 We're trying to address this same topic at one point in time, like a long, long time ago. It seems that way. I'm trying to figure out in my own head what's happening to the population that needs those beds. Is that really going up? Is it going down? Is it here in their testimony shifting populations? Or is it the same population coming back in, reutilizing the same bed? If I need 30 beds, how certain am I that that is the right number that I'm not underestimating the need, which also means I need to understand the population that's going to use those beds? And why are the consequences of not providing the beds in terms of, I'm not sure we all understand the population enough to understand what happens if they don't get the services that they need. That's a lot of questions. That's a lot of them. We'll throw it at Dr. Biratini and see if he can take us to have that. Well, I think that it made me a little simplistic. The population would be those people presenting with a psychiatric emergency. So we actually have, we can characterize that very well. We know, we literally meet all of these folks. And they are presenting with a psychiatric emergency. They are not all the same people all the time. Some of them are new. I'll just point out, we have a state that is blessed with many colleges and universities. And we bring thousands and thousands of young people here from out of state every year at an age when they are at risk for the first grade of psychotic disorders and bipolar disorder. So those are people that are unknown to the system. They themselves have no indication that they're going to have this need. And they come to us and we meet them and take care of them. Another one of your questions was, how do we know if we have the right number of beds? And that really is an excellent question. The answer is, we will never know. So I think there are two ideas I have about that. One is, we should struggle to find the target number, whatever that number is. And I think there are a lot of people with expertise who will bring ideas to the table. We have to have a way to adjust that number depending on what we find to be true once we have the beds. And we have to operate those beds at about 85% capacity, not 100% capacity, because at 100% capacity, we do not have room for the next person. So there are some guidelines about how to do this. It's fraught, but I think we can do it. And I think there are some ways that we can create a safe path forward to get the job done. So I heard another part of this question being readmissions. I mean, if there's any way we could get any data on that, it doesn't necessarily have to be now. But if you could get it to us so that we could post it on the website so that we don't know others can see it and could help us in our decision-making. I can do for involuntary. Yeah, beyond that. But we can see what we have and get you at least what we have easily. OK. Thanks. Other? Ken? Thank you. I guess expressing appreciation is necessary here. I think clearly it's a fairly poignant moment in the history of the Green Mountain Care Board, from my point of view. I think that as an observer, the board in its earlier years in the end talked a lot about mental health and some of the crises facing mental health. But ultimately said, this is really not our domain. And I think that in some ways it's only perpetuated and maybe expanded the sense of problem. So that's just one overall comment. And I do have a couple of comments. You know, it's kind of almost ironic that we're here at the discussion today that's really talking about overtures. I think Tom Pelham asked some important questions from the very beginning. The board had to deal with this a few years ago. And there was a good deal of difference and controversy within the board about what to do. And to be honest and transparent, there were some people that felt very strongly that overtures should go back to the rate payer. There were two deals made. And it didn't go in that direction. So from an old advocate's point of view, it was more of a viewpoint from the board of let's make a deal about overtures. And UVM Medical and Rutland both had overtures. And I remember Rutland came in and said, it's no question. We're just going to sort of put this back to the rate payer. And UVM had a more comprehensive plan, which the board narrowly approved. So in some ways, some policy has been set. And I think now we're sort of back in a very important discussion about what to do about overtures, because it really will have some impact on the presentation made about Argentina in particular. So I think it's important to add. And this is an observer and obviously a mental health advocate that I don't think that the hospital network has come forth with any proposal. I think only now that there's an issue that's come up. Commission of Homes sort of made the proposal. And it's created some potential for a very important, well, called intervention. Because the board, again, has the option, the worst option, in my opinion, which is doing nothing. It's just unacceptable. And I think everybody would agree if anything is to happen, it's almost a one-year time from any decision being made, which is an awful long time when everybody says, this is a health care crisis. So I just wanted to recommend a couple of things based on some observation. The board has clearly expressed some power in this issue, because it's gotten two very important people, two very capable people up front and center, which is really a good thing. And yet at the same time, if there's a proposal which is outlined very briefly, I think there has to be some testing, whether the institution, particularly the Dr. Parentini represents, is fully committed to this project, not only immediately, in a sense, because there's an overage issue and there's an opportunity to make a deal, but there's a real long-term commitment. And I think people here have asked you to figure out how to do that. I think, obviously, there have to be questions about, is there quality in the, I'll call the outline of a proposal? And I think there certainly is a lot of potential there. I would say that assuming that there is really legs to this notion, I would urge you to have a three-year financial footprint, because there's an opportunity, frankly, for a proposal to get off the ground, because there's an overage here of a considerable amount of money, but there really needs to be a three or four-year plan down the road, because one of the parts of history with psychiatry and mental health is often, frankly, just an undefunding and having innovative projects die in line. And I think the other issue, which is going to be really important, is to ask the question, who's going to evaluate the effectiveness of an intervention? When there were some proposals thrown out a few years ago, I remember saying, I don't think that we don't care more. It has the capacity to really evaluate a follow-up or even know what happened. And I've asked several times, and I could be wrong and correct me, there was a big initiative by UV. And I don't know that there was ever a reporting back, certainly wasn't done publicly, to say what happened with a number of millions of dollars that were invested. I think it's good that it was invested. And I remember standing up and saying, what happens three years later when you allow an investment with overages? So again, I commend you for the fact that we're here and talking about a critical proposal. I just hope that you will not, in any way, allow this to be one of the options of doing nothing. It's just not acceptable. So thank you. So I appreciate your comments, Ken. I'm starting to get nervous because I think they're starting to think too much alike. I'll tell you that right from the get-go, I've always believed that if we were to take this path versus a reduction in commercial rates, that there would have to be periodic check-ins, that there would have to be a strong commitment and a full oversight to make sure that at the end of the day, we're actually getting the return over my consumers by seeing the number of days in emergency departments going down. So it's a long way of saying, we've been spending too much time together. Yes, Sam? I just wonder if we can get a little bit closer on the proposal in Dr. Piratini's discussion. He doesn't come up with a