MEMBERS ABSENT:

Also Present:

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

Meeting Recorded:

CD HCRC 3/14/07, CD #1 and #2

Documents Distributed:

1.         Convene                                                                                                        CD 1, Tr. 2

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

The Chairs agreed to reorganize the agenda to help various witnesses with their schedules.

2.         AGENDA ITEM  3 d.  Expanding Coverage for Uninsured,

Update on Catamount Health premium filings                                                     CD 1, Tr. 3

                        Christine Oliver

The filings have been received, and distributed to staff at the legislature. For a single policy premium, MVP Healthcare came in at $388 and BlueCross BlueShield came in at $413. The filings also include plans for chronic care management, etc. BISHCA’s actuary is evaluating the filings, using the statutory criteria. There is a 45-day review period. During this period, as is usual, BISHCA and the companies negotiate back and forth. (The third possible group who had expressed interest in filing, is building their Vermont network, getting permits, and may file in about nine months.)

Q: re cross-subsidies, allocating overhead, concern re impact on other Vermont ratepayers.

A: BISHCA does review this as part of the review process.

3.         Overview of Agenda: Identify Key Issues in Implementation                 CD 1, Tr. 4

                        Jim Hester

At the last meeting, the Commission reviewed a long-term strategy for HC reform. For today’ meeting, they want to focus on several key areas.

In two main issues, staff have identified key concerns: he wants to make the commissioners aware of those critical concerns.

Re the IT initiative, there is a new development;

And the last item on the agenda—moving forward on long-term strategy.

4 a.      Blueprint for Health,

                        Overview of Blueprint timeline and design        

                                                              i.      Chronic Care Model

                                                            ii.      Pilot communities

                        Jim Hester

The original model had six pieces—all need to come together. The pilot communities are testing these models. We are now seeing some concerns re three of the elements.

            First: Care coordination at the community level. How can it be more coordinated? Hans Kastensmith will give an overview on this, with discussion by Bea Grause and Jessica Porter.

4b.       Blueprint for Health, Care Coordination at Community Level

Kastensmith: Care Coordination is designed to support practitioners. Support is to include a care coordinator—i.e., paid staff. At the same time, there are concerns re overlap: an overlap with insurers and their own care management programs. So Hunt Blair is drafting a section for the new legislation—essentially, “coordination for care coordination”—to help transition from insurer-provided care management to community / practitioner care coordination.

Bea Grause: Hans is describing a new way to approach this problem.

Hans: This care coordination is very people-intensive, even when electronic health records are fully working. The coordination effort will always be there.

It is a big battleship to turn—a profound change.

Q:  This conversation needs to be taken to the pilot communities.

Hans: we are actually in full implementation mode re the registry. We are transitioning from the Vermont Health Record, to the CCIS: Chronic Care Information System.

4 c.      Blueprint for Health: CCIS Implementation                                                         

                        Hans Kastensmith

Looking at the planned schedule of milestones in the process for the Chronic Care Information Systems implementation, they are about seven weeks behind. The process was very lengthy—documenting and gathering all requirements; medical guidelines, sign-on systems, hosting, etc. But it is working along. He is not too concerned.

Jim Hester: the RFP process, coordination with VITL, selection of provider—each of many steps took longer than planned. So there is concern a possible loss of credibility with physicians.

Hans Kastensmith: The new target date is now July-August 2007. They now need more communication with providers.

Bea Grause: She recommends that the Commission focus on communication with the end users. They need a careful communications strategy. Two big pieces are IT implementation and payment reform.

4d.       Blueprint for Health: Payment Reform Pilot                                             CD 1, Tr. 5

                        Ken Thorpe

Ken: Essential to get payment reform figured out, as roll out Catamount Health. It is essential to get this into place. It needs two things:

1)      Coordinate this new view with MVP and BCBS re managed care

a.      Monthly management fee for every person who is enrolled in a coordinated care plan;

b.      Provide a “bundled fee”:  “Evidence-based case payments”—prepay on a monthly basis for all the evidence-based preventive services that we want the physician to provide.

            These are the two innovations in care coordination. We need to start planning this out now, looking perhaps to provide this in the fall as Catamount Health rolls out.

2)      The second thing: What functions will physicians do in this pilot—and indeed statewide-- that

a.      they don’t currently do?

b.      and b, that health plans currently do provide?

There will be different activities that we ask primary care physicians to do; there are opportunities, in areas of overlap—redirect existing premium dollars to physicians as they assume broader responsibility?

An output / result of the pilot: we will need a fairly standard plan for how to pay physicians, as they assume broader areas of responsibility. Need to make sure, in the planning process: develop this expeditiously.  Part of the Blueprint as well. And diffuse this payment model throughout the state, like the delivery model. Current payors have different models for paying physicians.

We need to develop the Pilot appropriately.  New opportunities and expectations for primary physicians. And IT model must support this.

