 Good afternoon everyone and welcome to the Green Mountain care board meeting. My name is Kevin Mullin chair of the board And I'm about to convene this this afternoon's meeting The first item on the agenda will be the executive directors report Susan Barrett Thank you, Mr. Chair. I first want to announce some upcoming meetings So this evening we the board will conduct its primary care advisory group meeting Starting at 5 p.m. And the and it goes till 7 the link is on our Website and then next week. I just want to remind folks that we'll be hearing From and we'll have an all-day meeting. It's starting at 11. We're gonna take a break at about one and then come back at We'll probably work until the first session is over and then we'll come back in the afternoon We're gonna hear on as related to our sustainability planning with the hospitals per 159 of 2020 in the morning. We're gonna hear about Price and costs in the hospital and then in the afternoon. We're going to hear about the capacity and quality So I just wanted to remind the board and the public that that will be happening next Wednesday And again note this the time starting at 11 a.m. I also wanted to announce a public forum that the state is conducting and in conjunction with this let folks know that there is a new website on the Department of Financial Regulation website that is a link to the Issue on wait times and the investigation that the state is pursuing On this website, you will see that there are two listening sessions occurring The first one takes place again next Wednesday busy day for state folks starting at 5 30 in the evening and going till 7 30 and then the next one is at on November 4th and that starts at 12 and goes to 2 the links are available Both on the link to the website on DFR is available on our GMCB website, but I'd encourage folks to take a look at the information There's also a landing page where consumers can share their stories of wait times if they have them and I just wanted to draw everyone's attention to that. I know The Jessica Holmes board member Holmes will be at those listening sessions representing the Green Mountain Care Board And then last but not least, we do have several public comments periods ongoing. So I want to announce those as a reminder. First, we've opened on a public comment period on the draft health care workforce strategic plan, which we will hear from the director of health care reform momentarily on that. That is that public comment period opened on October 15th And we will close that on Monday, November 1st, 2021. We'll also be sharing the draft health care workforce strategic plan plan with our upcoming general advisory committee meeting, which I forgot to announce, which is Monday, October 25th. The next public comment is on the prescription drug technical advisory meeting or subgroup. We had a meeting last week where they were a subgroup put forth some of their recommendations. So we are offering a public comment on that information as well. And that goes until October 25th. The next is regarding the FY 22 guidance and reporting requirements for Medicare only non certified accountable no organizations that public comment period ended yesterday. And I know, Russ McCracken will address the results of that in his presentation. And then we also have before us the one care Vermont FY 22 budget and we are accepting public comment. We open that on October 1st. We'll accept public comment until November. I'm looking at the state here. Our presentation for to the board is November 10th from staff. So we want to make sure if you do have public comment you get that in before the 10th. And then last but not least, we have an ongoing public comment period on the potential next agreement with the federal government on the on an all pair model. The administration. You just went silent Susan. Somebody muted me. I was going on too long. Well, you've heard this one several times from the I announced at every meeting that we are conducting an ongoing public comment on a potential next agreement. And we are sharing any of those comments with our partners at H.S. and the governor's office as they are leading that those negotiations. And I am finally done. Thank you, Mr. Chair. Thanks, Susan. The next item on the agenda are the minutes of Wednesday, October 13th and Friday, October 15th. Is there a motion? I move them. Second. It's been moved and seconded to approve the agendas of Wednesday, October 13th and Friday, October 15th without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. Let the record show that the motions were approved unanimously. So now we're going to get down to really the heart of today's meetings. And I did want to at least call out one member who has joined us today. And that is Beth Stearns from Senator Sanders office. And Senator Sanders has been very dedicated to workforce issues, especially when it comes to nursing. And we at the Green Mountain Care Board have pledged to work with him as he strives to do what can be done. He's taken some great steps such as trying to triple fund the National Health Corp and putting $14 million more into GME dollars. And so Beth, we're very grateful that you're able to attend today. And we look forward to continuing to work with you to try to make sure that there is an adequate workforce in Vermont. Great. Thank you. I'm interested to hear the presentation today. So thanks so much. And with that, I'm going to tee up the presentation which we're about to hear from Ina Bacchus. Ina has been tirelessly working on the strategic plan for workforce development in healthcare. And she's had a lot of help with some great people that she pulled together to work with her on this. And I know that, for example, Vaz has participated as have many, many others. And I know that Ina's grateful for all that help. And what we have in front of us to review is really something that I've been waiting to see for a while. And I just want to thank Ina in advance for all the work that she's done to date. And it's something that, you know, too often people just believe that there is a shortage of workers period and healthcare doesn't always rise to the top. And yet we end up paying in healthcare no matter what. We pay in both dollars and we also pay in quality. So at current, we've heard that some people, including Ina's boss, are paying $200 an hour for travelers. And that just doesn't seem to make a lot of sense. And yet our hospitals can't turn somebody away at the door. They have to treat everyone that comes in. And so they're forced to hire travelers at a much higher cost. So we're paying for it in terms of what we're paying for healthcare. And we're paying for it in quality. These travelers are incredibly dedicated professionals, but when you're not a long term worker in your setting, you don't know the equipment as well as somebody that is. You don't know what other services are available in the area and a whole slew of things that draws down on the quality. So anything that we can do to grow our own supply of healthcare professionals in the state of Vermont is so essential. And with that, I'm going to turn it over to Ina Bacchus. And I know Ina that everyone is anxiously awaiting to hear what you have to say. So welcome. Thank you. It's good to see everyone. And thank you for the introduction, Chair Mullen. I do have a lot of gratitude for the advisory group that worked to inform this plan for workforce development, healthcare workforce development in the state of Vermont, as well as the many professionals from across state government that also contributed to this plan in an informal capacity. And specific to their expertise in a variety of ways. And Chair Mullen, your attention on this issue over the years is also much appreciated. You've been an outspoken proponent and supporter of healthcare workforce development activities. And that is certainly appreciated and this strategic plan, I hope will help to bring us forward in the coordinated approach to address the healthcare workforce issues today. Shall I share my materials or will they be shared on my behalf? Which would you prefer? Either way. Well, if you're comfortable driving, go ahead and drive. Absolutely. I'll do that. Can everyone share, see my screen? Yes, we can. Is it, I can move it into the slideshow mode if that would be better? It would be better. Yeah. Okay. Perfect. Okay. Act 155 of 2020 was an act relating to increasing the supply of nurses and primary care providers in the state of Vermont. And this legislation established that the director of healthcare reform in the agency of human services shall maintain a current healthcare workforce development strategic plan. The key word here being current. And so this, this strategic plan here is now a current strategic plan version as the board well knows the last workforce development strategic plan that it approved was in 2013, I believe. The in establishing and maintaining the current strategic plan, the director should consult, shall consult when an advisory group composed of 11 members. Here are the members of the advisory group for your review. The membership did need to include one member of the Green Mountain Care Board's primary care advisory group, a representative of the Vermont state colleges, the area health education centers workforce initiative, federally qualified health centers, representative of Vermont hospitals of Vermont physicians of mental health professionals, dentists, naturopathic physicians, home health agencies, long term and long term care facilities. And Act 155 required that the director of healthcare reform or designee chair this advisory group in service of creating the healthcare workforce development strategic plan. As I already mentioned, I'm very grateful for those who participated in the development of this plan from different areas of state government, as well as those who participated informally in the group, not as advisory members but joined discussions at different periods of time. Are you seeing the slides advance? We're still on the advisory advisory group membership slide. Oh, am I? There we go. The advisory group explored a large range of topics related to workforce development, including a comprehensive assessment of workforce development challenges and opportunities in the following areas of coordination, data and monitoring, financial incentives, education and training, regulation, practice, recruitment and retention and federal policy. As I said, or as I may not have said the plan is really focused on nurses, primary care physicians, dental care providers, mental health and substance use disorder treatment professionals that are working in all settings, including acute care, long term care, medical office settings, in-home settings, community based settings, dental and mental health at substance use disorder treatment settings. We acknowledge in the plan that future work is necessary to delve more deeply into the barriers for non-licensed allied health, direct support professionals, persons working as personal care attendants and home care aides, peers and community health workers. These workers are also in short supply in the health care workforce and are absolutely essential to the workforce. So we in the plan make clear that in addition to some recommendations related to this cohort of the workforce that further work is also needed in this area. The strategic plan builds on and updates recommendations from the Rural Health Services Task Force Workforce Subcommittee Report of 2020. So you're also familiar with that report and that report really served as a critical anchor and starting place for our group's work, particularly given the proximity and time between the advisory group's work and the work of the Rural Health Services Task Force Subcommittee. As well, there was significant overlap in the participants in those groups. So we were able in some senses to pick up where those recommendations left off. In the category of coordination of healthcare workforce development activities in the state of Vermont, the report makes two recommendations. And these recommendations are very much necessary in order for the later recommendations in the strategic plan to be organized in such a way where there is accountability and coordination for accomplishing those recommendations. So we recommend that there be an interagency task team from the state of Vermont and that at a minimum this task team should include the Agency of Human Services, the Agency of Administration, the Agency of Commerce and Community Development, the Department of Labor, the Agency of Education and the State Chief Prevention Officer. As you'll see as we work through the recommendations in the plan, many of the recommendations do rely on coordination among different actors in state government as well as in the private sector. And we believe that a team that is identified to coordinate with one another as well as with the healthcare workforce is a critical component to carrying out these recommendations. We also recommend that the State Workforce Development Board be integrated with or rather that