 Good afternoon. Thank you all for joining us. This is. It's 30th February 17th and it's. Like 101. So. What we're hoping to do what we're planning to do this afternoon is use some time. To hear. That what we, we heard from the green mountain care board. With a proposal or actually with their. A budget proposal. And we also wanted to have the opportunity to hear from. Hospital. Hospital sustainability. Report. And. That included a proposal. With a budget proposal as well that accompanied that. And. Clearly we wanted to also have the opportunity to hear from. Hospital. Association of hospitals. And we're. And we also wanted to have the opportunity to hear from you. And we also wanted to have the opportunity to hear from you. From the boss to join us this afternoon and. Green Mountain care board to come back and try to. Spell out more what their proposal. The financial proposal entailed. And I see that they've. Number of folks from green mountain care board are here. But I'd like to start first by. Fighting. Devon. If you can. And I understand there's some. That you have that you might want to share. On the screen. Cause there's a little technical difficulty in getting it to us. Apparently. But. Let me, let me turn it over to you, Devin, and invite you to. Comment. On behalf of us. About the green mountain care board hospital sustainability. Proposal. Great. Thank you. Devin green from the Vermont association of hospitals and health systems. And yes. I do have a PowerPoint that I sent like four times. And for some reason it's not going through. So let me share my screen. Believe me, we are all sympathetic to. Our hybrid world. Yes, thank you. I appreciate that. So thank you for having me come in here to talk about Vermont hospital sustainability and the. Green Mountain care boards proposals. So I'm going to go ahead and talk about that. Before. We do that. I did want to. Speak a little bit about who we are when I say I'm representing Vermont hospitals. We are 15 nonprofit hospitals and two government hospitals, although I don't represent. Vermont. Psychiatric care hospital. But those are the, those are the three hospitals. One is critical access hospitals. One academic medical center. Seven designated hospitals who serve. Mental health patients. And one FQHC. I do want to. Sort of. Step back and think about what our hospitals look like, because I think. When we hear from the consultants, we know that there are a lot of hospitals that share services. We have a lot of hospitals that share services. And if we just. Cut down on some of those services that will help. But that's not where we are at today. We have a lot of hospitals that share services. I know North country and NBRH. Up in the Northeast kingdom. Share services. We also know that there are hospitals who. Employee physicians on a part-time basis, we have a lot of hospitals that share services. We also know that there are just a couple of procedures being done. That could potentially be done by a Dartmouth. Hitchcock medical center doctor coming in once a week. So. A lot of the things that the consultants talked about hospitals doing. We are doing them. As always, I think there's room. For improvement and discussion about what. Optimization looks like. I think there's room for improvement and discussion about. The health care reform system already. I also want to just take you back to pre pandemic and where we were going with healthcare reform. We were moving towards global or not towards global budgets, but towards value-based care with one care in our ACO. That. Effort resulted in a Medicare savings of $122 million. That was statewide. We were moving forward. We were moving forward. And we were moving forward. The other states. Our spending was going down. At the same time, we were following that issue of. You know, Moving people away from high cost care. We reduce hospital stays and length of say by 9.3%. We reduced specialist visits by 7.7%. And we decreased by 22%. that the struck a good balance between trying to move away from that high-cost care and move towards preventive primary care without losing quality, which you can see in that decrease in unplanned readmissions. Can I just jump in for a minute, Devin, and I think it's important that you're talking about pre-pandemic rather than because there's a course in during the time of the pandemic everything has been on its head in terms of measuring all kinds of things. So I don't know what the underlying statistics are that you're using, but this is for the pre-pandemic period that you're referring to generally. Yes, this specifically is the healthy on days of 2019 where we were all innocent and we were just moving along having no idea that a pandemic was about to hit us. So because of our sustained effort of moving towards value-based care, of having the Green Mental Care Board and our hospital budget process, you can see that our margins decrease significantly over the years. And I put on here, so this is a graph I sort of took from the Green Mental Care Board that had our margins. We had looked at that last year. I also put on here a CMS sort of cost inflation indicator that they always predict for hospitals. And I can present a citation for that, but you can see here with the light blue line on top just how significant that amount of our margin is from the sort of inflation increase that and cost increase that hospitals were expected to see. So a lot going on there. We were definitely a lean system going into the pandemic. And as you can see in FY 2020, particularly lean with about 3 million margin for the system. That's on the system-wide cost of roughly I had that number. I think and the Green Mental Care Board might know better. I mean, it is about I don't want to say it off the top of my head. We'll ask them to help us understand. We'll look it up right now. I can throw out a number, but I'd rather not. We'll look it up. Yes, thank you. Okay, so that's where we were going into COVID, very lean. Here we have the COVID emergency response, which, you know, everyone has COVID exhaustion, and you don't necessarily want to relive this, but I just have to take you all through this to show what the hospital did and all the folks who are working in the hospital did. So hospitals set up incident command that they acquire PPE and other supplies. You also help the state acquire PPE and other supplies. We stood up COVID specialty units. We partnered on alternate care sites on staffing those and standing those up. We suspended procedures. We stood up statewide testing and statewide vaccination. I think here it felt natural for us to work with the state of Vermont to do those statewide vaccination and statewide testing efforts. In other states, when I talk to them, they're stated that that was not something the hospitals vaccinated their own people. They would vaccinate their patients when they came in, but they were not standing up statewide vaccination efforts. We were doing those with, you know, thousands of pages of spreadsheets and names that we were getting from our local healthcare providers and trying to vaccinate those in the first wave. It was extremely stressful. We had people calling up and asking why they weren't getting the vaccine before other vaccines. We had, you know, veterinarians calling up and wanting the vaccines. So it was a huge, huge effort. And I'm really pleased that we were able to contribute so significantly to Vermont's high vaccination rate. We moved and retrained staff as we moved them to different areas of the hospitals. We administered monoclonal antibodies. Again, this is a really intensive work where you have to stand up, you know, put these in separate units because we know that all these patients are going to be COVID positive. Have it in an infusion center. You also have to sort of triage who gets it because these are all treatments that are limited in supply. And so providers are having to make decisions about who gets this sort of treatment and who needs it the most. And again, extremely time consuming and extremely stressful, as well as adapting to new data policy and regulations. So we heard recently about how the vaccine implementation is going to look like and it is extensive. We are going to have to have records for anyone who comes in, you know, more than twice to our buildings, including people who are doing construction work outside and who eat in our cafeterias. So there is just a lot going on in terms of the COVID emergency response. And here we are today where we have COVID, we have the effects of COVID, but we're also coming out of COVID. And we really are at a breaking point. So as of February 4, Vermont has the highest percentage of hospitals reporting critical staffing shortages at 64.7 and 1%. Just as a comparison, New Hampshire's reporting the number of their hospitals that are at this critical staffing level at 6.67%. We're currently utilizing FEMA and Vermont National Guards to help out at the hospital. Okay, go ahead. Representatives, I really don't understand. Can you spend a little more time with staffing shortages at 64.71% meaning? So more than half of our hospitals are saying there are critical staffing shortages. The hospitals report to a federal emergency management database. And the question is, are you at critical staffing shortages? Have you had to change your practices? And more than half of Vermont's hospitals have answered yes to that. Okay, at some point, it'd be helpful to know what that means in terms of critical staffing, because I really recognize that. So that's helpful. So I don't want it to be misinterpreted or confused that there's a 64% staffing shortage of any hospital in Vermont. That isn't the case. And that's what I was just, as you look at this and different people present us with data, we've had people saying, well, we have a 30% turnover rate or we have a 45% vacancy rate. And that's not what this percentage is referring to at all. Yeah. No, what this is, that is not what this is referring to. This is referring to how many hospitals, the percentage of hospitals in your state who are at critical staffing shortages. So over half of our hospitals are there. And, you know, a couple of weeks ago, it was Vermont at 64.7%. And then there are hospitals closely after it in the 60s. What we're seeing now is that the nearest hospital after it is at about 20%. So fewer hospitals across the nation are at critical staffing shortages. We remain high on critical staffing shortages. At some point, not right now, but I'd love to just be useful to understand what the underlying criteria are for, quote, reaching that significant point to be