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

MEMBERS ABSENT:

John Bloomer, Jr.

Also Present:

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

Meeting Recorded:

CD HCRC 12/20/06, CD #1, 2.

Documents Distributed:

Minutes of Oct. 24, 2006 meeting

1. Convene; Review and Approve Minutes from 10/24/06.

Senator Leddy convened the meeting at 9:00 AM in Room 11 at the Statehouse, Montpelier, Vermont.

He gave a tribute to the late Representative Clint Martin. He also noted that due to the funeral for Rep. Martin later today, this meeting has been compressed.

Sen. Leddy asked for a motion to accept the minutes. The motion passed unanimously.

2. General Implementation Update and Five-Year Implementation Plan Report [CD 1, tr. 3]

Susan Besio, Director of Health Care Reform Implementation

Document distributed: Vermont Health Care Reform Activities. Sorted by Date & Topic—Dec. 19, 2006

Received approval from the Joint Fiscal Committee for the ESI implementation; Employer rules approved by the Leg. Committee on Administrative Rules; Cost Shift Task Force Report submitted Dec. 1; Advanced Directives Rules approved Dec. 13, will be adopted in two weeks; the web site will go live soon.

State employees health benefit plan—Jan. 1, CIGNA. CIGNA will have a state director in Vermont, and that person will attend Blueprint meetings—this is a significant change.

Local health care coverage planning grant—a group in the southern part of the state has received a grant—in the Windham County area.

Sen. Leddy: the HCRC should follow this, study the ideas.

Besio, cont:

Draft Rules, adverse event reporting—are in process. They have an interim guide now.

Safe staffing/patient care—VPQHC is working on this.

Uniform credentialing—the final form was distributed in mid December, to take effect Jan. 1.

Comprehensive plan for outreach and involvement—are planning this, will submit initial proposal to the Robert Wood Johnson Foundation.

Five-Year Implementation Plan—submitted Dec. 1. It includes some recommendations for statutory amendments.

The web site will be up and live by Jan. 2 nd. It is a repository for all these documents, task force, spreadsheets, RFP’s, etc. They will send out the link to all on Jan. 2.

Q: Seasonal employees report?

A: Task force has had final meeting; report being drafted—with the Secretary of Administration.

Q; Uniform credentialing—access?

A: Free to health care professionals.

3. Employer Assessment Rules [CD 1, tr. 4]

Tom Douse, Department of Labor

Document distributed: • Rules Packet: Final Proposal: Cover Sheet; and Rules for the Administration and Collection of the Employers’ Health Care Contribution

Tom Douse noted some key comments they received:

• Accept secure electronic records
• Adjust rules re employees who turn 18
• Re those who refuse employer’s plan: employers not be required to gather information re the other provider (discussion of 75% rule)

Discussion here: this might be valuable for data collection in the future. Will need further discussion.

• Clarified some wording re mandatory waiting periods for coverage

Most prevalent comments:

• Re paying assessment for non-resident employees who work in Vermont
• Excluding employees re coverage regardless of the source of the coverage
• Please exclude part-time employees. (Discussion followed).
• Exclude per-diem nurses, substitute teachers, day workers, high school athletic coaches, etc.
• Employees funded by grants
• Students—college, etc.
• One situation: a school district which gives its administrators cash to buy benefits.

Next steps: Rules were approved last week, are final. They will hold employer seminars to give out the information. They plan to send out notices to 22,000 employers in the state.

Recommendation from commissioners: include worksheet in early mailing.

4. Cost Shift Task Force Report

Mike Davis, BISHCA [CD 1, tr. 5]

Document distributed: • Cost Shift Task Force Report to the Commission on Health Care Reform. Dec. 1, 2006 (BISHCA)

The Task Force, about 12 individuals, met throughout the fall to produce the Report by Dec. 1.

More art than science; recommendations in three key areas:

1. Hospital budget reporting area—can formalize and improve some in this area. BISHCA will work on this.

2. Insurance rate process—will need more time and a better understanding—rely heavily on actuaries—will need to put more effort to trace dollars.

3. Cost shift relative to the rest of the health care system---do not have tools now to track costs throughout system. One example: home health industry.