number. He says it's not five or six, which means it's not a picky you number. I think he said that 30 of 37 could be derived from looking at the data of people that are needed right now. Could we get a closer number? Could we just ask him again to come as close as he can to the number of beds he's talking about? We can ask him again. I just want to throw out the caveat that in a haste to try to do something quickly, we don't want to do something that's irresponsible either. And it would be irresponsible if they didn't actually go through the process of trying to figure that out in a much more comprehensive manner with Dr. Piratini. I'm trying to think of a more elegant way to dodge the question, honestly. I really don't know. Honest answer is I don't know what the number of beds is. I do know that we need to try to derive that number. And I think based on our experience, because we've done this before, I think we need to figure out a method to adjust the number based on experience over time. Because even if we arrived at a beautiful number based on today's data, we have an aging population. We have a federal government whose participation in the funding is unclear. We have the entire state trajectory for expenditures and the availability of resources. These are well beyond my skills. But I do know that we would have to create mechanisms to make adjustments based on the future reality that we would see. And so I would start with the number and then try to bracket around that so that we have some flexibility going forward. I know it sounds like I'm not answering the question. But it's the best answer I have right now. Are there other public comments or questions? OK, we're going to quickly. First of all, thank you very much. We tried to cover too much in a short period of time. But we know we're going to have further conversations on this and it's just very grateful. I did get a chance to thank them while they were in the room. But if you notice, both the chair and my chair of the House Health Committee were in here paying attention. And again, Commissioner Bailey has one focus with just the greater universe. And our focus is mainly on taking pressure off of the emergency department. So I'm encouraged by the incredibly rapid response to Dr. Holmes' initial inquiry. I think that everybody is moving in as expeditious a way as possible to try to come up with the answers so that we can try to answer that fundamental question if this is a better return for the long-consumer. So thank you. Thank you. So with that, we're going to quickly. Board members, chair of your chairs, we're going to form a semi-circle up here. And we're going to invite Susan Palmer to come out. And I'm so sorry because I can't hear her. There, that's the DS. So it's my great pleasure to introduce a very dear friend of mine, Susan Palmer, who's going to be our facilitator for this afternoon's session. What we're doing this afternoon is really what a lot of organizations would do in some sort of retreat fashion, but since we are a public body and can't retreat, we get to see us all on stage doing it together. So I wanted to introduce Susan briefly, and then I'll turn it over to her to introduce her our afternoon. So Susan and I have known each other. It will be 25 years this fall. It's a really long time. We met at Cornell Law School, where I was a second year. She was a first year, and I saw that the incoming class had somebody who was affiliated with Vermont, so I immediately stalked her out. Susan was a little bird undergrad and got a master's degree in English from UDM, was with me at Cornell for law school, and then also has a certificate in leadership coaching from Georgetown University in DC. She practiced law. She was the dean of Bloomberg College. She's done various other academic and teaching administrative functions, and currently, she owns her own leadership coaching business, and is really doing us quite a big favor by helping us out this afternoon. So thank you, Susan, and I'll turn it over to you. Should I grab the mic for the introduction? She would be helpful. Yeah, I don't pick it up on the tape. You can't pick it very far. Thank you, Robin. I really do mostly one-on-one leadership and executive coaching now, and some training and consulting, so I appreciate what Will described as this wonderful opportunity for me to stretch my facilitation muscles today. I'm delighted to serve the board today to help facilitate a conversation about the Green Mountain Care Board's common vision, the purpose of our conversation, which I think we'll be able to complete in an hour to an hour and 10 minutes, at least to get you started in the direction I think they are headed, will be, but the purpose of which is to have you share with each other the written paragraph we've hopefully prepared. It was going to be just a paragraph, and maybe no longer than three or four sentences, on what each of you believe is the common vision for the board, and the purpose of that is to inform and clarify the board's work going forward. As Robin pointed out, this is something that you might do at a visioning retreat in another type of organization, and what we'll be doing in order to put you on that path today is spending about an hour in what I'm calling a common vision exercise. I'll be asking you to get yourselves into pairs for 20 minutes, you'll be interviewing each other for 10 minutes each in that 20 minute exercise about the statements that you wrote regarding the Green Mountain Care Board's common vision, and then then we're going to do a one by one report out around the circle where I'm going to ask you, each of you, to please present the main case of your partner's thoughts on the common vision and the results of the interview. Yeah, so that really requires some special attention and some listening. I tried to leave room on the interview sheet, which you also have in your packet. It says interviewing exercise at the top. There are eight questions I'm asking you to interview each other on. I'm sorry, there isn't more room for notes there. You might need additional paper. But the thrust of it is to really dive deep and understand where each of your common vision statements come from and what that might mean for the board going forward. Are there any questions about the purpose for the mechanics and the logistics of what I'm inviting you to do? So we have to read our statements. Yes, so let's discuss. So I need to have an hand. Yes, you do need to have an hand and if you don't as you get into the care you can go fetch it. Is there a suggestion from Kevin regarding how to care people up or shall we do it randomly? I wish we had taken little cards because that would have been the best. I think we could be able to do it together. That'd be perfect because your concept would be random and that would be good. Okay, so I'm just gonna start right in front of me and put Tom and Roger together. I'm gonna put Maureen and Susan together and Kevin and Jessica. All right? Great, all right. So please go fetch your vision statement if you don't have it with you and then come back and do your interviews. I'll start the clock as soon as Tom gets back to the start of the book and for the first 10 minute interview I'll give you a five minute warning. Okay, and then at 10 minutes I'll ask you to switch partners. Great. And do we ask these questions? Would you say? I would, yeah. Just come right out and ask them if you're a journalist interviewing a subject for an article. Yes. Yes, they're gonna work over there. I said it's too good, we should noisy and distracting. Okay, all right, well decide who's gonna go first. We know we have the best ideas, we don't want you to the problem. Yeah, except now everyone's gonna hear your microphone. Yeah. Alrighty. Okay, so the clock starts now on the first 10 minute interview. Can we take notes for both of them? Yeah, sure. Take notes on yourself and the other person who ever works best right now. All right, so I didn't want you. Is that what we're gonna do? Yes, so I'm interviewing one of our students. Are you doing my statement? Sure. Yeah, I'm gonna have her first. The cabinet's gonna issue me, so I'm gonna go for the next. All right. What we're seeing about that. We're gonna get her first. And then we're gonna get her very rough. I'm gonna go for her first. I'm gonna go for her first. And then I'm gonna go right and I'm gonna say U.S. Post Office. And then I'm gonna go right and I'm gonna say industrialized nation, multiple health programs, and the United States health care system, and the present home care system, and it's brought to you by the House of Representatives. Thank you. Thank you. Thank you. Thank you. Thank you. I'm Vermont's Leonard B. Abbramats. Thank you, Mr. President. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. All right. Let's finish up. So I'm going to leave this. What do you think I bring my character to the next three to five years? Maybe that is really what's most important. That's your mission. What's his mission? That is what I think. What's his mission? Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Well, he knows staying within the gold post that's what he knows. Yeah. But he also knew it. So he's going to leave it in the past. I'm just a lot of re-courstant as well. Is certain that you like those temperatures or some options with white funders or whatever. I showed you that picture. It's a dog. It's a dog. I didn't see it. All of a sudden it's just flash. It's white binder. What are some of your personal values and experiences that you've had in your social sciences time? Well, when they take a lot of movement it's actually right on the back of my head. Yeah, yeah, yeah, I can. Is there anything that you'd like to add? I don't know. I don't know. Okay, board members, you have 5 more minutes for this first interview. 5 more. How about 1. 2. 3. 4. 5. 5. 6. 6. 7. 9. We're going to have questions from the board. Right here. Right here. Oh. That was totally wrong. Yeah. Is there anything you'd like to say? I'm more about what's very important than what we're asking for. You start with that. I have a fight to follow up on that. I'm just going to help you out. I have a question. I see that as a, what's that? That's a great question. I have a question about what the goalposts are. So again, like you heard from the statutes, it was helping us realize that we are not just happy that we're doing this. It's just great. It's just great. Yeah. So raise your hand if you're done early, if you're ready to switch. Just bear with me. You guys are all done. Oh, great. All right. Well, why don't we switch now, and that'll help us make even more smarts for many of us together. All right. Okay. So if you haven't switched yet, what do you do? A new 10 minute clock starts now. Oh, you're out of time. Okay. Good. We thought we were going to be fine. I know you're out of time. No. No. The new 10 minutes starts now. So my goal is to enter into the board any sort of thing. So when I get to enter into the board, I'll be like just the primary board. Please enter for yourself. Fine. Yeah. But I think you should have for you guys any steps right after the meeting. Okay. Okay. So I think I'm going to have. Okay. So I think as a provider. I think our client industry has worked really well. I think for the last 10 minutes we've been doing sort of the same as the last 10 minutes. I think we've been doing some good business. And we've been doing some good business. So I think we've been working really well. I think we've been working really well. Okay. So I don't think that any of the should have the expense of the provider to bring the money back to the provider. Yeah, I think that's how it is. That's really good. Thank you. So I think that our system is a primary care access and a successful way of doing it. Yeah, exactly. Okay. What do you think we're going to do about this? I think very similar to what you said, I think that we will, like, be able to see that we are a part of the lay-in company in Latin America. So we're going to be able to see how much stress it's got, and I think our partnership is going to be stronger and stronger. I think I actually think we're going to have to do that. Okay. What sort of information do we process in Latin America? Yeah. There's five minutes remaining if you need to answer the second interview. Raise your hand if you need a few more minutes. Yeah, okay, five more. So basically my last 15 years is really good in healthcare and looking at how we achieve, you know, it's been called different things, like different ways, but essentially, I feel like the state is trying a lot. Okay. Wow. So I think it really comes out of that. Okay. Is there anything you might have to be different? Yes, I think for me, it's awesome to be a part of a five-person meeting before I'm either working out or a leadership role. Every day. So I think working together in that way is also something that I would like to say to you. Awesome. That was the first one. Okay. I mean, I actually think that the financial institutions here are so great that they would be able to do that. I think everyone said that. Did you go close? Did you tell her? Great. Beautiful. Thank you. We're just waiting for Susan who's going to grab some water. So I think we can go ahead and start, but maybe start with a different scene. Kevin and Jessica finished the first. So I'm wondering if I could put the spotlight on you guys and ask you to go first. Which one of you would like to introduce the other person? And I'm going to try as slowly as you can. I'm going to try and capture some fairly comprehensive notes. Are you going to go first? Sure. I don't know what the... Yeah, I agree with you. So people want to listen, you can come down, but you have to stop talking. Do I have to use a mic? No. We don't have a mic that's passable. Is it taping from up there too? Yes, I believe that's what that is. Yes, we have the tape right here. So I am going to read Kevin's mission statement. I have two layers here. So please identify me if anything runs through it. So the mission of the remand and care board is to attain the triple aim of access, quality, and cross containment. Our vision is to use a five-year time frame for successfully moving from deeper service to population health through the all-care model. Our emphasis should be on making sure all drama residents receive the right care, the right time, the right setting, and the most efficient and effective eating policy. And one more time, three. Which I should probably know from reading the materials. Access, quality, and cross containment. Thank you. And what else did you learn about Kevin's vision during your interview? I learned that one of Kevin's personal values and beliefs is equity between people. And so that it shouldn't depend on who you know or your wealth. Whether you have access to high quality care or not. And a lot of these personal experiences and work on the logistics of people calling and bringing their circumstances out of influence. I think that I also learned in terms of how to achieve our mission better. I'm very interested in better management of data so that we can make more time to observe the signals. One other thing that you've learned or realized in this process is that its preconceived notion about the growth rate in NPR should be less than the state's gross state product. I think it sort of has moved away from that as a given. Realizing that there's a need to make investments out front in order to achieve long-range health protocols. In terms of why Kevin believes the GreenMet and Care Board already exists. He believes it exists for the sake of the monitors. Very succinct. And if the GreenMet and Care Board does not exist, I believe that growth in spending would outpace the monitor's ability to sustain a quality system. Can you repeat that one? If the GreenMet and Care Board does not exist, growth in spending would outpace the monitor's ability to sustain quality systems. Is that enough for you? Did I miss anything? Yeah, let me ask Kevin if there's anything that you would add to Jessica's summary of your vision and kind of some of the key highlights from the interview. Is there anything you'd like to get up here? Okay. Beautiful. I'm deliberately not putting names on these. Oh, thanks. I'm going to do it one more time and layer them. Oh, okay. So, Kevin, it's your turn to share Jessica's vision and what you learned from her interview. Sure. So, Jessica's common vision for the Board is that the GMCB shall use its regulatory authority to ensure that Vermont's healthcare delivery system is accessible, cost-effective, and high-quality and sustainable. The Board