called a critical staffing shortage. Yeah. Yeah, I can send you the exact question that we have. Again, it's basically saying, are you right now changing your, the way you provide care due to staffing shortages? Yes or no? And so if you say yes, you're a hospital that's reporting a critical staffing shortage. Do you mind us interrupting you with questions along the way? No, I don't mind. Representative Goldman, I think he has a question. Thank you. I'm just curious to know your thoughts about the difference between Vermont and New Hampshire, which is pretty stark. Yeah, I was surprised to see that too. I'm not sure what is happening there, but I agree. It is pretty stark and we're routinely compared. So I'm not sure. Is there a way to understand it better? I mean, just so that we could understand the 64% in the context of a larger system or a larger country. Yeah, I mean, I think it could very well be. And again, I'll have to talk to my New Hampshire counterpart, which I did not have a chance to do before today. But as we've talked about before, especially with having a critical access hospitals, if you have one person who's out, if you have a couple people who are not able to staff their position, it can have a huge impact on the hospital and the services that they provide. And I think New Hampshire has quite a few more hospitals than Vermont and also larger systems there. Thanks. The other thing that we're, oh, because of this critical staffing shortage, hospitals are currently utilizing FEMA and the Vermont National Guard. As we've all learned during this pandemic, the healthcare workforce, the healthcare clinicians in the National Guard are all within our current workforce that we need to have working, but we have been able to utilize the Vermont National Guard to do nonclinical work to try to further free up healthcare workforce. So things like bringing food to patients, driving delivery vehicles, maintenance. There are a bunch of different ways the Vermont National Guard are pitching in right now to help with some of our hospitals. Additionally, at our hospitals, there are about 100 people who are waiting in hospital beds for subacute or long-term care placements. So this is in addition to the 130 beds that the state has opened using contracted nursing at some of our skilled nursing facilities. So when we hear about things like inefficient care or low-value care, I feel like this is right there. This is the wrong care in the wrong place. These people are looking to go to more subacute care and instead they're in a higher level of care and they have been there for months and months potentially. And so this is an area where we really need help going forward and we don't see this getting better as we go forward because the workforce issue causes such a ripple effect for hospitals. So when we don't have enough workforce in our long-term care facilities or in home health, then it backs up into our hospitals. Again, as we've seen in mental health too, where we have people waiting in places that they shouldn't be waiting and it affects our capacity as well. There's also, as you well know, 35 people who are waiting in emergency departments for mental health placement. And we've also heard that due to lack of respite care, there are individuals being dropped off in emergency departments with no emergent medical needs, but there's no place else for them to go. And so they're in the emergency departments that are also extremely stressed right now. We have had in the recent past, I think it's gotten better at this point, but we've had emergency department physicians calling up to 40 hospitals to transfer patients, transfers that really should have taken minutes because they were so critical to health are taking hours. And we have hospital nurses riding in ambulances because we have a lack of paramedics. So when there isn't a paramedic on board, but a paramedic is needed, a nurse will leave the emergency department and leave it and go on to the ambulance. And because we're transferring longer, that could take a really long amount of time to again impacting the quality of care providing and impacting the health care system. And I know we all want to just get COVID over with and get out of this, but we're really facing an uncertain landscape right now. So we have our workforce crisis, we have the subacute crisis, we have the mental health crisis. We have hospitals reporting that patients are coming in sicker than they normally would. When we've talked to hospitals about a lot of people being in emergency departments, we've asked them if they should really be in urgent care and they've said no. We've seen that COVID is potentially creating another crisis where people didn't get their screening and so there could be an influx of cancer patients. There's also new findings about long-term cardiovascular effects that could be a result of COVID, which could also make an impact on our system. And then just to add to that is the warning from President Biden about potential cyber attacks from Russia. And so we've seen what happens when there's a cyber attack on one of our hospitals, it really does impact our system in a big way and it can happen for a very long time. So we are very fragile right now and we've been finding all of the surrounding ideas out there are not helping us form a sort of predictable, sustainable path going forward out of COVID. These are some of the things that we've been fielding just this week and they are not all working in tandem. In fact, a lot of them are working against each other. So we're talking about global budgets today. Senate Health and Welfare was talking about reference pricing, which would take out $16 million from the hospital system. Again, last year our margin was $3 million. At the same time, folks want us to look more into access to specialty care and what we can do to increase the amount of specialty care that's offered. But we should also be investing more in primary care, but we're not going to increase premiums with that. So that will likely result in cuts in reimbursement to specialty care. And then we have sustainability planning where we're going to look at what services are considered low value and what services should be provided where across the state. And at the same time that we're doing that, we should also be investing more resources into partnering with higher education on workforce. And we're just going to play and have to do more workforce there, unless we get a significant amount of help from the state. So all of these are a little bit mutually exclusive. They're all pulling us in different directions. They all have different goals or not always the same goal. And so it is really difficult for us to figure out where we go from here when we're already coming out of COVID pretty fragile. So we do think that this is a good time to rebuild and reset and work with Vermont to get on the same page of where our goals are and where we should be going with our healthcare system. Vah supports building some sort of consensus from the ground up with a community driven process as a vision of how to strengthen Vermont's healthcare system. We think we're really well positioned to do this. We have our community health needs assessment and those sorts of avenues to get community feedback. And so we want to be at the table for that. But we do think a new payment model needs to include hospitals as part of the governance process and to inform decision making. So like I said, hearing consultants say that we aren't doing enough or that we don't share services or that we provide low value care. We want to be able to talk about what's actually happening on the ground, how either we are sharing services with other hospitals or that we are employing part time physicians who actually do a lot of procedures elsewhere. We want to provide that nuance that consultants can't always get to in the short amount of time that they're working on Vermont issues. Do you have a question you'd like to ask? Yes. So let me I want to be clear. As you perhaps know last week or the week before the Green Mountain Care Board presented this report on sustainability. And from what I understand what you're saying is you're on board with that you agree with the Green Mountain Care Board's plans to move ahead. Is that correct? I am saying that now is a good time to hear from our communities about what they need from their health care system. And that is what the Green Mountain Care Board has said. I agree that that's a discussion that we need to have. And I want to start from a place of, you know, talking to the community and seeing what they need as opposed to a top down sort of situation of move these beds over here and move these beds over there. So I think we'll come back to hearing because I think I think what Representative Page may be representing I don't want to speak for him but that there's actually some overlap significant overlap in your vision of getting to absolutely the sustainable system. The Green Mountain Care Board did talk about reaching out to communities and I just picked up on that and thought that's pretty much what what you're saying. So therefore you're in agreement. But I mean quite frankly quite frankly Representative Page if it seems like this is the direction the committee is going in we want to make sure that we are there and able to have a voice. But if you wanted to put that three to five million dollars into what is going to happen to the sub acute the people who are waiting for sub acute beds in our hospitals or towards mental health we'd more than support that as well. Well let me just say for the record I was one individual representative here did not favor the plans for the Green Mountain Care Board so it was just my two cents. Well let's let's let's hear the rest of the presentation and then we'll and hear from the Green Mountain Care Board and then we're going to have opportunity for much more discussion and I don't see us making any kind of decision here today as such but this is really an opportunity to ask a lot more questions and hear from the hospital association so go ahead sorry go ahead Dan. Great thanks. So like I said we are willing to have that discussion about value based care. We want to be sustainable too. We don't want to sit here and say we don't want our hospitals to survive. We want to make sure that there's a way for them to stay here and serve our mentors too so we do want to be a part of that discussion. We do want to manage expectations around what value based care means for people so that we all have a shared understanding of that. So value based care provides