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

MEMBERS ABSENT:

John Bloomer, Jr.

Also Present:

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

Meeting Recorded:

CD HCRC 6/19/06, CD #1, 2, 3.

1.  Convene; Review and Approve Minutes from Jan. 12, 2006

Senator Leddy and Representative Tracy convened the meeting at 10:10 AM in Room 10 at the Statehouse, Montpelier, Vermont. Sen. Leddy asked for a motion to accept the minutes. The motion passed unanimously on a voice vote.

2.  Review Commission Responsibilities   Senator Jim Leddy  

Sen. Leddy stated that this is an important meeting of transition: how will we implement this critically important legislation? The Administration and Legislature are now in this together—differences are now behind us. The tone at the bill signing in Rutland was one of coming together. We now need to redefine the role of the Commission, and need to collaborate with the Administration in a partnership. The Commission must be careful not to overstep the Legislature’s role. He is encouraged that Susan Besio has been appointed as the Director of Health Care Reform Implementation.

Commission Responsibilities.  Catherine Benham, Cassandra Edson, Maria Royle.

Document distributed: No. 191 An Act relating to Health Care Affordability for Vermonters (excerpts) Sec. 21 etc.

The Commission is now “in the Green Books’’—is officially in statutes. Sec. 901, Creation of the Commission—modified to reflect the law.

Sec. 902 describes the duties of the Commission:

§ 902. Duties

(a) Beginning in the interim of the 2005 legislative session through July 1, 2009, the commission shall:

(1) monitor the development, implementation, and ongoing operation of health care reform initiatives as defined in section 2222a of Title 3 and the initiatives contained in H.861 of the 2005 Adj. Sess. (2006), An Act Relating to Health Care Affordability for Vermonters, including Catamount Health;

(2) study areas of health care reform as required by the general assembly; and

(3) receive input and make recommendations, generally, to the house committees on health care and on ways and means, the senate committees on health and welfare and on finance, and the general assembly regarding the long‑term development of policies and programs designed to ensure that, by 2009, Vermont has an integrated system of care that provides all Vermonters access to affordable, high quality health care that is financed in a fair and equitable manner, including the following:

(A) extending universal access to diagnostic or other services to all Vermonters;

(B) methods of reducing the cost of health insurance or providing alternative coverage through Catamount Health to individuals who pay 10 percent or more of their gross income for premiums and cost-sharing or medical expenses;

(C) strategies for reducing the cost of health insurance or providing alternative coverage through Catamount Health to individuals in the individual or other high cost markets; and

(D) determining needed analysis and criteria for implementing a health insurance requirement by January 1, 2011 if less than 96 percent of Vermonters have health insurance by 2010, including methods of enforcement, providing proof of insurance to individuals, and any other criteria necessary for the requirement to be effective in achieving universal health care coverage.

(b) Nothing in this section shall modify the jurisdiction of the health access oversight committee to monitor Medicaid and Medicaid waiver programs.

(c)(1) The commission may request analysis from the office of Vermont health access, the department of banking, insurance, securities, and health care administration, and other appropriate agencies. The agencies shall report to the commission at such times and with such information as the commission determines is necessary to fulfill its oversight responsibilities.

(2) The agency of administration or designee, the agency of human services, and the department of banking, insurance, securities, and health care administration shall submit monthly progress reports on Catamount Health and the Catamount Health assistance program. For Catamount Health, the reports shall include enrollment, projected enrollment, and other information as requested by the commission. For the assistance program, the reports shall include revenue and expenditures for the prior months, enrollment and projected enrollment, projected expenditures related to enrollment for the fiscal year, demographic statistics for participating individuals, an analysis of any effect on employer conduct, and other information as requested by the commission.

In the Budget Act, Act. No. 215, Sec. 70, $300,000 is added to the Commission budget.

Sen. Kitchel said to be careful about the interface among health care agencies—the Commission, Health Care Oversight Committee, OVHA, BISHCA, etc. The various legislative oversight roles need to be coordinated, to avoid duplication, and avoid undue burdens on staff.

Rep. McFaun asked re workers compensation—where are the responsibilities listed about that? Cassandra Edson will research this.