There are opportunities and limitations. They can use BISHCA’s hospital budget reviews to measure and monitor; but this is limited to hospitals and providers employed by hospitals. Cost shift information for other providers is very limited. Will need to address these reporting limitations.

There is a limit to how much the cost shift can be reduced by the State of Vermont. Medicare reimbursement is controlled at the federal level; and there are federal limited to Vermont’s Medicaid reimbursements. It is problematic how to extend efforts to measure the entire cost shift across all providers in the health care system. Report makes four recommendations regarding BISHCA; five additional recommendations that will require more time and analysis.

Discussion:

Best available measurements indicate a total cost shift of $195 million to the private sector.

But complications include the issue of cost shifts among employers as working couples switch coverage; and growing factor of employers paying their employees to not take their coverage. Only anecdotal information so far.

5. Technical Corrections and Policy Issues [CD 1, tr. 6]

Herb Olson, BISHCA; Robin Lunge, Legislative Council

Document distributed: • Proposed Amendments to Catamount Health. Herb Olson, BISHCA

As several agencies begin to implement the Health Care Reform Acts, issues needing clarification arise. BISHCA is meeting with Legislative Council land Joint Fiscal Office as well. This is a long list of 25 items, not time this morning to go over all of them. There are five recommendations under Catamount Health, seven under Premium Assistance Programs, five under chronic care, and eight other issues. Many of the issues are also raised in the Five-Year Plan.

Some highlights:

Catamount Health --#2 and #3 in Catamount Health: eligibility issues. These include voluntarily leaving employment; possibility of an employer restructuring to make employees eligible for Catamount Health.

Reimbursement standards for hospitals and other providers—need to be clarified.

Premium assistance --The whole area of premium assistance programs: trying to have an integrated system to get coverage for low-income people. We need to make sure we get this right.

#5: Timing issues re ESI, and picking up coverage.

Chronic Care --Putting the vendor at risk; AHS case management; align time frames.

Other issues –#1: Individual insurance market—getting assistance from Robert Wood Johnson Foundation--

Elliot Wicks doing study. Will get recommendations in a study to the Legislature in January.

#2, Re multi-payer data collection—very important. Need to be able to use Medicare and Medicaid data—issues re confidentiality of data.

Q: Several of these issues are at the national level—there are some challenges. Meetings with Senator-elect Sanders and the entire congressional delegation—useful to consult with them and itemize and plan re these issues.

Note re item #5—there is a typo—re loan re medical records--should be “medical” not “Medicaid”.

Please note also: An immunization study is also under way.

Q: Need to create a timeline for this list—which items need to happen when, schedule for legislation.

Q: Re #3 under Chronic care, align time frames—clarify?

A: AHS timelines, relative to Blueprint—closely interrelated, need to make sure the two processes are aligned properly. See page 22 of Strategic Plan, under Milestone 4.3, second bullet, footnote.

[CD 2 track 1]

Legislature will need to sort out these issues, organize cohesive work among the various committees.

6. General Discussion [CD 2 tr. 2 ]

Kenneth Thorpe

Ken Thorpe thanked both Representative Tracy and Senator Leddy for their leadership.

Scope and breadth of reforms here far surpass work in other states; is a complicated process. Enormous amount of changes that need to be organized and implemented.

Great challenge is that Vermont is trying to do this within a fee-for-service and fragmented health care delivery model.

The Blueprint is the centerpiece of what the legislature passed last year. Chronic care management is key.

1. Bidders are submitting bids to manage Catamount Health
2. OVHA is in the process of selecting a vendor to do chronic care for Medicaid.
3. State of Vermont is developing chronic care management contract with its new health insurance provider, CIGNA.

All these need to be aligned with the Blueprint, and at the moment there really is no Blueprint—the guidelines are not yet developed.

Need to nail down the delivery and payment systems. State is at a critical juncture; how can they accelerate this model. How best to accelerate what the Blueprint protocols and processes will be: a coordinated care model.

He also has concerns that Susan Besio is overwhelmed and probably understaffed.

It is a major, major implementation challenge—transforming the fragmented delivery model.