the Healthcare Workforce Development Advisory Group be integrated with the State Workforce Development Board to ensure alignment with overall workforce development initiatives and to certainly ensure that the healthcare workforce needs are clearly reflected. The Healthcare Workforce Strategic Plan Advisory Group would serve as an official subcommittee to the State Workforce Development Board and the advisory group would be integrated in a manner to ensure that the strategic plan implementation is aligned with broader workforce development initiatives in the state of Vermont. Healthcare Workforce Data resides in numerous places. This is a theme that is carried through in revisiting past workforce development strategic plans, workforce development reports in this state of Vermont that healthcare data resides in numerous places within state government and outside of state government. And further, there are some significant gaps in the healthcare workforce data that exists today. I mentioned earlier the importance of supporting activities for the non-licensed healthcare provider, non-licensed care providers in the state. Those are a key example of data that we do not have at this time. Data about non-licensed direct care providers doesn't exist in a way where it can be incorporated with a larger set of data. Data to describe demand, such as employer vacancies, retirement projections, et cetera, are not clearly integrated in a view of healthcare workforce data. We recommend that a lead entity is identified as the healthcare workforce data hub and that this data hub would be responsible for aggregating all relevant workforce data, including data from Vermont's talent pipeline. The entity identified data gaps, such as what I just named, as well as other data gaps that may exist regarding healthcare workforce data, and that this entity issue regular monitoring reports no more than every two years to inform policymakers and others about the status of Vermont's healthcare workforce. Further, we recommend that supply and demand modeling be employed in the state of Vermont to track healthcare workforce. The healthcare workforce data hub should explore and recommend an ongoing process and necessary funds for healthcare workforce supply and demand modeling for use by healthcare employers, healthcare educators, and policymakers. This supply and demand modeling could become an input to your own health resource allocation plan as an example of its use by policymakers and regulators. The next category or domain for recommendations in the report is the category of financial incentives for healthcare workers living and working as permanent employees in Vermont. These recommendations really break out into two categories. As you can see here, offsetting educational costs, so financial incentives and offsetting educational costs, as well as financial incentives that would promote permanent healthcare employment and residency in Vermont. The cost of education for healthcare providers is a barrier to growing the pool of healthcare professionals working in our state. There are existing programs. I'm hearing a little echo. Tom, it's your screen that's flashing blue, so maybe Tom, you could put yourself on mute. Go ahead, Ina. Thank you. And as I was describing, certainly the cost of education was cited as a key barrier for healthcare providers and barrier for growing the pool of healthcare providers working in the state. We have existing programs of loan repayment that include service agreements where the recipients are required to practice in the state of Vermont. In this model, the programs are already highly subscribed. They are competitive programs and not all applicants receive or will receive awards. In 2019, only 59% of applicants received awards. The funding through these loan repayment programs has largely been allocated for MDs and APRNs. As you're aware, healthcare employers are increasingly related to the educational costs. Related to promoting permanent healthcare employment and residency in Vermont, healthcare employers are increasingly relying on costly traveling staff to ensure access to care for Vermonters. By the end of 2021, Vermont's hospitals are projecting to have spent more than $75 million on non-employed temporary traveling staff that are hired through staffing agencies. In a communication to the advisory group, the Vermont Association of Hospitals and Health Systems reported that Vermont providers continue to leverage staffing agencies more than ever. I think you heard this in your discussions of the hospital's budgets. The use of travelers for hospitals has increased and the total costs associated with these services has increased 50% from $50 million to $75 million that I share. Skill nursing facilities are another example and there are many other examples of healthcare providers that are relying on costly traveling staff. Chair Mullen, as you mentioned at the start of this report. And so these recommendations are, again, both recommendations to offset educational costs and recommendations to promote healthcare employment and residency in the state of Vermont. In terms of broadening, so the first recommendation to broaden and expand loan repayment. We recommend that based on an evaluation of existing data and potential new sources of data that the area health education center should develop a proposal for expanding its service based loan repayment program to include more healthcare professionals and professional types and to increase the current program offerings. Recommendations should include the funding necessary to increase loan repayment programs as well as the funding necessary for including additional professional types. Increasing scholarship funding created by Act 155 of 2020 and identifying a permanent funding source is also a recommendation. Act 155 of 2020 not only created this advisory group, but also created new scholarship programs for nursing and primary care professionals that are also contingent on service agreements. I think that service agreements that are tied to financial incentives are incredibly important for ensuring that those who receive assistance are then practicing in the state of Vermont as healthcare providers for a given period of time. The interagency task team implemented per the recommended, the interagency task team, which we recommend be established, it should recommend whether and how the scholarship and service opportunities should be expanded to more healthcare professional types and recommend an ongoing funding source. We also recommend evaluating the effectiveness of the existing scholarship program available to Vermonters who attend dental school. And here the Vermont Department of Health in collaboration with the Vermont Student Assistance Corporation and AHEC should evaluate and revise the dental scholarship program as needed to align with other pipeline and recruitment strategies. And the final recommendation in the offsetting of educational costs category is to make financial assistance options for healthcare workforce clear, transparent and easy to find. And this is especially true in light of some recent changes and potential changes to the availability of funding opportunities such as the public service loan forgiveness program, as well as the very recent, although changes in terms of National Health Service Corps funding that is available. Now, to the promoting permanent healthcare employment and residency in Vermont, we recommend that we revisit the tax incentive proposals that have been made by the administration. The tax, the state interagency task team should evaluate incentives utilized by other states to recruit young professionals and healthcare workers to live and work as permanent residents of a state. This includes ideas or existing programs such as the main opportunity tax credit, the governor's nurse retention tax incentive which I just referenced, and the potential for multi-year tax exemptions. The team should also consider tax exemption for preceptor income to encourage more healthcare professionals in Vermont to participate in educating new professionals. Further, the task team should consider whether tax incentives should be offered to employers who are offering housing or other benefits to permanent full-time employees. And the task team should recommend to the legislature whether an expanded tax incentive model holds potential for recruiting a broader set of healthcare professionals to live and work as permanent employees in the state. The advisory group in this report also recommend that there be work to identify the financial barriers to recruitment and retention of the non-licensed workforce. Also, the interagency task team should also look at this issue to understand what barriers exist for the non-licensed professional workforce to participate in the healthcare field in Vermont. And consideration should be given here for benefits, glyphs, housing costs, transportation, childcare, and competition from other industries. We also recommend that there be consideration of one-time funds for employers to attract permanent employees. Specifically, the state interagency task team should identify funds to be made available to a range of healthcare employer types to offer incentives such as sign-on bonuses, retention bonuses, relocation assistance, and housing support for permanent employee staff. In this proposal, we would expect that these types of benefits be linked to service agreements again or contracts with healthcare employers so that the workforce is dedicated to working in Vermont for a set period of time. We also recommend consideration for a longer term grant incentive program. Again, the task team should evaluate what opportunities there might be for a longer term grant incentive program to entice healthcare professionals to seek permanent employment and residency in Vermont. A program like this could be modeled after or could expand on the remote worker grant program. Moving now to the recommendations in the education and training domain, there are not enough clinical educators and preceptors to educate healthcare workers in the state of Vermont. I think likely, Chair Mullen, that that is something you've discussed before with the board. There are more persons who want to work in Vermont in the healthcare professionals than can be educated in our current system. Precepting places significant demands on healthcare organizations and preceptors are not adequately compensated for the one-on-one instruction that they provide to students in the healthcare professions. And more opportunities can also be created to streamline the path of licensure for nurses specifically so that employees can work and earn. I think there's also a big topic of discussion as well in our advisory group was really around how we support people in moving through the healthcare pipeline and at any point in the healthcare pipeline as well. And so there are certainly activities that can streamline advancement through the nursing career ladder and also that can provide for upskilling of existing staff. As an example, the Legislature appropriated funding for a joint project between VTC and skilled nursing facilities to create new LPN slots designated for current LPNs that are working in facilities. These individuals can continue working while participating in educational programming that would be provided on site in nursing facilities across the state. And these facilities were the program provides for funding to cover tuition and fees necessary for prerequisite courses and the LPN program as well as a stipend for those students, those students who would need to reduce their work in order to accomplish their course work. So the recommendations in this arena include increasing enrollment in nursing programs. And here we recommend that the Office of Professional Regulation facilitate a work group between schools of nursing and clinical sites and clinical sites and healthcare organizations to establish a preceptor model of clinical training to maximize opportunities for student nurses to obtain required clinical time and minimize the need for nursing programs to recruit additional faculty. The work group should consider preceptorships across the care continuum, including home and community-based settings. The work group should also evaluate any gaps in compensation between academic faculty and practitioners, identify possible solutions and make any further recommendations necessary, including funding. The work group should also consider how nurses transitioning to retirement could be incentivized to work as nurse educators. And the work group should identify any additional barriers to increasing enrollment in nursing programs in the state of Vermont. The advisory group also recommends support for transition to practice programs for professional roles. Here we recommend that the State Interagency Task Team explore American Rescue Plan Act funding to make startup investments in transition to practice programs. These investments will offset the cost of hiring new graduate clinicians and support infrastructure and