 My name is Bruce Hammery and I'll be moderating this session. We greatly appreciate each of you taking time from I know the end of a busy work day and from time with your families to join us in this conversation. We really want to hear from each of you about the experiences you have. You've had your patients have had your families have had in obtaining and having healthcare in Vermont. And the purpose will really be to spend the majority of the evening listening to you. So in housekeeping, I'd ask just three things. One, please stay on mute until you're ready to speak. When you are ready to speak, please raise your hand with that little gizmo at the bottom of the screen. And we'll call on you in order. And secondly, we have a moderate number of participants on the on the call. So please try to keep your comments reasonably brief. We're going to go through a very short set of slides to introduce the process and what we're trying to do introduce our team a little bit. And then we'll spend the majority of this two hours listening to you and getting your advice input and experience. Gradual next slide please. Okay, so Act 167 passed by the state legislature last year requires the Green Mountain Care Board working with the agency of human services to conduct a data informed patient focused community inclusive engagement process aimed at helping Vermont's hospitals reduce inefficiency, lower costs, I would say, constrain cost growth, pardon me, improve population health outcomes, reduce health inequities and increase access to essential services while maintaining capacity for emergencies. The Green Mountain Care Board is asked Oliver Wyman, the team I'm leading to do this. And so what we're doing is down below we are conducting listening sessions of both the general public, the provider community writ large including nurse practitioners nursing home people EMTs pharmacists physical therapists and dentists other health professionals you can think of, as well as legislators members of disenfranchised and group suffering from inequity hospital boards, and hospital leadership groups, as well as others so we're involving all these in listening sessions and trying to learn what is going well, what is not going well, if if the case is either well or not well why and how could things be improved. We're conducting these meetings now through just through November 25 and Thanksgiving Day. We conducted roughly 100 last month we have about another 50 in the next three weeks, just to give you a sense of scale. At the end of this time, we'll take the information that you give us, combine it with a lot of state reports on workforce, mental health issues, housing issues in equity issues, it plans state health plan data from the Green Mountain Care Board Department of Census and so forth, and construct some options, which can, which we, we expect will assist in achieving the goals I outlined a moment ago. These will then be subjected to extensive analysis over the winter. We'll come back in early spring late winter, and take the results of the analyses, potentially reformulate those suggestions, and then we will come to your communities in person to deliver those so we'll meet. My team and I with your hospital leadership group and the board. And then we'll conduct a general meeting of the community and my area Massachusetts called town meeting, but something similar in person to get feedback on what those proposals and options might be. We'll then take that information back reformulate those options as needed, and then present that in a final report to the Green Mountain Care Board and the legislature. So repetitive process opportunity at several points for input. By the way, we have also spoken with a number of the leaders directors and so forth of the various state agencies. We still have some of those to go. Next slide. As I said, my name is Bruce hammering. I trained as a physician I've been in this practice teaching, administrating and now consulting for over 50 years. I was a professor and associate dean at Penn State and then ran the university hospital and then moved to geisinger where I was the system chief medical officer and ran the clinical side of the house. Three hospitals group practice of about 1500 physicians and advanced practice people 70 clinic sites and a budget of about 3 billion. My colleague and this is miss Elizabeth southern one. Elizabeth has her masters and systems engineering from MIT. She's worked with me and my partners at Oliver Wyman for 10 years in the areas of healthcare redesign. She also has expertise in health and equity. She staffed the Pennsylvania governor's commission on inequity and healthcare and has done similar work in California and San Francisco. Our engagement manager is Mr Sam winter, who has a rough a little over 10 years of experience in healthcare consulting and has been with us at Oliver Wyman for a little over three years. Petera Chewecki is a neuro pharmacologist with research in alcohol and tobacco dependency has spent a little over two years at Oliver Wyman working with governmental payers. Medicare and Medicaid, and Miss Gretel Gonzalez who's running this meeting behind the scenes is handling a great deal of information and logistics around this effort. So here's the plan. We're going to do a very short context setting, spend the vast majority of the time hearing your comments, experiences and advice. And then we'll give you a few ways to continue to let us know your thoughts and and any additional information you'd like next slide. So this just says what you already know, things in the US and in the state in healthcare are generally not going well. Hospital and healthcare costs are going up given driven by not only costs of supplies and drugs but also by staffing costs. There are shortages of every sort of healthcare professional imaginable. Including workers in the cafeteria and housekeeping departments McDonald's pays more in many instances hospitals have unsustainable margins and families are unable to afford care and I'll show you date on that in a minute. So certainly in Vermont. This threatens the stability of the healthcare system writ large, and certainly the hospitals and the smaller hospitals in particular operating margins are declining days cash on hand are declining. And we've spoken to two, at least two of the hospitals in the state who have triggered bond covenants because of one or the other of these issues. And as you, as you know, if you trigger a bond covenant and don't get it fixed somebody else runs the hospital. Patient access and wait times are terrible, and have not gotten better over the last year and a half at least next slide. Vermont's been very successful at getting people insured. Vermont has just a little over one third the rate of uninsured people as the US in at large, but of people under Medicare age 40% with insurance are considered under insured that is they can't afford the out of pocket expenses for co pays deductibles prescription drugs or over the counter meds. So they avoid health care or delay getting it. Next slide. This shows the economics of it. US census in 2020 found the median income for a family of four in Vermont was a little over $67,000. When you deduct the the state and federal income tax. The family's taking home a little over $43,000 a year. And if you look below, if the family and the employer can afford the, the total premium for a platinum plan. That's almost $40,000 a year. That has the lowest deductible and co pay, but still, if someone in that family is sick shown on the lower right. The family could expect to pay as much as $5,000 out of pocket for their medical expenses. And remember that's out of a total family net income of about 43,000 so huge amount of money. Next slide. This is the wait times this is a survey done by secret shopper telephone method about 18 months ago. We see the range of times in days from 21 to 87. During this time we did hear stories of people waiting six to 12 months and more for needed medical care, certainly been hearing those stories in our conversations. This fall as well. Next, next slide. Okay, so this is the last slide before we show you a couple of general discussion questions. About the house rules, I would add only that you should feel free to make comments or offer questions on the chat. We'll be monitoring that we've also had people send us web links and that sort of thing to information, I'll promise you we do look at those. So if you want to do that that's certainly appropriate. The, we're not able to talk about individual instances this is a provider group but just need to say that if anyone has a specific issue they need help with it. The appropriate way to get that is to talk to the state health care advocate phone number and website or list. Next slide. Okay, so a couple of general questions that we'd like to get your thoughts and comments on what issues are you encountering that limit your ability to provide care to more people. What issues need to be addressed to make health care more efficient and affordable to people. What problems are your patients and their families or your family, having and get an obtaining preventive services and medical care. And if your patient needs help from somebody else specialist social service agency whoever. What do you have to do to get that form. And who do you have that doesn't and how long does it take. How might we improve health equity. Certainly a lot of issues around poverty, rural locations, transportation, gender inequality, language difficulties, ethnicity, those sort of issues what sort of issues are your patients experiencing. And certainly if you could had a blank sheet of paper money was no object, and you were king of the world what would you do to make things better. Not sure that approach will work, but we would certainly be interested in knowing your thoughts so with that, I'm going to stop and wait for hands to raise or people to sign on by face and wave. I know you have more to say than this. So please, Dr. Greenberg. All right, I'll go ahead and get started I guess my name is Matt Greenberg I'm an emergency physician here at Central Vermont. I moved to the state in 2010. I had about five years in practice prior to that so I've got a little over 20 years under my belt. I've seen tremendous changes in medicine over this time. Some for the good and some for the bad. I see problems these days that we never experienced in Vermont, and we're only heard of 20 years ago and begin our city hospitals. There's so many areas that I think we are in need of I don't even know where to begin. I think you mentioned that we