporting standards—clinical performance measures: how do these interact with Medicare? Possibly piggyback on that?
2. We said we would address paperwork, including a uniform claims form. We need to accelerate this. What are the road blocks?

Also, we are building an infrastructure—IT—but need to send a clear signal to primary care physicians. This is on the critical path.

Q: Re the OVHA RFP: will that drive the discussion of reimbursement practices?

A: Yes, that and Catamount Health.

We need to signal the direction. Medicare is moving in this direction, too: the idea of a “medical home”. We need to keep this aligned with Medicare.

SECOND AREA: Health financing side.

There are three populations of uninsured—within the 65,000 Vermonters who are uninsured:

• About 26,000 or 40% are currently eligible
• About 20,000 have incomes over 300% of poverty
• And the rest are the group in the middle, for whom we will provide financial assistance.

The issue is targeted outreach. Best practices from other states include presumptive enrollment. Can we reach the top standards from other states re VHAP? Target is 80% enrollment. Vermont is now at 50%. Target: get 25,000 enrolled. This will depend on how we roll it out—how we plan and do outreach. If we get there in 3 or 4 years, we should reach the overall goal: 96% of all Vermonters covered by 2010.

We must consider: How do we encourage the pool in group b? (Over 300% of poverty).

Q: Chronic care protocols?

Answer: Are starting to roll our protocols for 5 or 6 conditions. There are two levels:

a) We must identify a set of evidence-based preventive protocols for diabetes and other conditions.

b) Second level: what is effective clinical management of diabetes, hypertension, etc.? These are more complicated.

Q, Sen. Mullin: Re properly funding our Medicaid reimbursement. If we don’t, a train wreck is ahead. Are we keeping pace with the rate of medical inflation?

Thorpe: He and Steve Kappel will have to check and get back to you on that.

6. Identify / Prioritize Key Implementation Issues

Hans Kastensmith, Consultant to the Commission CD1, Tr. 5

Re preventive medicine: We need to be able to survey a population of patients—and identify those at risk, not just those currently diagnosed with chronic conditions.

Also, care coordination—physical coordination in a practice—is critical.

Addressing a health care information technology fund: to fund electronic medical records (EMRs) and practice management systems. He and VITL are working on ideas re funding. They have given their reports to the legislative committees.

He is also working closely with Susan Besio and Sharon Moffatt on CCIS (the automated processes for enrolling in Catamount or ESI premium assistance). They are facing a “course adjustment” in the implementation schedule. They want to go carefully to make sure that the program is an overall success. Susan Besio explained that the automated processes for enrolling in Catamount or ESI premium assistance may not be in place on October 1, but if they are not, it will be done manually until it is automated (and we still have October 1 as our target).

Q: Is there a disincentive to enroll (as a patient) re the amount of data being collected?

A: We are addressing data sharing. The data is no different from the data on patients that is on paper now. There are currently pretty good controls.

7. Next meeting

The date is already set for the next meeting:

Wednesday, March 14, from 4:30 to 7:00 PM.

Location is room 10 in the Statehouse.

Meeting adjourned at 6:15 PM.

Respectfully submitted,

Loring Starr