instructors. The State Interagency Task Team should evaluate the opportunities for ongoing program funding. Organizations seeking funds for transition to practice programs would be required to complete an application and participate in a selection process. You really heard clearly that it's difficult for employers to bring on new graduates because those graduates really do require a time of training and residency in order to be integrated and as successful as possible in the field. Without this time and dedicated resources for this work, it can lead to frustration and burnout for these new nurse graduates who are entering the workplace really for the first time. We also recommend strengthening incentives for preceptors for all professions. Here the University of Vermont College of Medicine in collaboration with primary care physicians should identify and implement appropriate incentives for preceptors such as payments for teaching, access to training and career advancement faculty appointments or preceptor income tax exemption. We also recommend that as leading the University of Vermont College of Medicine explore opportunities to expand family practice residency programs. This work in collaboration with primary care physicians should convene a work group to explore opportunities to expand and fund family practice residency training and retention opportunities with an emphasis on increasing the number of family medicine physicians who are trained and remain in Vermont. We also recommend modifying the curriculum to introduce primary care earlier in medical school. The University of Vermont College of Medicine should modify the curriculum so that medical students see more emphasis on primary care. For example, students should start rotation with primary care early on in their programs and continue that into the second or third year. We also recommend establishing a physician assistant education program. Here the Vermont State Colleges should study and provide a report to the legislature on the potential to offer a physician assistant education program including an analysis of employer demand for the program. The study should include a timeline to implement and identify the financial resources necessary to develop, equip the staff and operate such a program. And this should include a timeline to obtain accreditation and set up the first cohort. We also recommend modifying the curriculum to prepare students for work in interdisciplinary teams across the continuum of care. And here the state colleges and other institutions offering nursing curricula in Vermont should modify curriculum where necessary to prepare students for practice across the continuum of care including the settings where we've really including all of the settings of care that this report emphasizes. We also recommend developing and identifying strategies to streamline the advancement through the nursing career ladder and up skill staff. And here we recommend convening health care providers, including hospitals, long term care facilities and home health agencies and higher education programs to develop and identify needs for on site delivery of training and education programs to up skill existing staff and to identify ways to streamline advancement through the nursing career ladder. The advisory group and this plan also recommends that we ensure that health care career education is offered to all students before leaving middle school. Here we task the agency of education with recommending a strategy to introduce all students to health care careers prior to leaving middle school. We also recommend advertising and recruiting for existing apprenticeship opportunities that are already available and supported by the Department of Labor. And moving now to to recommendations about regulatory changes that could facilitate expanding the health care workforce in the state of Vermont. The Office of Professional Regulation is and has been an essential partner in creating clear pathways to clinical practice for health care professionals. And so either a number of recommendations here for the Office of Professional Regulation in this effort. The first is to advertise and promote the uniform process for endorsement as the fast track for health care professional licensure for all OPR regulated professions. This is a very exciting opportunity to collaborate with health care employers as well as the agency of commerce and community development to include the fast track in how we talk about health care employment opportunities in Vermont as well as in pretend the think program. The fast track for health care professional licensure should be widely advertised. The fast track endorsement allows someone who is practicing in another state for three years to quickly be licensed in Vermont. The applicability of this avenue should be emphasized for those mental health and substance use disorder treatment professionals as well as other regulated health care professionals. But this is a this is a pretty exciting and really innovative way to more quickly bring people into working in the state of Vermont as licensed health care professionals. Additionally we recommend that Canadian health care workers be differentiated from international health care workers and that Canadian our Canadian neighbors have an expedited path to licensure as health care professionals in Vermont. Here the OPR should evaluate the avenues and statute and rule for differentiating a path for Canadian health care professionals to obtain licensure in Vermont and propose these changes accordingly. In the interim the office's interim rule administrative rule for assessing foreign credentials does create an accessible process for licensure. The OPR should create a resource on its website related to those administrative rules while the permanent statute and rules are being revised. The Office of Professional Regulation should also consider reducing licensing barriers for telehealth practice taking into account recommendations of the workgroup created by Act 21 of 2021. Here the OPR should compile and evaluate methods for facilitating the practice of health care professionals throughout the United States using telehealth modalities and making recommendations to the legislature. We also recommend that the OPR evaluate further opportunities to remove barriers to licensure for mental health and substance use disorder treatment professionals specifically and that this review take place within the next five years. We also recommend a temporary waiver of licensure fees for first time licensed nursing assistants. The interagency task team established by this recommended and to be established as a result of this report along with the OPR should quantify the annual revenue from first time LNA licensure and propose an alternative funding source in lieu of the licensing fees for this group. Telehealth is a vehicle that is essential for maximizing the availability of health care services as well as for ensuring that workforce is existing in a state to meet health care needs. There are several recommendations in terms of how telehealth can be further incorporated into practice so that there are more opportunities for Vermonters to receive health care through these modalities. The first recommendation is to maximize Medicare flexibility and reimbursement through the all payer ACO model agreement. AHS along with Green Mountain Care Board showed negotiate for more flexible reimbursement policy to address service site and geographic restrictions for telehealth including reimbursement of audio only services that are more expansive than mental health care after the end of the federal health emergency as well as well as reimbursement of more services including telemonitoring and services provided in what are deemed to be urban settings but are in Vermont. I think we're hard trust to think of any setting as truly urban. The plan also recommends developing commercial reimbursement models for audio only services and task the Department of Financial Regulation with continuing to facilitate the development of value based perspective or capitated payment mechanisms for commercial payers for audio only services for implementation by 2024. The report recommends expanding telehealth coverage including remote patient monitoring telemonitoring services to include diseases and conditions beyond congestive heart failure. The Department of Vermont Health Access should examine emerging technologies and review associated medical literature on the clinical benefit and current best practice to determine if sufficient evidence is available to support the effectiveness of remote patient monitoring for diseases and conditions beyond congestive heart failure. And telehealth billing requirements should be clear. The Department of Financial Regulation should ensure clarity around billing requirements for for commercial payer coverage of stored forward telemedicine and interprofessional consultations. And finally the the last recommendation related to telehealth is to explore a statewide telepsychiatry telepsychiatry program in emergency departments similar to North Carolina statewide telepsychiatry. This would could be similar to the North Carolina statewide telepsychiatry program. That would help treat and divert psychiatric patients that seek care in emergency departments. The Department of Mental Health in collaboration with VAZ should study the potential to establish and offer this statewide telepsychiatry program in Vermont emergency departments. Moving on to recruitment and retent retention for health care professionals in the state of Vermont and broadly recruitment and retention of the workforce in the state of Vermont. Many of the recommendations here are our recommendations that are that really do support workforce development on the whole and are inclusive of health care professionals as well. The first recommendation is to inventory and highlight state programs that support recruitment and retention of health care professionals. This is a recommendation for the interagency tasks team and Department of Labor. The team should inventory and promote existing state programs to assist health care employers in recruiting and retaining staff both temporary and permanent. For example, the Department of Labor should clearly advertise its role and availability to assist organizations that are seeking international staff members. And the DOL can also promote the apprenticeship program that I spoke about earlier and can certainly promote and and continue its efforts to recruit current or former armed services members with health care training. We also recommend modifying or expanding programs that support working and living in Vermont broadly. The interagency task team should identify strategies to support workforce development and employment in Vermont including available housing and child care for all professionals and health care workers. The task team should identify and highlight existing opportunities for health care employers such as the Vermont mental housing investment program and recommend to the legislature how these programs or others could be modified, expanded or newly implemented for greater impact. We also recommend creating a marketing campaign to promote health care careers in Vermont and capitalizing on the existing incentives to live and work in Vermont and capitalizing on our overall workforce development strategies in the state. This marketing campaign could and should be aimed at recruiting health care providers to Vermont as permanent residents working in the state for health care employers. And the marketing campaign should leverage regional health care employment recruitment centers and their existing networks as well as resources for drawing health care workers to the state. Vermont is one of the most COVID-19 vaccinated states in the nation. There is a new worker relocation program in the state and the fast track for health care professional licensure does speed the opportunity for out of state persons coming from out of state to enter the health care workforce. We should also promote health care careers to new Vermonters in partnership with the Vermont refugee resettlement program. We also recommend developing a cross system strategy to utilize section 9817 of the American Rescue Plan Act, which is specifically funding available to strengthen Medicaid home and community based services providers and mental health and substance use disorder workforce. The agency of human services should develop and implement an evidence informed cross system implementation strategy for the use of these funds specifically to support health care workforce development. We also recommend promoting wellness and peer support programs, leveraging ARPA funds here and appropriations to the Department of Mental Health. And we recommend that the director of trauma prevention and resilience development should support efforts to address clinician burnout. And finally, we recommend reducing administrative burden cognizant that administrative burden is one of the most cited reasons for providers that may be