need every kind of professional and non professional out there and I think you're right I think the state needs more. I think one thing in particular to two points I'll try and make in particular. I think going against some of the grain. I think we need more inpatient hospital beds. You know I look back at some of my earlier training thinking about business models and the theory of constraints and looking at where bottlenecks are, and a lot of our bottlenecks are down and stream. They backs up all the way through the system and don't have places for people to go, then they back up, and I'm sort of bridging in the emergency department I'm bridging inpatient, and I'm bridging outpatient. And frankly I feel like I'm kind of in a unique position all of us here docs are and that we see everything we take care of everybody newborns 105 year olds, women men objuan trauma medicine infection so this global perspective and just seeing how things could just come to gridlock, whether it's we don't have enough psychiatric beds so we're boarding multiple psychiatric patients, which means I have less beds to see medical and trauma patients. One of the other things besides pure hospital beds is incredible lack of nursing home beds. Dr. Scott has a think on the last check the second oldest population in the country behind main. I see so many very very elderly frail elderly patients, and I have nothing to offer them. They come in their families can't take care of them or they're living alone in a trailer that they've lived in for 65 years, and there's no place for them to go. I can't admit into the hospital, because there are no beds and they don't need admission criteria. My care management can't find nursing home beds. So there's this huge lack of places to go. And I think one thing that sort of public health perspective in general has not taken into account when we talk about China increase efficiencies is one of the side effects of the great gains that we have had in medicine is less people are dying. And so we are, we have selected out sicker patients that are now in the system that 30 years ago simply would be dead. And that's a great thing we're saving lives were decreasing morbidity, but there are people walking around now that never would have lived for a month, never mind 10 extra years and whether that's people with severe cardiac disease people with organ transplants, whether it's newborns that were born immature or premature rather. You know, it's pretty routine to save 24 week premies these days, whereas, you know, 30 years ago that was unheard of. So we had we're saving more lives, but we're adding more complex, very expensive patients to the population, and inherently we're going to need more resources, more beds, etc to take care of them. You know, for a while we were improving Medicare and improving efficiency. And in some ways, we may have almost hit peak efficiency for some things, you know, in the old days, for example, appendicitis, you know, when I was in training appendicitis was a three day admission. Appendicitis now is you get your surgeon go home. A little bit before my time, myocardial infarction was at least a week in the hospital. Now you get your calf and you're maybe, yeah, two weeks maybe. Now you get your calf in your home, you know, maybe the next day. And, and we're saving people and people are going back and forth to the cath lab four or five times they might have seven nine steps. It's amazing medicine, but it means our patient population is complex. And when we come back to Vermont, you add complex patients that are very, very old, with very few, or less young healthy people to balance out that insurance pool. And it becomes very difficult. I'll just throw, I know I'm taking a lot of time I'll throw two more issues out there homelessness. Can't believe how many homeless people are in Vermont it seems too cold to be homeless in Vermont, but our numbers of homeless people that we're seeing the V in the emergency department is outrageous. And again, the amount of resources trying to find places for them, you know, just a warm bed to sleep in at night. It's, it's rough and in particular central Vermont has a very large population of homeless and universally they have mental health problems, physical health problems, past trauma and often substance abuse. I'm fortunate that I work at central Vermont where we have actually really amazing substance abuse resources. It's the one shining light that I've seen improve in resources where most of our other resources have declined in recent time. And transportation is one other thing I'll just throw out there is that the need of transportation is region is terrible. It is pretty much a routine and I even hate to say this but there's nothing around it. People don't have cars and often at night don't have people to call their people routinely just spending the night in our waiting room, because they have no way to get home they came in by ambulance. And there's no way there are no cabs there's no Uber. There's no way to get these folks home so transportation is a huge issue both getting people in and out of the emergency department and also in and out of their own primary care visits. There are a lot of other issues but I'll stop there and let other people talk. Thank you very much very informative. A lot of problems we by the way we are looking at the whole ecosystem so this is because I understand what you just said right to a lot of what brings people to the D or the hospital happens before the hospital because of stuff they can't get the same going home or elsewhere so thank you very much. Dr staffer. Hi, thank you very much. I want to first of all, first of all say thank you for for having these listening sessions. And I want to thank Dr Greenberg who I worked with for many years for for all of his thoughts. I think he really hit many of the nails on the heads. Just for background. I'm a recently retired family doctor here in in Berlin and have been working in this area for over 37 years. So, I think that if I were to sort of build it down to a couple important things. The workforce, you certainly mentioned in your introduction. And Matt also talked about that we, we certainly don't have enough providers doctors, the events practice nurses and PAs. And so that certainly is one of the reasons that we have an access problem, both in primary care and in specialty. I want to throw in one thing which doesn't often get mentioned but being a university Vermont medical school alum, and also on the admissions committee. Currently, I'm, I'm appalled at the, the bottleneck as Matt talked about, in terms of Vermonters getting into the medical school we have very limited number of spaces that are allotted to the UVM medical students to you, sorry to to Vermont residents getting into medical school. And my understanding is that that really is a financial decision. The medical school gets a lot more money from out of state students than they do from in state students. But if we want to be, if we want to be getting doctors in Vermont, we need to be getting Vermonters into the medical school. It's very hard to recruit doctors to center Vermont. Specifically, because, unless they have family here or grew up here, or have some action. It's, there's not a reason for people to come here that the money can be made elsewhere. There has to be some other, some other reason for that. And I think, unless, unless the legislature can support the medical school better and allow more Vermonters. And there are many qualified Vermonters who are not getting into medical school, unless they can do that then we're shooting ourselves in the foot in terms of a workforce. I think that, again, you mentioned the long waits for referrals and that is so true from from my standpoint as a family doc. It's, it's very disheartening to tell a patient that they need to, they need to see a specialist and then find out that it's going to be months before they can see the special. You know, sometimes we can, we can pull strings and work our magic and use our network for the local, the local docs and, you know, plead and and get them get them in but but that certainly doesn't work if you're talking about sending them elsewhere. And so there seems to be this wall at the New Hampshire border we I have patients who have wanted to, especially pediatric patients who needed to have some referrals and there was nothing available at UVM and Dartmouth won't accept them because they're from Vermont. Yeah, yeah. So, for instance, a pediatric psychiatry referral pediatric neurology referral. They say no I'm sorry you're from Vermont can't help you. They sort of drew this demarcation. So, so we've got a problem as far as as access to to many different things. Recently, there was a trying to get an echocardiogram. It's for sent from odd. The order was put in last week and the appointment is for January. And that's just, you know, again, it's it's a lack of echocardi cardiogram. So it's it's not just as you say it's not just the doctors it's not just the nurse practitioners of PAs it's also other other technicians. So, in terms of, again, for access when when I think about my practice and my practice is part of both UVM and CVMC. We haven't we haven't been able to get enough doctors so that's one problem but the other thing is just the amount of time that we have to to see patients. When I was in practice prior to computers coming in I would see 20 to 25 patients a day. So a full day is 15 patients if and it's hard to do that if you want to get home for dinner. So, there's a lot of computer time that's done, you know, in in your quote unquote free time in the evenings the early mornings before work on the weekends, and it's just leading to a lot of burnout. One thing I think that would be really really helpful would be to have scribes. That would make family practice docs primary care docs a lot more efficient. And we could perhaps see more patients at least not burn out as easily and have more time, you know, at home with the family and that sort of thing. So, I'm not sure, I'm not sure how we get more more docs I'm not sure how we get more nurses and nursing shortage is really showing up as well. And I got to say, despite, despite everything are the nurses are fantastic they're committed. They're, they're wonderful. We are so blessed as family practitioners in this area to have such an amazing ER thank you Matt and crew. They just do an exceptional job, we have, you know, thank goodness that our CVMC has expressed care, because when patients call up and they need acute care. We're usually full, and we have to