incentives for preventive care and better health outcomes which is the direction we want to move in right. We've been saying this for a long time. This is what we said with the all pair model. We want to provide better health outcomes for our patients. We don't want to be hoping for a bad flu season so that that will bring in revenue for us right. We all agree that fee for service is not the way to better health necessarily so we do want to be a part of that conversation but I want to manage expectations around you know this and affordability especially when our system is so lean as it is now. So it will not result in instantaneous premium reductions or anything like that. The Pennsylvania model that the Green Mountain Care Board has been discussing has a very you know modest target of 35 million in savings over seven years. This is much more about taking aligning the incentives so that they move towards preventive health and less towards this is going to reduce your premiums tomorrow. What it's going to do is provide better health so that the cost of health care would hopefully go down over decades because the prevention that we do now will help later. But most of all we need a predictable and sustainable model going forward and a predictable and sustainable direction going forward. Right now with all the ideas that are swirling around and all of the sort of priorities that are swirling around I think whatever our hospitals can invest in they're not going to be able to invest in long term because it's unclear where we're going. We're of course going to invest in workforce right now and more immediate things but it's really difficult for us to think about long-term investments where we have competing goals coming at us from different directions. In terms of how to immediately impact the system in one thing and I just took the slide right from the Green Mountain Care Board's presentation I'm sorry Elena and Susan and Kevin I hope you don't mind I should ask you permission but I think this slide really helps illustrate that what would help and have an immediate impact on your health care system and help it so that the price doesn't increase as quickly for our commercial pay or commercial insurer consumers is an increase in Medicaid reimbursement and a more sustainable Medicaid reimbursement and when I talk about that I do talk about that not just for hospitals certainly for hospitals but also system-wide because as I just mentioned we're seeing the impact of what happens when there's underfunded Medicaid for our long-term care services so really the most sort of immediate helpful impact to hospitals and the rest of the health care system would be through increased Medicaid rates and more sustainable Medicaid rates and that's where we were going earlier in the session when I came and talked about workforce and investing in workforce that those increased investments they go to the commercial rates and that's the sort of only release valve that we have at this point and so this is why a sustainable Medicaid reimbursement would help us the most so I'll just say it again sustainable Medicaid reimbursement it would be immediate impact for us and then also looking at care coordination and setting us up for success in that value-based direction whether it's continuing with the current all-payer model or other sort of value-based models I think it's worth putting the care coordination in the hands of the providers at this point we know that payers have a lot of care coordination efforts and we think it'd be helpful to shift those resources over to providers so finally just once more our recommendations our community driven process to determine local needs we need to address waiting in hospitals for mental health patients and the sub-acute beds those are our most immediate needs right now and again that's the most sort of wrong care in the wrong place issue that we need to address and then having a hospital voice and the development and government of the value-based model not just listening to consultants but having hospitals at the table in a formal way and then provider-based care coordination framework shifting the provider resources that we now see with the payers over to providers as well as a sustainable Medicaid reimbursement and that is my presentation thank you so much for having me I will stop sharing so I can see everyone yeah well thank you and I as I think it'd be fair to say that's there's a lot more to be said about much of what you've outlined here as well this is but I think it's helpful to have you lay out some of the broad and specific challenges that the hospital system in Vermont is facing at this point in time I'm I'm going to just not comment further at this point because I think it'd be useful because we also get here from the green on care board initially in their presentation and we felt like because it had specifically because it also had a budget request item along with it that we while we had not had the opportunity to delve as deeply into the sustainability issues that we wanted to hear more from the green on care board about what given their analysis and the proposal that they're putting forward to ask them to say more about what you're asking for two to five million dollars for a process of moving towards the global budgeting and for hospitals and we wanted to give them a chance we wanted to ask them like well say more because that's we don't feel like we've heard enough we need to understand what you know what what it is that you would be doing with that and again I think it's also tied to the general proposal of the analysis and the conclusions that would lead to that request so I'm going to see we have a number of folks from green on care board I'm going to turn to Kevin just at least to get us started as the chair of the green on care board and then Kevin I'll welcome you to have others participate or however you wish to proceed and again if it's okay we'll ask some questions along the way and I think we've allowed enough time that we can have questions and not feel like we're cutting off either of your presentations so yeah just fire away at any time for the record Kevin Mullen chair of the green mountain care board and thank you mr chair and members of the committee and joining me today are Susan Barrett the executive director Elena Barrabi who is working on the sustainability project and Jean Stetter just in case there were other budget questions we weren't quite sure from the email if you might go into other questions so we wanted to be prepared so that's the team that's with me today and before I I start on the the five million dollar request that we have for sustainability I just want to say that I agree with everything that Devin has just said to you and the reality is is that we would hope that our our request for the five million isn't competing against other needs that are out there so for example on the workforce when I testified with your colleagues in the house commerce committee you know they had done some analysis on some New England states and it was a lot more dollars that were being spent there and I told them I hadn't done an analysis of the New England states but I had to listen very patiently to Governor Huckle in New York on her 10 billion dollar healthcare workforce initiative and obviously New York's a much bigger state but when you divide that out by the 22 plus million people in New York it works out to about 494 dollars for every person in the state of Vermont you do that same math in Vermont you get about 315 million that would be the equivalent investment in healthcare workforce and yet from what I've been able to ascertain so far from the budget in the discussions it looks like it's probably closer to 40 million that will be spent in Vermont but you know I could be missing something it's very hard and as you know it's it's even hard sometimes for legislators to keep track of everything that's going on in the building but that's what I'm aware of and I would just say I met with Devin's board yesterday and they're tired they're beaten down it's been a tough couple of years and yet I still sensed a sense of willingness to work together and we totally agree that it should be a community-driven process and not top-down and I wasn't involved in the negotiations of the current model but it was always meant to be provider-led and in fact if you look at any of the descriptions of the all-payer model agreement it's a provider-led agreement it's not a government-led agreement and so Devin also mentioned adequate sub-acute or step-down beds and sub-acute is something we're keenly aware of. One of the things that has been a huge bottleneck for our hospitals has been for monitors who are literally trapped in emergency rooms waiting for inpatient acute psych beds and you know that's not proper care and if we're truly going to have parity between mental and physical health we would never tolerate somebody with a broken leg being stuck in an emergency room for you know days or weeks at a time and yet we're at that point and you know we took and did an enforcement action against UVM several years ago that would require them to invest in inpatient acute psych beds and that process got slowed down and halted by two factors one that the numbers came in too high initially and number two the pandemic but they're back working on that and they'll be submitting a CON this spring and I just I'm very very worried from the outside looking at it that there could be a train wreck here because I hear from advocates that feel that they haven't had enough sufficient stay say on a community system and so we've passed that feedback along to UVM and we hope that's working but for any mental health system to work there has to be that community-based system and we at the Green Mountain Care Board can't solve all those problems we're trying to do our part by trying to make sure that there are sufficient inpatient acute beds but we we need help from the legislature to make sure that the community system is there and we hear that constantly and one of the things that takes up the acute beds is when you can't place someone in a subacute setting and so it's it's all pieces of a jigsaw puzzle so we would we would not be able to sleep at night if we thought that the five million that we were asking for was competing for those type of dollars and and we hope it's not what we're trying to get is a crack at one-time dollars that might be able to create the conversations system-wide about how we can do better and move towards more value and away from volume so I just want to make it clear that some people