Update on Vermont Health Care Reform

1. Update on Vermont Health Care Reform AcademyHealth State Coverage Initiatives Program National Meeting Albuquerque, New Mexico July 30 - 31, 2009 Susan Besio, Ph.D., DirectorVermont Health Care ReformVermont Health Access (Medicaid)

2. Vermont Health Care Reform 60+ Initiatives • Improve Quality • Provider Access • Promote Wellness / Prevention • Blueprint for Health • Accountable Care Organizations • Health Information Technology • Quality Transparency • Increase Coverage • New Coverage Options • Premium Assistance • Integrated Marketing and Outreach • Contain Cost Growth • All of Above PLUS • Cost Transparency • Statewide Health Resource Planning and Review • Prescription Drug Cost Containment • Administration Simplification

3. Expanding Coverage: Green Mountain Care • New Catamount Health Plan offered by private carriers (Individual Market) • New Premium Assistance for Catamount Health and ESI • Integrated marketing, outreach and enrollment across all state-sponsored programs (50% eligible for existing programs but not enrolled) Dr. Dynasaur Medicaid VHAP Catamount Health or ESI Catamount or Premium ESI Premium Assistance Assistance 100% + other criteria Over 300% 150 - 185% 300% Income Eligibility: Federal Poverty Level

4. Enrollment Results(since November, 2007) Enrolled New Programs Catamount Full Cost 1,243 Catamount w/Premium Asst 7,710 Catamount ESIA 577 VHAP ESIA 948 Sub-total 10,478 Existing Programs Adult Medicaid Increase 2,336 VHAP Increase 7,022 Dr. Dynasaur Increase 4,047 Sub-total 13,405 TOTAL 23,883 Uninsured rate: Fall, 2005Fall, 2008 ALL9.8%7.6% Children: 4.9%  2.9%

5. Snapshot of Selected Initiatives to Address Access, Quality and Cost

6. Provider Access Safety Net • 8 FQHCs (40 sites) and 14 Rural Health Clinics • Free Clinics • 10 free clinics and 2 dental programs • In 2008, served 6,188 patients, provided 12,435 services and received over $2 million in-kind support for medications, services, labs and hospital support. • Provide access to health care for uninsured and underinsured by providing: • Assistance with enrollment in Green Mountain care programs, • Provide care for urgent medical needs, including low-cost medications • Assistance to find a primary care home Medicaid Rates • PCPs protected in FY2010 Medicaid rate reductions • Pay at 2006 Medicare rate for Evaluation and Management codes • Dental Dozen (Medicaid – Health collaborative) Fair Contracting Standards • To support providers in negotiations with carriers

7. Loan Repayment Fund • Vermont’s program has one of the highest retention rates in the country • 99% stay in VT for one year after receiving award; 89% stay from time they received award. Due to service commitment AND community engagement/support

8. Blueprint for Health Integrated Projects • Single approach across 3 Primary Carriers and Medicaid in 3 (of 12) Hospital Service Areas during 2008 and 2009 for: • Medical Home: evidenced-based practice, clinical micro-systems support • Community Health Teams (joint funding by all payers); integration with Medicaid CCI • Payment Reform (single methodology across all payers for provider metrics and incentive payments) • Health IT Hospitals PCMH PCMH Community Health Teams NurseCoordinator Social Workers Behavioral Health Dieticians PCMH & Substance Community Health Workers Abuse Services OVHA Care Coordinators Public Health Prevention Specialist PCMH Public Health Prevention Health IT Framework Global Information Framework Evaluation Framework Operations

9. Community Activation & Prevention Prevention specialist as part of CCT Community profiles & risk assessments Evidence based interventions Evaluation NCQA PCMH score (process quality) Clinical process measures Health status measures Multi payer claims data base (VCHURES) Population Indicators Blueprint Integrated Pilot Summary • Financial reform (2 major components) • Payment to practices based on NCQA PCMH standards • Shared costs for Community Care Teams • Medicaid & commercial payers • BP subsidizing MedicareMultidisciplinary care support teams (CCT Teams) • Local care support & population management • Prevention specialists • Health Information Technology • Web based clinical tracking system • Visit planners & population reports • Electronic prescribing • Updated EMRs to match program goals and clinical measures in DocSite • Health information exchange network

10. Accountable Care Organizations • An ACO is an entity that enables networks of health care providers to become accountable for the overall costs and quality of care for the population served by: • Bending the medical cost curve – savings over projected trend line of costs • Improving the health of the community population and the patient experience • Capturing part of shared saving to reinvest in local community health system • Work focuses on payment reform, data collection and care delivery models • Goal: Test the ACO concept in a small number of ‘early adaptor’ community provider networks that have key integrator capabilities 3/09-12/09 Customize design • Identify qualified ACO pilot networks/sites • Encourage shared savings pool across multiple commercial payers • Plan for Medicaid participation and waiver filing • Advocate federal legislation for Medicare participation • Create financial impact model for ACO • Continue broad based stakeholder workgroup for design input • Coordinate/integrate design with Blueprint medical home Q2 2010 Startup of initial pilot

11. Health IT • Goals: • common level of high quality healthcare for individual patients and populations across all practice and human service settings • guideline based health maintenance & prevention, care for chronic conditions, and eRx • provide the suite of health IT and data services that meets the needs of different practice settings • Progress to Date • VT Information Technology Leaders (VITL) - statewide HIE • Statewide Health IT Plan • Health IT Fund: 0.2% fee on paid medical claims for 7 yr • Electronic Health Record: fund implementation for primary care practices • Fund state-wide Health Information Exchange infrastructure