actually, you know, send so much of our acute care to express care. And again, thank God they're there because they're doing a lot of the, the day to day acute primary care for for our patients. We have, again, the specialists that we have are are excellent and they're working their their tails off, trying to see people and get get stuff done, and they don't have enough enough help as well. Our hospitalist system is is fantastic. It's, it's wonderful to to be able to give our patients over in patients over to to that that team. So those are some of the goods and the bads and I'll stop there and let somebody else talk. Thank you very much. Could I just ask a quick follow up question. Sure. I mean the double AMC data is pretty clear that if you take a state resident train them in a state medical school either undergraduate or residency that about a third of them stay in state. If they do both undergraduate and graduate medical education is about two thirds stay in state. I'm just interested in following up on the comment about a limit or some cap on the number of Vermont residents. Do you know what that number is. I'm don't quote me on it but I'm thinking out of out of 110 or so in a class at UVM I think it's on the order of 35. So it's a reasonable proportion of the class but but still fewer than could be admitted. Oh, absolutely. Absolutely. And I would say that again I'm a graduate of the medical school and the UVM family practice program. Here I am. And I train somewhere else I'm not sure that you know that would have been the case. But I certainly think and and many of the medical students who want to go into family practice are highly sought after by our family practice residency program. So, again, it's a it's one of those things where if you can get them in you can get them to stay. Right. And have you been able to get some to CVMC. Do you appreciate with you all. Yes, yes, we have we have a very strong teaching program, the UVM students come down to, to CVMC in all the different specialties it's a it's a wonderful program. Great. Thank you very much sir appreciate the information and the comments. Yes, sir. Thank you others please. Dr Clark. I'm actually a nurse work in home health, although I can't say as I'm representing my agency more I'm listening because I'm interested in starting an adult day program in central Vermont. And, but I, in my work I, I, I hear all the things that Dr Riemberg is saying. We see them as people come out of the hospital. We have incredible staffing shortages in home health. We see a lot of the community side of, of, you know, the social determinants of health. The lack of resources that people have the poverty. But I, I guess I'm jumping on. I'm putting my eggs in the basket of community health. I have hopes that working in the community with an actually an intergenerational model, which is being run. I know specifically being run in Wisconsin, I went to a conference there recently where they talked about, you know, kind of how to set up an intergenerational care model using adult day and childcare, both huge problems in Vermont. And also how the childcare part influences medical staff and how they graduate either in or out of working, whether they can afford childcare. Sometimes these are, you know, people who are not necessarily nurses or doctors, but possibly but also, you know, nurse, you know, licensed nursing assistants, or PCAs, these kind of people that really have a large role to play in the community nursing. That's gotten just my, my take on it is, is that I feel like a more holistic model that partners with the community and also I feel like there's a, there's a financing part there that's that we can't just rely on on kind of government programs that people think are there that aren't really turning out to be sufficient. And I think that we need to kind of garner the community support and say, look, we can't we're not going to be kind of looked after by government programs anymore these, you know, choices for care, long term Medicaid they're not, they don't really work. The program exists, but it doesn't meet the need. And so what are we going to do to meet that need for, like Dr Greenberg said the people who are living longer with chronic disease. So, that's my. That's great and just be interested in the, the comment about the adult daycare and the intergenerational model. You have there are in Vermont, a lot of folks who meet the criteria for dual eligible that is both Medicare and Medicaid. There are programs elsewhere that, you know, an agency or a group will take responsibility for a group of those folks use those dollars to provide sort of intensive adult daycare with a pharmacist and a PT and a dietitian and transportation meals that you're saying. As I recall from, but not, you know, I'm from living in Massachusetts, not Vermont, but there was a program a pace program in Burlington that closed down a few years ago. Do you know anything is anybody trying any of those sorts of things to make use of that sort of continuous money. We'll get to Dr Richter in just a minute she may have a comment. So I know there used to be a project independence which was an adult day program in Barry. And it was one of a few that closed down during COVID. There are some fairly successful adult day programs in Middlebury and Bennington. Yes. And I think with a lot of community support there. There are some other adult day programs in associated with Gifford and then one in Clintonville and one in Morrisville. Based on my kind of observation I went there to visit. I was struggling a bit more felt kind of isolated from the community. And I think that's really a big player in adult they is, are they engaging in the community. Eventually using the resources of volunteers of transportation. You know, are, are people willing to engage and support their elders and in the case of intergenerational, they're, you know, the young population. Thank you very much. Very helpful. Dr Richter. Thank you. And I appreciate you having this, these listening sessions. I realized that some of the stuff that I'm going to say actually is up to the legislature to deal with. We're going to include it. That's okay. I am a primary care doctor actually just recently retired from primary care but still practicing addiction medicine. And so I would say, you know, we can't get out of this or fix this problem without a system. We don't have a system away of, of, of fixing it if we don't have that. And everyone is not included. It's, we're wasting an internal in an enormous amount of money at administration. We spend 34% of every healthcare dollar on administrative costs just to collect the money and pay for the services that we all recognize we need anyway. The other pieces most of the hospital costs which people are talking about are fixed. And so if we keep trying to say, oh, we're going to keep people from getting care. Well, then who is going to pay the bill so it without a global revenue budget which again other countries have figured out. We're not going to fix that either. We, we have too many of certain kinds of hospital beds not enough of others I agreed with the ER doctors in regard to that. Primary care, it's a lot of it has to do with the fact that the conditions of practice are intolerable. And majority of us remember a very different time and I think Dr. Stafford was saying that how many patients you could see many years ago versus how many you can see now. A lot of that has to do with the paperwork that is useless and basically just to increase reimbursement. So, you know, I think, again, if we don't look at this as a systemic thing where we have to include everyone guarantee insurance coverage for most of care. We will not fix the problem. I mean we keep trying basically we're doing the same thing over and over again. We're doing the same thing over for the last 50 years so we will not get out of this without a system looking at the needs of the population and doing health planning for resources. I mean basically for fixing basically right sizing the healthcare infrastructure, because we're spending a lot of money in areas because that's where the money is generated from that's cardiology ophthalmology and orthopedics. We're paying entities whereas you don't see as many ICU beds because that's very poorly paid. So, without looking at this from a systems level which I realize a lot of that is the legislature. I don't feel that we're going to fix it. And until we have everybody in included comprehensive publicly funded healthcare system with a budget around it and public accountability. We'll really see how we will fix this. Again, I think we if we have to look at a systemic approach. I also would like to add though that in the 1980s, I believe it was Rochester, New York. Actually did an experiment where that healthcare financing administration gave them global revenue budgets they included everybody they had a lower rate of uninsured, and they lowered their, their state health insurance costs to be 45% below the national average and 33% below the national average. It was 1991 the general accounting office did a report about this. There's a lot of data and basically they reduce the duplication of services, which allowed them to have more money to spend on essential other essential services. I think that's something that the Green Mountain Care Board really needs to seriously look at because it's already been done. It was well documented. And it to me as a model of what we could do in Vermont, because this was done even with current, you know, in the United States of America under our current paying, you know, the way we pay for healthcare. So, right. No, thank you the Rochester experiment is being repeated in Maryland and part of Pennsylvania, and is under consideration for Vermont. It's not something that my groups involved in that's a separate effort, but just FYI, the feds have issued a or will issue a request for interest for up to seven states for a global payment model for hospitals, and an increased payment for primary care providers, broadly read, including the FQHC and rural health clinic so that a global revenue budget or a global payment for each patient because there's a big difference as you know, no, I know and I, and I'm not, I can't speak intimately to the details of people looking at this but in theory, in, or in concept at least what it would do, probably based on inpatient revenue but it would give the hospital a fixed budget for a year and 12 equal payments and a lot of technical stuff to worry about in that. But just so you know, people are thinking about things relevant