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Vermont Medical Society Health Care Reform in the Green Mountain State


Title: Paying for Health Care Reform: Single Payer vs. Democratic Candidates Proposals Author: Len Rodberg Last modified by: Justin Campfield Created Date – PowerPoint PPT presentation

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Title: Vermont Medical Society Health Care Reform in the Green Mountain State

Vermont Medical SocietyHealth Care Reform in
the Green Mountain State
  • Paul Harrington, Executive Vice President
  • October 5, 2011

2009-2010 represented the greatest level of
Health Care Reform Activity in Washington since
the enactment of Medicare and Medicaid in 1965.
  • Two major bills
  • H.R. 1, Signed 2/17/09 American Recovery and
    Reinvestment Act of 2009 (ARRA). Creates Health
    Information Technology incentives for meaningful
    use of certified Electronic Health Records 44K
    Medicare, 64K Medicaid.
  • H.R.3590, Signed 3/23/10 Patient Protection and
    Affordable Care Act (PPACA). Expected to cover an
    additional 32 million Americans by 2019, boosting
    the percentage of non-elderly Americans with
    insurance to 94 percent from the current rate of
    83 percent. 418 billion in Medicare savings over
    the next decade

Meaningful use of Certified EHR Technology
  • EHR meets established standards and includes
  • patient demographics and clinical data
  • medical history and problem lists
  • clinical decision support
  • physician order entry
  • capture/query quality health care data
  • Use e-prescribing Electronic exchange of patient
    information and integration with other systems
    and, EHR reporting of clinical quality data
  • Rule issued by CMS in Spring 2010 with three
    phases 2011, 2013 2015
  • Increased coding complexity due to need to be
    HIPAA 5010 compliant by Jan. 1, 2012 and the
    change from ICD-9 to ICD-10 by Medicare on Oct.
    1, 2013. ICD-9 has 15,000 codes while ICD-10 has
    68,000 codes.

Patient Protection and Affordable Care Act (PPACA)
  • Individual Mandate
  • Requires all U.S. adult residents to obtain and
    maintain acceptable coverage for themselves
    and their children beginning in 2014 (phased-in
    tax penalty for those without insurance)
  • Insurance Market Reforms
  • Require all health insurers to offer basic plans
    that are guaranteed issue, with no health status
    underwriting, with no pre-existing condition
    exclusions and maximum rating bands of 31.
  • Subsidies to purchase insurance available through
    exchanges to low-income individuals
  • Up to 400 of Federal Poverty Level (43K
    individual, 58K couple 88K family of four in
  • Health Insurance Exchanges
  • State or federal run exchanges available in 2014
    to give individuals the ability to choose from a
    variety of private plans and receive subsidies.
    State can set insurance company participation and
    set conditions for participation.

PPACA Areas of Major Controversy
  • Creates Federal Reserve Board-like organization
    for health care (Independent Payment Advisory
    Board) using base-closing model. Starting in
    2015, estimated saving 23.4 billion over
  • Medicare payment reform ACOs, bundled payment,
    geographic variations, value based purchasing
  • Fails to reform Medicare Sustainable Growth Rate
    (SGR). Absent additional Congressional action,
    Medicare physician payment will be cut by
    approximately 29.4 in January of 2012.
  • Failure to enact medical liability reform.
  • Multi-state challenge (26) to the laws
    individual mandate to be decided by U.S. Supreme
  • The challenges allege the law infringes upon
    constitutional rights of the states by mandating
    all citizens have qualifying health care coverage
    or pay a tax penalty. By imposing such a mandate,
    the law exceeds the powers of the United States
    under Article I of the Constitution.

Accountable Care Organizations (ACO)
  • Section 3022 of PPACA creates the Medicare Shared
    Savings Program using Accountable Care
    Organizations (ACOs)a model of integrated care
    formulated to reduce costs and improve quality.
    They are slated to begin January 1, 2012.
  • Major Concerns with Proposed ACO Rules
  • Department of Justice and Federal Trade
    Commission mandatory antitrust review for ACOs
    with over 50 market share creates barriers for
    rural states.
  • Retrospective Patient attribution to ACO makes it
    difficult to provide case management for high
    cost patients
  • Inadequate and retrospective payment amounts
  • Adverse impact on Academic Medical Centers and
    high quality/low cost states like Vermont
  • Final rules due late 2011.
  • Physician leadership is often cited as a key
    element of success.

