Presenter: 2018 analysis shows primary care accounted for about 6–10% of Vermont health spending; lawmakers press on targets and implementation

A legislative committee reviewing S.197 heard a presentation on a Green Mountain Care Board report that measured primary care spending using 2018 all‑payer claims and non‑claims data. Alina Barabby, identified in the transcript as director of policy at Dreamman Care Board, told members the analysis — prepared under Act 17 of 2019 and done jointly with D.VA — found primary care accounted for between 5.9% and 10.2% of total health care spending in 2018. "That report found that between 5.9 and 10.2% of healthcare spending is on primary care," Barabby said.

Committee members pressed Barabby on the report's definitions and methods. The Vermont definition used in the analysis included family medicine, internal medicine, general practice, pediatrics, nurse practitioners, physician assistants, naturopaths, OB/GYNs and osteopaths and covered services such as office visits, preventive care, care management, mental health and substance‑use treatment. Barabby said identifying clinicians by claims is imperfect: "there isn't a great way to identify those kinds of clinicians" when they work in specialty settings, and newer methods allocate based on claims patterns or workplace affiliation.

Members raised the data vintage and scope. Barabby confirmed the analysis used 2018 data because of claims lag, and she said some non‑claims spending could not be allocated and therefore is excluded from the estimate. Asked about the dollar implications of the percentages, Barabby cited a 2018 total cost of care figure used in the report of roughly $2.63 billion; applying the report's percent ranges yields the rough primary care dollar amounts, though she cautioned allocations depend on whether the measure covers only people who accessed care or the whole population.

The presentation compared Vermont to other New England states. A regional NESCO report using narrow and broad definitions found Vermont had relatively low commercial primary care spend (4.9% on the narrow definition versus Massachusetts at 8%), with variation by definition. Barabby also said Medicaid showed the highest share of primary care spending in the analysis — in part because mental health and SUD treatment were included — while Medicare's share was lower (about 5.5–6.5%), and she warned comparisons across payers can be "a little bit apples to oranges." "We are likely comparing apples to oranges a little bit," she said.

Members asked how the report ties into payment reform and S.197. Barabby said the analysis served as a baseline used in ACO/"ahead" negotiations and that states take different approaches — some set primary care spend targets inside rate review or payment models. She suggested that Agency of Human Services and Blueprint for Health would be partners for designing a payment model, and that the Green Mountain Care Board already has some authority to review rates but would need funding and staff to implement a formal rate‑setting program.

A committee member cited a 2016 board estimate that implementing a fee‑for‑service rate‑setting program could cost up to $2.3 million, depending on complexity and structure. Members also discussed provider payment levels: testimony referenced existing PMPM payments of about $63 plus $5 (total $68) and anecdotal pediatrician requests near $100 PMPM; Barabby noted compensation is often mixed — "you can have hybrid models where you have per member per month for some services and carve out fee for service for others."

A speaker identifying as representing the Medical Society urged moving beyond measurement to setting a goal and making measurable progress year to year. Committee members noted other states have set targets in the 12–15% range and that some advocates propose higher levels; Barabby and members cautioned that international comparisons reflect broader social investments (education, housing, food security) and that any target should be tied to a clear policy goal and feasible implementation plan.

The session closed with members asking staff to clarify remaining data gaps and resources needed to operationalize any spending target or rate‑setting function. No formal vote or motion was recorded in the transcript.