should develop a seamless approach to regulation across all areas of jurisdiction and rely on evidence and data to drive resource allocation decisions. It should develop and maintain methods for evaluating system-wide performance. Finally, the Board, through its regulatory oversight, should oversee and evaluate payment and delivery reform efforts that encourage value over volume and seek to integrate all social determinants of health into the delivery system. I'm really impressing myself with what I'm actually able to capture. So, one thing that I learned in the process is that I would be an absolutely terrible reporter because I can't write fast enough. It's hard. And some of these are pretty complex concepts, too. And people might even be talking about the same thing that you were talking about, but use a little bit different language of understanding. So, yeah, that's normal. Kevin, would you please repeat for me the triple aim if it's offered in any different language than this? She redefined it a little bit differently, but it's pretty much the same. But she also added sustainability, which I believe is key to the whole discussion. Great. So, I'm going to call it sustainability plus other three for the purposes of note-taking. You guys will know what that means. What else did you learn about Jessica in the process of interviewing her about the common vision? So, it reinforced some of my beliefs about Jess to begin with that she's a very evaluative person. So, evaluation is a key word throughout? Evaluation is key throughout many of the answers to the questions that you posed. And that she wants to make decisions that are based in certainty rather than anecdotalness. I'm rewriting what Jess has said. Yeah, I'm going to play the game of telephone, and I'm going to put certainty in quotation marks unless that offends you. I'm a leadership person. We don't think that thing exists. Yeah. I would get data for that. But I don't think there's ever certainty. Yeah. Yeah. Yeah. Great. Yes. Was there more, Kevin, to that? The decision making? So, also clear if you read between the lines in what Jess is saying is that she's looking for efficiency, whether it's streamlining the CLN process or what have you. She's always trying to make things better. Continuous improvement. Continual quality improvement. Yeah. Yes. Yeah, I include quality there. Yup. What else did you notice what jumped out at you from your interview with Jessica? In addition to the data, there's compassion behind decisions that she wants to make. I think that her values like empathy and compassion, determination, collaboration, these are all the type of qualities that make me proud to be on the same board as her. Beautiful. Beautiful. Anything else you'd like to highlight before I check in with Jessica about your reporting? No. Great. Thank you, Kevin. Do you have anything else you, anything you want me to highlight that you don't think made it up here for doing the best they can with a lot of language? I do think that's great. Great. Okay, so what pair would like to go next? We've got Robin and Tom or Maureen and Susan. Look up. Beautiful. And which one of you would like to introduce the other person's common vision first? Can I, let's see what I did. I interviewed Maureen first. Okay. So Maureen's vision is to oversee development of innovative healthcare delivery and payment systems designed to control rate of growth of healthcare costs and maintain healthcare quality in a transparent process partnering with consumers, a lot of healthcare professionals and state and federal organizations. Great. I'm going to ask you to repeat that. Yeah, I actually did, where did I put it? You guys are going to have all this material if you want to do things with it too anyway, but for the purposes of the group hearing this all for the first time, I'm going to try and do that. Oversea development of innovative healthcare delivery and payment systems designed to control rate of growth of healthcare costs and maintain healthcare quality in a transparent process partnering with consumers, healthcare professionals and state and federal regulations. Okay. Go back to control rate of growth of healthcare costs, maintain healthcare quality in a transparent process partnering with consumers, healthcare professionals and state and federal organizations. She really kind of got everything in her sentence, but there's more. Yes. But wait, there's more. Okay. More. And I can give you the crib notes that I took or I can read her statement. Yeah, I can see it's a fairly, I can see it's a small font. Yes. Thick and dense. So why don't you finish the statement and I'll see if there's any key things to do. Okay. High points to evaluate regularly for improvements in access, quality, data collection and cost and effectively use guidance and enforcement to deliver results. Achieve administrative simplification in healthcare financing and delivery through actionable system-wide resource allocation and health information technology plans, which effectively promote efficiency, reduced waste and control costs. Promote healthy lifestyles to improve the health of the populations driven by the availability of appropriate affordable healthcare to all the monsters. Great. We're going to need another sheet. I'm so sorry. No, I think what is that item that I just... That's what I have ordered? I think the... It is. It's the microphone that's very important. I'm going to do this. That's a good idea. So continuing on, Maureen, is that the complete vision statement? What was her statement and I... Do you have any crib notes to add to it? Yeah, I mean I had just key words. Yeah. I picked out words, transparency, evaluate, administrative simplification, reduce waste, promote wellness, bring control costs. Beautiful. Thank you. And what did you learn about Maureen and her common vision for the more during the course of the interview? So I knew going in that Maureen had a lot of financial expertise. That's her background. But what I was impressed by was how she reminded me, which I feel like we have gotten kind of away from this, is that how we do everything transparently at this board, like this. Exactly. And what a huge benefit that is to the monsters. It may not always be easy for us, but it's a huge benefit to the monsters in the system. Thank you for that. And also her linkage of the financial simplification, her ideas on making financial simplification and healthcare financing, and a focus on electronic medical records to improve, oh I would say electronic medical records and maybe health information technology, same thing, to improve the triple access quality costs. And then one other take away was her ability to recognize that healthcare is still not affordable and that there are issues with co-pays and high deductibles. And why did that seem important to Maureen? I think because she's recognized, she's seen it in her own life, in her own personal experience. The kind of very complicated system of care that we have and how it doesn't always make sense. Yeah. So in addition to affordability or related to it or connected in some way is the complexity. Which probably ties back to the innovation. Anything more you'd like to add before I check in with Maureen? Okay, I think that's it. Is there anything else that you would like captured that Susan didn't get to say? I think just on the healthcare and affordable complexity is just, you know, that it should not discriminate on the pay. Yeah. I just wanted to think I had maybe more for the future, but, you know, that we really can become a national leader, you know, in like, capitated payment systems and just be a model that people are going to be looking at as if we really take a system-wide view of healthcare, reading the prevention, and how many choices. So that for a long-term vision is to have to be in the forefront nationally. Yeah, the wellness that is something that's prevention. I don't know if that was in there. Yeah. That's another one. Yep, wellness. You got it. You got it. Beautiful. Thank you. All right. Would you kindly present Susan's vision? Yeah, would you comment on vision? So vision is to attain the triple aim of cost, quality, and access for all the monitors. Through successful implementation of the all-care model, moving away from fee-for-service while supporting the economic