3.  Studies—Work plan and timeline   Steve Kappel, Joint Fiscal Office  

Documents distributed:

• Sources of Health Care Funding, Vermont 2002 (pie chart) / Vermont Health Care Spending—Household View
• Act 215 (H.881) FY 2007 Sec. 295a
• H.881 Financing Study Proposal

Steve Kappel briefly addressed the health care financing and economic study. Background: In the last two years, two large studies were planned. These turned out to be too big to accomplish in the time allotted.

This current study will address where the money comes from and how changes will affect Vermont’s economy. So this study will be separate from studying the delivery system. The study hopes to address how raising money differently for health care may affect the Vermont economy.

One preliminary task is to update current data—he will get data from at least 2004, hopefully 2005.

Walter Freed asked where workers’ comp revenue is in this analysis. He and Rep. McFaun said that this needs to be included in the study. Steve Kappel said OK.

Kappel discussed his document “Act 215 (H.881) FY 2007 Sec. 295a.” This section from the Appropriations Act provides the directions for the study.

Steve Kappel proposed one option: arrange for Tom Kavet, consulting economist for the Legislature, and Vermont State Economist Jeffrey Carr to work on this study together —hopefully they can come to consensus. Tom is interested, and the Administration is considering this idea.

Sen. Leddy asked what Steve Kappel’s role would be. Answer: Coordinator, facilitation, bring his background on the data.

Time frame: The study is due Jan. 15, 2007; Steve hopes to have it done earlier.

Rep. Ancel asked if the study could look at combinations of financing.

Answer: Yes, but acknowledging that Vermont can’t change federal and ERISA effects.

Rep. Tracy asked how long it would take to bring these players together.

Answer: The Administration said they will get back to Steve by the middle of this week.

Rep. McFaun asked if the Study will address how financing changes could affect rising costs, and the rate of cost increases.

Answer: No, this study is limited. Rep. McFaun noted that we will need to address this issue.

Steve reviewed his document, “H.881 Financing Study Proposal.” It summarizes his presentation, and has a proposed work plan on the back.

Rep. Maier said that we need to address not only employer movement, but employee movement as well.

Re keeping on track re timelines, Steve Kappel suggests that Rep. Tracy consult with Catherine Benham re any interim reports that the Commission may want.

Sen. Kitchel: Does Steve Kappel now assume that the Commission has now given its sanction to this proposal? There were general nods of consensus from the Commissioners.

Rep. McFaun referred to the Steve Kappel’s proposal, its discussion re Sec. 902, the 10%?

Answer: This is to address the issue of people who are uninsured.

Catherine Benham discussed the study that Dr. Ken Thorpe is involved in. He is working on a study of single-payer and possible impacts. He expects to have this done by the end of August. It is important to make sure that these various studies are coordinated, so Dr. Thorpe will work with Steve Kappel to coordinate. Steve’s responsibility is to make sure this is coordinated.

Question: other studies Thorpe may do?

Benham: Later in this meeting, Agenda item 7 will address this—Implementing the Blueprint, Medicaid/OVHA, and implementing Catamount Health.

Question: Will the study include possible effects on current plans, benefits and costs—specifically, the state employee plans?

Comment from Rep. Ancel: Regarding the process, we pulled back—have defined what’s manageable over the next six months. But there are other major issues which can be addressed or need to e addressed in the future. These immediate studies are not all the work that needs to be done.

Sen. Leddy agreed: There have been misunderstandings, from commissioners and others, re current and future expectations. We need to be very clear re work and expectations.

4. Implementation   Mike Smith, Secretary of Administration, Susan Besio, Director of Health Care Reform Implementation  

Secretary Smith introduced Susan Besio. She has been hired to spearhead the implementation. Her office has been moved up next to his, to signal the Administration’s seriousness in this work. Smith noted the need to be meticulous in the planning and coordination of the implementation. He said that he and Susan Besio met with Hans Kastensmith, the Commission’s IT consultant, this morning to start discussing information technology issues.