may think that we're testifying differently than what Devin has said and we're not I think we're saying the same thing and in as far as government reimbursement we have been the strongest voices on saying that you can't balance all the needs just on the commercial payers because as Mike Fisher will tell you that you know Vermonters are struggling to pay for their insurance today and it was very clear to me yesterday that Devin's board is really hoping that if government isn't there to help pay for all the workforce needs that they're saying and they have to do it anyways that we would take care of that in commercial and I had to push back because I just can't see how you know a huge double digit increase in commercial rates is going to benefit anyone because all it's going to do is make more people uninsured or underinsured so I'm in agreement with everything she said with that being said the only way that we really have a good healthcare system in the long haul and make sure that we don't see hospitals having to close their doors is to begin to have this conversation on sustainability and so with that I think I'm going to turn it over first to Alayna to walk through the five million dollar ask and just throw out questions as we go right thank you I will share my screen can you see a table yes oh but I think we might many of us have it on our own device as well all right wonderful um so this kind of builds on the presentation that we went through last week and details the five billion dollars for the recommendation number one and I think recommendation number three is definitely alluded to sustainable Medicaid payments kind of goes with this like you you really won't see that translation into kind of the commercial rate without this global payment on top of that so I think there is some nuance there to think through but the global payments um you know first you know just remind everyone what global payments are they're fixed often prepaid amounts of funding for a certain period of time for a specified population rather than fixed rates for individual services Alayna Alayna it's at least in the committee room it's a little hard to hear if you could be closer to the mic or something and slow down and slow down it's not just the committee room I'm having a tough time hearing you too Alayna is it better maybe to slow down the rapid rate of very slow and loud slow and loud I can do that okay so global payments are this allowance right that we would provide to hospitals that would free them from having to think about volume in order to bring in revenues so there are many ways to operationalize global payments in some states I think you know Devin alluded to this in Pennsylvania their global payment is set up to focus on rural hospitals and to maintain sustainability in Maryland their global payment model is focused on curbing cost growth so they're coming at it from different angles they have different mechanisms for establishing the amounts and for paying hospitals so I don't think either of these models can be picked up and replicated in Vermont but I think there's something to be learned from each of them and to think about what this could look like to work in Vermont specifically and that's why the community facilitation is so important because it needs to be a Vermont based model and if you take a look at where Maryland started with the high costs that were seen in Maryland the hospitals are right Vermont is starting in a different place and so whatever model is developed in Vermont has to work for Vermont it's it's not a model that can be picked up and used in Maryland or Pennsylvania or any other state absolutely yeah and so I think that you know really speaks to the first step that would need to happen to really move this work forward and that's to establish goals for the Vermont hospital global payment so you know we've talked through the sustainability planning work on what you know we think are particularly important goals but I think there's you know more work to do to solidify that and get a concrete not to not a laundry list but a couple succinct goals that we could work towards and include in this payment as this were as this to be designed so certainly hospital solvency where look where volumes are low is a big concern supporting equitable access for all Vermonters to high quality care what does that look like and how could a payment support that moderating total cost of care growth so care happens in the hospital but also outside the hospital and there's a relationship there so while this would be focused on hospitals we need to understand the impact on the broader delivery system and how care will be utilized and then we need to recognize varying community needs and I think that's a key theme that that many of us share so that should be centered to this work the second step would be to work we possibly a question I think we need to need to kind of stay in touch with whether there's questions so that I'm not cutting you off in mid sentence if possible but I think Paige has a question or to pose is that right yes are there any other we go ready are there any other states besides Maryland and Pennsylvania that are doing global payments there are different ways of thinking about global payments these are just the like kind of the biggest most comprehensive models so we could look for other go ahead Susan I think I believe Rhode Island's legislature is pursuing this and I know that we could share some of the details that they're working on that's the only other one that I that comes to mind for me at this time and do we have a do we know how long this has been going on with Pennsylvania and Maryland do we have a track record for these yeah so Maryland's been going longer but Pennsylvania has only been going for a couple of years and Pennsylvania is different than Maryland and that Pennsylvania is a rural model and what the federal partners are looking for there is trying to because there have been so many rural hospitals that have closed across the country how do you get sustainability in a rural environment and so that is a true rural model and whenever we talk with people in Washington when they talk about equity they talk about equity in a lot of different ways and they even include rurality in that discussion of equity and and and one final question chair mullin or whoever um do we have any records of how many rural hospitals have closed in Pennsylvania I mean how successful have they been in sustaining our rural hospitals in Pennsylvania I will say sorry I I talked to my counterpart in Pennsylvania this week and the none of the hospitals have closed um it is a voluntary program uh the Pennsylvania model and so those hospitals join voluntarily and will will Vermont's be voluntary that will depend on what's decided in the community conversations I mean we don't want to prejudge representative page what the Vermont model will look like if we're doing that then we're we don't even need to have the conversation we're just designing it ourselves and nobody would buy into that period it has to be a a model that's developed by people in the field and they have to be comfortable with where it's headed thank you for saying that appreciate it right and we need to understand the implications of certain design elements and what that means Elena don't forget to speak up and get close it's just it's very hard when you're not able to hear so all right can you hear me now are we good to go on we can and just for the committee members when I had a meeting with her earlier she was loud and clear but she was broadcasting from her basement and maybe it's the chain of location now I'll go back to the basement next time um okay so I think so that second piece I think you know we talked about hiring consultants but working with our communities and making sure that the that we consider a number of design options and really understand the implications of you know various approaches to doing this work um so this design work would inform whether statutory changes were necessary um in the next legislative session and any additional resources so these dollars that we've proposed here are really just to get the conversation going and to come up with some designs and some options that could then be implemented and can I just add very very quickly here when we say we um it is the state of Vermont um especially when it when talking about the federal agreement and just to be clear we work with the executive branch the governor and ahs and they are leading the negotiations on the next model um certainly we we we at the green mountain care board would not be able to go to the federal government on our own and so working with our partners here in Vermont and then working with our federal partners in order to work um to bring medicare into what whatever we land on as uh as a Vermont will be essential right and how can I just say yes yes I'm sorry it would it would be helpful at some point Susan or Kevin to share with us what kind of interactions you've had with the executive branch about this proposal as well so that we're not uh having a conversation just with ourselves and with Vaz but knowing that there's a part of this that's that there's a critical role to play for the executive branch as well so someone could give us some sense of that maybe we can ask them the conversations have been mainly with the director of health care reform in a back us and just briefing her on this and um at this at this point she has been um somewhat supportive and uh believes it's it's an option that should be explored she hasn't jumped on and said this is what the administration believes should happen so I don't want you to believe that that's the case represent golden that has a question I'm not sure if you've gotten um this far down the road but I'm wondering about a little bit of a sort of imagination case study um of how you might spend the summer in a certain location um you know I live in the sprinkler hospital area so have you been able to give any thoughts to be a little more concrete on how you might operationalize this for us and that might be too you might be way you may not be there yet we are not there yet yeah I think we're kind of struggling on how to see it um 1.4 million you know I know a lot of it's actuarial I don't know how much of that is actuarial and how much is community based what we're envisioning is um an effort led by um a professional facilitator um with medical experience so that um people like yourself um will understand that the facilitator understands what their lives are like and um begin those conversations and I would say