engine that are found in our healthcare landscape. So all of this to not be at the expense of providers and hospitals. Any more to your vision? And I don't think I mentioned this, but protecting the safety net as well. We say the safety net we say, you know, for those who can't access self-care because they can't afford it or they don't have the financial means, the safety net of care. We need to make sure we're protecting that. So the safety net of care or the safety net of benefits, subsidies, and other financial resources as well. I would say it's all relevant. Okay. So I'll just leave it at that. Beautiful. And then things I've learned about the things that are worth it. You know, through regulation build a strong, vibrant healthcare provider network and system of care. But then, too, that don't over-regulate, but that regulation can make things better if we have this transparent process. So there's the balance between, you know, how much do we regulate, but the fact that at the end of the day, our regulation will be giving, will be benefiting the system. You know, it just learns every day from the staff, from the board, you know, living with the doctor. And, you know, really that this is for the sake of the mothers and people coming for our state. So I think that was what's added where the people haven't necessarily said that. But where, you know, the doctor spoke about all the college students coming up. And if we didn't exist, the financial and regulatory institutions would not be as strong as they are today. And she gets a lot of this from her personal experience and just, you know, realizing the importance of, you know, hospitals and a healthcare network, you know, to communities. Anything else you would like to add, an observation, kind of looking back over your interview? No, I mean, just really that her passion really comes through, you know. You know, she talks about it and, you know, her dedication and experience and it's really a benefit for the work of the board. Probably. Thank you. Now, do you have anything to add? Did I miss anything or risk your drives? Anything in the notes? I just, I think she got it, but I learned, I think from my personal experience, but I also learned, and I didn't say I learned from the staff, but I also learned from this board and their expertise. I think I'm set up. Great. Beautiful. All right, last but not least, we have Robin and Tom, which one of you would like to present the other ideas for her? I'll just go back. All right, so, she covered your rock with a paper. That's right. Don't forget the accent now, Kevin, what's the accent? I can't do the accent, so you're all going to have to just live without it. So, Tom's statement is, Bernie Sanders is right in saying that the U.S. spends the most on healthcare per capita of a new industrialized nation while the World Health Organization ranks the U.S. healthcare system at 37th among nations slotted between Costa Rica and Slovenia. Further, Vermont's spending per capita is among the top care among states while Vermont's population health statistics profile among the best among the states. Given our relative position in the world and nation, it's reasonable for Vermont citizens to expect the capita health care costs to decline modestly in population health to improve meaningfully and measurably. These broad structural rules to improve the health of Vermonters and make healthcare more affordable to be achieved by a care board and staff diligently guides the APM or the all-care model to success and exercise the board's regulatory powers to foster physical discipline across the state's healthcare system. So, what I tried to boil that down to was a modest decline of cost along with measurable health outcomes via all-care model and dealing with cost. Is that accurate, Robin? Yes, I would also, though, I think I would put up there a foster physical discipline across the system. Through the regulatory authority. I think that Tom can obviously correct me, but I think that was sort of a key piece for him. And that was through, did you say regulatory? Through our regulatory authority. Thank you. And what else did you learn about Tom, his work about the common vision during your interview? Well, I think, I actually knew this, but I want to say it in case other people don't. Tom, some of his personal values and beliefs come out of growing up as a native Vermonter and seeing sort of the struggle of our fellow Vermonters around affordability and those sorts of things. Also, as a public sector leader and commissioner of finance and management for nine years, that framed his understanding of the ability to control costs and see good things blossom from that environment. I think Tom is also data-driven, so he did do some research in terms of framing his vision. Yeah. And that he wants to really see the board as a team, the board members as a team. So this is a different role than he's had in the past. In the past he's been in like a leadership role where he was really the guy in charge. This is a different kind of environment. There's been an adjustment for all of you. Yeah. And in terms of sort of the next three to five years, I think we would measure ourselves successful in achieving the common vision if we had a clear sort of set of goalposts around the all peer model so that we could measure that we are achieving those. And so he talked a little bit about needing more data to understand in each decision how it's that impact on those sort of five-year metrics that we've set up in that agreement. And then he is focused on the board existing for making Vermonters healthy and keeping people out of the courthouse and that without us saving off the monopolistic tendencies of private sector health care providers would not be possible. Would you repeat the last one? Yes. That part of the role which is saving off from the monopoly tendencies of the private sector. Thank you. How did she do, Tom? Great. Is there anything missing from your point of view? Well, it's just an emphasis. My experience as finance commissioner is that tough love is very often what allows good ideas to blossom. You know that if you have a process where money gets wasted and we're not used efficiently it's money that can't be invested in good stuff. And so there's two sides of the coin and finance commissioner's role was keeping a lot of great hairs. But at the end of it, it's going to look back at all the good stuff that happened from the behalf to the champion lands, et cetera. And I just think that's a... The farmers will always say the soil is very thin here and so you need to use your resources carefully. So I kind of want to get that out because sometimes people don't understand that side of the equation. At least you still have your... Is there anything else that you'd like emphasized up here or anything else that's missing? Now, if you're all set. I'm set. Beautiful. All right. So last but not least, would you tell us about Robin's commission? I can't. I mean, one of the things that we started talking about here about reporters and I think that the reporter wouldn't be the reporter because they can't read my little... So here's Robin's statement. My understanding of the board's common vision mirrors the triple aim, reduce costs, improve quality, and improve access to care. To me, this means approaching our statutory duties of insurance rate review, hospital budgets, certificate of need, approving the workforce and HIT plan, et cetera, balancing these three aims. These aims are further defined in the all-pair model agreement which sets up a target of 3.5% for total cost of care, which was derived from historic state economic growth and sets three population health goals, identifying priorities for improving quality and increasing access to primary care. Our role in the agreement is as the regulatory body over private industry into monitor progress toward those goals. Great, thank you. So I'm at triple aim and then there was a list including insurance rate review, et cetera. You all know what that means, you know, with balance. And then I need you please, Tom, to pick up where that leaves off so that I can get the other key components of Robin's vision. Okay. Insurance rate of hospital budget, certificate of need, approving the workforce and HIT of plans, balancing these three aims. Yeah. Did I help