Sen. Leddy said that he appreciated Secretary Smith’s making the time to come to the Commission meeting today; and said that he and Susan Besio had a preliminary meeting Friday. He noted that in the past, in state government administration of health care issues, no one person has been in charge—this is simply the way things have developed over time. It is very important to have Secretary Smith’s commitment; and very important that he has hired Susan Besio. He also noted the Administration’s quick action in hiring her.

Presentation by Susan Besio, Director of Health Care Reform Implementation:

Susan Besio plans to be at all the Health Care Reform Commission meetings, for the entire meetings. Both Governor Douglas and Secretary Smith are very committed, and are keeping in close touch.

This reform can have a dramatic impact on the quality and affordability of health care for all Vermonters. She is starting to learn all the details of all the relevant legislation, including “SorryWorks!” etc. She feels, humble, appreciative, and excited. Her role is the choreographer of all these pieces—to make sure that they are all happening. She will also work to identify areas of unintended consequences—such as timelines that don’t jibe, etc.  She will also write the Five-Year State Plan for the Administration, and wants to consult with the Commission on this.

She started officially on June 5, and is transitioning into the job this week.  She is reviewing Acts 190 and 191, and developing spreadsheets on all the components and details. She is meeting with staff of the Legislative Council and Joint Fiscal Office regarding legislative details and intent. She has developed a long list of people to meet with, including the members of the Commission and the other people at this meeting. She also hopes to have a website available soon—in the next week or so, and to coordinate with the legislature to make sure that this website and the legislative website have the same information.

Besio next reviewed her background and curriculum vitae.

Question: what is her authority within the administration, and what support does she have?

Answer: She is currently consulting with Herb Olson and John Crowley of BISHCA; Betsey Forrest has been reassigned to work with Besio on premium assistance, ESI and Catamount Health—so Betsey will be her primary contact at the Agency of Human Services. Besio has identified lead people for each of the major initiatives. Re the Blueprint for Health, she is working with Acting Health Commissioner Sharon Moffat and others. The Blueprint has become coordinated with Catamount Health.

Question: So Betsey Forrest has a new job? And are there other changes in state government?

Answer: Betsey is splitting her time between OVHA and Health—she reports to Joshua Slen.

Re the Blueprint for Health, Commissioners briefly discussed the information technology contract. Hans Kastensmith explained that essentially it was awarded to General Electric; the final issues have been worked out.

Commissioners noted the enormous challenge of keeping all the different pieces of the implementation coordinated, and of organizing and coordinating all the work. They asked if Besio could bring to the Commission a list: who is accountable for all the deliverables? There are lots of competing priorities. They requested an organizational chart, listing essential accountability and expectation. This would be very helpful. This list and chart would be part of her spreadsheets. (The Vermont Association of Hospitals and Health Systems is also preparing a timeline.) The Commission needs this information as a basic resource.

Rep. Ancel asked Susan Besio to please identify and share with the Commission a list of technical amendments to the legislation that may need to happen.

Sen. Leddy noted that these questions show Besio’s tremendous responsibility—and her limited resources. Essentially, we are requiring tremendous reorganization—without reorganizing. The Commission’s role is to keep informed but not to overstep and get into operational details. Success in this implementation will depend on the willingness of different areas of government to break down traditional silos and cooperate. He asked Besio, do you have sufficient resources and are they in the right places?

Sen. Kitchel: In last year’s budget we asked the Secretary of Administration to produce a report on the current status [of reorganization]. Did we receive it?

Sen. Leddy: We did get a piece of paper, but no report yet. So we need to review the language in last year’s Appropriations Act. But we can’t press the Administration too hard, since we are behind on our own reports.

Sen. Kitchel: This report may have been premature last year, but now is essential.

Susan Besio said that as we dig into the implementation, issues may emerge on how various pieces are working together. Regarding her staff, she is confident: “I anticipate that this is going to work.”

Rep. Maier asked Susan Besio to come to the July Commission meeting and tell the commissioners the three or five substantive next steps—the top five things that need to happen and when.

Susan Besio offered a preliminary answer:

1. Understanding the data assumptions behind all the different modeling. We need a consensus—for example re ESI data; or the number of people eligible for Catamount.
2. How all the different chronic care initiatives hang together. She has started meetings with the Dept. of Health. There are four or five different big chronic care pieces. (Rep. Maier: re chronic care, a challenge will be to keep OVHA and Medicaid woven into that.)
3. Developing a good Catamount Health plan. This has a very aggressive deadline—August 1. She is meeting with BISHCA.
4. The IT piece—it is vital as infrastructure. We need a time line re how it rolls out; and evaluating this.

