VAHHS Legislative Report

For the week ending March 2, 2007

NOTE: THERE WILL BE NO LEGISLATIVE REPORT FOR THE WEEK ENDING MARCH 9. The Legislature will be on Town Meeting break. The next report will be March 16.

Political Overview

The House Education Committee has been developing a consensus on general strategies to address the cost effectiveness of the education delivery system. They are being guided by overall principles that include: improvement of the quality of education, a commitment to equity among schools and students, understanding the expectations of the system, lowering the growth rate of spending and making the connection between the education property tax and expenditures more transparent to the taxpayer. The Chair of the education committee was clear that the bill will not have all the answers as the issues are complex, affect every child and the General Assembly needs to take time to address it meaningfully. The focus is on: governance, which will require several years of public process; contract negotiations at the supervisory union rather than district level; high spending penalties; credentialing of school business managers; mandates at both the state and federal levels resulting in significant costs; special education and health care. Down the hall, the Ways and Means Committee is evaluating the excess spending penalty. Under Act 68, if a district spends over 125% of the average per pupil spending from the previous year, its tax rate on the additional spending is increased by a multiplier. Other items under consideration are simplifying tax bills, modifications to the common level of appraisal and capping the size of adjustments of bills for income sensitivity at $10,000 with consideration of an asset test.

FY 08 Budget

On Monday, February 26th, Joshua Slen gave an overview of the Medicaid budget. The testimony consisted of an explanation of the Medicaid program and the Governors' proposed budget of $749,342,679. Medicaid is the largest insurer in Vermont from a dollars spent perspective and second in the number of covered lives. Twenty five percent of Vermonters are covered by Medicaid. Slen reviewed his department’s role related to Catamount Health, clinical initiatives, the chronic care management program, Global Commitment, and information technology.

Impact to Hospitals:

The current budget proposes new money for hospital rate increases for SFY 2008 (July 1, 2007) of $2.0 million. Also itemized in the budget proposal is the full year impact of the rate increase that went into effect on January 1, 2007.
The SFY 2007 increase from January 1, 2007 – June 30, 2007 equaled approximately $1 million for hospitals. On a go forward basis, the 12-month benefit of this increase is $2.0 million. This increase has already been factored in the base payment rates effective on January 1, 2007.
The combined effect of the SFY 2007 and the proposed SFY 2008 increases equal a total of $3 million in higher reimbursement from current SFY 2007 levels.
In addition to hospital rate increases, the SFY 08 proposed budget includes physician increases of $2.0 million, and home health increase of $400,000.

Vermont State Hospital (VSH)

The Senate Institutions Committee heard testimony on the Vermont State Hospital from Michael Hartman, Deputy Commissioner of Mental Health at the Vermont Department of Health (VDH), and Beth Tanzman from the Division of Mental Health. Tanzman reviewed the issues related to the Institute for Mental Disease (IMD) exclusion, the Certificate of Need (CON) conceptual CON application, and the importance of integrating mental health with general health services. The committee had numerous questions on current capacity at existing facilities and the possibility of increasing psychiatric beds at current designated hospitals. Tanzman stated that although hospitals may have capacity within their facilities, the designated hospital psychiatric units are at capacity. The committee reviewed the options of a 40-bed stand alone facility, a 40-bed integrated facility and a 68-bed integrated facility along with their associated estimated costs.

Budget Adjustment

The Senate passed the Budget Adjustment on the Floor Wednesday. If the House concurs with the Senate proposal of amendment, the bill will move forward to the Governor for his signature. If the House does not concur, a conference committee will be appointed with three House and three Senate members to work out the differences.

Medical Marijuana

An Act Relating to Medical Marijuana passed on the Senate floor on Thursday and now moves to the House. The proposed amendment to allow a registered patient to possess or use medical marijuana in a nursing home or hospital was removed.

Health Care Reform

The House Health Care Committee heard testimony from the Administration on the Catamount Health Budget. Director of Health Care Reform, Susan Besio, stated that the goals of the legislation passed last year were to increase access to health care, increase quality of health care and controlling costs. The Governor has proposed using Catamount Health funds for sustaining the individual market, Blueprint for Health and Medicaid provider increases. Legislative leadership is concerned about using Catamount Health funds to support expenses in the Medicaid program.