12. HIT: Fitting the pieces together Federal HIT/HIE Policy, Oversight, & Standards - Office of the National Coordinator (ONC) State HIT/HIE Policy, Oversight, & Standards – OVHA/HCR State Government & Public Health Vermont Health Care Providers & Institutions Public Health surveillance, registries, & other public health functions Health Information Exchange (HIE) “Cloud” for interchange of health records, demographic data, image files, clinical messaging, & other digitized health information Operated by VITL Tertiary and Community Hospitals Primary Care & Specialty Providers Medicaid health programs case management functionality and connectivity Federally Qualified Health Centers & Rural Health Clinics Free Clinics Other Medicaid & AHS case management functionality and connectivity Mental Health/BH/SA Providers Long Term Care Providers Other state agency & dept. case management functionality and connectivity Home Health & Hospice Providers Community Human Service Agencies (Family Centers, Area Agencies on Aging, etc.) Individual Vermonters: connectivity to EHR Portals, Personal Health Records (PHR), Health 2.0 applications and Ix Services Law Enforcement, Corrections, & Court System

13. Quality Transparency Hospital Report Cards • Vermont hospitals required to publish annual reports on: • Quality of Care • Infection Rates and Prevention Measures • Patient Safety • Nurse Staffing • Financial Health • Costs for Services • BISHCA web-site contains comparative Report Cards across Hospitals Consumer Price & Quality System • Purpose: to empower people to make economically sound and medically appropriate decisions • Insurers with at least 5% of the commercial market must file Consumer Information Plans describing how they will provide price and quality information to their members • Hospitals and Hospital-owned Practices must file Consumer Information Plans describing how they will provide price and quality information to uninsured consumers • Phased-in to full implementation in 2013

14. Health Care Quality Organizations • Vermont currently has a private, non-profit Vermont Program for Quality in Health Care with a board made up of hospitals, insurers, physicians, and consumer representatives • Funded by hospitals and insurers • BISHCA required to study health care quality organizations in other states • How do other states and countries analyze quality and ensure quality improvement? • Report due on January 15, 2010 to include recommended modifications to existing program if appropriate

15. Cost Transparency • BISHCA Certificate of Need (CON) process for state approval of health care facility expenditures for : • high cost construction, purchase, or renovation ($3 m for hospitals, $1.5 m for other health care facilities), • purchase or lease of diagnostic or therapeutic equipment ($1 m), or • offering of a health care service or technology that has an annual operating expense that exceeds $500,000 for either of the next two budgeted fiscal years • BISHCA monitors and controls increases in hospital costs through annual binding hospital budget review process • Public Oversight Commission (POC) makes recommendations to BISHCA regarding annual hospital budgets and Certificate of Need applications • Health Resource Allocation Plan (HRAP) • Legislatively-required plan developed by BISHCA • Includes an inventory of specified health care resources, and recommendations for appropriate supply and distribution of those resources • Purposes: • Resource document for state policymakers and for certificate of need process; • Introduce new science, technology, standards and benchmarks to support regulatory functions; • Introduce new ideas and policy considerations for feedback and further discussion

16. Cost Containment:Variation in Utilization Study • Legislative-mandated Study by BISHCA with report by January 15, 2010) • Report must identify treatments or procedures • for which the utilization rate varies significantly among geographic regions within Vermont, or • where the utilization rates are changing faster in one geographic region than another • Report shall “determine the reasons for the variation” • Report shall contain “recommendations for containing health care costs by reducing variation, including promoting the use of equally or more effective lower cost treatment alternatives, prevention or other methods of appropriately changing utilization.” • BISHCA must consult with hospitals, Vermont Medical Society, and insurers to make recommendations regarding variation in utilization analysis

17. Cost Containment: Health Plan Administrative Costs • Legislature mandated BISHCA, in collaboration with the Agency of Human Services, to provide an administrative cost report • The report shall “identify a common methodology based on the current rules of insurer reports to BISHCA for calculating costs of administering a health plan in order to provide useful comparisons between the administrative costs of: • Private insurers • Entities administering self-insured health plans, including the state employees and retiree health benefit plans • Offices and departments of the Agency of Human Services • The report shall “compare administrative costs across the entities in Vermont providing health benefit plans.”

18. Pharmacy Cost Containment in Vermont Law • Pharmaceutical Manufacturer Disclosure of gifts or other economically-valued marketing to prescribers • Pharmaceutical Marketer Disclosure of the average wholesale price of the drug being marketed • Protection of Prescribing Information from Pharmaceutical Marketers • Pharmacist Disclosure to consumers of the usual and customary retail price of the drug (upon request) • Mandatory Pharmacist Alternative Drug Selection of lowest priced therapeutically equivalent drug • Fee Imposed on Manufacturers ($ .10 / claim for publicly funded programs) to Promote Generics and other Low-cost Alternatives • Academic Detailing for Prescribers • Generic Voucher Pilot for Free Samples

19. VCHURES (Vermont Healthcare Claims Uniform Reporting & Evaluation System) • Multi-payer claims database administered by the State • Includes eligibility and medical and pharmacy claims data for private comprehensive major medical benefits (insured and self-funded), Medicare Parts C and D, and Medicare Supplement. • May include Medicaid and Medicare claims data if approved by CMS • Resource for reviewing health care utilization, expenditures, and performance • Harmonized with similar claims data collection initiatives in other states to support uniform reporting standards for insurers, and future regional and national research • July 2009 - First consolidated eligibility and claims data set for the paid claims period of January 2007 through December 2008

20. For more information Vermont Health Care Reform Web-site: www.hcr.vermont.gov Health Care Coverage Information: www.GreenMountainCare.org 1-800-250-8427