you? Yeah. And then what comes after that? Oh, after that. These aims are further defined in the all-pair model agreement which sets up a target of 3.5% for total cost of care, identifying priorities for improving quality and increasing access to primary care. And that's what our role in the agreement is as the regulatory body over private industry into monitor progress toward these goals. Well presented, thank you. What else did you learn or observe about Robin and her idea of the common vision as you went through the interview questions? Beyond the safety. Yeah. Yeah. Well, it's clear to me that Robin is all in the all-pair model, which is a good thing. And I personally, being new in the board, have found great value in talking to her right from the beginning. The fact that we're paired up here seems almost natural because our cubicles are right next to each other and I could roll my chair over across the hall and be like, what's this mean? So, and she's, you know, her, I'm happy to see that twice in her presentations she talked about affordability and the money in line with the state economic growth. And she's got a specific measure for what she's hoping for in terms of affordability and cost containment. And it's not just a general, you know, feel-good goal. I mean, it's very specific. And that she is very committed also to achieving the population health goals. Over the next three to five years, again, consistent with that, she really wants to see the success relative to the APM. I mean, I was a little bit more pessimistic in that I said success or failure. And for Robin, it was only success. I'm goal-oriented. I'm goal-oriented. And, you know, look, and she wants to achieve the financial goals, the quality goals, and an interesting twist also was just a better alignment of the regulatory processes that as we go through this, you know, we can learn how to do it better through experience and that, you know, similar to Robin and the CON process is like, you know, keep our house renovating it, you know, as we go along. Very oriented to data and input information. And I mean, that's kind of what has driven her and her experiences of working in the legislature and he lacked the 15-year commitment to healthcare pursuing the purple lane. So there again, it's just an all-in commitment that's what we're doing. I didn't know Robin was a native reminder, but she, like me, said that part of her vision comes from being a native reminder and then pursuing a public service career after that to ensure a good, a big healthcare system, again, at a cost that can be afforded. In terms of what she might do differently, here again, we have some similarities which is, yes, there's something she can do differently and it's in her work experience and she's never been on a board. She's used to work for a governor that kind of drove the bus and, you know, she helped her drive that or worked for a legislature, but now it's kind of as a peer in all those peer relationships and managing those. And it's just anything you'd like to say more about. I mean, I'm curious about data and the more data it's helpful. Very simple on the Green Mountain Care Board exists for the sake of Vermonters and the Green Mountain Care Board did not exist and I agree with this that cost containment would not be achieved and importantly, it would not be a transparent environment. Good job. I made it up. I thought that was lovely and comprehensive. Is there anything, Robin, that you would like me to add or emphasize or you wouldn't quite make it up here in the way that you would like? I certainly did a... Yeah, no, I think that it's pretty well captured the job. The only thing I think I would add is that one other area that I feel like I'm still working on as a board member is in my other roles I was in a very creative... Like I had a very creative... I was a lawyer, but I was a creative lawyer. I feel more like a lawyer in this role than I have in a long time. It feels like there's less opportunity for creativity, so I want to continue to explore that because I'm not sure that's so true. I think it's more just... when you grow up as a lawyer and you spend time in court when you're in a regulatory process and I work for the courts, right? So I tend to think like a judge in this role. That's really interesting. Which to me feels less creative. So what would you pair with creativity? Not necessarily it's opposite, but what's the quality or feeling of the adjective? I mean the way she expressed it to me and I did have a note here she said that it's easier for her to fall about having a lawyer that's a complicated course. So is that expertise? Is that a rule follow? She needs to enhance her creativity. I think it's more following a little bit. Yeah. Yeah. Coloring outside the lines a little. Great. Wow. There's a lot of material. And between your notes and then what we've got up here I hope there's just a lot already for you to work with. I am noticing the time. We have about ten minutes remaining. That doesn't include time for public comment. So I just want to check in and ask Kevin how much time would you like me to spend on at least getting you started on the next activity or thinking in the next way? So I feel comfortable that we really don't have to open it up to public comment until about 4.15. Okay. Yeah. Yeah. So we have I would say 20 minutes for the next thing. If we have 20 minutes I would like to first spend just a couple of minutes in what do you need? Okay. Okay. In debrief just kind of taking a pause and ask you collectively how did you experience this interview with us? How would you characterize it? What if anything did it do for you? Were there any surprises? I'll start. I thought it was very positive to reinforce my belief that we have shared goals we sometimes state them a little bit differently but at the end of the day we're still focused on the same things. Yeah, there's a lot of common themes through everybody's vision that you would expect if we try to come up with that. What else did you notice? Any surprises? Any observations? Just in general before we move on to actually naming some of those commonalities? Was it fun? Was it not fun? How did you... So I wouldn't characterize it as fun but it was much more pleasant than I thought it could have been. What was more pleasant than you might have expected? What was more pleasant? I think that's a tough one to answer. I guess I would say I'll jump in while you're thinking but it was less awkward doing it in this format than I was expecting. It's a little bit like being in a fishbowl. Oh, it is. It is being in a fishbowl. I want to honor that in all of you. It's impressive what you were able to come up with and what you were able to share and how you created your own space despite the rest of the auditorium and all the other things that you've been through today and the coming and goings of audience members. I would add that it definitely was less awkward than I thought it would be yet it's also a bit forced in the fact of having to do it in a public situation and we really weren't quite public if we're separated and talking privately. I mean we were public but we really weren't part of it. So it was our way of saying we're here together in a format where public would be more efficient and we'd come out with similar, we'd come out with a similar and maybe even better product through the end. So it was definitely less awkward than I thought it would be but I also would work completely open in the whole time. I think that's a great thing to just notice and to acknowledge. Thank you for that. I work with these people all the time and I talk to them all the time because I talk all the time as everyone knows but I thought it was good at least for me to stop and listen. I thought that was very valuable. I listened to Maureen obviously during our exercise but I noticed how the board listened to each other and would give you the report back. I thought that was it just shows another characteristic of the board and the respect that they have for each other. That's valuable. Yeah, it's a superb team. Yeah. Alright, thank you for that. So, now, that one isn't going to work very well. It's probably the best, actually. Let's get down to what you noticed. There's some stuff that's pretty obvious across the board and then there were some subtleties