The Technical Amendments bill that was on the fast track and passed by House Health Care weeks ago has come to a grinding halt in House Ways & Means at the request of the leadership. At issue is a proposed amendment by Rep. Heidi Scheuermann (R-Stowe) that would include part-time employees as well as seasonal employees in the employer assessment exemption. The House Health Care committee was leaning towards pulling that section completely out of the bill, and after hearing testimony on Thursday, opted to wait until after Town Meeting break to take the bill up.

The committee continued to take testimony on H. 380, An Act Relating to the Regulation of Health Care Facilities, more commonly known as the Certificate of Need (CON). The committee will keep this as a separate bill rather than incorporating it into a larger bill that the committee released on Thursday (details below). Provisions of the bill include: elimination of gap jurisdiction, more clarity on the application process, changes to the community needs assessments, requirements on reporting of nurse staffing, and a state immunity provision that would allow the Department of Banking, Insurance, Securities and Health Care Administration (BISHCA) the authority to have conversations with hospitals about markets and closings. VAHHS is happy with the changes except the state immunity provision. The committee will vote on the bill the week they are back from Town Meeting. They are waiting to here from the attorney general’s office on a provision that requires the attorney general’s office, in consultation with the commissioner of BISHCA, to investigate alleged irregularities, complaints, and unfair or deceptive acts in commerce by private mobile health facilities providing diagnostic or preventive health screenings.

Meg O’Donnell, Director of Government Relations and Assistant General Counsel at Fletcher Allen Health Care, testified on health information technology at Fletcher Allen Health Care and CON issues. O’Donnell began by giving an overview of the hospitals, clinical services provided, and vital statistics related to number of beds and visits. O’Donnell stated that Fletcher Allen Health Care is very involved at the state level on health information technology (HIT) and participates on the Vermont Information Technology Leaders (VITL) board, VITL work groups and the Blueprint. There is no question of the need for HIT investments to improve quality, patient safety and operating efficiencies. Existing systems need to be linked and gaps filled to truly have an electronic health record. Over the past year Fletcher Allen Health Care has done preliminary work to standardize clinical processes. A steering committee was formed and CSC Consulting was hired to: assist with the request for proposal process, work internally to determine what is needed clinically, develop a strategy and assist with vendor selection. O’Donnell highlighted some of the CON implications with this project. BISHCA confirmed the work the hospital is doing does not require a CON, but the hospital is concerned that a conceptual CON may be required if the final cost exceeds $20 million. There is a lack of clarity in law on the intent of conceptual CONs for projects like this that have few or no planning expenditures. Language passed last year (18 VSA § 9440b) was designed to streamline HIT reviews once the statewide HIT plan under development by VITL is done, but that will not be done until 2008 at the earliest because rules must be promulgated. Fletcher Allen Health Care and VAHHS are supportive of language that would take HIT projects out of the conceptual CON process.

Greg Farnum, President of the VITL, testified on Friday on two primary topics: 1) the need for an Electronic Medical Record (EMR) funding program, and 2) a proposed statutory language that limits VITL’s liability as Vermont’s exclusive Regional Health Information Organization (RHIO). Farnum stated there is a need for a program for providers to get connected with an EMR. Data shows approximately 1,500 doctors would benefit from an EMR funding program. The need is great to have EMRs to digitize all the health care data that is exchanged. The program is a 4-year program that would be provided to approximately 119 Primary Care Physicians (PCP) and 103 specialists a year to implement EMRs across the state. National figures estimate a cost of $22,000 for software, training and installation; $13,000 for hardware; and $25,500 for ongoing maintenance, support and other costs over three years for a total cost of $60,500 per physician. The program cost per year for four years for both PCPs and specialists has a total cost of $18.2 million. Discussions in committee have centered on PCPs only. Chairman Steve Maier stated that how to fund this is still being discussed. He would like to see providers have a financial investment in this. Farnum stated a physician workgroup was established to discuss funding in addition to other issues and the group felt that their investment will be time and change in practice. The group strongly believes a loan forgiveness program should be established should providers be required to make a financial investment. The benefits of financing EMRs are reduced drug adverse events, fewer duplicated lab test, less duplicated imaging, greater formulary compliance, data available for managing chronic conditions and an increase in quality of care. On the consumer side, Farnum stated that 51% of consumers are willing to pay for EMRs, if the price is reasonable, and 67% of the consumers say EMRs are important in choice of physician. On the physician side, 90% of physicians say EMRs allow for easier sharing and gathering of information, 88% of physicians say EMRs provide access to more comprehensive patient information and 80% of doctors say EMRs reduce clinical errors. Farnum also reviewed proposed language on statutory limitation of liability for VITL. VITL is a private nonprofit organization that is seen as a public good. Through contracting processes, VITL has run into difficulties around indemnity. VITL is a conduit of information which takes on risk for data that is collected and needs protection against that risk. The committee will consider this further.