to that Rochester experiment that you that you referred to. But again, if the hospital CFOs and other people have been involved in those conversations. Okay, and, and as we used to say in the Navy that's well above my pay grade that is the, the Green Mountain Air Board and the legislature. But thank you for your comments. Other comments and thoughts please is very helpful to me please please keep going. If you were my students I'd start calling on you. Yes, sir, Dr. Stafford. That was just me clapping my hands for your comment. I'd start calling on people. Well, you know you know the group why don't you do that. You know them by name and what they do and I don't appreciate your help. Dr. Hurran would you like to jump in I think you've got some things to say. Yes, I apologize I can't show my video. I have dressed down for the evening and I'm not going to let you guys all see what I look like in my relaxation clothes with chasing my dog around the kitchen. I agree with most of what has been, been said the example that I always the situation that I always want to try to convey to people is that you know the cost of. You know I'm a nutrition gynecologist in a, at Central Vermont where our births are going down, but our acuity is going up. And it is costly to have services available regardless of whether or not they are needed, or actually utilize right and if they don't get utilized they don't necessarily get built and they don't create a revenue right so. I tend to not infrequently a situation where I need the, though that's totally fine. There's variable pronunciations for my name that are that are totally acceptable. I'm just just for the record not married or related to John Hurran the urologist so that I pronounced my name differently from him mainly to show that that difference but um, but at any rate, where was I. I may have a patient who say is trying to have a trial of labor after cesarean or who I just came in yesterday with to help out a midwife with a patient whose baby was not in a good position and was not coming down well and the cord was compressed and. In these situations I may need to have the or the operating room and resources available, but I'm really hoping not to use them right like I'm I'm hoping that this baby is going to come out vaginally and have a normal vaginal birth. But if there's a situation where that's unclear that that's going to happen. I need a anesthesiologist a pediatrician a circulating nurse for the operating room a scrub tech I need them already. Right, just in case, and that's class Lee and if I don't end up using them that's a win for the patient because she doesn't have her abdomen sliced open, but it's, I've, I've called in all these people who need to be paid and. One's paying the hospital for paying them and what's also happened also sometimes happening as I'm telling the orthopedic surgeon. They can't do the case that they're going to do for which everyone will be paid well, because I need everybody to stand by, because this lady whose baby is who's trying to birth. This situation needs to play out and it might take 30 minutes or it may take four hours to try to figure it out and in the situation that I had. Just yesterday, the she did the deliver vaginally and everything went well and then the general surgeon was able to do her surgery afterwards and it all went well but sometimes it's challenges more challenging than that and sometimes I have somebody who's going to have a trial of Mary Ann and I have her all booked because she's going to be maybe induced. And then it turns out that like oh well now there's an add on orthopedic case so the kind because of all the financial pressures what the operating room and team will say is like, you know what can you not induce your patient because the team that was going to be available for your patient we now want to utilize them for an add on orthopedic case, and that's going to make everybody more money. I'm constantly in the situation of trying to argue for resources that I'm hoping not to need. And, you know, it's challenging right I mean staffing on our we have a low volume, but the labor floor needs to be staff 24 seven right and if you call off we used to have a situation where if census was low, the nurses get called off well that's not fair. You've booked your time you've set up you set your time, and you're expecting to be paid, and you're available those for that 12 hour shift. But now you're sent home and your option is you can either be unpaid or you can use CTO on the current nursing recruitment structure and that's current nursing environment like you can get a job where you're going to get your hours there's no reason to put up with a job where if you're a young nurse who's maybe going to have a baby and maybe wants to save your paid time off for your maternity leave. There's no reason to put up with a job where you're going to be told that you have to get a job that you have to go home similarly I mentioned in the chat that were short on pediatricians well if their pediatrician is going to take call it is paid less to take call than what they would need to charge pay a nanny to take care of their kids. The pediatrician is not going to take call and if the pediatrician has another, you know, breadwinner in the family that it doesn't take long to realize this is not a sorry, Dr. Greenberg I'm not mentioning any names. I mean, it doesn't the math doesn't work to say I'm going to commit one in every fourth night for this parent and this family to be available on the possibility that there's a newborn that needs to be born that needs a pediatrician or a possibility that somebody comes in and hits the emergency so I think that ability to choose that need to staff for for possibilities and just to pay for the not just the fee for service but we need an infrastructure that says if there's a certain number of baseline services that we need to have available regardless of whether they're needed or not and I think there's the current fee for service infrastructure there's no reason for everybody to stand by waiting for a healthy baby to deliver when you can make more money for placing somebody's hips though. So that's Alan there. Very important points and right on got to have the infrastructure and the staff and it costs money to have that and keep them around. So thank you. Dr. Penning. Hello, I couldn't find a little hand up icon. That's okay. You waved your hand. I'm a retired family physician and doing some volunteer work at a free clinic nearby. So keeping my hand in. I want to endorse everything Dr. Richter said, I know she's been at this for many, many years. We absolutely need a more rational functional health care system. Certainly, you know, going back a few years give President Obama credit for the Affordable Care Act and for Vermont for expanding insurance coverage but insurance coverage does not guarantee access. As we have found out. You have a dysfunctional system and you increase coverage you have a bigger dysfunctional system you don't have a better system. So we need to address that but even if we had that. I have to put a plug in for the need for more primary care physicians, even if we had this this much better universally available healthcare system we need the primary care physicians there to do the work. We do have a workforce shortage across the board, as has been mentioned many times. The biggest deficit and the one that's more rapidly increasing is in primary care physicians and there was a study. I forget if it was for the Green Mountain Care Board or provided by them. But it looked at the workforce changes, I believe was 2018 to 2019 so before the pandemic. There were at least a couple of dozen health care professional categories listed. The only one that had a really significant decrease was primary care physicians. Pretty much everyone else had increases some very significant. But that's nothing significance been done to address that there are some scholarships to cover part of the overwhelming cost of medical school and other educational debt, but it really needs to be funded to come if we want more primary care physicians in Vermont, we've got to make it attractive. One thing that would make it attractive would be to fully fund loan educational loan repayment that and creating a much better practice environment which has already been mentioned. We want to, we're competing with the rest of the country this is a nationwide shortage as I'm sure you know. We want to make a more attractive practice environment. And again, not to belabor the many problems we've had with prior authorization EMR is etc etc. So those are the things that really need to be addressed and need to be addressed really soon they should have been addressed decades ago because it's been growing since then. So, thank you. There are a lot of medical medical schools started in the late 60s and early 70s to try to fix this and it didn't happen. So, thank you points points noted. Jeremiah. Hi good evening. Can you hear me okay Bruce. Yes sir. Okay. So I agree with most of the comments that have been made and I really appreciate comments from my colleagues, Dr Greenberg and Dr Stafford. I'm a primary care physician a family medicine physician in central Vermont, I have been practicing here for 15 years and prior to that I was five years in Colorado. I actually grew up in Pennsylvania went to medical school in Pennsylvania. And I went to it was Hanuman now it's Drexel. Oh yeah, or my dad went. Okay. And then I did my residency training in West Virginia and ended up in Colorado for five years. I just want to share kind of my experience with primary care and how it's evolved over the last 15 years in central Vermont to sort of give a picture of I think where we are right now. When I first moved here. It was a practice that was owned by the hospital we had five I think or maybe six primary care family medicine, first practitioners physicians, and I worked full time I saw patients at full time schedule, and I saw probably 18, maybe 20 patients in a day. So we adopted the electronic health record and as as we all know that slowed things down reduced efficiency. And so I you know I was fortunate enough to work with a group of administrators who were willing to try scribes and so to Dr Stafford's point you know I worked with scribes for about five or six years. And I remember my wife, exclaiming one evening why are you home so early. Because you know it's sort of, it's sort of brought back a part of my life that I didn't have for for quite a while, being able to be home in the evenings with my family. So it was a tremendous, tremendous