These are her top four.

Rep. Maier asked her to please reprise this at the next meeting.

Susan Besio requested that she be the Commission’s contact in the Administration, regarding questions and what’s happening—so she can learn the commissioners’ concerns and issues. She would like to hear from each of the Health Care Reform Commission members: what issues you are most passionate about and what areas you see as key areas of concern.

Rep. Tracy asked that she please coordinate with the legislative staff re the information on the legislative website. He noted that Blue Cross/Blue Shield also has sent out a good information piece.

Susan Besio’s direct phone number is 828-0566; or contact her through Robin Strader, 828-3222. Besio’s e-mail is susan.besio@state.vt.us.

Sen. Mullin: We need a package that’s affordable for Vermonters and that will contain costs and improve quality of life at the same time.

Sen. Kitchel: We must look at things in a systematic way—so that all the people who will make this succeed will do so as a constructive and collaborative effort. We can’t have areas of resistance.

Rep. Ancel: This is a huge step, but it is a first step only. It is very important that this achieve quality insurance for those who lack it—and bring down costs. This is what we have promised.

Rep. McFaun: Agrees with Sen. Kitchel. To Besio: Your biggest challenge—to get those people in state government to do it. His passion: Everybody in Vermont gets covered with quality health insurance; and the trend in escalating costs is brought under control.

Rep. Maier: We do know how to expand coverage to new populations. But the big important thing is chronic care and the Blueprint. This is new and essential. It is often done wrong. This is the real key, and there is much uncertainty, including among providers. There is conflicting data. We must be careful and clear. Information technology is a big part.

Sen. Cummings: Yes—agree re collaborative process and the details. If all we do is provide low-cost insurance to people who are uninsured—that is not enough. The real crisis is in the under-insured. We will have to address this to be successful.

Sen. Leddy: You are hearing a united voice here. He urged Susan Besio and staff to revisit and stay focused on the Six Principles and values formulated by Coalition 21. They united us, and remain our values and our goals.

Re your role to influence and drive state government, your biggest role is to bring all of us together—advocates, legislators, state government—we need to work with you—and hospitals, insurers, providers—and consumer and employers. We must struggle to stay as united as we can.

Rep. Tracy: We have reached a tipping point. Many are watching—and not just Vermonters. Let us continue the public dialogue—not just a one-time discussion. We need to share information, and allow people time to digest it. We really want this to work. And the Commission is a partner.

Sen. Kitchel: Efforts to promote health will be essential. Is this part of Susan Besio’s role?  Is how we are using our public health resources part of your work?

Sen. Leddy: It is, very explicitly—it was part of S.310.

Answer (Besio): Yes, this part of my agenda. I am consulting with Acting Commissioner Moffat. There are various reports.

Sen. Mullin noted a private sector effort: in the press, the Rutland Herald has really stepped up efforts to raise health care issues.

Susan Besio thanked the Commission very much.

Sen. Leddy said that we need to schedule at least two next meetings.

[Break for lunch]

5.  Blueprint for Health--Implementation and timeline   Sharon Moffat, Acting Commissioner of Health  

Document distributed: 2006 Legislative Report from the Vermont Department of Health: Vermont Blueprint for Health: Preliminary Report on Implementation Structure. Recommendation and Timeline. June 1, 2006.

[On the web at http://healthvermont.gov/prevent/blueprint/docs/060106leg_report.pdf ]

Sharon Moffat said that she would first focus on the Preliminary Report on the Blueprint, and then address information technology questions. The Dept. of Health (DOH) is working with legislative staff to get the 2006 Legislative Report posted on the legislature’s website.

