S.88 Amended and Passed out of Senate Appropriations Committee

We understand that the there should be a vote on the Senate Floor this week, possibly Wednesday. We have just now received the final mark ups on the bill that passed (see attached and below). Stay tuned for more details as we get them (the Policy Committee will be putting up an analysis at www.workerscenter.org/newS.88.4.2.10 and you cna see our break down of the previously version here: http://www.workerscenter.org/newS.88 ).

If you have not contacted your Senators yet, please do now. You can email them by going to www.workerscenter.org/takeaction
Or you can call and leave them a message at the Sgt-at-Arms Office, 802-828-2228. Tell them you support healthcare is a human right and that you support a strong version of S.88 so that Vermont can lead the way in making helathcare a public good for all residents.

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TO THE HONORABLE SENATE:
The Committee on Appropriations to which was referred Senate Bill No. 88
entitled “An act relating to health care financing and universal access to health
care in Vermont” respectfully reports that it has considered the same and
recommends that the bill as amended by the Committee on Health and Welfare
be further amended as follows:
First: In Sec. 1(12), by striking the words “as a human right” at the end of
the sentence
Second: In Sec. 2(1), by inserting at the end of the subdivision, the
following sentence: All Vermonters must receive affordable and appropriate
health care at the appropriate time in the appropriate setting, and health care
costs must be contained over time.
Third: By striking Secs. 4 through 8 in their entirety and inserting new
Secs. 4 through 16 to read:
Sec. 4. 2 V.S.A. § 901 is amended to read:
§ 901. CREATION OF COMMISSION
(a) There is established a commission on health care reform. The
commission, under the direction of co-chairs who shall be appointed by the
speaker of the house and president pro tempore of the senate, shall monitor
health care reform initiatives and recommend to the general assembly actions
needed to attain health care reform.
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(b)(1) Members of the commission shall include four three representatives
appointed by the speaker of the house, four three senators appointed by the
committee on committees, and two nonvoting members appointed by the
governor, one nonvoting member with experience in health care appointed by
the speaker of the house, and one nonvoting member with experience in health
care appointed by the president pro tempore of the senate.
(2) The two nonvoting members with experience in health care shall not
be in the employ of or holding any official relation to any health care provider
or insurer, or engaged in the management of a health care provider or insurer,
or owning stock, bonds, or other securities thereof, or who is, in any manner,
connected with the operation of a health care provider or insurer. In addition,
these two members shall not render professional health care services or make
or perform any business contract with any health care provider or insurer if
such service or contract relates to the business of the health care provider or
insurer, except contracts made as an individual or family in the regular course
of obtaining health care services.
* * *
Sec. 5. APPOINTMENT; COMMISSION ON HEALTH CARE REFORM
Within 15 days of enactment, the speaker of the house, the president pro
tempore of the senate, and the committee on committees shall appoint
members of the joint legislative commission on health care reform as necessary
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to reflect the changes in Sec. 4 of this act. All other current members,
including those appointed by the governor, shall continue to serve their
existing terms.
Sec. 6. HEALTH CARE SYSTEM DESIGN AND IMPLEMENTATION
PLAN
(a)(1) By February 1, 2011, the joint legislative commission on health care
reform established in chapter 25 of Title 2 shall propose to the general
assembly and the governor at least two design options, including
implementation plans, for creating a single system of health care which insures
all Vermonters have access to and coverage for affordable, quality health
services through a public or private single-payer or multipayer system and that
meets the principles and goals outlined in Secs. 2 and 3 of this act.
(2) One option shall include the design of a government-administered
and publicly financed “single-payer” health benefits system decoupled from
employment which prohibits insurance coverage for the health services
provided by this system and allows for private insurance coverage only of
supplemental health services.
(3) Each design option shall include sufficient detail to allow the
governor and the general assembly to consider the adoption of one design
during the 2011 legislative session and to initiate implementation of the new
system through a phased process beginning no later than July 1, 2012.
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(4) The proposal to the general assembly and the governor shall include
a recommendation for which of the design options best meets the principles
and goals outlined in Secs. 2 and 3 of this act in an affordable, timely, and
efficient manner.
(b) No later than 45 days after enactment, the commission shall propose to
the joint fiscal committee a recommendation, including the requested amount,
for one or more outside consultants who have demonstrated experience in
health care systems or designing health care systems that have expanded
coverage and contained costs to provide the expertise necessary to do the
analysis and design required by this act. The joint fiscal committee may
accept, reject, or modify the commission’s proposal.