they would start initially probably and again this is just shooting from the hip so I always get in trouble when I do this but initially those conversations in the community would start with um the leadership at a the local hospital and their board and then be rolled out to a much broader based community conversation but that's just me shooting from the hip about how it might work and after if we're successful in achieving these funds and we hire a facilitator they may tell me that I don't know what I'm talking about which is not unusual so I think that is that it's more on the 3 million side when we're going to be out in communities talking about delivery system reform on the 1.4 million side I think that's really looking at payments and making sure that the payments are going to work in a way for each of our hospitals so there's that will be iterative but again there will be actuaries it's going to be a lot of accounting work and looking at historical trends um but I think on that 3 million side what that looks like you know there's still going to need to be some data gathering and analysis I think we have a lot of data but I think there's still a lot of gaps need to understand what we're looking at we need hospitals at the table to help us you know identify other data that we have not looked at that would be helpful for advancing this work um and then we need to identify characteristics of high performing health systems in rural context and kind of you know share that vision um and get you know the local vision you know and try to synthesize these ideas so I think there's this you know what is possible and trying to understand what we could be doing that we're not and then engaging in those conversations um and that and that's you know part of that last the last the last tranche of work there at the bottom of the sheet that 3 million dollars um and that's really you know while the green mountain care board will be focused on the hospital aspect of delivery system reform that we will likely learn a lot more about other opportunities to change and to advance our delivery system reform efforts um that may require further legislation or that may require um hs to respond or other parties so thinking about how um what healthcare looks like in schools or mental health those are all areas that are likely going to come up um and we are happy to document we think it makes sense to document but I'm not sure that the amount of money we're asking for here or our authority would allow us to kind of go beyond the hospital um own services so I just wanted that to be clear as well sorry that I jumped ahead no that's and we can I'll add to as we um progress you know we would we would have that information and I like the idea of a case study as you said representative Goldman so that's helpful thank you I'm not clear where you are in your presentation to us at this point all right so we talked about the 1.4 million which is for designing the global payment then there's the 600 000 that Susan described that would support medicare's inclusion in the um subsequent proposal for the state's next agreement with cmmi that's kind of bigger than the board that we'd also need the administration and AHS to to recognize this as a path forward and then the 3 million which is to engage communities in discussing what delivery system reform should look like in order to ensure that we have a high quality efficient system for which the global payment would be paying for so um you know what those are kind of the three streams of work they're all kind of go together they need each other um you know we can't really have a global payment on top of a on a you know on an inefficient system so making sure that we're deploying our resources you know we've seen a lot of improvement but there's still a lot of room to go if we look at kind of avoidable utilizations um and you know low value care as Devin mentioned you know a lot of this will be long term but there are some there's opportunity I think we heard during the um VOS press conference yesterday there are a lot of workforce challenges that are linked to wait times I think if we think about you know tackling some of those issues as part of this redesign work um you know that would be really I think helpful for a lot of these streams of work that are seemingly disparate but quite integrated so um you know I think this could go a long way of Reverend Peterson has a question yes thank you chair uh and thank you for the presentation so far anyway um I want to talk about the scope of this um when we talk about hospital it seems to me and looking at this you're talking about the entire healthcare system from stem to stern the uh like I have a PA I go to work in a separate office but it seems like all that stuff would get changed is that right or no is this just hospital that changes and does that include people that uh work in other buildings but get there but are affiliated with the hospital how what's the scope of of the change I think that's a great question I think this is up to the communities right like we we are not going the board only has authority over hospitals through its hospital budget authority and rate setting um so beyond that the board in as part of a board process that's the scope but I think there's a lot of opportunity that might be identified through these conversations for other changes that would be helpful hospitals again are one piece of delivery system reform efforts that are required they're kind of a major piece um and so that's why it makes sense to focus there particularly with our hospital sustainability challenges you know I think that's kind of where we've identified a major threat um that's increasing particularly if our federal relief funds dry up or when they dry up um that doesn't mean there aren't other avenues that are important to consider and to invest in but you know this is where we were asked to take a look and where our authority lies and I'll just add to I think that's a great question representative Peterson we we also um you know we know that and Devin will probably agree and and I thought of this as she was talking about everything the hospitals have done for Vermont over the last two years and everything the people who work in those hospitals have done I'm going to get emotional it's been a long two years um but we cannot let these hospitals fail we need them and that's why we're here we we cannot experience another spring fields and and so we start with the hospitals but we all know that hospitals are just such a huge part of their community they're often the largest employer they're um you know I go back to Springfield if they did not have their emergency room where would those those community members go um and so so we we start there but it doesn't mean that it's not going to impact it's going to impact the community because the community relies on those hospitals hopefully that this type of a change would be an incentive to have even better communications whether it's an independent doctor or a doctor who is through a hospital system because at the end of the day it would benefit everyone if people are healthy and not sick so one of the things so for example yesterday we had a great presentation from the staff of Blueprint about a program that they run on diabetes management and and it's open to all Vermonters and yet we know that most Vermonters don't even know about the program and those are the type of conversations that we would hope would be happening so that I mean that is a chronic illness that if it's treated early is going to be more cost effective than letting it build it you know it's those are the type of things that we would hope that there'd be better care coordination that there'd be better communication but you know that will depend upon the community itself in in the long haul because they're the ones who once a plan is designed will have to carry it out. Well let me ask you a follow-up it's kind of divergent from that question but but as I sit here thinking about and looking at the handout or the screen here how who do you find that can come in and do this redesign how what people are there people experienced in this are there contract agencies who deal in this I see this being quite a number of people going in and analyzing everything in your hospitals and then having to redesign computer systems and all that cost I saw assume you're talking labor and and systems upgrade being where the five million will go but I don't know that. Yeah there are a number of healthcare consultants throughout the country and different firms have different expertise the biggest expertise that we would be looking for is the community facilitation and building skills and you know I I've personally been at conferences where different doctors have presented and I think that there's a pool of talent out there that would be able to facilitate the conversations in the communities. Okay she had hired them to come in do the work and and that's how it would go we would look at the systems you came up with and adopt them or not or whatever yeah okay thank you. So Kevin I don't want to cut anybody else off the question but I'm as I'm listening to both Devin's presentation and from the board Greenmount Careboard what I'm hearing you say is like okay the Greenmount Careboard has been charged with responsibility for hospital budgets that's where your authority lies with regard to this specifically and that you've been doing that for some period of time as a board working to use the authority that you have to try to sustain to try to support the healthcare system the hospital systems of Vermont but that fundamental to what you have as authority and what the structure has is the underlying fee-for-service system still that is the underpinning of the financial structures of hospital of medical services generally but hospitals including all hospitals and that the hospitals have been participating to some extent in the transition or transformation to value-based payments and express support for moving in that direction but what I'm hearing is that a sense of we're not moving fast enough to achieve kind of transformation that we need to to avert the the unintended fiscal financial challenges and and not just financial challenges but the challenges that then fall to the communities and to Vermonters if a if a hospital is struggling or if it fails it goes back to that uh that old uh oh go ahead sorry and I think key to this is that you are holding out that global budgeting for hospitals is an alternative framework to think about how to sustain the financial viability of our