A few highlights of the Report:

• Under “Organizational Structure” (pg. 2, under 2^nd paragraph), the committee added a purpose statement for the new committee: “The role of the Executive Committee is to advise the commissioner on creating and implementing the strategic plan for the development of the statewide system of chronic care and prevention; and to advocate for integration of Blueprint work within their own organizations and with their constituents and partners. “
• Activities under way already:
• The two pilot communities, Bennington and St. Johnsbury, are now “phase-in” communities.
• They have added four new communities: Springfield, Mt. Ascutney, Central Vermont, and Fletcher Allen (Just starting).
• Although the Blueprint sits in DOH, it goes far beyond one department to system change.
• Re Blueprint organization structure (page 3): there are lots of solid and dotted lines. This is a challenge and an opportunity. What are the relationships and how do we value these connections?
• The last part of the Report is the appendices—materials used in their discussions.

Q: Re the organizational structure: is there a position for communications?

A: There are two communications directors: Nancy Erickson and Linda [Dorrey]. They will work closely with Susan Besio.

Q from Rep. Tracy: What is the role of BISHCA, especially the Health Care Administration, in the Blueprint?

A: In the organizational structure, they are already on the Executive Committee. The committee includes BC/BS, Bea Grause from VAHHS, Paul Harrington from the Vt. Medical Society, James Hester from MVP Healthcare, Helen Riehle from the Vt. Program for Quality in Health Care (VPQHC), Joshua Slen—re the link between the Blueprint and OVHA, Pat Jones from BISHCA, Eileen Gurley (Director of Blueprint implementation), Ellen Thompson of DOH, and Jessica Porter (Operations Officer for DOH).

There are also new members, per the legislation:

• Dr. Mark Novotny, in the Bennington area (one of the two pilots) led the provider workgroup.
• Jeanne Keller has been appointed by the Business Roundtable.
• Tom Murray is the Commissioner of the Vt. Dept. of Information and Innovation.
• Mark Seroy directs community health care in Burlington.
• Bill Norwalk ND is a naturopath.

The executive committee meets monthly in person and via conference calls in between. Their main work is the Blueprint.

Q from Rep. Tracy: Getting back to the previous question—what is the role of BISHCA?

A: Sharon Moffat will have to get back to the Commission on that.

Rep. Maier: In the legislation there is a date in 2009: BISHCA will require providers to coordinate—if they haven’t by then—in providing chronic care. (Note from Paul Harrington, VT. Medical Society: the statute says “recommendation,” not “requirements”.)

Sen. Leddy: this is a critical area—if not THE critical area, re implementing the legislation. So there must be ongoing clear communications with BISHCA re progress and challenges in this area.

Sen. Kitchel: Regarding the Blueprint communities, especially in the area of IT, what areas have “requirements,” and what areas of work have “guidelines”?

A: Here are examples:

• Self-management—some communities have expanded self-management workshops.
• The money coming into communities is not in silos
• Walking programs—can inspire people to get moving. But there is a variety in how the community programs do the walking component.
• Re community wellness grants—DOH has added Kelly Doherty as a new point person for the various disease grants—bringing the various advocates and community workers together. They are trying to change the disease grant recipients from “passionate bulldogs” to sled dogs---all pulling together.

Commissioner Moffat thanked the Commission for endorsing the Blueprint and supporting chronic care work. She does have concerns re the accelerated timelines. The new registry is critical. There is a focus on pediatrics, i.e., diabetes. Pay for Performance is critical. They have a September meeting planned with BISHCA re Pay for Performance.

Timing for appointing a new commission at DOH: possibly one month from now—the earliest—to as late as late fall.

Sen. Leddy urged that Susan Besio be a party to the selection of the new commissioner.

Q from Sen. Mullin: What about the provider practices?

A: DOH is supporting Microsystems OfficeWork, through Dartmouth. They are working with provider offices, and with VPQHC.

Sen. Mullin: What areas of the state?

A: Bennington and St. Johnsbury for now—as well as with other early adopters around the state.

6.  Health Care Information Technology--Report   Hans Kastensmith, Consultant to the Commission  

Documents distributed:

• Volume 1: Healthcare Information Technology Overview
• Volume 2: Vermont Hospitals Healthcare Information Technology Detail
• Volume 3: Healthcare IT Supporting Documentation

[ On the web at http://www.leg.state.vt.us/CommissionOnHealthCareReform/default2.cfm ]

Hans Kastensmith: Regarding the Blueprint, cooperation between groups is growing, opening up, at a level better than he has ever seen elsewhere. If this continues, Vermont will get some seriously successful programs.