(c) In creating the design options, the consultant shall review and consider
the following:
(1) the findings and reports from previous studies of health care reform
in Vermont, including the Universal Access Plan Report from the health care
authority, November 1, 1993; reports from the Hogan Commission; relevant
studies provided to the state of Vermont by the Lewin Group; and studies and
reports provided to the commission.
(2) existing health care systems or components thereof in other states or
countries as models.
(3) Vermont’s current health care reform efforts as defined in 3 V.S.A.
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§ 2222a.
(4) the Patient Protection and Affordable Care Act of 2010, as amended
by the Health Care and Education Reconciliation Act of 2010; Employee
Retirement Income Security Act (ERISA); and Titles XVIII (Medicare), XIX
(Medicaid), and XXI (SCHIP) of the Social Security Act.
(d) Each design option shall propose a single system of health care which
maximizes the federal funds to support the system and is composed of the
following components, which are described in subsection (e) of this section:
(1) a payment system for health services which includes one or more
packages of health services providing for the integration of physical and
mental health; budgets, payment methods, and a process for determining
payment amounts; and cost reduction and containment mechanisms;
(2) coordinated local delivery systems;
(3) health system planning, regulation, and public health;
(4) financing and proposals to maximize federal funding; and
(5) a method to address compliance of the proposed design option or
options with federal law.
(e) In creating the design options, the consultant shall include the following
components for each option:
(1) A payment system for health services.
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(A) Packages of health services. Each design shall include one or
more packages of health services providing for the integration of physical and
mental health:
(i) all of which shall include access to and coverage for primary
care, preventive care, chronic care, acute episodic care, hospital services,
prescription drugs, and mental health services;
(ii) one or more may include coverage for additional health
services, such as home- and community-based services, services in nursing
homes, or dental or vision services;
(iii) one or more may be modeled after the health services offered
under Medicaid; and
(iv) all of which shall include a cost-sharing proposal.
(B) Administration. The consultant shall include a recommendation
for:
(i) a method for administering payment for health services, which
may include administration by a government agency, under an open bidding
process soliciting bids from insurance carriers or third-party administrators,
through private insurers, or a combination.
(ii) enrollment processes.
(iii) integration of the pharmacy best practices and cost control
program established by 33 V.S.A. §§ 1996 and 1998 and other mechanisms, to
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promote evidence-based prescribing, clinical efficacy, and cost-containment,
such as a single statewide preferred drug list, prescriber education, or
utilization reviews.
(iv) appeals processes for decisions made by entities or agencies
administering coverage for health services.
(C) Budgets and payments. Each design shall include a
recommendation for budgets, payment methods, and a process for determining
payment amounts. The consultant shall consider:
(i) amendments necessary to current law on the unified health care
budget, including consideration of cost-containment mechanisms or targets,
anticipated revenues available to support the expenditures, and other
appropriate considerations, in order to establish a statewide spending target
within which costs are controlled, resources directed, and quality and access
assured.
(ii) how to align the unified health care budget with the health
resource allocation plan under 18 V.S.A. § 9405; the hospital budget review
process under 18 V.S.A. § 9456; and the proposed global budgets and
payments, if applicable and recommended in a design option.
(iii) recommending a global budget where it is appropriate to
ensure cost-containment by a health care facility, health care provider, a group
of health care professionals, or a combination. Any recommendation shall
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include a process for developing a global budget, including circumstances
under which an entity may seek an amendment of its budget, and any changes
to the hospital budget process in 18 V.S.A. § 9456.
(iv) payment methods to be used for each health care sector which
are aligned with the goals of this act and provide for cost-containment,
provision of high quality, evidence-based health services in a coordinated
setting, patient self-management, and healthy lifestyles. Payment methods
may include:
(I) periodic payments based on approved annual global
budgets;
(II) capitated payments;
(III) incentive payments to health care professionals based on
performance standards, which may include evidence-based standard
physiological measures, or if the health condition cannot be measured in that
manner, a process measure, such as the appropriate frequency of testing or
appropriate prescribing of medications;
(IV) fee supplements if necessary to encourage specialized
health care professionals to offer a specific, necessary health service which is
not available in a specific geographic region;
(V) diagnosis-related groups;
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(VI) global payments based on a global budget, including
whether the global payment should be population-based, cover specific line
items, provide a mixture of a lump sum payment, diagnosis-related group
(DRG) payments, incentive payments for participation in the Blueprint for
Health, quality improvements, or other health care reform initiatives as defined
in 3 V.S.A. § 2222a; and
(VIII) fee for service.
