We are nearly halfway through this year’s
legislative session, with bill deadlines coming at the close of the week we
return after the Town Meeting break. The current week is a good one for
reaching out to Rep. Ken Goslant or me to talk about pending issues, since we
aren’t tied up in day-long committee meetings and floor sessions.
The weeks immediately after that deadline
will be the beginning of a much heavier load of floor debates on specific bills,
followed by work in committees on initiatives sent over by the Senate. The
state’s budget will also be coming out from the House and headed to the Senate
by the end of the month.
***
Health Care Committee
My committee has finished its input into
the budget and workforce bills and has three initiatives we are trying to
finish by the March 11 deadline.
We wrestled with a large, late-in-the-game
budget request from the Green Mountain Care Board – our state’s health
regulator and reform czar – for initiating several health reform projects. We’ve
spent five years on the major reconfiguration of financing that was supposed to
funnel the major payment resources into entities (“Accountable Care Organizations”)
that would pay health providers based on health improvements and care delivery,
rather than on the basis of each individual piece of service delivered. The key
element was the negotiation with the federal government to align its payments
from the Medicare system into this new payment system, joining with Medicaid
and commercial insurers, ergo, called the “All Payer” model. We ended up with
only one accountable care organization, by the name of OneCare. Those are the
two names the public may have heard referenced: the All Payer model, and
OneCare.
The $5 million request from the Green
Mountain Care Board is a bit of a “re-set” button being pushed, though no one has
quite said that. Not nearly enough insurance plans or providers have signed on
to the All Payer model yet to reach a critical mass that would create real
change. It is nowhere near its targets. And the 5-year agreement with the feds
is nearing its end. In addition, many of our hospitals are teetering on the
edge of sustainability, caught between rising cost pressures and the inability to
increase revenues enough to meet them.
So, how to recalibrate?
The Board is recommending two things: First,
a deep dive on the actual delivery of health care in each part of the state. It
would bring everyone to the table in each regional sector to talk about
priorities and how to improve outcomes. Perhaps some hospitals need to be
reconfigured to best meet local needs and maintain access. Perhaps there are
efficiencies in the infrastructures. How
do we best allocate resources? But the work is intended to be from the ground
up, not from top-down directives. That is a $3 million process that will also involve
data gathering and analysis and technical assistance to hospitals to facilitate
transformation initiatives.
Second, a reframing of how we move away
from the current, predominant fee-for-service model into payment based on value
received. That would involve establishing fixed payment hospital budgets: they
receive overall payments to achieve population outcomes, rather than for each
hospital bed they fill. Designing that system and renegotiating with the feds is
the purpose of the additional $2 million investment, including the costs of deeper
analysis of the hospital markets and their costs and expenses.
I drafted the language to put very clear parameters
of our expectations on how this process would move forward, including a report
back before any changes move forward, and we included this in our budget
recommendations to the Appropriations Committee.
***
Health Care Workforce
We prioritized three areas as most in need
of immediate investments in our recommendations to the Commerce Committee for
stabilizing the healthcare workforce. Workforce shortages cut across almost
every job sector, but my committee’s task was to identify responses for health
care.
We have many more applicants to our
in-state nursing schools each year than we have slots for, and we are
desperately short of nurses. Enhancing nursing education capacity needs to be a
high priority. We recommended emergency state investments in several supports
for that system, each addressing a specific current barrier. We lack nursing
educators; a nurse takes a huge pay cut if they move from clinical practice to
teaching. We proposed grants to nursing schools for a bridge to enhance
salaries. There is a lack of clinical placements for students; practicing nurses
receive nothing extra if they agree to take students under their wing. We proposed
grants to hospitals to add stipends. Nursing schools need sophisticated
simulation laboratories for students to practice in and they lack the capital funds
to upgrade and expand them. We recommended a capital grant fund. (Think of it:
would you prefer a student to try their first several IV insertions on you, or
on a dummy?) Norwich will be one of the direct beneficiaries if these
investments are passed.
I think the most positive initiative we
are seeking to fund is a grant program for seed money to start “pipeline” projects
modeled on one I heard about from Central Vermont Medical Center a few years
ago. It offers staff already working in front line positions the support to
advance their education and careers in exchange for commitments to continue to
work there. A nursing assistant, for example, can get paid time off for
classroom work plus scholarship funds so that they can afford to go to school
while still working and earning a salary, and graduate as a licensed practical
nurse. It has been a huge success, but the health organizations need start-up
funds to create these programs.
The second major priority area is in the community
mental health agency system, where year after year, the state budget falls
short of funding anything near the same cost of living or inflationary
increases that state employees or other government services receive. The
governor’s budget proposed a three percent increase this year, and we have
proposed making it 10 percent instead, to help with catch-up to market
salaries. We also proposed an expansion of scholarship and loan repayments for
furthering education.
The third priority area is to address
everything we can’t do in the first year of an emergency response, and that is
to lay the groundwork for a more cohesive, long-term response. Last year, we
asked for a strategic plan for this purpose. A cross-agency work group came out
with no less than 40 recommendations, most of them very common sense. But
someone has to actually follow-up to make them happen, to pull the players
together to reduce barriers and to develop healthcare career-building at
earlier points. We recommended staffing a time-limited position to implement
components of the plan.
Finally, one of the recommendations in the
plan was to establish a single point of information to gather data on the
healthcare workforce, which will enable future supply and demand modeling to
understand what needs to be targeted. We want that to be developed immediately.
This year brought to the forefront the way we have been playing whack-a-mole
over the past decade. One crisis pops up; we react. Another one; another
reaction. We have no bigger picture of where the most pressing developing needs
are – tied together with our changing demographics (read: we are getting older
and needing more health care.) We must create that core data if we are to ever be
able to act planfully instead of reactively.
***
Healthcare Bills
We’ll be looking to wrap up three bills during
the deadline week when we return.
The first is to address hearing aid
coverage in health insurance plans. We’ve been receiving urgent pleas to address
this issue over the past several years. It is a good illustration of how much
our hands are tied when it comes to regulation of insurance plans. We’ve taken
the first step of addressing coverage in plans that are offered on Vermont Health
Connect for individual or small group coverage. We expect that some plans,
beginning next plan year, will begin to include that option. Medicaid already
covers them; Medicare does not and we can’t do a thing about that since the
federal government controls it. (Some Medicare Advantage plans chip in towards
the cost.) Many large employer plans are also controlled exclusively under
federal law – but not all. So we will be looking into what steps we can take in
that arena.
The second bill is a step forward in
addressing financial assistance plans offered by hospitals in the state.
Although the vast majority of Vermonters are insured, many have very high
deductibles and are financially devasted by a major hospital stay. Hospitals
all do have assistance plans, based on income, but they all differ. If you have
your heart attack in the wrong county, all the rules – including basic
eligibility – will be different. This bill seeks to bring them into more alignment.
Finally, we hope to pass a bill that will
at least take the first steps in increasing the oversight of the shadowy
middlemen in the sales of pharmaceuticals. They operate within an incredibly
complex world of negotiating with drug manufacturers on behalf of insurance
company and making some of their money by paying less to a pharmacy than what
they pay for the drug. They have already been lobbying us about what an
important role they play in health care delivery; that may be the surest
indicator that we need to be watching them more closely.
***
Take advantage of our “down time” during
town meeting week by reaching out to me (adonahue@leg.state.vt.us) or Rep.
Goslant (kgoslant@leg.state.vt.us)
to share your concerns, priorities and ideas. We want to work for you – it is
an honor representing you.
No comments:
Post a Comment