thing that happened to use scribes and it did change the patient relationship which I think, I think we all understand that that the patient relationship changes when there's another person in the room. But the benefits were great and unfortunately the scribe program didn't last. It was financially feasible, if you saw enough patients but most of my colleagues weren't really able to keep up that pace and we just ended up abandoning when the pandemic hit. A lot of things went away and that was one of the things that went away so we haven't had any scribes since then we then went on to epic which is a, I think a better electronic health record system than we had before. And I have seen some of the, some of the benefits of being on electronic health record where there's a lot of tracking of data. So I work in quality as well and half of my, not half of my time about a third of my time is spent doing quality improvement work. And it's a tremendous amount of data that we can acquire and we can improve the quality of the care that we provide patients that way. So I understand the need for the, the administrative burden and the documentation and collecting all that data is really important. But on the other hand, I also see my colleagues, my, the people that I work with very closely and I watch them burning out. When we first started as I mentioned we had full time providers, everyone worked full time. Now in my practice, we have eight primary care people, and nobody works full time. They work on average half time. So the, it's just in primary care and family medicine, you know that everyone is so burned out that nobody feels that they can work full time anymore. I think that that's a big piece of what we need to solve. And I think that in our health network, we're certainly working on that and we're trying to transform primary care so that it is more enjoyable and more doable. But there's a tremendous amount of investment that needs to happen so I echo what Dr Penny said and Dr Stafford and everyone said about investing in primary care and I just implore, implore you to focus on that. Well, we'll be, we'll be, we'll be pushing it. I just want to ask you a question. I, we installed Epic at Geisinger in 1997, we were the second install in the US. And we spent a huge amount of time, this is, you know, Epic's done a lot since, but we spent a huge amount of time tailoring it to the needs of the individual specialist including the primary care folks, as specialists in their own right pick list, all that stuff, automatic documentation. And one of the things that occurred a little later was that some of our folk figured out you could actually have the patient enter most of that information. And, you know, we looked at, for example, rheumatology practice, and they spent, oh, this is 15 years ago now they spent 15 minutes getting ready for the inner, you know, for the patient thing with the lab and the drugs and trying to figure all that out, and asking the patient a lot of questions about joint stiffness and all that. And we could get that fixed so that the doc could spend his 15 minutes or whatever it was with the patient, talking to the patient about what to do next, not about asking 20 questions and that kind of stuff. Is your health system working toward that, or you still trying to figure out how to get people to use Epic? I would say that we're in various stages of adoption because the University of Vermont Medical Center has been on Epic for, I don't know, 15 years, maybe Dr. Stafford could probably tell us. But we recently went on to Epic just a few years ago at Central Vermont and the rest of the network, the organizations have more recently gone on to Epic. We benefited greatly, I think, from the historical work that had been done with Epic at the Medical Center. But I would say that we are probably not as advanced as we could be in terms of patient-entered data. We have a portal system that the patients can access. And so just recently I discovered that I can have patients put their blood pressure readings into the portal, for example. So that's great. But I think to answer your question, I think there's probably a lot more that we could do. Okay. Thank you very much. Very helpful. Hopefully when I get up there and can look you guys in the eye, we can have a little more conversation about this. I've traveled around the US and around the world doing some of this stuff. And it's interesting that I've seen people who use, for example, their MA. They spend some time training them, but they can get a lot done for them. And I guess one of the questions, you know, I just have for the group, I've been given to understand that the State Pharmacy Board has recently made it a little more difficult for your office staff to refill prescriptions. So somebody wants to comment on that at some time. Dr. Stafford, please. Thank you. Thanks, Jeremiah. I wanted to first of all that 2011 was when UVM went over to to epic. And in that we were one of the, the UVM outpatient offices that's when we went over and CVMC came in some years later. So I think, I think epic is a is an amazing tool, as Jeremiah says, I mean, there's so much information there that can be accessed, whereas before you were leafing through, you know, pages and pages and pages trying to find that X-ray report. So it's really in many ways. It's made finding information and sharing information, much more efficient. But, but there's an awful lot of redundancy and a lot of checking of boxes and things like that that really, really are time consuming and not particularly helpful. I don't, you know, really care about a lot of the stuff that that were asked to do. But one of the other things that's that's happened is in with the patient portal called my chart here. It allows, it allows the patient to, you know, message you directly and vice versa, which can be a fantastic thing. But in that patients are no longer able to get into the office to see their doctors. They're sending lots of lots of messages. And so all during the day and at the end of the day, we've just got a pile of work to do that has to do with patient communication to say nothing about all of the refills of prescriptions and whatever. And so, and so there's, but there's no carve out during the day to do this this work, which then of course ends up being on my time. So we're, we're asked to, you know, put patients through and spend the time, you know, making the money in the offices, and all that rest of the stuff is on our time. So it's, that's what adds to burnout is is the way that the system is set up. And again, I, you know, I talk a lot about the, our office because we are part of the hospital system. And so whatever happens within, you know, within our offices also has to do with the hospital and whatever we're wishing for in terms of resources got to come out of their budget. So, you know, sometimes I feel like the green board may not be as in tuned with what happens in the offices of the primary care doctors and how that relates to hospital budgets but, but that's got to be a huge drain on the hospitals. It's not just about inpatients and, and, you know, what happens on the hospital grounds. So that's what I wanted to add. Right. No, and that's, I think that's a very important point. Thank you. I think my sense is the focus has been really sort of inpatient and ambulatory hospital stuff but not really thinking about the associated physicians practices so we'll, we'll keep that in mind been thinking about it but you've brought it to the fore. Thank you. You're welcome. Other thoughts or as I would say to my students screams of outrage. Dr chase. You're still on mute sir. Hi there yeah. My name is Derek chase actually grew up in callous Vermont, which is about 10 miles from CVMC. I went to high school at you 32, which is like four miles and when I was eight. The pain set broke my arm had surgery at CVMC. And that's why I became a orthopedic surgeon. And I am a UVM class of 2008 alumni and suspicious that Dr Stafford even interviewed me. I'm not quite sure. I was also Freeman Foundation scholar and I accepted a scholarship for commitment to come back to Vermont after residency to practice and my residency and training and California and I on my promise and came back. And I have privileges at Gifford, and I provided services. I've been in Berlin now for a while. And I've moved on to becoming an independent contractor and I contract with the hospital. In New Hampshire, and by contracting with me directly instead of going through a locums company, I saved them about $2,000 a day $40,000 a month or half a million dollars a year. You know we hear administrators over and over again about complaining about locums and and travelers and I think it's an avoidable cost. And I really would like to thank you and the Green Mountain care board for really tackling this critical issue. I think cost is incredibly important and I think it is. By hand I think Chairman Foster, you know he said that, you know, the, the increase in health care is about 15% a year and Vermont income is two to 4% a year and it's just not sustainable. And I think there's a lot we can do to reduce costs and I think you just have to look at it and I think also the people who can have the greatest impact on reducing costs are physicians and providers. I was an economics major, and I grew up a thrifty Frugal Yankee, but the cost in the hospital is insane. You know, it's unlike any other industry where you buy goods and services and you have no idea how much it costs. I mean, I'd always joke in the OR there should be barcodes on everything and anytime a nurse opens something they should scan it and it should bring up a tally on the top of the. So everyone can see what they're spending. And you know that I think the Green Mountain care bar has done a great job looking at cost but I don't think it's good enough. For example, we look at the cost of inpatient admission or discharge and I mean, look at hospitals on that one metric. And of course hospitals are going to, you know, decrease their costs to, you know, not raise any suspicion, and keep that reasonable but then if you look at other costs like outpatient surgeries, there's such a huge range. So like a Gifford, it costs $60,000 for a knee replacement where, you know, Copley another critical access hospital costs 30. And you know, if you're doing 65 knee replacements and you're doing it, each knee replacement $30,000 more than your neighbor that's extra $2 million a year in costs and. You know, administrators, they don't even ask us to reduce costs we're not at all incentivized to