(v) what process or processes are appropriate for determining
payment amounts with the intent to ensure reasonable payments to health care
professionals and providers and to eliminate the shift of costs between the
payers of health services by ensuring that the amount paid to health care
professionals and providers is sufficient. Payment amounts should provide
reasonable access to health services, provide sufficient uniform payment to
health care professionals, reduce unnecessary care, and encourage the financial
stability of health care professionals. The consultant shall consider the
following processes:
(I) Negotiations with hospitals, health care professionals, and
groups of health care professionals;
(II) Establishing a global payment for health services provided
by a particular hospital, health care provider, or group of professionals and
providers. In recommending a process for determining a global payment, the
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board shall consider the interaction with a global budget and other information
necessary to the determination of the appropriate payment, including all
revenue received from other sources. The recommendation may include that
the global payment be reflected as a specific line item in the annual budget.
(III) Negotiating a contract including payment methods and
amounts with any out-of-state hospital or other health care provider that
regularly treats a sufficient volume of Vermont residents, including contracting
with out-of-state hospitals or health care providers for the provision of
specialized health services that are not available locally to Vermonters.
(IV) Paying the amount charged for a medically necessary
health service for which the individual received a referral or for an emergency
health service customarily covered and received in an out-of-state hospital with
which there is not an established contract;
(V) Developing a reference pricing system for nonemergency
health services usually covered which are received in an out-of-state hospital
or by a health care provider with which there is not a contract.
(VI) Utilizing one or more health care professional bargaining
groups provided for in 18 V.S.A. § 9409, consisting of health care
professionals who choose to participate and may propose criteria for forming
and approving bargaining groups, and criteria and procedures for negotiations
authorized by this section.
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(C) Cost-containment. Each design shall include cost reduction and
containment mechanisms, which may include a fee assessed on insurers
combined with a global budget to streamline administration of health services.
(2) Coordinated local delivery systems. The consultant shall propose a
local delivery system to ensure that the delivery of health care in Vermont is
coordinated in order to provide health services to the citizens of Vermont, to
improve health outcomes, and to improve the efficiency of the health care
system by ensuring that health care professionals, hospitals, health care
facilities and home- and community-based providers offer patient care in an
integrated manner designed to optimize patient care at a lower cost and to
reduce redundancies in the health care delivery system as a whole. The
consultant shall consider the following models:
(A) mechanisms in each region of the state to solicit public input;
conduct a community needs assessment for incorporation into the health
resources allocation plan; a plan for community health needs based on the
community needs assessment; develop budget recommendations and resource
allocations for the region; provide oversight and evaluation regarding the
delivery of care in its region; and other functions determined to be necessary in
managing the region’s health care delivery system or furthering
cost-containment.
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(B) a regional entity organized by health care professionals and
providers to coordinate health services for that region’s population, including
developing payment methodologies and budgeting, incentive payments, and
other functions determined to be necessary in managing the region’s health
care delivery system or furthering cost-containment.
(3) Health system planning, regulation, and public health. The
consultant shall evaluate the existing mechanisms for health system and
facility planning and for assessing quality indicators and outcomes and shall
evaluate public health initiatives, including the health resource allocation plan,
the certificate of need process, the Blueprint for Health, the statewide health
information exchange, services provided by the Vermont Program for Quality
in Health Care, and community prevention programs.
(4) Financing, including federal financing. The consultant shall provide:
(A) an estimate of any additional costs for providing access to and
coverage for health services to the uninsured and underinsured, any estimated
savings from streamlining the administration of health care, and financing
proposals for sustainable revenue necessary for funding the system, including
by maximizing federal revenues.
(B) a proposal to the Centers on Medicare and Medicaid Services to
waive provisions of Titles XVIII (Medicare), XIX (Medicaid), and XXI
(SCHIP) of the Social Security Act if necessary to align the federal programs
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with the proposals contained within the design options, or to promote the
simplification of administration, cost-containment, or promotion of health care
reform initiatives as defined by 3 V.S.A. § 2222a; and
(C) a proposal to participate in a federal insurance exchange
established by the Patient Protection and Affordable Care Act of 2010, as
amended by the Health Care and Education Reconciliation Act of 2010 or for a
waiver from these provisions when available.
(5) A method to address compliance of the proposed design option or
options with federal law, including the Employee Retirement Income Security
Act (ERISA), if necessary.
(f)(1) The agency of human services, the department of health, and the
department of banking, insurance, securities, and health care administration
shall collaborate to ensure the commission and its consultant have the
information necessary to create the design options.
(2) The consultant may request legal and fiscal assistance from the
office of legislative council and the joint fiscal office.