choosing to leave practice. The legislature should review the results of reports being submitted pursuant to Act 140 of 2020 and take further action to implement recommendations included in those reports. And finally, the final, well, not, not finally, there, we also have some future considerations that we outlined in this report. But we this report also recommends federal policy to support health care workforce development and specifically related to traveling health care staff agencies and traveling health care staff staffing agencies that are are exempt from providing housing stipends. They're not taxed for per diem such as meals and incidentals, non tax travel reimbursement, specifically looking at strategies to minimize the increasing trend towards travel staffing that is resulting in unsustainable cost increase for health care employers. And this also includes anti poaching provisions directed at travel staffing agencies, as well as price gouging prohibitions directed at travel staffing agencies. As we already discussed, traveling staff agencies are necessary for Vermont's health care employers to ensure that care is available. But the rates for these staff are are unsustainably high for employers in the state of Vermont. That's really the theme of this report. This workforce development strategic plan is really around developing the permanent and employed health care workforce in the state of Vermont. There are also some other federal policy recommendations here, supporting the connect act to make permanent. Many of the federal waivers that enhance telehealth during the COVID public health emergency, supporting the heat act to eliminate the Medicare telehealth reimbursement penalty for home health agencies. The Skills Act to create a pipeline of workers for the long term care sector, specifically the Better Care Better Jobs Act to increase federal funding for long term care home and community based services. The Bipartisan Health Care Workforce Resilient Act to expedite visa authorization process so that more international workers can join our workforce raising the H2B cap as well so that more international workers can join the workforce. And as we've recommended, and it also recommended in the rural health services task force report, Medicare waivers that would allow for those who are credentialed professionals to be to be recognized by Medicare for reimbursement for services for mental health and substance use disorder treatment at parity with the way our Medicaid program recognizes these credentials for reimbursement. For recognizing alcohol and drug abuse, licensed alcohol and drug abuse counselors, licensed clinical mental health counselors, licensed psychologists and licensed marriage and family counselors, specifically, if Medicare joined with Medicaid in the first thing for these services by these licensed professionals, that would mean more availability of services for mental health and substance use disorder conditions. And finally, supporting increased funding for graduate medical education residency and training slots to create more health care workers. Spencer, if you could mute yourself, you're getting a little bit of feedback coming through. Finally, we identified some specific areas for future consideration, but that we did not task an entity with at this time in the in the strategic plan. And this includes the current and future need and demand for dental professionals in Vermont should be reflected in in the. Sorry, I'm having trouble here in the Vermont State Oral Health Plan and compiled by an informed group of key stakeholders. BDH Oral Office of Oral Health, the Vermont State Dental Society, the Vermont Dental Hygienist Association, Vermont Technical College. The Center for Technology among them and the purpose of informing the of this work group would be to inform the Oral Health Plan to be led by BDH's Office of Oral Health. And provide a roadmap to reduce the burden of oral diseases among Vermonters. Additionally, we recognize that there is very much need for children in need of psychiatric care waiting for weeks in emergency departments and similar delays and discharge for older Vermonters that need psychiatric care in a long term care setting. And future workforce discussions should include policy proposals for developing workforce, developing the workforce in psychiatric care for pediatric patients and mental health care and long term care settings. We also think there's future work to advance a coordinated approach to promote health care careers in K through 12 educational settings. Well, the report is very clear about a recommendation for middle school. We think additional work is needed to think about the entire K through 12 educational experience and how that promotes careers in health care. And finally, considering future work for considering whether simulation for clinical for clinical experience could be available or more widely available for healthcare professionals. When healthcare professionals are not able to access enough hours of clinical training, how could simulation be an appropriate substitute. And that that concludes the report's recommendations as well as future considerations. So at this point, Ena, are you hoping for open for comments and questions? Yes. Great. So I'll start it off. Where will the buck stop and what's the accountability for seeing these things through and how will progress be reported out to Vermonters? And that's it. Those are very good questions. The report is it needs to be maintained by the director of healthcare reform and the advisory group. And in maintaining the report, I imagine that we will be following up on the tasks that are described and are tagged or tagged throughout the recommendations. The the interagency task force is or a task team, I'm sorry, as you observed in the report also has a number of responsibilities and will be undertaking those in coordination with other healthcare partners. And that team will be starting its work in the very near future. And when you say the very near future, what's your estimated start date? I think there's been informal work with the team already. And the team will come together formally, I would say in prior to the legislative session beginning. Okay. You mentioned in your presentation the work on the pipeline. And last I knew, you know, Mary Ann Sheehan had done a lot of work on this, but I think that the funding had dried up. Is there anything to get her and that team back on task? I think that that's a important question and discussion. And I don't know that they are necessarily not on task. I know that Mary Ann has been doing some work in the field to survey healthcare providers regarding their vacancies and their current vacancies and anticipated vacancies, I believe. I can't speak with authority on what Mary Ann and that particular project is doing, but I think it's really important that they are part of the discussion. Okay. Great. You know, this is a really exciting day to see this get, you know, really started. And with that, I'll turn it over to board members to for comments and questions, board members. I can go ahead. Thanks very much for the presentation. Kevin asked one of my questions, which was going to be what's the process for accountability. I'm also wondering if when you would think you'd have not a specific timeline, but sort of a rough timeline of short term, medium term, long term, obviously a bunch of the tasks would need to be prioritized by the interagency task team. But I wanted to get a sense of what you were thinking in terms of those next steps. In terms of the next steps of actually kind of arraying things in the short, medium, long term or what we actually think would be more short term versus longer term work. Either or both. And yeah, I think that there are key recommendations in the report such as in particularly those recommendations that include follow up with the legislature that those are all depending on your definition short term work. I see the work that needs to be done by the task team to look at the tax incentives as being near term, short term work, the work by the team to evaluate incentives for current for permanent employment that incentive opportunity to be in the near term. Similarly, the work regarding our home and community based services funding to be in the nearer mid term as example, longer term strategies, I think are those that require a lot of stakeholder engagement, you know, significant process through work group and collaboration. And the development of proposals that may take more time and that are not necessarily bound to a legislative timeline. Thank you. For instance, I would view, you know, the incorporation of of or modification curriculum for instance of a longer term type of workflow where that should really be ongoing and a process for evaluating how curriculum should be ideally responding to an integrated workforce. Thanks. One of the areas I was interested in is in many of our hospital budget hearings we often hear about different programs that the hospitals are running in order to either recruit or retain staff and of particular interest to me in the past has been a program which both Brattleboro and CVMC have been very active which is similar to what you were describing with the nursing home program that was funded where the employer really nurtures their workforce through a series of increasing responsibility and licensing steps. So, I was wondering if the group had talked about those programs, how you see those fitting in it seems like it's a good, it could be a really good model that could be spread and is sort of organically spreading but not, I would say in a fully organized way. Because I would say both BMH and CVMC have shown very good results with their programs, for example. We did talk about those programs and Steve Gordon was a participant in the advisory group. We thought the recommendation that reflects the streamlining of the path to licensure and the upscaling. We think there's more work that's necessary with organized work group to talk about those sorts of opportunities or those sorts of programs and how to potentially scale programs of that kind. Okay, great. And then my last question was, it looks like there are some of the recommendations involved parties that were not represented on the advisory group and I'm just wondering if you could explain how you have or will handle making sure those entities are aware of the recommendation and working with them. Yeah, well, that is, we did have participation in the advisory group from non-advisory members. And so some of those members or some of those participants certainly worked in collaboration with other advisory group members to craft recommendations. And where those recommendations were made regarding state agencies that did not participate in the work group, there was coordination behind the scenes to be sure that those state agencies understood where recommendations were reflected in the report. Okay, great. And then that's it for questions. And my only last comment would be, you may have already done this, but there was some demand modeling done as part of the SIM grant that I think the Department of Labor, if I'm remembering correctly, was very much involved with. So it may just be worthwhile looking back at that because I think there were some potential lessons learned on how to approach that type of modeling. But I think Matt Barrowich would probably be the person to talk to about that. He did participate in a subcommittee that helped to inform the thinking around the supply and demand recommendation. Great. That's all I had. Thank you. Thank you, Robin. Who would like to go next? I'll jump in. I want to build a little bit on Kevin's question and Robin's in terms of having a view going forward. I did do a little word search of your 26 page report. And in that report, there are five, five shells, four of them are in Act 155. So most of the shells apply to you, you know, and but there are 73 shoulds. And that's 73 shoulds across a broader way of state government. And so I do think in terms of, well, first I think that the work you've done is extraordinary. You and the team, I mean, it's my first one of my first introductions when I came on the board was at a meeting in Hamilton, which I think Kevin shared, you know, where the person got up in front of the audience and said there were somewhere down the road going to be night. We're going to be short. I think it was like 1900 nurses. And here we are down the road and we are also compounded, you know, by the pandemic. So you've done a very important job here and a very good job of kind of, you know, having all the marbles at least on the table. But I do worry that in government, things can get lost. And so the sooner we can have a timeline so that for each of your what you call actions required, you know, we know who's responsible and when they're required to have it done. So it allows participants to have that peer pressure on the process, you know, to keep it moving down the road. And also who might, if it's not moving down the road at the pace