reduce cost. Or same thing with quality where we're all paid a median supposedly a median salary and we all probably have some kind of productivity incentive bonus, but we have no cost incentive we have no real quality incentive. So I think those are our big issues, and I don't think anything's going to be a quick fix but I think, you know, we got to look a decade out or or something and see what, you know, we want our health care system to be like then. So that's just some, some of my input the other input I had to follow up on Dr. Corian's comment about on call or staff availability. Orthopedic surgeons don't mind if you bump us we understand babies and mothers come first, we can fix our fractures with when time allows but I think it would be helpful if healthcare systems reduce costs. They can provide more staff and more access and I think that would be a beneficial thing to do. I also am a big fan of scribes, but one thing that's coming in the pipeline, and I work at a hospital that's part of the main health system, and they have this program of AI. So, not actual physical people scribes but AI, you know, doing your correct like, you know, hey Alexa, do a level three new patient encounter, and they listen to it and they type most of it in so I think embracing technology like that. Same with, you know radiology getting AI to read radiology, or x-rays or films, you know might be a cost savings so just some ideas. Well, and certainly there are dictation systems that would input directly into Epic as well but thank you I guess a quick question for you I mean your your point about directly contracting with the physician, rather than going through a locoms agency or some sort of general agency is certainly a one way of reducing the cost of of acquiring the physician services. Is there a way to to generalize that I mean certainly the the locoms agency sort of like a, you know, I don't know a search firm in a sense and that they have a group of people that you can call and get and have a fee for that. But what other way to do that, would you think about. If you look at if you listen to some, I think CVMC budget hearing, as well as North County budgets hearing. I think North County said locoms charge up up to 200% yep, and I think a couple people at CVMC said 60 to 100% above the cost of an employed or directly contracted physician. I mean, those companies have to make money and they, they have to make a profit and they're a little bit like leeches they don't do a lot. They just they're kind of a middle man that they're kind of opportunists is really what I think they are so. And I'll tell you with CVMC. My own experiences. You know I applied on the website and I didn't hear back for three or four weeks I called everybody, I emailed everybody. And no one replied. I'm still waiting to hear. And I found out they only have for the entire UVM health network, they only have two recruiters, and they're brand new, and they're each two recruiters for for Vermont they have a third recruiter for New York hospitals, but each of them are handling 200 applications. And then they were, they were new they were overwhelmed. And you know you hear on the green mountain care boards. Public hearings which are which are awesome but you hear over and over again administrators complaining about recruitment costs and retention costs and locoms costs and travelers costs but I don't see them making an effort to mitigate those costs. So, just my two cents there. I don't think your question. I hope it did. No, no, it does and I appreciate the information I mean this is the sort of thing I'm after. Right, I mean this. You know, there are some of these things that can be fixed by the appropriate people. I'm not sure Green Mountain Board is the group to fix that. But, you know, having I've had to gizing or if you don't know it is a 400 bed. Level one trauma liver transplant hospital in a town of 5000 people in the mountains. So I've had to recruit I used to know where the nearest Korean Presbyterian church was just as an as an illustration of if you want to recruit doctors to small towns. The things you're mentioning are very important in terms of the detail and I'm sort of hoping that one of the things my team and I are are bringing to this is a bit more of an eye on the clinical needs and what the infrastructure is and you know that you can't just you know move something from here to there because you got an extra 20 patient days or something so. So I really appreciate those comments thank you. I'll just say the other took to the point of, you know, the cost of locums agencies for physicians and traveler agencies for nurses is this really you have to invest in retention. And the people when they say they're burning out and when the nurses say, this is not sustainable because I'm getting called off of my shifts, some weeks and being asked to work overtime other weeks that's not sustainable. You don't say ignore ignore ignore until they leave and then you have to pay travelers. And when the pediatricians say, it's not sustainable to be taking all this call because I could make. I could go for daycare for my family, and I could get the same job somewhere else that's near a tertiary care center where I could do outpatient pediatrics and not take call. You don't just dismiss them you listen and say, Hmm, something's a problem here. So, so you can know no one's just like walking away there's still nurse labor trained nurses in the central Vermont area that are not working, working at CVMC and we're hiring travelers there's still competent pediatricians that live in central Vermont that are not working at CVMC. And I don't know what we're going to do with that when we get to the to the end of the pipeline with them but like, it's not. We're, we're invested we're having to pay the, like, I think part of it is this like being penny wise and pound foolish business right like what and everyone's worried about the cost, just for their particular cost center for their particular budget year, and not the overall cost. So that's what I have to say about that. Thank you very much, Mr Fisher. Good evening. Good evening everyone Mike Fisher, health care advocate I, I guess I kind of wanted to jump in a little bit in response to Dr chase kind of had a question response but maybe it's to anybody. I kind of get it. Why we don't say to doctors, hey be concerned about cost. Hey, you should be saving money I kind of get it that we want doctors to focus on doing the job and doing it well. And so, I'm intrigued by that by Dr chases comment you know nobody's asking you know doctors to be concerned about cost. And I kind of wonder how, you know from your vantage points providers how would you, how do you balance that tension. Dr ran for had her end up first I think and then Dr chase. Thank you. That's an old hand you can go to touch chase on that. Okay, Dr chase. Sorry you're on mute sir. So I totally understand and I totally agree. There's a great article in June and the New York Times I think it's called the moral crisis of American doctors, and it speaks of this kind of hot topic called moral injury, which is a huge contributor to burnout and part of that is, you know physicians are being handcuffed to not provide. You know the optimal care we want to provide and that can be because of administrators or health insurance or lots of reasons for this burnout but I think it's a, I think it's June 15 and New York Times it's a great article. And I would respect that but in terms of cost. So, so I do shoulder replacements I do hip placements I do knee replacements. It's one hospital. So I first worked at Northwestern, and I just use the implant that my partner was using because he had already been using it was called a Lima, and it's from Italy. And then I moved to Gifford like seven years ago, and brought the weapon was interested to use it there and I found out that implant costs $18,000. So if you were like a deput which is a Johnson Johnson company that implant costs $7,000. And this company Lima they're offering to fly me to Italy for training, I didn't go and do anything. I don't have, I don't have any royalties or consulting fees from any industry. So this is an example of like an easy way to reduce cost and it doesn't you know, sacrifice patient care. I don't want to pigeonhole physicians and my colleagues to, you know, not use stuff that they know delivers good outcomes and good patient care, you know, I do think everyone should choose a little bit but I think we need to be aware of the cost of the health care we provide. And that's my big thing is, I just don't think physicians are aware of the cost they provide. I mean, you know hospital charges should be, you know, I think it's CMS mandated. And I think that there's another Vermont statute that mandates that hospitals list the prices of their services on the websites. Most hospitals do some don't. And I just don't think doctors look at that. And I think even if we did want to reduce the cost. I think there's a lot of administrative barriers to actually doing that. I think there's a lack of transparency in hospitals, actually, allowing us to see the itemized cost of the services we provide. That's my opinion. But, but I do agree. It is a balancing and I don't want to. I think it does create moral injury by handcuffing physicians and the medications they can prescribe the referrals they can send the implants they can use I think there should be some broad leeway but I don't think you should. I think that's my opinion, but I don't think you should be using implants that are twice the cost from a company in Italy that's willing to fly you there. So, thank you. Great point. Thank you. Thank you, Dr. Ricker. I think we should also distinguish between charges and costs because we know that due to the charge master. Sometimes, you know, one hospital may charge 60,000 for a hip replacement and another charge 30,000. Whereas that hospital that charges 30,000 may charge 60,000 for something else. And it really just comes to how can we get the money to pay our fixed costs. So that again, this is crying out for a healthcare system and a global revenue budget. I don't think physicians or patients are in the position to be able to determine when they're in the middle of treating patients. You know what what is going to be more expensive less expensive I think roughly we can, you know, we know roughly but but I prescribe hundreds and hundreds of drugs. And for me to know each one that's what the whole purpose of the formulary is and why every other industrialized country has a formulary that they they vet what is the cheapest