(3) The commission or its consultant may engage with interested parties,
such as health care providers and professionals, patient advocacy groups, and
insurers, as necessary in order to have a full understanding of health care in
Vermont.
(g)(1) By January 1, 2010, the commission or its consultant shall release a
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draft of the design options to the public and provide 15 days for public review
and the submission of comments on the design options. The commission or its
consultant shall review and consider the public comments and revise the draft
design options as necessary prior to the final submission to the general
assembly and the governor.
(2) In the proposal and implementation plan provided to the general
assembly and the governor, the commission shall include an analysis of each
design option as compared to the current state of health care in Vermont,
including:
(A) the costs of providing health care to the uninsured and
underinsured in Vermont;
(B) any potential savings from creating an integrated system of health
care;
(C) the impacts on the current private and public insurance system;
(D) the expected net fiscal impact on individuals and on businesses
from the modifications to the health care system proposed in the design;
(E) impacts on the state’s economy;
(F) the pros and cons of alternative timing for the implementation of
each design, including the sequence and rationale for the phasing in of the
major components; and
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(G) the pros and cons of each design option and of no changes to the
current system.
* * * Immediate Cost-Containment Provisions * * *
Sec. 7. HOSPITAL BUDGETS
(a) The commissioner of banking, insurance, securities, and health care
administration shall implement this section consistent with 18 V.S.A. § 9456,
with the goals identified in Sec. 50 of No. 61 of the Acts of 2009, and with the
goals of systemic health care reform, including the goals of containing costs,
ensuring solvency for efficient and effective hospitals, and promoting fairness
and equity in health care financing. In addition to the commissioner’s
authority under subchapter 7 of chapter 221 of Title 8 (hospital budget
reviews), the commissioner of banking, insurance, securities, and health care
administration shall target hospital budgets for fiscal years 2011 and 2012
consistent with the following:
(1) Except as provided in subdivision (5) of this subsection, the total
systemwide rate increase for all hospitals reviewed by the commissioner shall
not exceed 4.0 percent;
(2) Except as provided in subdivision (5) of this subsection, the total
systemwide net patient revenue increase for all hospitals reviewed by the
commissioner shall not exceed 4.5 percent;
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(3) Except as provided in subdivision (5) of this subsection, the total
systemwide hospital operating margin percentages shall not exceed those
percentages allowed in fiscal year 2010;
(4) Consistent with the goals of lowering overall cost increases in health
care without compromising the quality of health care, the commissioner may
restrict or disallow specific expenditures, such as new programs. In his or her
own discretion, the commissioner may identify or may require hospitals to
identify the specific expenditures to be restricted or disallowed.
(5) The commissioner may exempt hospital revenue and expenses
associated with health care reform and other expenses, such as all or a portion
of the provider tax, from the limits established in subdivisions (1) through (3)
of this subsection if necessary to achieve the goals identified in this section.
The expenditures shall be specifically reported, shall be supported with
sufficient documentation as required by the commissioner, and may only be
exempt if approved by the commissioner.
(b) Consistent with this section and the overarching goal of containing
health care and hospital costs, and notwithstanding 18 V.S.A. § 9456(e) which
permits the commissioner to exempt a hospital from the budget review process,
the commissioner may exempt a hospital from the hospital budget process for
more than two years consecutively. This provision does not apply to a tertiary
teaching hospital.
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(c) Upon a showing that a hospital’s financial health or solvency will be
severely compromised, the commissioner may approve or amend a hospital
budget in a manner inconsistent with subsection (a) of this section.
Sec. 8. 18 V.S.A. § 9453(c) is added to read:
(c) The commissioner’s authority shall extend to affiliated corporations or
similar affiliated entities of the hospital as defined by subdivision 9402(13) of
this title to the extent that the commissioner reasonably believes that the action
is necessary to carry out of the purposes of this subchapter.
Sec. 9. 18 V.S.A. § 9456(h)(2) is amended to read:
(2)(A) After notice and an opportunity for hearing, the commissioner
may impose on a person who knowingly violates a provision of this
subchapter, or a rule adopted pursuant to this subchapter, a civil administrative
penalty of no more than $40,000.00, or in the case of a continuing violation, a
civil administrative penalty of no more than $100,000.00 or one-tenth of one
percent of the gross annual revenues of the hospital, whichever is greater. This
subdivision shall not apply to violations of subsection (d) of this section caused
by exceptional or unforeseen circumstances.
(B)(i) The commissioner may order a hospital to:
(I)(aa) cease material violations of this subchapter or of a
regulation or order issued pursuant to this subchapter; or
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(bb) cease operating contrary to the budget established for
the hospital under this section, provided such a deviation from the budget is
material; and
(II) take such corrective measures as are necessary to remediate
the violation or deviation and to carry out the purposes of this subchapter.