The committee distributed a draft copy of their next bill on health reform. Provisions of the bill to be discussed include: increasing access to affordable health care coverage; household income calculations for determining eligibility (i.e. individuals who are 18 to 21 living with parents would be considered a separate household); appropriations for the Blueprint for Health for staffing, implementation across the state and sufficient payment to providers; a number of requirements for health insurers to participate in the Blueprint; a requirement that the board of nursing establish a work group to study and make recommendations on expanding the scope of practice for advanced practice nurses; appropriating $880,000 to the Area Health Education Centers for the loan repayment program; requiring the Health Care Commission to hire a consultant to study how the current and future resources and capacity in state government best coordinate to achieve the goals of the Blueprint and other reform initiatives; establishing in one or more of the Blueprint communities a medical home pilot project for use with Medicaid beneficiaries, Catamount Health and the state employees’ health plan; allowing the Commissioner of BISHCA to approve the creation of one or more health care provider bargaining groups; requirement that the Office of Vermont Health Access, in consultation with VDH, issue requests for proposals for pilot projects from a geographic region or a network of health care providers across multiple regions to coordinate the delivery of quality health care services in an efficient manner; and establishment of a health information technology fund. The committee will resume work on the draft and attempt to vote it out the week they return.

Patient Choice and Control at the End of Life
The House Human Services committee worked late into the evening Thursday and passed H. 44, An Act Relating to Patient Choice and Control at End of Life, on a 7-4 vote. The committee spent the entire week hearing from both proponents and opponents of the legislation. It establishes a process that would permit patients with capacity to request medication to hasten their death. Patients would be required to make three requests for the medication: an oral request, a written request and an oral reaffirmation request to their physician not less than 15 days after the initial request. The patient’s physician would be required to make a determination of whether the patient has an incurable or irreversible disease that would result in death within six months. The physician would be required to discuss all feasible end-of-life services such as comfort care, hospice and pain control and would be required to inform the patient of the probable result and potential risks associated with taking the medication to be prescribed. The bill also requires the physician to refer the patient to a consulting physician for second opinion to confirm capacity, diagnosis and prognosis of the patient. Either physician must refer the patient to counseling if the patient is identified as having a mental disorder or disease that causes impaired judgment. No medication can be prescribed until the counselor determines that the patient is not suffering from such a mental disorder or disease. Physicians are required to report the number of mental health screening referrals that were made, as well as the number of written requests for medication that were received, regardless of whether or not a prescription was written. The bill expressly states that health care professionals have no legal duty to participate. The bill will be referred to the House Judiciary committee when lawmakers return the week after Town Meeting.