The technology portion of the Blueprint:  re the contract with GE-Orion: the system Orion is considering has built-in flexibility, to adapt to clinical work flows. They are also going to pre-enter a lot of data for the practices—“pre-populated”—to make it less painful for practices and DOH. He hopes these examples will help adoption by providers.

Hans Kastensmith then discussed the RFP process.

Hans said that his Report (the 3 volumes, listed above) will be on the web by tomorrow, June 20.

Overall, the state is doing pretty will on healthcare IT. Hospitals are working to bring their IT up to standards, by 2010. Not all are using the best pieces of IT. Most will have EMRs (electronic medical records) internally by 2010. And half are supporting EMRs for their associated doctors in the field or local area. The majority of hospitals have advanced medication dispensing systems. This should greatly reduce medication errors. There are various bar-coding solutions. Some hospitals also have high-tech medical imaging systems, including night-imaging. Two hospitals are doing this. There are also examples of technology sharing.

Sen. Leddy: Very impressed by the depth and specificity of this report. He said that Hans’s work has been very beneficial to the legislature and to providers. He noted that as we move forward, Hans has become a resource for the legislature and for providers, and he hopes that this cooperation will continue. As Hans is moving to be a resource in implementation as well—well beyond the usual role of a legislative consultant—these become new organization waters. This is OK so far, but we all need to keep aware.

Hans said that he is aware of this. He hopes to continue to work by invitation, and not to interfere.

Going forward, the Joint Fiscal Office has asked him to draft a statement of work for the next year. This would include:

1) Implementation management

2) Continue to support the Blueprint and VITL to help implementation.

3) Assessment of ambulatory care IT—similar to this hospital study.

4) Inventory of state-run health care IT systems, and help with synergies.

5) Identify and produce recommendations for gains and efficiencies

Q from Rep. Maier: Could Hans be available—on request—to providers as they plan IT?

A, from Rep. Tracy: Steven (Maier) and Kevin (Mullin) have done a good job of monitoring Hans Kastensmith’s work for the Commission. Hans, Sen. Leddy and Sen. Mullin would need to control and limit this part of Hans’s work.

Sen. Leddy asked Rep. Maier and Sen. Mullin to work with committee staff to review this work plan.

7.  Commission overview   Catherine Benham, Staff Director  

Document distributed: Memorandum to Health Care Reform Commission: Highlights and Update on Commission.

Catherine Benham reviewed her memorandum. Section one is an overview of changes. The Commission was established in statute; its mission has been modified; studies language was modified.

Section two reviews the Commission budget. FY06 will end with approximately $375,000+, available to roll over to FY07. For FY07, an additional $300,000 was appropriated, with up to $200,000 for IT. Joint Fiscal Officer Steve Klein discussed the budgeting for staff support.

Sen. Mullin asked to see this documentation.

Section three of the memorandum covers requests from staff to the commission. Catherine Benham asked that the Commission appoint subcommittees to supervise the various studies.

Co-Chairs Rep. Tracy and Sen. Leddy proposed the following subcommittees:

IT subcommittee: Sen. Kevin Mullin and Rep. Steven Maier.

Ken Thorpe studies subcommittee: Rep. Ancel, Sen. Kitchel, and John Bloomer.

Financing studies subcommittee: Rep. McFaun and Sen. Cummings.

The subcommittees will report back to the co-Chairs.

There was committee consensus re these subcommittees.

Regarding reimbursement for travel, per-diem expenses: Catherine Benham suggested that members get pre-approval from the co-chairs.

Rep. Tracy: We need a plan for outreach and education. We need to be more proactive than reactive. Sen. Leddy: for the next meeting, we will plan to discuss outreach. He asked members to please share ideas with Catherine.

Rep. Maier: We need to consider what support and work the commission needs for staff now.

NEXT MEETINGS: 
Tuesday, July 25,
Monday, August 28, 9:30 AM.

The meeting adjourned at 2:40 PM.

Minutes respectfully submitted by Loring Starr

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