that people want or expect, you know, who is the enforcer here. I mean, sometimes, as you know, in state government, you need somebody to make it happen and to break break log jams and I that's got to fall to somebody as opposed to a task force, I would think. One question I have is, I have the close out report for divas budget, you know, for 2021, the 52 points of light, you're probably familiar with those. And so they ended fiscal year 2021 with an over or unspent funds of $16 million. And that's not a lot of money in divas land, but it's still a lot of money. And I'm just wondering if in your process, whether you will start to go kind of comb through state government to escrow private escrow funds, and not have departments that can go to the purposes that you've outlined in your strategic report here, because money, you know, can be set aside and and be available to support some of those things. I know that the 16 million part of that is global commitment is probably not eligible but a good chunk of that money is general fund or state dollars. So when I look at some of the numbers associated, like for example, the, the, the travelers money. You know, I, it's, it's this, these kinds of numbers are over scale that if they can be escrowed. And have someone maybe from finance or management or just kind of looking through government to say hey look we don't need it today we don't need it six months from now but we're going to need it to do that. I'm also curious as to, I call it the tip for nurses the tax incentive program and property taxes but this that the legislature twice rejected that and but I don't understand why they would do that because you're getting in the future tax dollars from an employee that you might not have if you didn't provide the incentive. It's the tip concept and so what is it, what is the resistance in the legislature to that. I don't want to, you know, I don't want to represent the legislature and but I think that there was some. I think that there were some concerns about lost revenue but as you just said the revenue does not exist if the individual is not working in the state of Iran. I think there may have also been concerns that the, the program was too narrow in only providing the incentive for graduates of Vermont colleges and wanting to see that those incentives perhaps be extended beyond, particularly because we do have limits on how many we can educate in the state of Vermont. And I think that that is, you know, the spirit of this recommendation and what the team will take on is really a review of what types of opportunities and tax incentives could be pursued and perhaps exploring, you know, revisiting models in other states and what those look like in order to propose something to propose a new model. And if I could follow up on that Tom, I think you hit it on the head with the fact that you're creating a new base and sometimes when you expand your revenues you don't get to see the dollars immediately but over time it could have a significant impact. And what I've heard from legislators is that just as there are those who don't believe that TIF works, that it only goes to those projects that would have gotten it anyways, there's some concern about whether or not it goes to people who would have been working in Vermont regardless of whether or not there was that tax incentive. But even harder on legislators is trying to sell it to their constituents who often are really complaining about the fact that listen, why are you giving it to a tax incentive to somebody new when I've been here paying taxes all along and what are you doing for me. So it seems like it's a no brainer, but there seems to be a lot of resistance on some fronts. And so it's never an easy sell no matter what the proposal is, but you're right this is a way to, you know, these are good paying jobs. And this is a way to create a base not only for tax revenue, but also for people who end up being volunteers in the community, serving on local boards. It really is something that can make a huge difference. So let's hope that we see some progress. Well, I know that that's the same issue with TIF and there's probably some merit to that I mean no program is perfect but on this one. You know, it's also Vermonters that might decide to go into a career, because of this attacks tax advantage and it just, it, you know, I'm sure there will, you know, there will be some leakage, but I think the overall gain is bigger than any any leakage that might occur. I have just a couple other quick ones. So you know that the legislature tasks of folks to take a look at the benchmark plan for the QHP population, and that that legislation basically has two parts to it. One is just to make sure that the benchmark plan is aligned with our population health goals, and then the other is about adding I think five or six different benefits. And so I'm just wondering as we go down the road because that report is due I think in this category is is the demand for attention and for resources that are outlined in in your strategic plan. Are they in any way in conflict with you know the kind of view of the benchmark plan. I don't see them being in conflict with taking existing resources and making sure they're as well aligned as possible with their population health goals, but I can see a conflict between expanding benefits at a time when we're trying to stabilize the existing infrastructure. Does that make any sense to you. And I think I might need some clarification on your question Tom because were you were you asking about the resources and staff time available on those two projects or you're talking about your title. I was talking about benefits of staff time I don't think it I mean that's a one time but I'm thinking about some of these benefits that the legislature one looked at that they're expensive. I think they're they're expensive. So, I think that they, you know I don't I don't see that those things are in conflict at this time, particularly without you know the recommendations and that in the thinking from that HB work group, you know I don't see a conflict at this time. And so my, my last this is more an observation is that I know that you have ACC communities and development kind of overseeing this the housing challenges that you put before them. And I would advise that having been a former housing commission, a lot of resources aren't at the agency level. They're over the Vermont Housing Conservation Board and VHFA. And so you just want to might make sure that those folks are engaged in your housing efforts because that that's where the money is to do what you want to do. So, we certainly imagine that the task team will have to be working really collaboratively and cooperatively with other partners, but did want to assign some accountability for particular state agencies, but that's a really good recommendation and thank you. Yeah. Well, good luck to you this you've done a great job as I read through this it was a very comprehensive overview, but when I did that the tally of shells and shoulds. It gets a little scary so may the force be with you. Yes. Sure. So I will also extend my thanks to you and I know the hard work here for the you and the entire advisory group here putting this together it's very comprehensive. I'm glad others raised the accountability issue because I think that's really important. So this is not just a report that gets, you know, put on the back burner somewhere and is not revisited. But let me ask you another question is I'm thinking about how you prioritize the recommendations and how we start to think about, you know, how we should allocate scarce resources. In my mind I think about, okay, if I were to think about the recommendations in here I'd want to have a matrix, which is like high and low impact and high and low feasibility, so that the resources were being dedicated first and foremost to the high impact high recommendations. And part of me when I was reading through it I was thinking about well, I can't really discern what the impact of some of these recommendations are because I don't have a sense and this may be more a task for the interagency team, but thinking about, you know, how do we evaluate what's the data on the effectiveness of some of these recommendations and I'll give an example of do we park money in the scholarships or do we park money in loan repayment which has a as a bigger impact on recruitment and retention of healthcare and I, you know, and maybe that data already exists to do that evaluation right, you know, is there data already out there that tracks how long recipients of scholarships stay in the state versus how long recipients of loan repayment stay in the state or how do we start to think about that so I guess what I would just ask is how how we can start to compartmentalize or identify the high impact high vis visibility initiatives and where those resources are going to come from. Also, I guess the second question but You know, I, I thank you for your question we as a work group in fact created kind of rubric to and criteria for these recommendations and that you know that was really created pretty early on in our work together to really consider like what's feasible. What has it what has a significant impact and we agreed on I don't have them in front of me but I think a set of five criteria and because of the I think because of the breadth of the issue and the different The different entry points to get at this issue stemming from the very near term. How do we ensure that you know Like for instance if I'm a healthcare employer I'm going to be thinking about how do I ensure that I can renew that contract with the travel agency as a for instance or if I'm trying to bring on traveling staff and I have nowhere to house them or there's no identified housing. That's extremely near term but of equal importance is the fact that we're not educating and growing our own health care workforce enough of our own health care workforce in the state and so we had to balance as a work group those very long term type of strategies to improve that That bolster the education system and so I think that that was a challenge for us and kind of just in this variety of recommendations that really span different approaches and I think also some of the evaluation about the you know dollar impact for instance it's something we talked about quite a bit in the advisory group And it was difficult for us to evaluate the impact without having done the work to assess the program and that's where a lot of these recommendations they really are recommendations for a body of work to occur that we weren't able to accomplish in our time meeting together So the recommendations are getting work started on evaluating the opportunities for the loan program for instance and where and what types of new professionals professional types might be better might be advantaged by being able to participate in a program like that But I feel that I absolutely understand wanting to matrix the recommendations in that way and certainly I think the advisory group does too but we didn't feel fully prepared to be able to assess the recommendations using that kind of criteria without them being mature in some senses I think we acknowledge that not all of these recommendations are mature. There's a lot of work that has to happen here. The report describes a lot of ongoing work. Is that something that could be a part of the task of the interagency task group to make sure that they're you know thinking about feasibility but also impact in the way in which they're prioritizing the you know their final recommendations or work streams out of it I think it's a really great recommendation and we should really carry through the criteria that we developed because we did as a group agree to I believe five criteria maybe fewer maybe three But I think we could carry those through Just a quick question about the National Health Service Corps additional funding and those applications being funded in areas that have lower HPSA scores those health professional service area scores I'm just wondering if you could talk a little bit about which areas in Vermont might be impacted if at all I and by how much I mean is this going to be something that we're going to be able to benefit from really I guess I believe it's it's a time limited but whereas in the past we were not really able to benefit because we weren't scoring low enough basically there are enough new dollars that are being infused that there are going to be more eligible people yes Okay so we're going to score low enough now be or the dollars are going to be high enough to be spread farther is that it more The dollars are higher to be spread further I don't think our score changes okay need more dollars but that's where a colleague on the on the advisory group would if you wanted to learn more about that Stephanie Peggy Luca from the by from by state primary care would was the participant that really helped to educate me about that program I think that would be something certainly we can follow up with you on Yeah okay that's great I