Legislative Wrap: New health care accountability, reform ideas emerge

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Lawmakers spent the session providing oversight on Gov. Peter Shumlin's ambitious health care goals, and most of the new reform ideas came from the lawmakers themselves.

The House Health Care Committee dedicated time every week to chronic problems with Vermont Health Connect, and the committee's signature bill this year was dedicated to accountability for Shumlin's all-payer model of payment reform.

On the Senate side, lawmakers worked to slow the growing power of hospitals in the health care system. They spearheaded legislation to require notifying patients that their out-of-pocket costs might go up if their private doctors' offices are acquired by hospitals, and they sought to pay hospitals less to dispense prescription drugs.

Both chambers dedicated time to addressing the high cost of prescription drugs, leading to first-in-the-nation legislation that will require drug manufacturers to justify when their prices increase dramatically.

Pharmaceuticals and Hospitals

Vermont's became the first state legislature to pass a law requiring pharmaceutical manufacturers to provide information on how they set their prices. The companies oppose the measure and came all the way to Montpelier to testify against the bill, only to face stiff opposition from even the most conservative Republicans.

drugs

The first price transparency measure started in the House Health Care Committee as H.866. The committee chair, Rep. Bill Lippert, D-Hinesburg, pulled it back into committee in an effort to strike greater consensus on the panel.

With the clock ticking down, Rep. Bob Bancroft, R-Westford, offered price transparency language that the committee agreed would help limit the state's exposure to lawsuits, then attached transparency language to S.216.

Republicans in the House backed S.216 unanimously, but the bill had no teeth to force compliance. Once the two chambers went to conference committee, the Senate added language that would allow the attorney general to take pharmaceutical companies to court if they don't comply.

S.216 directs Vermont's Medicaid program to decrease how much it pays certain hospitals to dispense prescription drugs. The bill requires the state to follow the formula in a program called 340B.

In a tacit criticism of the University of Vermont Health Network, lawmakers passed another bill, S.245, that requires hospital systems to notify patients when buying an independent practice, so patients can prepare for the typical increase in out-of-pocket costs.

The Senate also knocked down Shumlin's proposal to put a new tax on independent doctors and dentists before it could make it to the House. Shumlin expected to raise $17 million with the tax, match it with $22 million in federal funds, and send $4.8 million back to providers in the form of higher reimbursements.

Instead, the Senate put language in the budget bill, H.875, that directs the Medicaid program to divert about $4 million from its payments to academic hospitals to increase how much it pays primary care physicians.

Women's health initiatives

Shumlin proposed in his original budget to make it harder for low-income pregnant women to qualify for Medicaid. The measure would have prevented Medicaid from paying for about 300 pregnancies and saved the state $2.25 million.

Peter Shumlin, Phil Scott

Gov. Peter Shumlin greets Senate President Phil Scott before delivering his 2016 budget address. File photo by Roger Crowley/VTDigger

The governor reversed his position a day later, and his spokespeople said they didn't fully understand the consequences of their proposal when they made it. Pregnant women in Vermont continue to be eligible for Medicaid if they make up to 213 percent of the federal poverty level.

The Legislature did pass a bill to codify portions of the federal Affordable Care Act, guaranteeing Vermont women — and men — free access to birth control. The bill allows women to get 12 months of birth control pills at a time and lets men get free vasectomies.

The bill increases how much Medicaid pays doctors to insert intrauterine devices and contraceptive implants. Architects of the bill say the increased reimbursement will make doctors more likely to stock the devices in their offices, so more women can get them inserted on the same day they ask about them.

Toward the end of the session, Sen. Jane Kitchel, D-Caledonia, added a provision to the birth control bill that creates a special enrollment period on Vermont Health Connect for pregnant women. Previously, uninsured women who became pregnant and did not qualify for Medicaid needed to wait for an open enrollment period to get insurance.

Vermont Health Connect and Integrated Eligibility

The House Health Care Committee spent nearly every Wednesday interrogating Shumlin's health care team on the status and future of Vermont Health Connect. In the end, lawmakers decided to spend $250,000 on an independent review facilitated through the Joint Fiscal Office.

In October, Blue Cross Blue Shield of Vermont was the first to request an independent technical review. Vermont Legal Aid joined the call in January, when the backlog of changes to be made to customer accounts exceeded 5,000. Republicans then called for any review to be divorced from the control of the Shumlin administration.

Over the course of the session, lawmakers learned that the health exchange's billing vendor had been sold; heard from a strategy consultant that Vermont should not be implementing new functionality on the exchange; and learned the state would change course on two other major pieces of health care information technology.

Lawrence Miller

Lawrence Miller is chief of health care reform for the Shumlin administration. File photo by John Herrick/VTDigger

The Agency of Human Services has formally postponed updates to the core component of the Medicaid Management Information System. The state has also been negotiating with Speridian Technologies Inc. as a possible company to stabilize the exchange before laying down framework for integrated eligibility — a sort of one-stop shop for people to learn what benefits they qualify for.

Lawrence Miller, the chief of health care reform for the Shumlin administration, testified repeatedly that the state did not need another review to say what it already knew. He has instead been working through a "punch list" of major problems in the exchange, and the state says it has sought competitive bids to fix those problems.

On Wednesday, Miller said the backlog of customer changes of circumstances remained around 3,500. He also rebutted a VTDigger article about state officials' dissatisfaction with the exchange's main contractor and clashed with Rep. Doug Gage, R-Rutland, who pressed Miller for details about the contractor's billing.

All-payer model, etc.

This year's omnibus health care bill, H.812, became known around the Statehouse as the "Christmas tree bill" because, as it evolved, advocates sought to add any health care reform proposal under the sun to the legislation.

The final version of H.812 directs the Green Mountain Care Board to regulate accountable care organizations — the intermediaries between doctors and insurance companies that the Affordable Care Act allows as a method for changing health care payment.

Much of the regulation is designed to protect consumers as health care payment reform moves forward. Provisions require public notice periods for certain accountable care organization functions and give Vermont Legal Aid the right to review an organization's budget.

H.812 also tells the Shumlin administration it can only enter into an all-payer model agreement with the federal government if it reaches certain standards. One of those provisions makes sure that Vermont protects Medicare, even though the federal government will not allow the state to make any changes that are bad for beneficiaries.

At one point, H.812 included funding for studies of reform proposals that came from former single-payer advocates: Dr. Dynasaur 2.0 and universal primary care. One would expand a popular Medicaid program to everyone under age 27; the other would provide government-funded primary care to Vermonters of all ages.

While the House originally approved $140,000 in state funding (plus $170,00 in federal money) for the Dr. Dynasaur study, the universal primary care proposal always sat on the back burner. That led to tension between advocates who, just four years ago, would have been allies in the fight for single-payer.

In the end, the Legislature decided to study both the Dr. Dynasaur expansion and the universal primary care proposal. Dr. Dynasaur will get $100,000 in state money (and federal funds will roughly double the amount). The Agency of Administration will review academic literature on universal primary care at no additional cost to the state.


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