Q: Re bundled payments—part of care delivery calls for “care teams”—how would the bundled rate work with this? How affect payment methodologies?

A:  The monthly management fee could include time for a nurse to work with the physician, to work with patients in the office and at their homes; time for physician to manage the planning.  

The Pilot will certainly need to explore these boundary issues—including health plans’ current call centers.

May want to build other metrics into pilot—including ambulatory care issues; among other metrics built into performance measurements.

Q: What about patient satisfaction?

A: The idea in the Blueprint is to put together a personalized care plan; patients should have more face time with either physician or nurse—which is currently a problem, especially for those with multiple chronic conditions.

Q: How coordinate these new models across all plans and payors—not just Blueprint?

A: Intent is to have the state health plan, Catamount, & Medicaid conform with the Blueprint principles: and as health plan payors incorporate this coordination into their work with these programs, it should make sense for them to incorporate the coordination across their other commercial lines of business.  As we have a delivery model, we must have an embedded payment model. Part of the Blueprint model. Key part of pilot is to work up front with these carriers, about how to do this.

There was also a discussion of possible pilots / demonstrations elsewhere. Approaches are evolving; but most do not work with small one-or two-physician practices.

Jim Hester: These two parts of the pilots—care coordination and payment reform—are still relatively undeveloped. The third component, information technology, is highly complex, and is necessary to support the first two parts. So hence the importance to keep the commissioners informed, to help keep all the parts on track and moving forward.

Q: Who has responsibility and accountability, to keep all these parts moving forward?

A, Besio:  The Commissioner of Health is responsible for operationalizing the Blueprint.

A: Jessica Porter, Dept. of Health: I am the Director of the Blueprint for Health—full-time with this responsibility since January.

Q: As a legislator, a concern: the fact that we have only an acting commissioner, not a full commissioner. The current acting commissioner has so many issues on her plate; we are asking a whole lot for one person in that position. Think the Commissioner needs a bit more support from the Administration as she tries to carry all this out.

A: (Porter): The administration did indeed change my position to full-time working on the Blueprint, as of January . So there ha been a major shift. And the Blueprint Executive Committee has been very supportive. They are all working hard on the Blueprint.

Further comments from the Commissioners: :

• However,  the Commission will continue to need to monitor this process, very carefully;
• we need to figure out what expertise is out there, and bring it in—we have a responsibility as well, in this partnership;
• you in the Administration need to keep us informed, and let us know if your resources are inadequate, so that we can help in a timely fashion;

Note from Jim Hester: a related issue: there is already considerable pressure from the community to expand the pilots elsewhere in the state; he would urge the Commission and Administration to resist this pressure. Resources are already stretched thin, and it is essential to develop the programs properly in the pilots first.

5.         Approve Minutes from 2/13/07                                                                    CD 1, Tr. 7

The minutes from February 13, 2007 were approved unanimously.

6.         Expanding Coverage for the Uninsured                                                   CD 1, Tr. 8,

            Gap Between Enrollment Projections and Legislative Goal                 CD 2, Tr. 1

                        Steve Kappel and Jim Hester

Jim Hester: Quick context: Issue is where are we on this goal, expanding coverage for the uninsured? Current estimates, goal, consequences of all budget projections. Financial consequence, of higher premiums coming in; possible consequences of increasing enrollment. This is a heads-up re possible gaps.

Document distributed: Catamount Fund, Revenue and Expenditure, FY 07 – FY 10

Steve Kappel: Document is two difference scenarios.  Looking at the side that says “96% covered”:

Based on decisions you have made so far, what we think enrollment will be; what actions needed to get to 96% coverage?

Estimates are based on: 1) How many people are eligible, 2) and of those eligibles, how many will sign up. Data from BISHCA’s insurance survey; worked on by BISHCA, various consultants, JFO. Pretty solid model now.  These models are set up re year 2010. They have calculated estimated take-up rates. Warnings: take-up rates are rough estimates. Only reflect economic factors—do not include outreach, etc.

S. Kappel walked the commissioners through the 96% Goal model. Various scenarios are affected by the Governor’s proposed budget, which moves some Catamount Health funding around. He then compared the “goal model” with the “consensus model”.

This all presumes a steady number of people who are uninsured—and we are actually seeing a trend of increases in that number.

Q: In the Budget Adjustment Act, there is a Senate Amendment—a request for appropriation r outreach: $3 million. The Administration does not care for that language.

A discussion followed, re the Governor’s Proposed Additional Expenditures—re addressing the cost shirt, re Medicaid reimbursement rates.

7.         Expanding Coverage for the Uninsured

            Plans to Increase Enrollment: Outreach, Eligibility, Re-Engineering   CD 2, Tr. 2

                        Susan Besio, Kevin Veller

Documents distributed:

• Vermont Health Care Reform Activities, Sorted by Topic & Due Date, Feb. 26, 2007: Health Care Implementation Status Update for the Joint Commission on Health Care Reform;
• Overview of Vermont Education, Outreach and Enrollment Strategy
• Potential Re-Tooling Ideas for the Medicaid / VAHP / Dr. Dynasaur Eligibility Determination and Enrollment Processes

Susan Besio introduced Ms. Kevin Veller.