Pre-trial Screening Panels

The Senate Judiciary Committee took testimony from representatives from the Vermont Medical Society (VMS) and invited guests of VMS and the Vermont Trial Lawyers Association. VMS Executive Vice President Paul Harrington told the committee that they should follow the leadership established by Maine and New Hampshire by passing pre-trial screening panels. Although Vermont premiums look good compared to other states, they continue to increase significantly. Chairman Richard Sears stated that there is no disagreement there is a problem, but how we solve it is the issue. Dr. Leonard Trembley, an OB/GYN from St. Albans, testified that he has had to change the way he practices due to a lawsuit filed against him. He stated the current system is slow, unpredictable, wasteful, expensive and unfair for all parties. Physicians are practicing defensive rather than evidence-based medicine for protection. Dr. Trembley believes that pre-trial screenings are a step in the right direction. Gordon Smith, Vice President at the Maine Medical Association, stated that pre-trial screenings have worked in Maine. Smith stated that the system in this country is broken – it is not good for the patients and it is not good for the doctors. The only ones happy are trial lawyers. Senator John Campbell (D-Windsor) asked if the malpractice rates in Maine have gone down with the passage of the legislation. Smith stated premiums have leveled off and stressed the issue is not about premiums, but fixing a system that is broken. Trial lawyers do not support the legislation.

S. 124 – Planning and Evaluating Options for Inpatient Psychiatric Hospital Services

An Act Relating to Planning and Evaluating Options for Inpatient Psychiatric Hospitals Services passed the Senate on Thursday. The bill provides for an independent evaluation by the general assembly of the options available to the state regarding the provision of inpatient psychiatric services now provided at the Vermont state hospital. It allows the committee on committees of the Senate and the Speaker of the house to spend up to $100,000 to retain one or more consultants to compile, analyze and review what has been done to date and explore the development of one or more regional psychiatric facilities. The consultant will also investigate the necessary steps to meet conditions of participation or waivers of the Centers for Medicare and Medicaid Services to enable the participation of the existing state hospital in federal funding. The consultant or consultants will report preliminary progress on or before May 1, 2007 jointly to the chairs of the House and Senate Appropriations and Institutions Committees, the Senate Health and Welfare Committee, and the House Human Services Committee. A final report is due to the above mentioned committee chairs and to the Secretary of Administration no later than June 30, 2007. The bill now goes to the House.

S. 128 – Eliminating Certain Sunsets on Forensic Examinations at Designated Hospitals

An Act Relating to Eliminating Certain Sunsets on Forensic Examinations at Designated Hospitals has passed second reading on the Senate floor. The bill eliminates the sunset on allowing court-ordered forensic examinations of criminal defendants at designated hospitals.

CORRECTION:
Last week’s Legislative Report on the Health Department’s FY08 proposed budget mistakenly stated that the Women, Infants and Children’s (WIC) program would be eliminated. The WIC program is not eliminated, but is reduced by $600,000 in state general funds.

Bills of interest that were introduced this week:
H. 368 – AN ACT RELATING TO THE REGULATION OF PROFESSIONS AND OCCUPATIONS: This bill proposes to modify statutory provisions relating to the office of professional regulation and the following professions and occupations: nursing home administrators; accountants; architects; barbers and cosmetologists; chiropractors; dentists and dental hygienists; embalmers; professional engineers; funeral directors; nurses; optometrists; osteopathic physicians; pharmacists; real estate brokers and salespersons; veterinarians; land surveyors; opticians; radiologic technologists; psychologists; clinical social workers; clinical mental health counselors; hearing aid dispensers; real estate appraisers; occupational therapists and occupational therapist assistants; dieticians; private investigative and security services; acupuncturists; marriage and family therapists; psychoanalysts; psychotherapists; tattooists and body piercers; naturopathic physicians; athletic trainers; midwives; electrologists; speech language pathologists and audiologists; auctioneers; respiratory care; motor vehicle racing; and alcohol and drug abuse counselors.

H. 372 - AN ACT RELATING TO THE RENDERING OF NURSING AND MEDICAL SERVICES BY PROFESSIONAL CORPORATIONS: This bill proposes to authorize nurses and physicians to render services as a professional corporation.

H. 376 - AN ACT RELATING TO PROMPT PAYMENT OF ELECTRONIC PRESCRIPTION DRUG CLAIMS: This bill proposes to require a health plan to pay by electronic funds transfer within eight days any prescription drug claim submitted electronically.