hospital system that that and that turns that accelerates and actually completely moves toward a different financial paradigm for funding hospitals taking all of the monies that are involved including you're asking for you know if the government if the federal government will participate with Medicare that including rolling Medicare into that transformed financial funding of hospital services and and I think I think part of where I get where it gets a little confusing is because then we also talk about well we're going to go upstream and we're going to prevent things and we're going to save people from having the difficult medical conditions they haven't and frankly we've talked about that in lots of different ways with the blueprint for health we've talked about that with I mean everybody talks about that when they come in to talk about I've got a new prevention program and as Jane Kitchell has said and others who've chaired the appropriations committee if I had if I if I could save all the money that people say we're going to save by giving them their money well we would have saved all kinds of money but it doesn't actually it doesn't happen in a time frame where you actually save the money that you're going to spend right now and I think there's a for me there's a little bit of disconnect between the saving of money by doing all the prevention work and the urgency of moving to a global payment model which one is urgent and the other is long term and and both both can be true the both are important that can be true which I which I understand but they're not in sync with each other in terms of the kind of transformation that is achievable we're not going to we're not going to have that kind of savings in the short term with long term prevention it's it's actually where we all want to end up yeah but it's not going to hear and that's part of the reason why we um you know people struggle with trying to fund any programs that go after the social determinants of health because the payoff on that could take a lifetime and that that is the struggle but picture that in people have come to agreement today in Vermont that we need to move away from volume to value but we're still stuck in a system where some payers are making the providers reconcile to a fee for service world and it's not true capitation so if you don't have true capitation you're still doing that unnecessary what I would call administrative work that doesn't have anything to do with direct healthcare for any Vermonters to make sure that you get paid and this would in my mind alleviate some of the need for the chasing of the dollars so it I think that it would be a system wide simplification and a system wide focus on what's best for the patient okay I'm gonna I'm gonna turn to representative black and then represent Peterson or others who haven't spoken if you wish to speak before so thank you everyone who spoke in I mean this is very lowering I understand I have I just I'm wondering if you if anybody wants to speak to this that if you feel as though moving to a global payment system hospital payment system would mean consolidation would be more or less likely under that scenario because I worry about consolidation I think what you would see and I wouldn't call it consolidation I think you would see more collaboration and I think I use this example in your committee once before but I'll use it again during the troubles that Springfield was going through one of the proposed solutions was to have an alignment with Dartmouth and what the proposal was was to have three hospitals with one management team so that mona Scottney Springfield and Valley Regional had one CEO one CNO one CFO etc and that's the type of collaboration that I would hope to see and if you're close to other hospitals does each one of you have to do everything or can you have agreements with each other so that there can be a center of excellence for whatever that particular scope of medicine is in one hospital in a different center of excellence for a different scope of medicine in a nearby hospital so those are the type of things that I think would be possible I I certainly don't envision having one player gobbling up all the entities in Vermont that that certainly is nothing that I've thought about and I think we need to remember the alternative right so if hospitals continue to decline their financial health continues to decline they close they affiliate they what are their option so I think remembering that counterfactual is really important and then you know if this is a financial sustainability the idea is to preserve access hopefully you'd be preserving the entity as well right like I don't I think these are actually related but in the other sense and left to market forces that to to build on what Elena just said and these hospitals potentially might have to affiliate or worse close so the goal is to sustain the services in the communities does that answer your question representative black gives me a lot to think about thank you okay if I could just add seven green from buzz I think a lot of I think a lot of the answer lays in the the details of whatever payment gets proposed and you know it it all depends on the like the Pennsylvania model is based on your last three years or your last year whichever is higher and so we have to think about if that would make sense for hospitals here or if we want to do that differently and also are there federal dollars available to help us with that transition to more value-based care we didn't see that come to fruition with the first iteration of the all-payer model and so we have as a part of that there's more of this lean system instead of the upfront investment in the preventive care I can't speak for the board but I know that I have heard that some of the board members have said that they would not enter into another agreement if that funding wasn't and I know it was there Devin and I have come back and forth it was it was in global commitment I believe but it has to be very those transformation funds must be there for the hospitals and in Pennsylvania for example there was there is funding for the hospitals and I just want to say Maryland Pennsylvania were throwing out these examples and in fact in Maryland and they've been around since the 80s somebody had asked how long they've been around I might be I might be misquoting but a very very long time might even been the 70s they are they are really built on a fee-for-service system and I don't want to get into all the details but we would want to go forward we we wouldn't and again I can't say exactly where we we would be that would have to be worked out with the federal government but Maryland is certainly just to say Devin that is it something that I think the feds would be interested in replicating in Vermont and again I can't speak for them but I could imagine they would say that and Devin anybody that would propose including 2020 and any type of calculation would would be laughed at I think. Yeah at least 2020. Yep. So I'm just going to let us have the opportunity to just continue to think talk amongst ourselves with them here as a resource so I think that that could be that could be useful and so I'm again I'm welcoming anyone who hasn't spoken but I just wanted to follow up please go ahead. Okay so we would have to in order to actually implement something like this which obviously you're asking for the five million to start the ball rolling get everything start negotiating are we chasing federal dollars? I think what we're trying to do is to make sure that we have some input into Medicare reimbursement and the reason why everybody was so intrigued with the last agreement was that all prior iterations of health care reform hadn't envisioned a way to include such a big piece of the dollars in the system which is Medicare and so I wouldn't say that I would say the main goal is to make sure that we could try to keep all payers in the conversation because if some pairs are left out then you still have the chase for the fee for service dollars and that is not a direction that we believe is helpful. I maybe I'm not understanding I mean essentially if we enter into an agreement with CMS Medicare for some sort of alternative payment model the federal government invests in that payment model within the agreement and so those are additional federal dollars that's not you know fee for service that would be we would have an influx of federal dollars to be able to implement something like this. I would say oh sorry I would say I think that's what Devon was referring to is that it's essential that as we look at continuing to move more and more of her members reimbursements to those fixed monthly payments then we need to make sure that there is the transformation that transformation is supported by if Medicare is participating by federal money. Now the the issue and I think Kevin made a really good point the issue today is that and I go back to Elena's picture from last week I think it was when there was the guy literally standing with one foot on the boat and one foot on the dock and the the hospitals right now are in the most difficult position because they have some fixed payments and they have stepped up and they have done the hard work of moving what they can to fixed payments but and I think chair Lippert said it really well by by first looking at the communities and understanding what what they want in their community and what they need for their community members that we design a system moving forward for a global payment and that will allow more more dollars in those fixed payments for the hospitals. There's really two pieces that as as I take it is what Devon is is saying and she can jump in and correct me if I'm completely wrong but what I hear and this goes directly back to I think why we didn't have as much success as quickly as we had hoped for with the all-payer model agreement. If you talk to board members who around at the time and I wasn't around but I spoke with Jessica Holmes and she predicated her affirmative vote in support of signing the contract on the fact that there was going to be hundreds of millions of dollars for delivery system reform and that didn't happen and so not only do you have to help people change the way they've always done business but the second I think even bigger piece and Devon maybe I'm misunderstanding what you're saying but I think even the second even bigger piece is you can't get somebody locked into a system where they're doomed for failure from the start and I'll give you an example I don't know maybe three decades ago maybe longer now. The federal