one out of you know a class of drugs for example. The other thing is if we want to save money, there's no better way than to have everyone have access to a primary care and again I know we've said this a bunch of times, but that is the only thing that has been shown only sector to improve population health, lower levels and improve quality. And yet we really are doing, it seems that in the Vermont we're doing everything to discourage primary care. We knew five years ago that most of us were retiring. And you know so I think again if we want to do something about it the other point. And again I think maybe some of this has got to be done at the national level, if we fully funded medical education for those who agreed to go into primary care. We could get more primary care people going into primary care, but we also have to improve the conditions of practice. But the other point is when you're talking about costs and charges. It's really difficult to do that because we have to know what 80% of the population uses 20% of the care and 20% use 80%. Those patients are really, really expensive anyway so once someone in this is in the ICU, they're the ones generating most of the cost in the system itself. And I think it's really hard maybe as an orthopedic surgeon, you can choose a cheaper implant or whatever. But I press thesis I don't think that's that you know, as system wide that that's really the way to go. Like I just say just for that for the knee replacement example just at my hospital by reducing the cost to, you know, what copy or other critical hospitals do that that would be roughly $2 million a year which would be roughly 4% of our net patient revenue. So that's just one procedure. And you know the other thing I've been thinking about is this this cost, cost shifting how we, you know, charge commercial payers more to subsidize Medicare Medicaid, you know, bad debt that kind of thing but another way we kind of shift is with these procedures we, you know, like you said, Dr. Horton the orthopedic surgeon gets paid a lot so we charge a lot because we can to subsidize, you know, primary care and I agree with you 100%. You know, in Vermont needs critical access and we need critical access to primary care preventative care, mental health, and we need critical access to ER care, and emergency things. So I grew up in Vermont, my kind of joke is I think Vermont health care should be like, Cabot cheddar cheese, it's affordable, it's quality, and you can find it everywhere. You can find regular Cabot cheddar cheese everywhere, every little town, but if you want like smoked habanero Cabot cheddar cheese, yeah, you got to go to Cabot or you got to go to one of their factory stores but for Vermont health care, we should be able to have quality, you know, critical access to the basic services and absolutely UVM is a great asset, even CVMC is a great asset. Lots of patients from these critical access hospitals get transferred there. But big picture, I do agree with you about primary care preventative care. Everything you said burnout, you know, our staff availability on the weekends. It all makes sense. Let me just note there are some simple things we did up my cardiac surgeons and actually the orthopedist at geisinger standardized the instrument sets used for surgery. Because the surgeons often have different gadgets that they want for various reasons. But when they standardized those instruments sets. It simplified the central sterile supply and reprocessing thing and actually with that damaged instruments stuff that was open but never used had to be re sterilized we saved about $2,000 a case. Yeah. Okay, so there are some operational, you know, not trivial stuff because not easy to get surgeons to agree to give up their special professors gizmo. Yeah, but there are ways to do it. Right. Yeah. Okay. Sorry, Dr Greenberg. I'm going to say cost transparency is huge. I agree with everything that's been said before but it also does come with a little bit of a moral dilemma. So one of my colleagues jokes with the medical students we see all the time that one of the most expensive things in the hospital is an ER physician, a mouse and a middle finger pointer finger, because in a matter of one minute, I can order $10,000 worth in tests. And some patients need that but some don't. And, you know, I have a rough estimate of what some things cost but most things I have no idea I'll be honest I have no idea what a CDC costs. There's been some talk that maybe we should know what each of these things costs. What I do know is that an ER visit is very expensive, and sometimes if I notice on a chart that someone is self pay. Does it change my management. I hope not but I see that there and you know I see someone who comes in a 40 year old 35 year old guy who's got some chest pain. I don't think this is a heart attack, but it could be. And you know if I go through and all I order all that lab work that we would normally do for chest pain work up. And I start thinking about, oh, could you have a PE and came in a little tachycardic it's probably just anxiety but he falls out of my perk and my well score so I added D dimer and that came back positive and then I get a CT angiogram and oh good it's normal. Everything came back normal I think you pulled your muscle. I just gave that guy a $10,000 bill. And he might go, you know, that weighs on me. It's a tough decision. But then I've seen P es and guys just like that, who've had, you know, cardiac damage and I don't want to miss that so I think we try very hard to balance out risk and cost, and I think we could do a better job of that. We use scoring systems we use things we've tried to adopt good scoring systems like perk and wells. We've tried to find ways of, of making reasonable decisions. One example that I'm, I think is a great decision was previously for about the first 10 years I worked here, every hospitalization to the psychiatric department and usually even before hospitalization just to be seen by a psychiatrist to quote unquote, to really clear a person to say that they don't have a medical ailment causing their clearly psychiatric illness. It would involve a lab barrage that would include a CBC a comprehensive medic product panel, a TSH and a drug screen and an alcohol level. Now it doesn't matter that this person might have been here two days ago and had all those tests done. I'm thinking about this reasonably. And in most young people we don't need to do these things. You know a drug screen. I don't care if they smoked marijuana. It doesn't matter for their diagnosis. Maybe it does matter if they're using meth and cocaine and they have symptoms of that but if they don't have symptoms of that. It's probably not necessary. And that drug screen which is not very accurate it's neither sensitive nor specific costs somewhere on the order of $500 to $700. So why do we keep ordering these tests that are not used clinically. And I think that's the cost transparency at least at my level and I think every level, every department, every sort of individual clinic has a certain degree of cost cutting that can be done within a certain reason. But that being said healthcare is outrageously expensive and if we don't want to miss things and we don't want people dying on our shift. There's a certain amount of risk and that we can't avoid and a certain amount of cost that we we just need to order and and knowing someone's insurance status or, or their ability to pay can put a lot of pressure on a physician so to answer whoever asked that question. It's a really tough thing to know about, you know, someone's insurance status when you're trying to work them up. Generally, honestly, I try not to look, because I don't want it affecting my medical judgment. But there are other ways that cost transparency can be utilized and be very effective at reducing costs. Dr around. I completely agree with what Dr Greenberg saying in terms in terms of costs and certainly there's been studies right like that cost transparency or cost sharing for the patient that like it does decrease costs but it decreases cost of both unneeded and needed services right so like you. But but I just want to echo that because I agree with with everything that said on that but the reason I originally raised my hand was back in terms of discussion of primary care providers and investing in primary care. And the fact that relationships really matter like pay people patients value their relationships with their primary care provider and primary care providers value their relationships with patients. And if you have time for patients to be able to access their primary care provider and sit down and review the chart and take the history and somebody who really knows you. That that saves a lot of money and has better outcomes and all the all the things that I can't necessarily quote but you know I I bridge a little bit as a as an OBGYN I bridge primary care and specialty right because a lot of women identify their OBGYN as a primary care provider right but I don't know all the I don't know how to treat high cholesterol and high blood pressure and I didn't go into internal medicine because there were too many anti hypertension for my for my brain to keep keep track and I was just like okay I'm not I'm not going to do all that. I can keep track of the birth control pills that I can do but I can't keep track of all the the lipid drugs and all that but you know the to the point about the retiring PCP is like you know Dr. Stafford. Dr. Vassar Dr Kellogg like all these patients who see those PCPs they also see me and myself and my colleagues for their OBGYN care and I see these women and they come in and they say can you be my primary care like you're the only one who knows me you're the only one who who examines me like my primary retired that knew me for 20 years and now it's just a name on a on the chart of who I got assigned to and that person has by the way rotated three different times because people keep leaving and maybe it's a maybe it's a PA or nurse practitioner who's going to provide phenomenal care. But maybe it's a PA or nurse practitioner who's fresh out of school it doesn't necessarily have the training and expertise to to about so I think that one of the things that the system kind of gets gets a little unwieldy and as we hire into this network and we're just kind of like acting like we're treating which just as I think we're losing that the people both on the side of the what what motivates someone to go into primary care even though they don't get paid with the orthopedic surgeons get paid and what motivates a patient to