H. 379 - AN ACT RELATING TO THE PRACTICE OF CHRISTIAN SCIENCE NURSING: This bill proposes to allow Christian Science nurses to practice Christian Science nursing without being in violation of Vermont law that regulates the practice of nursing.

H. 380 - AN ACT RELATING TO THE REGULATION OF HEALTH CARE FACILITIES: This bill proposes to amend hospital reporting and licensing requirements; provide hospitals with greater flexibility in how community needs assessments are conducted; eliminate mandatory biannual revisions to the health resource allocation plan; require the public oversight commission to make recommendations regarding revisions to the health resource allocation plan; amend the certificate of need laws; and provide for the regulation of mobile health screening facilities.

H. 384 - AN ACT RELATING TO RETROACTIVE COVERAGE UNDER THE VERMONT HEALTH ACCESS PLAN: This bill proposes to allow Vermonters to receive coverage under the Vermont health access plan retroactively to cover medical care recently received.

H. 385 - AN ACT RELATING TO INCREASE IN MEDICAID REIMBURSEMENT FOR MENTAL HEALTH SERVICES: This bill proposes to increase Medicaid reimbursement for mental health providers by 10 percent from the 2007 amounts

H. 405 - AN ACT RELATING TO CAPITAL CONSTRUCTION AND STATE BONDING: This bill proposes to authorize bonding, appropriate capital funds, and address miscellaneous related items.

H. 417 – AN ACT RELATING TO THE VERMONT FREEDOM HEALTH PLAN: The bill proposes to establish the Vermont freedom health plan to cover certain health-related services for all Vermonters.

H. 421 – AN ACT RELATING TO SAFE PATIENT HANDLING: This bill would require hospitals and nursing home facilities to establish a safe patient handling program.

H. 433 – AN ACT RELATING TO THE NEXT GENERATION INITIATIVE OF WORKFORCE DEVELOPMENT THROUGH WORKFORCE DEVELOPMENT PROGRAMS AND INTERNSHIPS: This bill proposes to bridge Vermont’s workforce development gap by supporting workforce development and secondary and postsecondary internships with employers by enhancing existing grant programs and establishing new grant programs to be administered jointly by the departments of labor and of economic development, with assistance from the workforce development council. The grant programs are funded by the workforce education and training fund, which this bill codifies. This bill also ensures that employers in other fields, such as information technology, telecommunications, and health care are eligible for grants through the Vermont employment training fund. Finally, it makes appropriations in support of these and other workforce development initiatives.

H. 448 – AN ACT RELATING TO THE VERMONT STATE HOSPITAL GOVERNING BODY: This bill proposes to codify and revise the existing bylaws of the Vermont state hospital governing body.

H. 473 – AN ACT RELATING TO REQUIRING PARENTAL NOTIFICATION PRIOR TO PERFORMING AN ABORTION ON AN UNEMANCIPATED MINOR: This bill proposes to require that a parent or guardian of an unemancipated minor receive written notice at least 48 hours before an abortion is performed on the minor, unless the abortion is necessary to prevent the minor’s death or serious bodily injury. The bill also requires health care providers to provide pregnancy information and counseling to minors prior to providing services related to pregnancy.

H. 475 – AN ACT RELATING TO HEALTH CARE COVERAGE FOR YOUNG ADULT CHILDREN: This bill proposes to require health plans to allow parents to pay an additional premium to cover an adult child on their health plan until the child is 30 years of age.

S. 109 - AN ACT RELATING TO PROVIDING DEFENSE SERVICES AND INDEMNIFICATION FOR THE PROVIDERS OF HOME SERVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES: This bill proposes to require the state to indemnify the providers of home services for individuals with disabilities for claims brought against the provider arising from actions of the individual with a disability, and to require the attorney general’s office to provide a legal defense for such claims.

S. 113 – AN ACT RELATING TO RIBICOFF ELIGIBILITY FOR MEDICAID: This bill proposes to ensure that youth who are eligible for Medicaid are enrolled.