maybe but I'm wondering if you guys noticed also that were commonalities to your vision. Let me pop the no-brainer stuff up here first. It's a triple A. Yeah. Remind me what the acronym for that is. ACQ Access. Quality. He's got access to care. Yeah. ACQ was one and a pair of models. Yeah. Yeah, now that is interesting because there were a lot of different ways people phrased. It might be used and I didn't know whether they were the same or whether there might be some important differences to record. With my facilitator head on, I'm thinking I'm wondering if there's more to it than just putting data up here. I think it's data-driven decision-making. Fair enough. And why? I think of... Getting our decisions right, basically. How would other people put it? Same way, similar, different? I think there's a lot of ambiguity out there. You're the certainty guy. There's a lot of there's a lot of ambiguity. There's a lot of cuts in the healthcare and so when you... there's no way we're ever going to have certainty. I don't think we're going to have certainty if you have the decision-making. So I think it's to reduce ambiguity to the extent that you can with more data. And even the data isn't perfect, but narrow down the choice set based on evidence. I heard... Are we done? Are we done? Part of the data-driven decision-making is to deliver some of the end results that we've talked about. That's the only cost. It's really to get us where we want to go. Yeah, and I guess I would separate those two different things, because we could have data-driven decision-making and yet still not have any clue about how our decisions impact on the long-term goals. So help me phrase that. It's an evaluation piece. So there's data-driven decision-making, an evaluation that's based on data and metrics. And for me at least, tied to the APM measures. How do people feel about tied to the APM measures? Is that universal or people put that differently? From me and from the perspective of staff, they always go to the off-air model goals and where we're going with that in their work, so it would be nice to hear about the four things. I think that the one difference is I see the off-air model as a strategy to get to what I think the ultimate goals are, which is getting back to the AAA. So it's a means not an end in itself? Correct. And how do others feel about that? I agree with that, but I think it's a means, but it also sets up some measures for the AAA, because it says what does cost containment mean? It means that we're shooting for 3.5%, either quarter between 3.5 and 4.3% of total cost of care. So I have I guess it's a driver diagram in my head, which is the AAA. Then you have the measures for each of those goals. Access means X quality means Y in fact it means Y times 22 and cost means 3.5 to 4.3. And then below that I even see our regulatory processes and the ACO model as that the mechanisms to achieve those articulated goals which then roll up to the aims. So again, the ends are for all of you, the ACQ or how would you Kevin describe what the using evaluation the APM is a means to what end? So again for me the all payer model is the way to get us to the goal of making sure that everybody has high quality health care that they have access to that care and that they can afford that care. So I think that I like the way that Robin outlined it, but I also see Kevin's point that we're trying to get to the means to achieve the top level of the ACQ and I would add I liked it a little bit, sustainability because I do think that we have to be sure that whatever system that we have in place is sustainable over a long period of time and the piece about the evaluation process that I think is important is the all payer model measures I think to me are at the core of what we're measuring but I think that there are other there's data beyond that that we need to make sure that we're collecting in order to evaluate our system-wide performance even outside of the all payer model care. I'm equally interested in that, especially the care even though that's not the ATM measure so I guess I would say the all payer model measures give us a significant bucket upon which we should be evaluating some of my performance but it's not all inclusive. I'm just going to throw out for a conversation, you know, kind of a little bit of an opposite which is really substituting, really making it the ACQ and sustainability and although right now we're moving between an all payer model if some reason that didn't work which some that's not completely all in our control if people don't participate if things don't happen and if this is a long-term vision and in five years, you know the all payer model has failed it just didn't gain acceptance, they didn't get the savings if they wanted you know, I think it's alternate delivery systems potentially I'm not sure it's just the all payer model but I think to lock ourselves in there it's where we are right now but in five years what if single payer was back, what if this didn't work, so I'm just saying I think going to each work heaven was starting maybe really going with access, cost, quality, sustainability is what we're doing as a way to get there we're using the all payer model but if I play the yeah, go ahead I'm wondering if we're using all payer model to mean the same thing do you really mean the agreement or do you mean the ACO model ACO model that's helpful to me because to me I differentiate I'm looking at the agreement versus the ACO model and I totally agree with what you're saying the agreement still sets up these definitions if you will of and to your point they're not and below the, in my mind below sort of the agreement targets there's this one model that we're testing and it may or may not work and there may be other models that come along afterwards I found it interesting that the only person that mentioned fee for service I think in their written thing is you Kevin and within your written narrative and to me that's one of the underlying things that we're trying to transition from and that's what I was thinking too isn't this like what you guys are saying isn't when we say the all payer model would could we say moving away from fee for service towards value based care or population I mean all these buzz words have I been used when you have it the fee for service towards population the commonality that we saw was that I used encouraging value of the volume you know so I think we did there was multiple changes in payment model with fee for service is that worth recording as a common concept and how would you like me to record it which was which was so following the board's regulatory oversight should oversee and evaluate payment and delivery reform efforts and encourage value over volume and seek to integrate all social determinants to help implement delivery systems and we still have a lot of value over volume value over volume value over volume did you say social determinant and seek to integrate all social determinants to help implement delivery systems thoughts about that second part I struggle with the second part a little bit because I don't think that we can be ever that I think we have to be focused on what we do I don't think that the medical system should pick up the pieces that really the government system should be dealing with for the most part dealing to do properly okay so that's enough of a divergence that I'm not going to call it a common concept for the purposes of this exercise what else needs to go up here that was transparency that was the first one I was going to offer if you guys thought you were done because that sure came across to me the other thing that we don't see up there is collaborative because we have to work with our partners or else we're not going to be successful no matter what do you mean like the regulated entities or partners like the regulated entities all stakeholders yeah first let me clarify this because it came up in a variety of different contexts in your interviews this meant transparency with each other with the public with sort of the evolving work of the board over the coming period of time what if anything would you like me to make sure is noted here when you're going to be looking back on common language and concepts all of the above something that should not be included how will you know what this means it was