Recent Healthcare Reform Efforts in Vermont
  • The Blueprint for Health Primary care medical
    home, HIT, and community health teams
  • Vermont Information Technology Leaders RHIO, REC
    and HIEN assistance with EHR adoption and
    achieving meaningful use and e-prescribing
  • Catamount Insurance for uninsured
  • Act 49 practice variations imaging, ED use and
  • Act 128 Report by Dr. William Hsiao
  • three options for universal coverage

November 2, 2010 Elections Set the Stage for
Vermont Health Care Reform
  • Senator Peter Shumlin elected Governor --
    Campaign Promise to adopt single-payer system for
    VT. Governors bill H.202 is introduced in House
    of Representatives on Feb. 8, 2011.
  • Overwhelming Democratic Majority in new General
  • House (150) D 94, R 48, P/I 8
  • Senate (30) D 22, R 8
  • House Speaker Shap Smith and Senate President
    John Campbell

Major Theme in Legislative DebateNeed to Control
Health Care Costs
Governor Shumlins Health Care Reform
BillH.202 is signed into law as Act 48 on May
26, 2011
  • 5 person Green Mountain Care Board established to
    oversee cost containment strategies
  • Vermont Health Benefit Exchange created to help
    achieve universal insurance coverage, as required
    under the federal Patient Protection and
    Accountable Care Act (PPACA).
  • Bill anticipates the evolution of the Health
    Benefit Exchange into Green Mountain Care the
    states publicly- financed health care system for
    all Vermonters.
  • Much of the legislation is devoted to mandating
    numerous studies that will be the basis of future
    legislative action over the next several years.

Key Administration Appointments
  • Anya Rader Wallack, Chair, Green Mountain Care
  • Other GMC Board Members
  • Al Gobeille, of Shelburne
  • Karen Hein, MD, of Jacksonville
  • Con Hogan of Plainfield
  • Allan Ramsay, MD, of Essex Junction
  • Robin Lunge, Director of Health Care Reform
  • Mark Larson, Commissioner, Department of Vermont
    Health Access
  • Georgia Maheras, Deputy-Commissioner of Health
    Care Administration
  • Steve Kimball, Commissioner, Department of
    Banking, Insurance, Security and Health care
  • Harry Chen, M.D., Commissioner, Department of
  • Craig Jones, M.D., Director, VT Blueprint for

Green Mountain Care Board
  • Governor appoints Board subject to confirmation
    by Senate.
  • Green Mountain Care Board with a chair and four
    other members to take office on Oct. 1, 2011.
    Six year terms with the full-time chair receiving
    123k and the 4 others receiving 82k as 0.8
  • The Boards duties will include
  • Develop, implement and evaluate payment reform
    pilots (the first pilot is scheduled for Jan. 1,
    2012 and two more pilot would begin on July 1,
  • Develop and maintain a method for evaluating
    system-wide performance and quality
  • Set reasonable rates for health care
    professionals in order to have a consistent and
    acceptable reimbursement amounts

Vermont Health Benefit Exchange
  • The bill establishes the Vermont Health Benefit
    Exchange as a division of DHVA.  
  • Beginning on Jan. 1, 2014, the exchange will
    provide qualified health benefit plans to
    eligible individuals and small businesses.  
  • DHVA is required to maintain contracts with at
    least two health insurers, in addition to the
    multi-state plans required by the PPACA.  
  • Federal premium subsidies will be available to
    individuals who enroll in health benefit exchange
    plans provided that their income is above 133
    of FPL (29,861 for a family of four) and no more
    than 400 of FPL (89,808 for a family of four).

New Federal Funds and Coverage Impact of Vermont
Health Benefit Exchange Approx. 621,271
Vermonters (2008) Approximately 47,460 (7.6) are
uninsured (2009) -
No Exchange With Exchange New Impact
2015 2019 2015 2019 2015 2019
Number of uninsured individuals 50,000 53,000 32,000 31,000 -18,000 -22,000
Federal funds into Vermont 400 million 460 million 640 million 880 million 240 million 420 million

Green Mountain CareAKA Single Payer Plan
  • The purpose of Green Mountain Care is to provide,
    as a public good, comprehensive, affordable,
    high-quality health care coverage for all Vermont
    residents.  The implementation date would be 90
    days following the last to occur of the following
  • Enactment of a law by the General Assembly
    establishing the public financing for Green
    Mountain Care
  • The Green Mountain Care Boards approval of a
    benefit package
  • Enactment of an appropriation by the General
    Assembly for the benefit package and,
  • Receipt of a federal waiver to allow Green
    Mountain Care to receive federal individual
    premium subsidies and small business tax credits
    provided through the health benefit exchange by
    the PPACA (under current law, the state cannot
    apply for these waivers until 2017). Medicare and
    Medicaid waivers would be applied for separately.