S. 114 - AN ACT RELATING TO ENHANCING MENTAL HEALTH PARITY: This bill proposes to: (1) establish the goal of fully integrating mental health and substance abuse services with other health services, while establishing interim steps toward that goal; (2) prohibit the imposition of any type of greater burden in accessing mental health services, instead of prohibiting only financial burdens; (3) require deductible or out-of-pocket limits to be comprehensive for all services; (4) require that administrative and clinical protocols for provision of mental health and substance abuse services do not differ from those for other health services or create burdens to access; (5) require rulemaking to ensure consistency in requiring co-payments for routine and primary mental health care; (6) prohibit mental health carve‑out margins in excess of those for physical health; (7) require a health plan to set rates with mental health providers in the same manner as it sets rates with physical health providers; (8) require health plans to engage in mental health quality improvement projects, including one joint venture between all managed care plans and mental health review agents; (9) require health plans to demonstrate how collected data are being used to inform practices, policies, and the future direction of integration of services; (10) require health plans to demonstrate how quality improvement projects relate to the blueprint for health and chronic care initiative; and (11) support the priorities of the report of the Institute of Medicine, “Crossing the Quality Chasm (2006).”

S. 115 - AN ACT RELATING TO INCREASING TRANSPARENCY OF PRESCRIPTION DRUG PRICING AND INFORMATION: This bill proposes to increase transparency in prescription drug information and pricing by limiting fraudulent advertising of prescription drugs to consumers and health care professionals, requiring notice to clients by pharmacy benefit managers that certain types of contracts are available, strengthening the Medicaid preferred drug list, establishing an evidence-based education program, providing additional pricing information to the Medicaid program from drug manufacturers, requiring disclosure of education programs funded by drug manufacturers, and providing enforcement for prescription drug provisions under the Consumer Fraud Act.

S. 124 - AN ACT RELATING TO PLANNING AND EVALUATING OPTIONS FOR INPATIENT PSYCHIATRIC HOSPITAL SERVICES: This bill would provide for an independent evaluation by the general assembly of the options available to the state regarding the provision of inpatient psychiatric services now provided at the Vermont state hospital.

S. 125 - AN ACT RELATING TO ESTABLISHING A STATEWIDE ASSOCIATION CAPTIVE insurance company FOR MEDICAL MALPRACTICE INSURANCE: This bill proposes to establish a statewide association captive insurance company and require all health care providers and facilities to obtain medical malpractice insurance from this captive insurance company.

S. 126 - AN ACT RELATING TO THE CREATION OF A STATEWIDE DIRECT CARE PROVIDER REGISTRY: This bill proposes to require the department of disabilities, aging, and independent living to create and maintain a statewide direct care provider registry on the internet.

S. 128 - AN ACT RELATING TO ELIMINATING CERTAIN SUNSETS ON FORENSIC EXAMINATIONS AT DESIGNATED HOSPITALS: This bill proposes to eliminate the sunset on allowing court-ordered forensic examinations of criminal defendants at designated hospitals.

S. 139 - AN ACT RELATING TO REQUIRING VACCINATION AGAINST CERVICAL CANCER: This bill proposes to (1) require girls entering grade 6 to show evidence of HPV vaccination; (2) require those parents objecting on religious or moral grounds to sign a statement acknowledging receipt of information explaining the connection between the human papillomavirus and cervical cancer; and (3) appropriate funds to the Vermont department of health for purchase of HPV vaccines.

S. 140 - AN ACT RELATING TO CONFIDENTIALITY OF PRESCRIPTION INFORMATION: This bill proposes to ensure confidentiality of patient prescription records and prevent the use of this information for commercial purposes.

S. 141 - AN ACT RELATING TO SAFE PATIENT HANDLING: This bill would require hospitals and nursing home facilities to establish a safe patient handling program.

S. 142 - AN ACT RELATING TO A SCREENING PANEL FOR MEDICAL INJURY CLAIMS: This bill would establish screening panels for medical injury claims.

S. 95 - AN ACT RELATING TO SMALL BUSINESS ELIGIBILITY FOR CATAMOUNT HEALTH AND VHAP: This bill proposes to allow access to Catamount Health and the Vermont health access plan for small businesses and their employees without a 12-month waiting period.