Blue Cross urges rebalancing payments toward primary care as committee probes metrics and impacts

Courtney Harness, a representative of Blue Cross Blue Shield of Vermont, told the House Health Care committee on April 7 that the insurer supports F197’s goals of directing more resources to primary care while reducing administrative burden for providers.

“For the record, Courtney Harness, Blue Cross and Blue Shield of Vermont,” she said before introducing Dr. Wigle, the insurer’s chief medical officer, who laid out a plan to modernize reimbursement by rebalancing three payment “buckets”: fixed prospective payments (capitation) to support access and population health, variable value-based payments tied to measurable quality, and fee-for-service for individual encounters.

The witnesses argued the design could improve coordination among primary care, behavioral health and community resources, and better align payer models with state programs. Blue Cross said its existing Enhanced Community Provider Incentives program uses roughly 11 quality and cost metrics — including hypertension and diabetes control, cancer screening and total cost of care — paid as per-member-per-month amounts when providers meet thresholds.

“It’s not to build something new but to rebalance how dollars flow across the buckets over time,” Dr. Wigle told committee members, noting Blue Cross already operates in all three payment modes and has invested in statewide primary care infrastructure.

Committee members pressed for evidence that the scorecard and value-based payments change clinical outcomes and for protections against unintended effects. Representative Leslie asked what share of health spending goes to primary care; witnesses said they would follow up with an estimate and pointed to Green Mountain Care Board filings as a reference. Members also raised equity concerns: would practices serving sicker or more socioeconomically challenged populations be disadvantaged? Blue Cross said metrics are risk-adjusted and offered to provide outcome data and scorecards to the committee.

Blue Cross also described proposed hospital negotiations tied to broader redistribution, saying it has proposed reference caps in forthcoming 2027 hospital talks — for example, capping certain lab payments at about 300% of Medicare and some radiology payments at roughly 500% of Medicare rates — and acknowledged those proposals could materially affect hospital budgets and that some critical access hospitals report financial stress.

Several members questioned operational burdens. Committee members said scorecards, shoppable service guidance and more active patient steering could increase work for already stretched practices and patients with limited options. Members asked whether the design risks providers “gaming” measures or avoiding complex patients; witnesses said risk adjustment and program design are intended to limit those risks but agreed more detail and governance would be needed.

Blue Cross committed to sending the committee its scorecards, model details and outcome evidence. The presentation concluded with members urging the committee to weigh implementation supports, measurement cadence and protections for small and rural practices before adopting changes that would shift funding from hospitals and specialists into primary care.

The committee did not take a vote on F197 at the hearing; staff said witnesses would follow up with requested documentation for members to review.