Experts and advocates urge Vermont to use S197 to advance universal, publicly financed primary care

Experts, researchers and advocates told legislators on May 14 that S197, the state bill under consideration, offers a foundation for reshaping primary care but needs clearer commitments, broader definitions and stronger state leadership to reach the frontline clinicians and patients the law intends to help.

Dr. Elliot Fischer, a longtime primary care advocate, told the panel that S197’s payment‑reform elements — data collection, parity and a per‑member‑per‑month supplement — are “strong,” but warned that the bill should not require NCQA/PCMH certification as the sole condition for payment because certification can deliver money without ensuring the practices actually change care delivery. Fischer urged the committee to consider “a stronger commitment … to achieve universal access to advanced primary care,” and recommended that the Green Mountain Care Board, not AHS, lead the state’s payment‑reform report because the board’s public meetings would improve transparency and it has statutory authority to lead such work.

Dr. Song, a practicing primary care physician and researcher, told legislators that federal attempts to save primary care by adding fee‑schedule billing codes have repeatedly fallen short: many new codes are billed in fewer than 10% of eligible cases, he said, and codes alone do not deliver staff, infrastructure or time needed to provide the services behind the code. He described three recent federal code additions — a 2025 set of advanced primary care codes and three 2026 behavioral‑health integration codes — but cautioned that history shows low uptake when practices lack capacity or face onerous documentation requirements.

Drawing on state experiments, Dr. Song summarized evidence from Rhode Island, where primary‑care investment rose while total spending growth slowed largely because Rhode Island also instituted hospital price controls. He said the state’s primary‑care spending grew (an illustrative figure shown in testimony moved from about $48 million in 2007 to $84 million in 2023), with most new dollars delivered through non–fee‑for‑service payments.

As an alternative to relying on fee‑for‑service fixes, Dr. Song outlined a ‘‘primary care common fund’’ model that would pool existing purchaser dollars — Medicare, Medicaid, commercial plans, self‑insured employers and others — and direct them to practices on a per‑patient, per‑month basis off the fee schedule. He said that approach could touch more people, reduce administrative burden for practices, preserve consumer freedom to keep a PCP when changing jobs, and allow state choice about how to distribute funds. He emphasized the need for transparent governance, risk adjustment and targeted quality measures that reflect what patients value, naming continuity of care as a primary success metric.

Committee members raised familiar trade‑offs: fee‑for‑service avoids some risk‑adjustment problems but can reward volume; capitation or per‑member payments require careful risk adjustment and oversight to avoid panel‑size or access problems. A former billing manager testifying during the session said many codes go unused because documentation requirements are onerous and do not reflect the counseling clinicians already provide.

Public testimony from Ethan Park of Vermont Health Care for All pressed the committee to use S197 as a vehicle to move toward publicly financed primary care. Park recounted personal experience without insurance and urged several concrete changes to the bill: assign the Green Mountain Care Board (not AHS) to lead the primary‑care spending study; use the Vermont statutory definition of primary care at 33 V.S.A. §1823 (which includes mental‑health and substance‑use services) rather than a narrower model; break spending estimates out by payer categories (Medicare, Medicaid, commercial, federal, and out‑of‑pocket); and create an independent advisory commission (drawing on language from H.433) to recommend implementation steps after the cost study.

No formal votes occurred during the hearing. Committee members asked presenters and witnesses to provide written suggestions and promised to accept testimony and materials offline. The committee recessed to attend floor business and said it would return later that day.

The hearing foregrounded three decisions for the committee: who should lead the state’s primary‑care spending and payment‑reform work; whether to pursue non–fee‑for‑service approaches such as a common fund; and how S197 should define primary care and its success metrics. Lawmakers will next weigh written submissions and possible amendments before deciding whether to direct the Green Mountain Care Board or another body to produce the required reports.