government changed reimbursement towards V&As and they just took and locked people in where they were and so Louisiana that was spending you know a six or seven times the amount that Vermont was spending per person they still had all that money flowing yet Vermont was locked in to a very low dollar figure so Devon am I capturing what I think you're saying? Yeah no I think you've got it exactly right we need a couple different pieces to go forward on this and since we are so lean at the moment we don't have that ability to move from within ourselves to invest and we would need federal dollars and part of the issue with the federal dollars was that it took state dollars to draw down the federal dollars and I think you're remembering Devon. The catch was it took state dollars to get the federal dollars and people weren't willing to invest the state dollars to to bring down the federal dollars. I'm sitting here thinking that's where the money didn't come from because people said we're not willing to do that. Thank you board asked for yep and it became it became then a fight over the general fund as a match for federal dollars. What year is that? Well period of years. Pre-pandemic right? Definitely pre-pandemic but well before pre-pandemic and I mean seriously when they said well there's transformation dollars available but oh yeah but you have to match it with state dollars and then that state dollars were like felt it feels like it's being taken from somewhere else and in fact it wasn't being taken somewhere else because there's only so many state dollars and so I don't know if there's I mean I can you imagine a different scenario where there are federal dollars that aren't having to be matched by state dollars I don't know. I think we could get there when I talked to my Pennsylvania counterpart she had said because they had gotten some federal dollars but not enough either and so it sounded like one lesson that the feds have taken from that is that there is a need for an infusion of federal dollars so I don't think it's a guarantee but I think we're closer than where we have been in the past in terms of getting that federal funding for the transformation. Representative Goldman and I want to weigh in again at some point. My question is actually quick. You keep talking about lean but some people think lean is good and could you talk about how maybe lean isn't so good in this case because that's what I'm taking for it when we're looking at that margin slide that's pretty small. Yeah and I guess I you're right lean is not maybe the word I think the better word is probably fragile right and I think we need to going forward strike a balance between having and it has been so illustrative this week when we talk about wait times for specialists and primary care and global budgets and all of these various things we really need to as a state figure out our goals around affordability access and quality and figure out where that line is and I think the other thing to keep in mind particularly for hospitals is that along with a healthcare provider function we're also the key partner in terms of emergency management and emergency response function as well and so and we're in a rural state so there's only so far lean will take us without impacting access or impacting our response when an emergency comes I've got a question can I jump in chair yeah please go ahead I'm gonna just indulge we have I'm gonna say we can take another 15 minutes at the outside but to the degree I there's something in my view there's something valuable about us being able to actually talk with each other and question each other in a way rather than just hearing testimony and then not being able to engage so to the degree you're willing to continue indulging us this I think it's actually a plus what I hear here you know to me it's relatively exciting that we're looking at trying to do something different I'm wondering though about the provider the doctor nursing staff without a fee for service is this going to mean you're going to get buy-in from the provider I guess maybe maybe they'll love it I don't know but they're obviously a big part of the whole equation and I wonder if preliminary talk them and maybe they've probably known about this for years I don't know but can you explain to me what how they look at it well do you want to jump in Devin or I mean you represent I mean so I'll just say again it's what what are the terms of whatever we do next so I think my message if you take away anything today the message is that our health care system is fragile and we need to tread carefully going forward so and and hear from our communities about what direction we want to go in so I think I think the provider buy-in will depend on that community engagement and having hospitals and providers at the table to explain what's going on at the ground level and also you know the terms of any agreement going forward and the availability to change the way that you practice because this is what we're fundamentally asking providers to do we're asking orthopedists to not necessarily recommend surgery right away but to send someone to physical therapy first and and to fundamentally change the way they do business and I think as you all know if you try to you know if you get a new iPad or if you get something changes in your day a lot of those changes are really hard to implement and we would need we would need significant resources to do that sort of change management going forward and I think that building on that the communities just that that urgency to work with the communities I I just want to say the obvious which I think everyone in these rooms understands the hospitals haven't had a chance to to be out you know in working with the with us and the communities and a potential consultant because we all know how busy they've been we want that opportunity and I think that is essential and that's the urgency is to work with the hospitals to work with the communities I mean that that is step one and I don't see the hospitals and the green mountain care board on that point very far apart and then I would also just say a provider that actually is not chasing those fee-for-service dollars and being pushed to you know you gotta you gotta see another patient another patient and has the ability to focus on the things that keep patients well I mean that's that's the ethos of value-based payment and after we work with while working with the communities finding out what they need in order to succeed in that world is really the goal here. There would be incentives for specialists to get their patients back to their primary care provider more quickly than they do today sometimes we see some specialists hanging on to patients that really can be seen back in the primary care setting and it's an easy visit and so it's easy for a specialist to hang on to that person. Those are the type of changes that could help immensely because if they're not hanging on to those easy patients it frees up some of the problems that we have with access and wait times so those are some of the benefits that that could occur. I think you're going to see a whole wide range of reactions by providers my guess is that some are going to be very supportive and some are going to be very vehemently opposed to a change and I think there could be some age correlation I know at my age I hate change but when I talk to these young medical students that are doing some internships around the state that they're a lot more open than us old people. Okay thank you good answer it sounds like a lot of work to do in that area. I'm just wondering do we have any data or research indicating that specialists are clinging to patients because they have anecdotal evidence from primary care doctors. We have a primary care advisory group and we continue to hear stories from them. Okay thank you. So can I I want to just jump in here and just because you know it's interesting from my observation is there's actually close alignment on certain parts of what each of what you're saying. If I was listening to your your presentation Devin I was thinking when you're showing the margins the smaller and smaller margins I swear there was a somewhat similar analysis by the Green Mountain Care Board. This is part of the case to be made for making the change because margins are small because margins are not because hospitals are not sustainable with the margins that they have. Now the irony of course is that we've asked the Green Mountain Care Board to keep the margins small because in fact we want to keep healthcare costs down so you're damned if you do and then damned if you don't for the Green Mountain Care Board frankly at some level. I mean there's a part to that but nevertheless where you're saying the margins are getting so thin and and we know there has to be a there has to be some margin to sustain a non-profit entity in order to be able to reinvest in itself and there's there's still confusion on the part of some people about that but there should be no margin but that's simply not the case. But there's alignment around that there's alignment about around that something needs to be done we can't continue on the path we're on if something further needs to be done significantly there's alignment around whatever it is we do needs to intensively involve community involvement and the hospitals have to be central to that as well and as well as the communities. That leaves the question in part that the Green Mountain Care Board is saying our experience with trying to regulate on behalf of our monitors the hospital system is this is not working sufficiently and it's not because of margins and not like we're trying to lower the margins and you know that we get into these other issues but it's like we need to we need to think about something much more substantial like global budgeting and that's a proposal but that's not a proposal the hospitals have put forward the hospitals are saying we're going to we want to continue along the path that we are and raise some Medicaid rates you know we'll continue to try to be as efficient as possible and the case of the Green Mountain Care Board has made is the three levers that I remember that they had three ways to get from here to there were raise rates be more efficient cut costs be more efficient and remind me of the third because it's not really coming to mind but it is more volume more volume yeah more volume yeah because it's based on a fee for service system right and so and so we know how that that that but if if so they're making the case that you can't get to where you want to go where either of us want to