(No Transcript)
According to the 2010 Census brief, Vermonts
median age of 41.5 represents the second oldest
population in the country after Maine
Multiple Studies in 2012 2013
  • Reforms to the Medical Malpractice System. By
    Jan. 15, 2012, the Sec. of Adm. submits reforms
    to the medical malpractice system for Vermont.
  • Integration Plan. By Jan. 15, 2012, the Sec. of
    Adm. makes recommendations, on how to fully
    integrate or align Medicaid, Medicare, private
    insurance, associations, state employees, and
    municipal employees with the Vermont health
    benefit exchange and Green Mountain Care.
  • Aligning the Workers Compensation System. By
    Jan. 15, 2012, the Comm. of Labor evaluates the
    feasibility of integrating the workers
    compensation system with Green Mountain Care.
  • Universal Coverage. By Jan. 15, 2012, the Comm.
    of DHVA recommends any additional mechanisms to
    ensure that all Vermonters will obtain health
    insurance coverage.

Multiple Studies in 2012 2013 Cont.
  • Health System Planning, Regulation, and Public
    Health. By Jan. 15, 2012, the Sec. of Adm.
    reports on unifying health system planning,
    regulation and public health.
  • Payment Reform and Regulatory Processes. By
    March 15, 2012, the Green Mountain Care Board
    recommends changes to regulatory processes to
    align them with the payment reform strategic
  • Financing Plans. By Jan. 15, 2013, the Sec. of
    Adm. recommends two plans for sustainable
    financing. One plan is for the Vermont health
    benefit exchange in the absence of a waiver under
    the PPACA. The second plan would finance Green
    Mountain Care to achieve a public-private
    universal health care system.
  • Health Care Workforce Strategic Plan. By Jan.
    15, 2013, the Dir. of Health Care Reform oversees
    a health care workforce development strategic
    plan to ensure that Vermont has necessary health
    care workforce to provide care to all Vermonters.

Other Health Care Reform Initiatives
  • Congressional deficit reduction Super Committee
    recommendations are due 11/23. President has
    proposed 320 billion in Medicare and Medicaid
  • Congress must act by 12/23 to enact 1.5 trillion
    in debt savings over a ten-year period.
  • If Congress fails to pass a debt reduction plan,
    1.2 trillion in across-the-board cuts would take
    place evenly divided between defense and
    non-defense spending.
  • VTDOL is considering updating Rule 40 workers
    compensation fee schedule.
  • Last updated in 2006 for CPT and in 1995 for
    Anesthesia CF
  • Edit Standards Workgroup
  • to ensure uniformity and transparency on edit
  • DVHAs Proposed Privacy and Security Standards
    for the VT Health Information Exchange Network
    operated by VITL.
  • Impact on achieving meaningful use
  • VMS Education and Research Foundation (VMSERF)
  • Grant to foster physician leadership and address
    prescription drug abuse

Vermonts Fragile Health Care System
Due to expanded insurance coverage, State
estimates that the current shortage of 25 primary
care physicians will increase to 63 in 2015. VMS
assumes expanded coverage and aging population
will drive need for increased specialty care as
14 Hospitals in Vermont FAHC is States Only
Level 1 Trauma Center
Approximately 1,833 physicians in Vermont
Primary Care 35 (634) Family Practice 15
(279) Primary Care Internal Medicine 10
(175) OB/GYN 4 (75) Pediatric 6 (105)
Specialty Care 65 (1,199) Anesthesiology
5 (97) Emergency Medicine 6 (108)
Specialty Internal Medicine 12 (217)
Psychiatry 9 (172) Radiology 7 (129)
Surgery 9 (162) Other 17 (314)
Bottom Line Goals for Vermont Medical Society
  • Improved Patient Access to High Quality Care
  • Adequate Physician Supply to Meet Increased
  • Independent Evaluation of States Reform Efforts
  • Adequate Reimbursement from Medicaid and Medicare
  • Tort Reform to Address Defensive Medicine
  • Greater Patient Engagement in Improving Health
  • Reduced Administrative Burdens and Improved
    Practice Environment
  • Physician Involvement in Design and
  • Reform Based on Pilots Before Statewide
  • Partnering with hospitals and others in Advocacy