just wasn't sure if our scores had fallen perhaps because of the workforce shortages that we're experiencing or the dollars were you know I just but that's helpful any follow up with you The dollars it's really gotten an infusion of dollars Okay and just one more final this is very very very low hanging fruit but I thought I'd mention it and this my date my data might be old but I think OPR when they collect the licensing data I would be really helpful if this is not currently in the in their data collection is to understand whether the the licensed providers are active or not active and if they're full time or part time Because I think from a few years ago when we tried to access this information it was not clear whether or not everybody on there was they had their license but they may not have been actively practicing And furthermore they you know it would be helpful to know if they're full time or part time if you're trying to use that kind of data to assess supply of providers And you have a long list of providers but some of them are tired but keeping their licenses active but they're not actually practicing it's not really a true FTE So I wondered if that might be something very very low hanging fruit but if that data collection could more accurately reflect You know who is truly actively practicing in the state and especially as we are facing a increasing retirement of providers there's going to be more that may maintain their license for a few years as they You know go into retirement but they're not really actively practicing so my information might be outdated it was from a few years ago but something to look into But thank you Ina very very helpful Thanks Jess Ina we know that Governor Scott's committed to the implementation of your report But we also know that governors don't stay on forever and this is also what we know is that a lot of things in this report don't happen overnight it's going to take a lot of years of hard work And I'm just curious if you're going to go to the legislature and try to get something in the books where there's a commitment by the state of Vermont because we all know that priorities can change from administration to administration Do you have any plans to try to make sure that there's a long term commitment to implementing the plan specifically Yes The advisory group didn't discuss that that you know idea specifically you know the legislation does say that the director of healthcare reform is responsible for maintaining the plan And so in that sense we do have now a current and up to date plan and that position You know I believe has some accountability there for maintaining the plan already in Act 155 of 2020 and in doing so with the advisory group You know I know that you're incredibly talented and can do so many things but I worry that If the sole responsibility for getting this done is on your shoulders that maybe we're asking you to be able to do too much and that's one of the fears that I have because you're asked to do much more than just this report And so And that really is you know not not me and my role as an individual but the advisory group certainly thinking about the recommendation for the task team and I understand that a team doesn't feel it feels like the accountability is to diffuse among the team members But there really does have to be accountability that spans state government for this type of work because it is it is larger than any one agency is certainly larger than an individual individual position And so that's really this part of the spirit of the task team being that entity which steers a lot of this work The other piece is I think we've seen just outstanding inter agency and department collaboration in COVID to confront COVID-19 that has been incredibly efficient effective creative and That really you know partners have moved some pretty big mountains together in order to address COVID-19 and that's that's been inter like I said inter agency and inter department and we were really viewing that as a model for this work recognizing The current crisis in workforce which is true across the entire state And in all and sectors not isolated to healthcare although particularly acute in healthcare at this time That's really the spirit behind that recommendation and the inter the inter department inter agency accountability You know one of the things that jumps out at me is that Just as the Green Mountain Care Board is working on sustainability for hospitals We know that we've had a problem in Vermont with sustainability for our higher ed system specifically our state colleges And it seems like we have an opportunity if this is done right to create better sustainability for our state colleges because If we can expand the nursing programs we know that there's a pool of applicants that that wish to go if we can expand the tech programs if we can expand The dental hygienist programs if we can that helps create the pool that makes our state college system sustainable and also part of the plan Talks about creating a physician's assistance program at the state college system and not only would that help The sustainability issue for the state colleges but right now we rely We're very very dependent on UVM to create all our providers and if we can have a secondary source for some providers I think it's So essential to any type of play on that works over the long run so I think that there's huge opportunities here Tom talked about you know trying to earmark dollars across state government There's a lot of relief funds that haven't been spent yet is there any effort to try to make sure that they get allocated towards doing some of this work I think when we recommend that the task team evaluate funding opportunities I think You know we're really looking to the expertise that lies there to understand what funding may be available for some of these initiatives You know I don't think anybody's going to argue that this report needs to be carried out And everybody should be supportive of this report that the real tough thing is getting those resources and making sure that it happens and You know we just are all going to have to work together to make sure that happens So with that I'm going to open it up for public comment Does any member of the public wish to offer public comment on the Healthcare workforce development strategic plan And also I just want to before I call on the first person to remind that Susan said that we do have an open public comment period And Susan when are we scheduled to vote on on the plan Let me check Okay While you're checking I'm going to start going to the public The first hand that I see raised is Jeff team and on deck will be Susan Aronoff Jeff team and Thank you, Mr. Chairman now that I figured out how to get my camera on For those who don't know I'm Jeff team and CEO of the Vermont Association of Hospitals I just want to make a couple quick comments starting by thanking Ena and the department for the work that's involved in developing this strategic plan being so thoughtful and complete and Working to understand the nature of the workforce challenge and suggest the right set of solutions I also just want to say that Couldn't agree more with Ena that Vermont government entities have moved some big mountains together and that includes along with the provider community So I'm really grateful to Ena and AHS and BDH for working so collaboratively through us with us through some of the really tough moments of the past 22 months The hospital association as Kevin just said really hard not to support these things and we certainly support the slate of recommendations being put forward Because the workforce shortage and its consequence Its consequences are really the greatest challenge that hospitals face along with the broader field of healthcare providers I do want to underline that it's important. I think to look broadly at economic development Including ways to attract business create housing enhance childcare and build up communities work that really needs to be a prominent part of this So that if we do welcome people to Vermont, we can support them with the right infrastructure As we're seeing really play out right now workforce sits at the core of all the problems or many of the problems we have in healthcare right now And in hospitals whether that's responding to COVID and vaccinating Vermonters staffing eds or making sure there are enough people to prepare food and maintain facilities The access issues we face across the state are at least in part due to insufficient workforce. So with more physicians and nurses and specialists and other caregivers and other professionals We could help ensure that Vermonters get the best possible care at the right place at the right time Finally just want to say that with hospitals so extremely busy right now They continue to treat not only COVID patients but a broad range of others who have delayed care during the pandemic Have come in extremely sick require mental health treatment or are waiting for a long term care bed and this higher acuity Further stretches all levels of workforce which means that people can be tasked with more responsibility and more work hours So the workforce issue would really help ease this capacity crunch maybe not solve it But certainly help us through the current situation we face so really glad this work is taking place We will be involved as boss in every way we can and hope to see some real progress. Thank you so much Thank you Jeff. Next I'm going to call on Susan Aronoff and on deck will be Dale Hackett Susan Hi everyone. Good afternoon. First of all, you know that was awesome reports fantastic I want to speak about the home and community based workforce and in particular some of the Medicaid funded workforce And the services that the state that the agency of human services actually purchases and therefore can play a great role in increasing the wage So that the people who work for the designated agencies and specialized services agencies and provide services to people with disabilities Can have a living wage. So I'd like to see more in the report about the home and community based workforce. I know there's a mention that you're going to look into using some of the Increased F map money specifically for the home and community based workforce to have like an evidence based study, but I don't really think it's as complicated as all that I think we all know that it's a workforce that just hasn't kept up with inflation doesn't get pay raises has so many vacancies And if that workforce were more sustainable if people were able to get the mental health services at home in the schools if people were able to get services provided by the non license professionals and I'm going to talk about those in a second That that those dollars fund. I think there would be, you know, some of the backup at the ears, etc would be alleviated. So please consider adding more in the report about home and community based workforce, the Medicaid funded workforce And the immediate things that the levers at hand at AHS hands to increase rates of pay and make some of the pay raises, you know, permanent ongoing basis every other workforce gets a pay raise every year the hospital budgets go up every year, insurance rates go up every year. We've got a fight every year a new like it's ground had all over again to get a one, two or 3% pay raise for the designated agency and specialized services agency. Another group I'd really like to talk about is please connect with the governor's commission on the employment of people with disabilities. The bad news is in Vermont 50% of people with disabilities who want to work are working. The bad news in Vermont 50% of people with disabilities who want to work are not working. There's a lot of opportunity and Medicaid and elsewhere to pay for peer provided services. We could put a lot of people to work helping other helping their peers, especially in the developmental disability field, and in the psychiatric survivor world, there are people who would prefer to get their services from a peer, and we could put peers to work and we'd like to see something about peer employment in there as well and I'd be happy to connect with you offline about things people are doing in other states with their F map dollars to employ people with disabilities. It's something you could do to come into compliance with the home and community based conflict of interest rules, specifically it's a mitigating strategy to have peer provided services. I'd love to add to that. Sounds like I might have upset upset someone anyway thank you for the time. And great to see you all. Thank you Susan. So next I'm going to one last thing one last thing I'm sorry, one thing that you had in there. And those of you who have heard me, since I was on the sim grant, talk about this, you added finally something about getting Medicare to pay for the same clinicians that Medicaid pays for that to would help our designated and specialized services agency if they could bear Phil Medicare for the services provided by the same ranked clinicians to everyone you know 