The Administration has hired Ms. Veller for outreach and enrollment for Catamount Health. We  also have an outreach and enrollment steering committee. Our goal as a state is to get people insured—so her work will address all products—a broad reach—not just new Catamount products. From Medicaid all the way through.

Veller: I am impressed with the enthusiasm; there is a lot of work to be done. Veller is on contract, placed at OVHA, working with Susan Besio. She is based in Williston.

Q: Her background?

A: Most recently from Senator Jeffords’ office, worked on health and disability issues. Managing grants, doing Medicaid and Medicare coordination, with a focus on employment.

Besio: She is a systems thinker and project manager.

Q: We need to address both the vulnerable population AND the invincible population.

A: (Besio): There is a whole group of organizations willing to work on outreach: VPIRG, AARP, NEA, etc. The focus is to get broad-based, then get nuanced, message: “You need health care coverage!”

Hester: there is strong enthusiasm—all these groups are coming to the table: they are enthusiastic, prepared, and offering ideas and help.

Besio: Key elements:

a)      Steering Committee

b)      B) they have put out an RFP for a marketing firm

c)      C) They have four bidders, one is a Vermont company

d)      D) timeline to select vendor in next three weeks.

Kevin Veller is also meeting with insurance providers’ marketing people.

Susan Besio then distributed and discussed “Potential Re-Tooling Ideas for the Medicaid / VAHP / Dr. Dynasaur Eligibility Determination and Enrollment Processes”

This material includes why the Administration opposed “Presumptive eligibility”. She very quickly reviewed key points in the document. The second page of the document has detailed notes on information technology projects—the screening and enrollment process—web access.

It outlines a three-phase process.

Page 3 of the document is “Problems with True Presumptive Eligibility for VHAP.”

8.         Expanding Coverage for the Uninsured

            Funding Issues: Uses and Sources of Catamount Health fund             CD 2, Tr. 3

                        Steve Kappel

Document distributed: Catamount Fund, Revenue and Expenditure, FY 07 – FY 10

Steve Kappel discussed the Governor’s additional proposed expenditures from the Catamount Fund. The projections in his spreadsheet estimate that by FY 2010, the fund balance would be down to essentially zero. A caveat: all these estimates are based on the original estimate re the Catamount premium—not the initial proposed premiums from BCBS and MVP.

Discussion: this is a best-possible-case scenario. Hence the legislators’ concerns re the Governor’s proposed additional expenditures. There was also a discussion of federal match funds.

9.         Electronic Medical Record: Needs and Barriers                                     CD 2, Tr. 4,

                        Paul Forlenza, VITL                                                                            CD 2, Tr. 5

Document distributed: Secure Sharing of Electronic Health Records Between Doctors, Hospitals and Patients

Paul Forlenza discussed estimates of the number of primary care physicians, and cost per physician to introduce and adopt EHRs (electronic health records). The estimate, per provider, is between $60 and $100 thousand.

Currently, there are no designated funds for this project. One possibility is to work through the Vermont Community Loan Fund. VITL has explored various ideas, such as zero-interest loans, which would be forgiven if performance criteria are met.

Rep. Maier: The House Health Care Committee is working on this, but they are looking at just a pilot program—possibly a couple of million dollars.

There was a question re timelines; Hans Kastensmith discussed possibilities; we are looking for new money.

Q: Does the Administration support this?

A (Besio): We recognize the need, and are looking at options.

Q (Sen. Racine): It is important to have the Administration working on this discussion.

There was discussion of the challenges of implementing EHRs, including the lack of payback-benefits for providers. The long-term financial benefits accrue to the whole health care system. So this is a major challenge, regarding return on investment. There is already some considerable adoption in small practices, but they are not linked, not internet-based, etc. So we should recognize that these are not new costs.

Q: We need to coordinate this testimony of Hans Kastensmith and Ken Thorpe with House Health Care and House Appropriations.

Jim Hester discussed the possible role of the Commission staff in facilitating this.

10.       Commission Follow-Up                                                                    CD 2, Tr. 6

                        Jim Hester

Document distributed: Health Care Financing Analysis--Summary

Jim Hester gave a quick update on the work of Kavet and Rockler on the health care financing studies. They have a one-page summary, and an executive summary--but these are still in draft form.

He recommended that in the interests of time today the Commission set the date for its next meeting via an e-mail discussion. He will coordinate timing with Susan Besio.

Jim Hester introduced his new Staff Associate at the Commission: Dale Schaft.

The meeting adjourned at 7:05 PM.

Respectfully submitted,

Loring Starr