(ii) Orders issued under this subdivision (2)(B) shall be issued
after notice and an opportunity to be heard, except that where the
commissioner finds that a hospital’s financial or other emergency
circumstances pose an immediate threat of harm to the public or to the
financial condition of the hospital. Where there is an immediate threat, the
commissioner may issue orders under this subdivision (2)(B) without written
or oral notice to the hospital. Where an order is issued without notice, the
hospital shall be notified of the right to a hearing at the time the order is issued.
The hearing shall be held within 30 days of receipt for the hospital’s request
for a hearing, and a decision shall be issued within 30 days after the conclusion
of the hearing. The commissioner may expand the time to hold the hearing or
render the decision for good cause shown. Hospitals may appeal any decision
in this section to superior court. An appeal shall be on the record as developed
by the commissioner in the administrative proceeding, and the standard of
review shall be as provided in 8 V.S.A. § 16.
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Sec. 10. REPEAL
18 V.S.A. § 9439(f) (annual review cycles of certificate of need
applications) is repealed on July 1, 2010.
Sec. 11. INSURANCE REGULATION; INTENT
It is the intent of the general assembly that the commissioner of banking,
insurance, securities, and health care administration use the insurance rate
review and approval authority to control the costs of health insurance unrelated
to the cost of medical care where consistent with other statutory obligations,
such as ensuring solvency. Rate review and approval authority could include
imposing limits on producer commissions in specified markets or limiting
administrative costs as a percentage of premium.
Sec. 12. 8 V.S.A § 4080a(h)(2)(D) is added to read:
(D) The commissioner may require a registered small group carrier to
identify that percentage of a requested premium increase which is attributed to
the following categories: hospital inpatient costs, hospital outpatient costs,
pharmacy costs, primary care, other medical costs, administrative costs, and
projected reserves or profit. Reporting of this information shall be at the time
of seeking a rate increase and shall be in the manner and form as directed by
the commissioner. Such information shall be made available to the public in a
manner that is easy to understand.
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Sec. 13. 8 V.S.A § 4080b(h)(2)(D) is added to read:
(D) The commissioner may require a registered nongroup carrier to
identify that percentage of a requested premium increase which is attributed to
the following categories: hospital inpatient costs, hospital outpatient costs,
pharmacy costs, primary care, other medical costs, administrative costs, and
projected reserves or profit. Reporting of this information shall be at the time
of seeking a rate increase and shall be in the manner and form as directed by
the commissioner. Such information shall be made available to the public in a
manner that is easy to understand.
Sec. 14. GRANT FUNDING
The staff director of the joint legislative commission on health care reform
shall apply for grant funding, if available, for the design and implementation
analysis provided for in Sec. 4 of this act. Any amounts received in grant
funds, up to the amount appropriated in Sec. 15 of this act, shall offset the
general fund appropriation by allowing any remaining general funds
appropriated to revert to the general fund or reducing future general fund
appropriations. Any grant funds received in excess of the appropriated amount
may be used for the analysis.
Sec. 15. APPROPRIATION
The amount of $250,000.00 is appropriated from the general fund to the
joint fiscal office in fiscal year 2011 to accomplish the purposes of this act.
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Sec. 16. EFFECTIVE DATE
(a) This section and Secs. 1 through 6 and 14 of this act shall take effect
upon passage.
(b) Secs. 7 through 13 and 15 shall take effect on July 1, 2010.
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(Committee vote: ___________)
_______________________
Senator Kitchel
FOR THE COMMITTEE

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Comments

I have the recordings of these proceedings when this was bill was modified. They are on Faried's server at: http://www.faried.com/~vwc/files/ The recordings, straight from room #17, the Senate Health and welfare Committee Room are the links that begin with S.88 Amendment Hearings... There are two of them, #15 and #16 amr. If nothing else they are fun to listen to as the senators and the legislative counsel, Robin Lunge, who reads all the bills, joke with each other. Racine has a wonderful wry sense of humor. But they are also quite serious and Racine gets testy at times.

For each of these hearings the rooms are packed with health insurance lobbyists, the health reform commission, us, vpirg, Vermont For Single Payer, Bischa, and other groups. Usually it is standing room only, with people crammed into any open space. Senators that come in late have to crawl over everyone to get to their seats. When pages come in to deliver the notes they can pass through several sets of hands to get to the senator; the room is too crowded to move through. It's all because of us and what we're doing that this happens:)

Faried and I are putting more up on his server. Stay tuned.