65 and older than our DAs and SSAs would have a whole new funding stream. So thank you for that. Okay, so next I'm going to call on Dale Hackett and Walter Carpenter will be on deck. Dale. I gotta respond a little bit to what Susan said with an aging aging population and the state as old as Vermont is. You're killing yourself if you're not involving Medicare and any funding stream. Good point, Susan. Well done. Very good report but I have to ask you a question, because as I read the reports and I mean reports I've read many things. I'm always by the time I get done feeling like something is missing like we didn't catch every major factor. You are working with all this information. I assume you work with when they have the meetings you're there. Or you're getting reports on them. What, what do you get a sense of that's missing that you would call a really significant factor variable. I think the question makes sense because when you're in place to get all the information, you can see things that others can't see. And as I've read the report, I've got the feeling like it's a book that when you finish a story, it feels like the story was incomplete. So I'm trying to put you on the spot but do you have any response? I think you're right that in spite of all of, you know, kind of the iterative discussions that we had as an advisory group over quite a number of months that there is something that is likely missing here. What I would hope though, is that through the structures that will put in place, the advisory group being a permanent subcommittee of the statewide workforce development board, as well as the task team which will begin its work in very short order to carry out these recommendations for which it is specifically accountable. Those new structures will be a place for the missing information, if you will, to land, that we will have people actively working in this area, creating solutions to what we know to be this broad statewide crisis. I hope in some ways that there are some things that we have that we have missed that are better ideas than what we have because I think we certainly recognize that people are working very hard. Healthcare providers specifically are working very hard in during with some trying conditions. And I guess what I'm saying is I naively hope that maybe there's like one silver bullet out there that we missed, but I don't think that that's the case. But I do hope that these structures that we create are a real landing place for whatever might have been missing. Okay, thank you. Thank you, Dale. Next, we're going to go to Walter Carpenter and thank you, Walter, for those pictures of, I guess it was the reservoir. Yep. With some great foliage. So go ahead. That's my workspace, Kevin. It's a beautiful place to work. It's not all romance, but it is gorgeous. Just a couple questions. I think I want to build off of what Susan said and then what Tom had said, as well as what Dale has said. So I guess three tiers here, hopefully in one question. I may have missed it, but one of the things that I did not hear and Tom may have covered it and I may have missed it is pay benefits, like vision, healthcare, retirement, equitable, equitable pay, as well as how to ensure staffing levels. I didn't hear that in Ena's report. I don't know if I missed it, but I know pay is just from talking to nurses and doctors who come to my workspace, which many of them do that pay is a huge problem. And I'm just reading a public comment. Who is it by here? Deb Snell, Vermont nurses, president of Vermont nurses there with UVM Federation of Nurses and Health and it's about pay and benefits and measly 2% rate increases. And in burnout, the burnout this causes. I'm wondering, has that part of it been addressed? Or is it just left to the individual hospitals and practices to deal with or is there going to be a standard to some kind of minimum standard at least on this or or what? Because I think that's part of the huge problem. And that so many hospitals, for instance, try to, you know, they're so short staff because of a lot of these issues that if they need 10 people on a floor, for example, to pick a random example and they only have five, they'll try to do the same work. As they do with 10. And as a patient, I've had direct experience with this. So. I had a nurse fall asleep on my arm one time. I just looked over and her head was, you know, her hair was down. I woke her up. She was so exhausted that I often heard the gurney that I was on. So I keep. I keep going back to that. I think that was the missing piece there was talking about and the benefits that Tom was talking about. And definitely what Susan was talking about. So how's that not to connect anything. But that's, you know, I think that's that's a huge, huge issue. And I didn't see that in the report. I think that most hospitals today realize that it's going to cost them money. And what I hear from nurses, Walter isn't as much complaints about the compensation or the benefits, but it's complaints about the understaffing. It's the complaints about they want to give great patient care and in today's environment with not having enough colleagues working with them. It's very difficult to deliver the type of care that you want to deliver. Most nurses enter the profession because they want to go home at the end of the day and know that they've done something good for their fellow humans. And too often now they go home and they worry about what didn't they do because they were so overworked and taxed on that. And but you're right. Pay is an issue. But I think that if you look at it, I don't think that any hospital is trying to say we don't need to try to pay our staff as much as possible at this point in time. What really is tough is that everything slides downhill and who's often left behind are the skilled nursing facilities who can't compete with the larger organizations. And that's our most vulnerable part of the public and I worry about them more than anybody. I think that's the problem of the way we treat health care overall, which is rather as a business than as a public good. But that's not the issue here. I hear the pay issue, the understaffing issue all the time as well. I hear that all the time. And a lot of them just come to my park and just lay there, just half done because they're trying to get over it. And this was before the pandemic. The pandemic, of course, is added to all of this. But that is one thing and why people are leaving Vermont is they can't keep up. And people are coming to Vermont too. It's a national problem. It's very much a national problem. There's a lot of frustration out there. There's been a term coined for what has happened and it's called the great resignation. And a lot of it is people our age who just have said enough is enough. I don't need to keep working. I can survive. And that's unfortunate that they're under such stress that they don't want to continue to whatever they originally had thought would be their retirement date. It's not only happening in the hospitals or in the medical field, it's happening in the tourist field as well. And there's a definite reason for that is so many workers and in both areas are simply treated as migratory workers, basically like nothing. And that's the big issue. I don't know an industry out there today that doesn't have workforce challenges. The only difference I would say here is that in healthcare, it could become a matter of life and death. And also it's a situation where we're going to pay, whether we acknowledge it or not, because we're going to end up paying for travelers that at least probably right now today three times what it would cost for, you know, a working employer. So, you know, that's why this this report is so important. It doesn't matter if you believe in single payer, if you believe that government doesn't have a role. However, we deliver healthcare, we need people that are going to do that delivery. And that's really what this is about. And I can't say it often enough that the only way that we're going to be successful is when we grow our own supply, because this is a national and becoming a worldwide problem. And so if we don't, in our own educational system, create a pipeline of new professionals, we're not going to, we're not going to succeed. Well, I agree with. Yep. Chair Mellon, this is Susan. Can you hear me? Yes. Did you switch to public comment? Well, whenever anyone says what Susan said, and I said, oh, and that was Susan Aronoff. We have great first names, Susan. No, I just wanted to answer your question about when we have to approve this report. So the legislation says. Is that we have an open public comment period from November 1st, and our hope is to vote on this on November 3rd, that the legislation says that we have 30 days upon receipt. I believe receipt was October 15th, but I could be wrong. No, that's correct. The goal will be to vote on this on November 3rd. But a lot will depend on what we receive for public comment. And so I strongly encourage anyone that has public comment and suggested changes to this report to get them to our public comment portal and we'll immediately forward them to Ena. And with the hope that, I mean, you could nitpick a lot of things, but nobody could say that there isn't an incredible amount of work that would enter this report in a collaborative manner. And so I think, you know, again, I can't thank Ena enough for all the work that she and the people responsible for this report have performed for the state of Vermont. Is there any other public comment? Is there any other public comment? Hearing none, I wish to thank you, Ena. And you've heard our timeline and hopefully we will adhere to that. Next on the agenda, I'm going to turn to Russ McCracken and we're going back to the 2022 budget guidance and reporting requirements for Medicare only non-certified accountable care organizations. We began this conversation a week ago and, well, even before that, much before that, but we're coming back to it and Russ, if you could tee this up for us, it would be greatly appreciated. Thank you. Thank you, Mr. Chair and board members. I will share my screen here. Let me know if you can see my screen. We can. Great. Thank you. And so, as you mentioned, this is a continuation of the discussion from last week. I wanted to first talk to public comments. I, after these slides were posted this morning, we did actually get an additional public comment from Clover Health. I saw come in earlier during this meeting. They, they thank the board for the time and developing this guidance, but say that in their view, it remains overly burdensome for ACOs with a small footprint in Vermont. And they encourage the board in particular to consider an exception, an exception from this guidance for ACOs with a small footprint in Vermont. And that's one of the items that I will have flag for further discussion here. I want to summarize the, the comments from the meeting from Clover Health last week regarding standards for approving the ACOs budget, tying the reporting obligations to state health care goals, addressing the budget review timeline and adding the exemption. So I want to flag, I think a couple of points for further discussion. Though I think most of this would center around the question of an exemption for smaller ACOs with a smaller footprint. So just a note that in response to Board Member Pelham's comment last week, I will update the guidance adding a reference to the second statutory provision regarding the verification under oath. I don't, I don't think that's a contentious or controversial at all. I do discuss adding a question to the guidance that's asking the ACOs to report their expected payments to providers based on the FPP categories that are presented in the HCPLAN ACO framework report that you may be aware that it breaks FPP into four different categories. And so we'd ask a question to the ACOs to do the same as they report their payment to providers. The second point is an exemption from the guidance and reporting specifically for the Medicare only ACOs with the presence in Vermont of fewer than a threshold number of providers and or a threshold number of attributed lives. Clover asked the board to consider exempting any ACO with 30 or fewer participating providers or 2,500 attributed beneficiaries in the state. In some context, when Clover presented, they said they have 20 providers, it's one practice, but 20 providers in the state and approximately 2,000 attributed lives. So the healthcare advocate is going to offer public comment in opposition to any exemption from this guidance for smaller ACOs. I think it's worth, I think the board should consider an exemption here. I think that these are ACOs regulated by CMS. They're participating in a Medicare model. So the incremental patient or patient protection that the board is providing here. And also the concerns around alignment with the broader healthcare with broader healthcare goals in the state. So if you get to a smaller group and I think it potentially becomes disproportionate in terms of the amount of recording reporting