the process the transparency of the process are you like our process because I also look at transparency from our regulated entities in our work in terms of our process our process of decision regulating by virtue of the fact that our process is transparent it makes it transparent enough for the purposes of this exercise so the next I heard collaboration which was explicit or implied in all of the common visions and the interviews what would you like me to record regarding collaboration I heard all stakeholders that works for me I guess my only caveat on collaboration is that we are regulated entities which means we can pursue that in a we can pursue that to a certain extent but at the end of the day we have to make decisions that may not be perceived as collaborative so what's the transparent or not yeah yeah guided by our statutory responsibilities at the end of the day you have to approve budgets you have to approve rates I think what's interesting about it we have the regulatory process we have the innovation process and the evaluation process it's all under our portfolio when we regulate it's harder to collaborate because you're regulating you can't innovate unless you collaborate so to the extent that in our role as innovators we're moving towards more individuals we have to collaborate so I think that's where the rub is that's the potential yeah this is great work you guys I think we're starting to come toward the end of this list but I'm not sure that's just an instinct that I have other commonalities you noticed I think a lot of us are affordable and appropriate what was it for what was that about cost I agree we certainly got costs here didn't we we're thinking that it didn't quite come out I came out a little bit but I'm not sure now that I'm thinking about it a little more carefully I think I heard a couple people say I know I said it myself it's seamless integration of the regulatory process the things that I think the value of the remanded care board that you don't see in any other state is that we regulate hospitals regulate the terms and regulate this all-payer ACM we have a lot in our portfolio what that allows us to do is see the holistic picture of the whole system and actually be more efficient regulators we have to work towards the crosswalking between those jurisdictional areas but I did hear multiple groups of regulators in the process I'm not sure how we can articulate that better than I did but the fact that we have all these areas of regulation means that we should be able to do it better as we see everything I did kind of along that theme a simplification a simplification of efficiencies and do you mean efficiency internal or external I think that's efficiency internally efficiency within but I have an external simplification externally if we were looking at where people get their care how they pay for their care over time how they simplify that sounds external that's what I'm trying to clarify should you note this internally and externally I don't think it's feasible for us to drive administrative simplification in healthcare providers I think that's an operational task that you can't regulate I think we should encourage it but I don't think we could actually achieve it with our regulatory tools that we have if we're going with an APM type of model then out of that it would come so I think it's more of a process it's in five years down the road we really had a lot more there it should create some simplification and if we're oversight of the resource allocation plan as well as the information technology piece that we should be able to help promote simplification I mean it's not common but that's kind of where I was going was more if we really long term got things on the medical records things like that could that bring simplification for people I agree with it as a value I just don't have you tried to do administrative simplification from a much more direct powerful role I'm skeptical that we will actually achieve that so I agree with the value and the goal I just don't believe that we will that it's feasible for us to do that I don't think we'll be in the weeds in our moment I don't think we can regulate it on a micro level but I think we can encourage it through cost containment because then people are always looking for ways to save money so they can do what they want but it's we're sitting there measuring as we go along and some of our bills we regulate are more efficient than others that will come happen over time and then you know but it's not that we're going to go to the ones that are and mandated I mean they might there's maybe a career destruction here that we just can't as Robin said can't get a new lease on and I would just I would just add through our work in regulating these entities and we've started to do this through the all pair model and the ACO programs but aligning programs or where we can so it's not for providers or for regulated entities so that it's easier for them to be efficient so they don't have to do things five different ways that makes sense does it? It does but I think we have done that and the providers have not seen it and that is because there are federal requirements that we don't have control over so we've I think our team has done a really good quality it's been a really good job of aligning it across the state players but it's still not felt at the provider level because it's all another right right that we don't have control so I'm getting into a couple of clarifying questions which is the note that I wanted to end on and we are in the last couple of minutes here what other clarifying questions for your future consideration and discussion would you like me to capture today? There's one I'd like I just don't know if it's possible so that I know but I brought it up when we talk is that for me it would be nice to model oriented around something like the all pair hope that says here's 2022 here's the goal post because that is a timeline that we're on and here here are the kind of key paths that will get us there so that we can kind of step back in an individual decision and kind of have a sense of how we're affecting things like for example the re-benchmarking discussion that we had the other day part you know I was against it but part of it was I don't know what it means in terms of getting to the end game goals I just you know I feel like I'm flying behind it so if we had a model that we all kind of not fully agreed on but understood that and it's only three or four years down the road I mean we're through 17 we're well into 18 we're dealing with the 19 budget and all of a sudden it's going to be 2022 you know and aren't we making decisions as we go along through time that are in accord with the I think the goal that we all expel which is in the APM be successful I think that almost like a strategic plan around the APM and I'm also just brainstorming here and I just made a note to reach out to the Maryland folks the Maryland folks and see actually what they did in the early stages of their first agreement see if they have some ideas for us they've come to visit before so any others questions for your friend there consideration and discussion do you have a sense or something do you want the others to add that maybe if we do have some common themes in our vision how do we go from that to setting priorities that I'm working on so I think we need to take the vision and say okay you know it's part of the focus with that but that may be beyond the APM broader and may I even on the facilitator add one that perked up my ears I'm going to put it in the form of a question it may actually be a commonality and that is how does Vermont become a national model is that alright for me to add here just to be sure it doesn't get that relates to the success yes I think yeah well yeah yeah final thoughts maybe a positive national yeah positive final thoughts anything not up here that you want to be sure just gets down before we break for today well done you guys well done this is a huge amount of work oh it's my pleasure thank you so because we have to do it is there anybody from the public who has any questions or comments they would like to share with us except for three of you we tell what the others are yeah nothing can we you're welcome should I just wear something yeah it would be great and well done