maintain a relationship with their PCP is those relationships and the more we put things in the way between the between the PCP and the patient, the more we drive people into the emergency room and into the into those other places that are higher cost care because they can't access someone who just knows them well and understand that maybe they did strain a muscle and maybe they had a PE but somebody who you know and I think that we're we're losing that so. Thank you. Dr chase. Yeah, I completely agree with Dr horns points as well and I think that really speaks to continuity of care, which I think not only adds a lot to patient satisfaction, but I don't know if you've seen this the Department of Health. serious reportable events and you see how much that has gone up. Like it used to be like less than 50 a year in the state, and now it's almost triple and part of the reason that is is turnover and so I think that goes along with what everyone's been talking about is. You know quality, which is what one of the most important things is turnover also decreases patients satisfaction and decreases quality. And then to Dr Greenberg's point that the ER is a little bit different. I don't want. I think, for sure. You know, emergent care life threatening care. I don't think cost should be up there, but for elective procedures like like joint replacements and for things that can be scheduled out. I think you could have some. More analysis of the cost of the services you're providing. And I also want to make clear when I do discuss costs. I don't want any administrator ever telling me I can't use something, or I can't prescribe something that I know is the best thing for the patient. So a little bit of a double edged sword but I think it's just something to bring up in discussion and I also think I don't think an incentivizing physicians to reduce cost. I think it should definitely be a carrot and not a stick. And, you know, I think, I think some, I don't know how that's going to work. But I do think, since we are responsible for, I mean, we really oversee all the care on the state where the ones that diagnose the patient are the ones that order tests and treat patients and so we set that line of treatment. So I think somehow to make us more accountable and able to affect costs would be beneficial. Yeah, thank you. Well, you know, it sounds to me. I think it was Dr. Richter that pointed or perhaps you, Dr. Chase pointed out that was the purpose of a formulary, right, was to get the docs together to look at the data and what does the job and is reasonably affordable and, and no sorts of things and I expect that's emergency room crews done the same thing with how to deal with back pain and headaches and what gets a CT and what doesn't so their efforts being made in that I to me a big part of this is for the scheduled things you know because you know if you got a broken armor, you know blacked out you're not going to get carried to the hospital and worry much about what it costs but for anything that you schedule, or that you have time to prepare for, then you should be able to figure out or find out what it's what it's likely to cost you. And I think, you know, it's a difficult area I had a was did a visiting professorship and Toledo a while back and cab driver I was asking about this told me that he had got he. Well exactly Cleveland he he lived near the Cleveland Clinic he got his heart surgery at Mass General Hospital. I asked him why and he said because Medicare paid the same rate it didn't cost me anything either way. So multi factorial problem. Mr Fisher you always ask good questions, you need and you have an expert group here in my colleagues who are gathered. What other questions do you want to ask them. That's putting me on the spot that's that's good. I'm glad you're here. So, for those who don't know, I'm the healthcare advocate and, and we run a helpline for monsters call us every day. Trying to solve some kind of access to care problems, often this eligibility for a, you know, state or federal program. And often it's a problem and then, you know, the bureaucracy is not something is a miss something's not working for them. But I think the question so we hear the consumers side of the equation all the time we hear a lot from people who don't know how they're going to follow their, their providers advice and afford it. We sit in that space a lot. I guess I wonder how providers deal with that. What does it look like to you when you have a client, a patient who can afford it or maybe you don't know whether they can afford it struggling to follow your advice. How do you, how do you deal with that. Yeah, I mean so if a patient is cash payer out of pocket. I'll, I'll go look at, let's see if I can find it but for the Vermont Department of Health has hospital report cards and part of that is, they should have costs for services there and they should be listed by each hospital. So if someone wants like a MRI and they're out of pocket, I'll refer patients to that website and tell them, I'm happy to prescribe this MRI anywhere you want to have it done. And there's a huge difference. I mean a patient can save thousands of dollars by, you know, driving 30 or 40 miles to have an MRI somewhere else. So that's one way I would do it. The other thing is not all hospitals routinely collect patient satisfaction scores and comments. There's some mandated CMS thing but oftentimes, at least the, at least one hospital I'm familiar with doesn't collect any patient satisfaction on individual providers so you know that's also feedback that would be very helpful to have. Thank you, Dr. Riker. Can I add to the question before Deb goes. Are you are providers aware of their hospitals free and reduced care standards, you know, are you aware of what CVMC for instance covers at different incomes and is that factor into any of your decisions. Yeah, keep going. Well, I was going to answer just the question about patients affording thing. I mean, it's always good rx that's that coupon where they can get cheaper medications. Again, they're, you know, some of the newer meds that that's that doesn't save them very much. But quite honestly, I encourage people if they can to work off the books and they'll be eligible for Medicaid. That's it's illegal. And it's sometimes but I look at it is if that's how a patient is going to be able to get the care they need. I encourage them I've encouraged people to get married. I've encouraged people to get divorced. It's insane, but if to me I consider what I do as a physician to be the, you know, and for this person's health that is my Hippocratic oath. So if that gets them better insurance coverage, I have done that. I think it's absolutely insane. That I'm giving marital advice based on health insurance. But those are some of the things that I do because other than that what else can you do a generic drugs of course, you know, if if they're appropriate. But other than that, I'm, you know, I don't see this problem getting any better and till we fix it systemically. Yeah. Dr chase. Yeah, just one more follow up to Mr Fisher's question is the other thing if I have a uninsured patient who just broke something and they're really stressed about insurance and costs. All hospitals have someone in billing or some kind of patient representative. And I'll, I'll, I don't know that person personally, but I'll get the card. And I'll give it to the patient to contact and I kind of wash my hands that of it from there but that's what I do is if there's usually someone at every hospital, some kind of patient representative or billing who can go over those details with with patients. You know, a financial assistance person that can walk them through the reduction in payments or forgiveness or whatever. Okay. Other questions comments. We're in danger of giving you time off to go get a nightcap. Okay. Let's go to the last slide, Gretzl. This is just going to show you where to send comments. Excuse me, Bruce. Yeah, please go ahead. Matt had his end of Matt excuse me I've heard other people call you Matt so I'm calling you Matt. That's fine. Sorry, I was just going to add one comment it's not that the, the Medicaid observation rules are horribly painful and that is probably the biggest. The biggest financial interactions I wind up having with families is when I go to admit a patient and they want to know is this an observation admission or is this a true admission. And if I say often that decision in general that decision is not up to me. And I always defer it to the hospitalist as a hospitalist making that call. Sometimes I know I'm like you know honestly you're only going to be here one night it's going to be an admission, and then they refuse to stay. This is a huge huge huge problem. It's completely unfair it's arbitrary it makes no sense why should we be incentivizing more time in the hospital than someone truly needs. It's, it's ridiculous. And that would be amazing if somebody could fix that problem. I'll just throw that up there. So that's, that's one of those cost interactions that I run into that I have to deal with, and I agree with Dr chase. There's always somebody at the hospital you can affirm the patient financial services, although they're only there Monday through Friday, you know, eight to nine to five or whatever. Yeah, but that that observation status thing is one thing that just really gets in the way a lot and people are really upset about that. Thank you very much. Any other comments or. Okay. Okay, Groucho let's go to the last slide. This has been very, very helpful thank thank you all very much. So, if you want to deliver additional comments suggestions links to information. Please go to the Green Mountain care board website it's GMC board dot Vermont dot gov. And you'll have the opportunity there to select act 167 community meetings and please you can make a comment either written comment either with your name attached or without. They will all be posted, and we do monitor these and collect all of them. And so really would appreciate you're doing that at the bottom is my email directly to my own work account bruce dot hammering at Oliver Wyman.com. If you wish to send something there I'm happy to get it. I will acknowledge I got it probably won't be able to have a lot of chat with you back and forth we've got about 50 more of these meetings in the next three weeks. So, but I would appreciate getting your comments advice and experience by either route. So thank you all very much appreciate your taking the time. Thank you for your care to the people of Vermont. And you all have a good evening and a good week.