required of the ACO and the work of the board to really look through and evaluate everything that the ACO submits so that it I think is a point worth, worth discussing. The last one here is the annual reporting and review timeline. This is a point that I actually don't think needs to be resolved for the 2022 guidance. The 2022 guidance could be done off cycle in the sense that once the board approves the guidance, it could ask ACOs to submit as there's only one affected ACO by this guidance. Ask the ACO to submit information, say by the end of the year for review and a hearing in January, which was the tentative timeline that I'd set out in the draft. And then for 2023 and future years, we could, the board could revisit this question of whether this annual process should be done in alignment with the review and approval of one care, or whether it should be done over the summer. So I'm hoping to kind of align with when the ACO finalizes and provide our list with CMS. So I will, those were the four points I really wanted to set up for discussion, or really three points for discussion. So I will stop there. Thank you, Russ. I'll start off the conversation by saying that as busy as we are in the summertime, I do think that that might be the right time to be doing it and lining it up with the attribution of the providers. I do want to add any additional work to the summer, but I do think that that that could make sense as far as an exemption. I'm very curious to hear what the healthcare advocate has to say, but if it was a small enough number, I think I could support some type of implementation, especially when it came to, for example, if it was a few Vermonters affected by cross border work, things like that. Discuss adding question for ACO to report their expected payments providers based on the LA in categories. I'd want to make sure that it's not an incredible burden, but it seems to make sense. And as far as referencing 18 VSA, I don't think there's any argument there. So I guess I've started it off other board members. I would just say to the second bullet that, you know, and referencing the draft guidelines that fixed payments in the draft guidelines are mentioned three times. But, you know, but as we went through the hospital budgets and others, there are all flavors of fixed payments and some are even as the budget guy from UVM stated, some are either, you know, and I'm not saying I agree with them but his point was they have a negative impact because the administrative cost of following them and the risk of not knowing what your actual settlements are going to be is problematic. So, to me, the standard is the highest standard is a capitated payment. And that's where it's just disconnected from fee for service. And, but the way that the guideline was drafted. Yes, that's not the way it was aggregated so it just seems to me we, you know, and I'm making this up a little bit as I go along but that land categories made sense to me, you know, that was four categories. And if you're got a lot of your payments in the fourth category, you know, you are well aligned with where we're trying to go. If you have a lot of payments in the first category, you could be a negative force to where we want to go. So I'm just, you know, seeking to find have the guidelines give us some clarity as to what kind of fixed payments we're talking about. How are you on the other points of discussion, Tom. Well, the first one, the note one was fine. The only thing about the small acos is I just wonder if there's a lot of small acos is the adminis and therefore there's a loss of economies of scale. Is there do a lot of smaller acos add up to higher administrative costs, but that's a conceptual issue. That I have any insight about. So I'm open on you to hear from others. What about the timeline. Bring it on. You know, I don't know what to say about type lines it just it's never ending except for a few weeks here and there so. Okay, who would like to go next Robin or Jess. I'm happy to or unless you prefer to Jess. Jess always likes to go last. Good for her. So I see the note as a technical change, which makes sense. I'm fine with the land categories, although I think some of the land categories are really designed more around the payer ACO level than the ACO provider so. But I assume staff will sort that out. On the timeline I'm as Russ said I don't think that's a I don't think we need to make a final decision with on that at this point because I think it really would apply to 2023. Given where we are in the cycle so I'm open to it. In terms of what made sense I think the reason why we had normally pushed it till after the provider list is because it's difficult to provide the data until you know your provider list so I think we'd need to explore. Whether we'd be able to get good projections. Prior to the provider list. But I'm open to it. For sure. And on the exemption. I would say I could probably be talked into a very small exemption but overall. I'd rather not have an exemption. Okay, thank you Robin just. I guess I am last. Okay, so I am fine with one. I'm fine with the reference to the SA 993 74. I am also fine with number two. I think that perhaps I agree with Robin the staff might be able to think about what those long, you know, L.A. and categories are and make it more appropriate to this but in the spirit of trying to understand the fixed perspective payments and where they what types they are. I appreciate that and I think that's relevant. I'm fine. I'm with everybody else and that, you know, seems like we're busy all year round. I think, you know, if this is if that makes more sense. I'm fine with that. With the exemption. I do want to hear what the health care advocate has to say. I appreciate the desire to allow innovation and, you know, experiment with small pilots in the state so we can learn from them and not want to create such a regulatory burden that none of that innovation happens. So I am open to the idea of a very small floor, I suppose. But I'm not sure what that number should be. But I do think that if there was an exemption offered for, you know, a low floor that there would still need to be attestation that the ACO model that is being experimented with or piloted or tested in the state is aligned with health care reform efforts are happening in the state at that time. So I'd want to make sure that there is alignment with that, for example, that the, you know, the attributed lives would contribute to scale, for example, if we were still in an all pair model world. I would want to make sure that patients are made aware that their provider has joined an ACO and that they were educational materials given to the patients in that model about the model. And I would still want some submission of performance metrics, you know, so that we're understanding what's happening in those ACO. And I think I'm not sure exactly what that looks like, but along the dimensions of attribution, cost, quality, something. So we understand how those pilots are performing. So that's where I sit. Okay, thank you, Jess. I think many of us are waiting anxiously to hear from the health care advocates. So who from the health care advocates office is going to speak. Is it you, Sam? It's me. Thanks, German. Appreciate it. Good afternoon, everyone. My name is Sam. I think most folks know me, but just for members of the public, I might not. I'm a health policy analyst at the Office of the Health Care Advocate. So the HCA does not support an exemption from reporting requirements and guidance for Medicare only ACOs based on size or other related criteria, primarily out of concerns for consumer protection and the public interest. And while they accepted the compliance with reporting requirements allows state regulatory bodies to transparently evaluate the business model and approach of entities that want to operate in Vermont. It also provides a valuable opportunity for the state writ large to evaluate whether entities align with Vermont's forward thinking approaches to public health, which I've been mentioned, which includes seeking to achieve the quadruple aim and effectively implement the all payer model. So regarding the argument that successfully meeting reporting and guidance requirements would place an undue burden that would deter effective Medicare only ACOs from doing business in the state. We feel like it's a responsibility and duty of businesses and organizations to demonstrate their efficacy and potential benefits to Vermonters at baseline. There are entities like hospitals, both large and small, as well as one care Vermont to comply with similar similar regulatory requirements. And there's a long track record of legislation that stems from protecting the public interest in this regard. And presumably we're a Medicare only ACO to exist that enhances patient experience improves population health reduces costs and improves the work life of health their providers with an innovative approach which I think we all want. There is a mold to assume that they could also complete reporting requirements that are before us today, including in the guidance. If they're truly unable to disclose this type of information provided I think it'd be logical to assume this could be a red flag for Vermonters and for regulators. I think we will be open to reviewing the guidance to potentially reduce this burden but I don't think it's in the public's interest to prioritize claims of administrative burden over those of consumer protection transparency and public interest. Thanks. Thank you Sam. Are there members of the public who wished to comment at this time. Walter. I totally agree with Sam and the H and the advocate's office on this. They can't do it. They shouldn't be allowed to really. They've been in the news quite a lot. So there's a reason. Is there any other public comment. West did you have any draft motions or were you looking for the board members to make those. I didn't to share what direction we were going to go so I didn't present draft. I didn't do any draft motion language for today. Well seems like a couple of things. It's not what's controversy on work down the list and make decisions and try to get us to a final place. I know Robin you're our motion master is there any type of pieces you would like to make at this time. Sure. I. I move that we approve the draft guidance. Adding the reference to 18 VSA 93 74. And a question that the staff will develop related to the payments to providers. And the land categories. Is there a second. Second. Is there further discussion or questions from the board. So for members of the public who are following basically Robin has moved the first two points under discussion but has modified the second point to require the staff to come up with the. Actual categories and. Question. Yes. And I didn't include the exemption because I know other people have some interest in there but I don't. So since I'm making the motion I didn't include it. Certainly. If people should vote against it if that's important to them. I didn't think they would have to vote against it because there could be an additional motion if they wanted to. That's true. But this was the first couple of the table. Okay. And then I think with the timeline I don't think we actually have to address that. At this time so that's why I did not include that just to explain. Great. And who was the second again. Jess. Okay. Is there further board questions or comments about the motion. Hearing none before we vote I just want to open it up to any member of the public who wishes to offer any comment on the motion in front of us. Related to the first two bullets on the slide that you see in front of you. Hearing none is there any further discussion by the board. Hearing none all those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. Is there any board member who wishes to make any further motion at this time. Hearing none. Russ I think you have the approval of the guidance along with the the two changes. And is there anything else that you need from us at this time Russ. No so I think with that. I think we can make those two changes move the guidance out of draft form and consider it finalized and issued by the board unless there are there are other concerns. I don't think there's any other concerns right now Russ. All right. Thank you. Thank you. Is there any old business to come before the board. Oh I should. Sorry. Thank you. Thank you. And the relating to the prescription drug technical advisory group affordability some groups suggested recommendations that we discussed earlier. I did reach out to the co-chairs of the health care affordability task force and reached one of them but not both of them. In general I got a favorable response. I think we'll be invited to talk about those at front of that committee. Either this month or in November. That is great. Is there any other old business to come before the board. Is there any new business to come before the board. Is there a motion to adjourn. So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. Thank you everyone and have a great rest of the day.