Q: What communication and coordination is happening now among the three groups and the Blueprint?

A: Susan Besio: Some of these groups have representatives on the Blueprint Executive Committee. Blueprint Executive Committee has a retreat on Friday--this is important information for them to have.

Q: How do we make this all happen—do we need to have an additional high-level person somewhere to focus on this? More resources for Susan Besio? Other?

A: Resources are enormously lager in Massachusetts, for a narrower scope of changes.

Also—need to put the development of protocols on hyperspeed—not really starting from scratch. But also are trying to integrate processes and activities in a fragmented delivery model that is not is a single-payer system. But it is just as much a clinical management and delivery challenge.

If no broad model out there soon, real challenges for physicians, with multiple payers.

Note from Bea Grause: two key areas are IT and payment reform; and a reminder that Sharon Moffatt is in charge of the Blueprint, not Susan Besio.

Note from Paul Harrington: there are about five different chronic care models, and five different levels of reimbursement. Extremely challenging.

Note from Susan Besio: Perhaps could get an external expert come in, spend two to 3 months, investigate, because competing dynamics are challenging: the Blueprint is a broad public-private partnership, but it is comprised of vested interests. Difficult for that kind of organization to make difficult decisions in a quick way. Many different dynamics.

Leddy: sees three areas:

1. Multiplicity of issues
2. Not a partnership, a confederation.
3. Resources—legislature may not have provided enough resources to all the different agencies working to implement. Need to consider this: the next legislature, working with the administration.

Thorpe: If this were easy to do, someone would already have done it. But there are existing models: Group Health Cooperative, VA, Kaiser, etc.

Bur right now decisions are being made by three elements of state government that could go in different direction without guidance from the Blueprint.

Maier: Deadline for cooperation: July 2009, “or else”. Will need to see clear signs of cooperation, before that time frame.

Thorpe: Will need that sooner. Trains are already leaving the station.

Q: Re the response that the commission requested from Thorpe, re analysis from Richter and Hogan?

Thorpe: sent in a draft; staff does have that.

Q: Those three entities Thorpe mentioned earlier—will it be the OVHA process?

A: The anchor needs to be the Blueprint. You need a gold standard in your model and terms.

Other discussion: The OVHA contract will include Blueprint standards, and can be modified as the Blueprint gets developed. Need evidence-based standards and metrics. There are already national standards.

Also—the CIGNA contract specifies that CIGNA will have a state medical director.

7. IT Update [CD 2 tr. 3 ]

Hans Kastensmith, Consultant to the Commission

Re Blueprint: Kastensmith saw growing pains, he brought in a national expert on disease management implementation: Dr. Jerry Reardon. Could be a resource.

The Blueprint IT contract is pretty much on track. Some challenges on moving patient data among EMR systems—re confidentiality; clinical data repository. Will need to be discussed in committees.

VITL projects: Medication history, Vermont Technology plan, support to CCIS. VITL is doing a very professional job. Technology Plan already in draft; final copy to legislature in January.

Re OVHA: response to RFP, bidders’ conference.

A lot of things are starting to work, re technical cooperation. Example: OVHA has global clinical record, working re platforms.

Re EMRs: Also VITL is working on sources of funds to support EMRs—support for physicians in the field.

Working on pay-for-performance issues as well. Hope to fund a pilot.

Master Provider Index: In retrospect, it would have been good to fund that as well—did not in the legislation. Should revisit that this session.

Finally, state should look at issue of using social security numbers as identifiers—dangerous. State should look at this.

Leddy: Great thanks to Kastensmith for being a bridge and a resource to all elements.

8. Study Update [CD 2 tr. 4]

Tom Kavet

Model work is progressing on financing options—extremely complex. Still a work in progress. They are guardedly optimistic, although frustrated. This will be a platform for future analyses.

9. Set next meeting date

Catherine Benham, Joint Fiscal Office

Time is running over for this meeting; she will need to contact members of the commission later to arrange dates. They will also need to re-arrange dates for the interview meetings.

Some discussion of available dates followed.

Comment: Will need a director on board ASAP.

The meeting adjourned at 11:07 AM.