go through the paths that we've chosen up to this point in time accelerating those paths they're making the case don't get us there and there's a part of me that says let's look at that let's let's let's let's enter into that engage in that process you know vows and others and if this isn't the right path then demonstrate and not not in an hostile way but help us understand how in fact we could get to the same place that we want to be which is hospitals are valuable incredibly valuable hospitals are essential not incredibly valuable they're essential to our communities hospitals are of high value to us the services they provide and I think we need to be careful about not using language that actually will encourage people not to engage with us by saying there's care that's I forget what the phrase is but there's a kind of unnecessary unnecessary care hanging on to easy patients those are the kinds of things that actually I think scare people away or push people away because we're you're needing and wanting to actually have people engage rather than feel criticized or yeah I'll leave it there so I think there's and so my question is and my question is a green mount care board is it premature for you to be asking for us to give you three to five million dollars at this point in time now the reason is because there's supposedly federal money sitting around one time money and I think that's part of what's driving it but there's also the sense of urgency I think there is a sense of urgency that we don't really have time to do nothing or continue on the same path for too many more years coming out of the really stressful time we're in so I don't think it's just the money but it feels a little bit like we haven't you all haven't been able to engage sufficiently for us to make a conclusion to draw a conclusion that the three to five million dollar investment now is what we need to recommend unless you've already gotten to the conclusion that a global budgeting process for hospitals is a good out is in fact an important and positive positive path to move forward on yeah and I think I'm going to speak for myself and maybe our committee we have not done that work in great depth I think our colleagues in the senate have looked at that more closely for some period of time I think some of us and I'll include myself or maybe maybe more open to that concept because because because the the path down fee for service does not look promising it does not look promising so I understand that analysis but but there's some piece of further engagement that I think is necessary because we're not I think I think so that's why I think this conversation is useful that we need to find our way through to some you know what what is the next step that really helps move this decision-making conversation forward and it's I don't think it's just about the money anyway that's kind of my so I'm good I'll turn it down here and then I think we're going to need to stop for today and I think yeah I mean I think that we recognized and agreed years ago that fee for service was not going to get us there the issue more is so we struck out on a path that we thought was going to resolve that and it's not working the way we thought it would work we're not you know it was always a coalition of the willing meaning we get enough people we can't get enough we can't get enough participants we have not been able to meet those goals and we have a far lower percentage of actual transition to actual value-based payments than we had envisioned so so we've got to therefore recalibrate and refocus on how we get to that place that we all want to get you know I've made I have not hidden for several years my frustration about the fact that we were not really moving forward or very very slowly and people would say well change takes time but but but we you know we we have not been making progress any to any significant degree and we were stuck in a place that said but we've got nothing else to try we're stuck with keeping trying this because there's nothing else in fee for service clearly as well what I'm hearing now is this is another route to try forgetting there and and this based on what we've learned so far you know is the right way to work on it and in particular that community engagement which I think you know that didn't happen in developing the all-payer model and the way we started that and I think that's a significant piece of why it didn't move the way we expected to so so that's kind of the fundamental difference and I think you know when we look at this chart in terms of when things need to begin um you know there is the need now how long that money has to spread then and you know maybe it's it wouldn't all be needed this year because it's going to carry over but then we tie into the if it's available the one-time funds but but you know the timing chart you know does suggest that that it is needed now yeah yeah maybe it is yeah so I would just expand a bit on what Representative Donnie you said and that to me this this request for three to five million or five million I think it is yeah is not to move us to global budgeting it is to do the community process with the hospitals at the table which they haven't really been able to be at because they've been so busy that is the key three to five million dollars change takes money change takes time and I think everyone's focused on global budgeting we're really we just need to think this is the next stage and this health reform in our state and we need the community at the table and that takes money but that's that's actually not quite what they're saying right but that's how I'm doing it that's three million right so whatever the kcb five million dollars we get the community at the table we work to see if global budgeting is the right way and honestly it's the end of the day global budgeting might not be the right way but the only way we get to do it is if we are all at the table and I know Representative Lippert as the as the question later about the total dollars spent in our state on healthcare five million dollars is a drop in the bucket and yes we need to put more money in long term and subacute care and everything else but we also need to put money into this this action that we're trying to take it's it's almost 20% of the economy 6.5 billion dollars every single year spent by vermoners and at the end of the day maybe there'll be something that will bubble up out of one of these community conversations that's an even better idea but you know that that's the thing if you don't try you're not you're stuck with the status quo and the status quo isn't going to get you to where you want to be well I'm remembering okay well I was just going to say we're not advocating for the status quo what we're trying to say is our system is fragile right now we are advocating for greater Medicaid rates as well but we see that things that we want to move towards value-based care we see that that's the direction that the feds are going into and we want to do this in the Vermont way so I do see it as Representative Putin was saying as the community process piece right now I'm remembering we our committee sat in on some presentations that the Green Mountain Care Board had was more than a month ago now and what I remember in particular one of the presenters was saying basically saying there needs to be a deep community process uh to get to engage not just to engage the medical community but the broader community in order to go figure out how to have a sustainable healthcare system and I think that's that's an essential part of what is being put forward here and and I think I mean I don't know I guess I'll stop there I just I feel like some ways the having having people buy into global budgeting before there's a community process I think is part of the rub rather than having the community engage in the hospital system engage in a deep community process with global budgeting as a possible way forward and having people both be able to have explore that along the way and if not identify the other way that is going to work is is a piece of maybe reframing some of this in terms of process because otherwise you're having you're asking people to make to buy into something that they may not have any enough information or the faith to like well look we've we've tried other things we're not going to jump on this one next uh and and yet I think there's we there is evidence that this has worked in some places in some manner but as everyone said it needs to be if it's going to be the way forward it needs to be a Vermont based version which everyone is also agreeing on chair liver I have a question for you okay and I just want to make sure my terms are right when you say a community conversation ever rep hold and do you mean the medical community or you mean the community at large what when I hear community I'm wondering what we're talking about so we when we talked about that a bit the last time green mountain care board was in and I think we asked that question of them and so correct me if I'm wrong but it is a broad community conversation I mean yes it has to be driven by the medical piece but it's not just for medical professionals you're talking patients and the average average community member yes that's right am I everyone to be that I think we should be restricted to the medical community to start but that's just me oh I think that's how they friend it that they were going to start with the medical community and then spread okay yeah that makes right okay we are going to stop but I'm sorry just just a number I finally I feel so bad the head of our finance team has a sick baby and he still managed to answer me 3.3 billion was the hospital system that's just the house it's roughly 50 50 percent of our whole 6 billion I don't know right it is it's it's just under 50 percent and but that number also includes those for monitors who use hospitals elsewhere as well so it's not just the hospitals Kevin he said the um with the FPP NPR now I'm getting into you know why don't you get the revenue I'll send you a note how's that you can put some footnotes on it and get back to us perfect it's a lot of money it's a huge amount of money it's a huge and it's a huge part of Vermont's economy I think represented I hope it's really important that's 5 million compared to 5 7 billion billion right right okay thank you all I appreciate your Devin thank you for weighing in on behalf of the hospitals and others from the green market board thank you committee members I think I don't know personally I think this was a helpful conversation to have thank you okay thank you