 So welcome, and why don't you introduce yourselves for the record, and that we would like to hear your testimony. Good morning, Kevin Mullen, Chair of the Green Mountain Care Board, Ann. Susan Barrett, Executive Director of the Green Mountain Care Board. And I guess we'll just start. We have your power with the Power Board. Perfect. So I understood there was some testimony last week that talked about the creation of the Green Mountain Care Board, and just to clear up a few things that it wasn't solely about trying to create a single-payer system. And there was a lot more to it, and we can go through the statutory requirements of what's there. And many people say that Vermont has failed because they were unable to get to where we thought we could go in 2011. And I would say that we haven't failed, that we've pushed the rest of the country to still have that conversation. And we're seeing that conversation occur every day at the national level. And what we were able to do in the state of Vermont was once it became clear that there wasn't an appetite to fund the proposed Green Mountain Care health care, that the state negotiated with the federal government to agree to an all-payer model. And in some respects, it touches more lives than what we would have been able to touch if we had been successful in 2011, because we never would have been able to touch the Medicare lives under the proposal that we were considering at that time. So I would say that Vermont hasn't failed. We continue to be at the forefront nationally in trying to reform health care with the triple aim of not only trying to control costs, but to make sure that citizens have access to care and that the care is quality care. So I just wanted to clear up that from the testimony that was reported back to me that you heard. So thank you for having us here today. And before I review our value proposition, I do want to introduce folks that you're sitting there to Alina Baraby. You may have seen her face here following testimony, but just as a formal introduction, she came over to the board about six months ago from the Department of Education. She worked in finance over there. She has a long career, well, not that long. She's not that old. She has much experience in finances, in academia, in strategy and lean improvement. So one of the things that she's been working on, and we'll get to this later in our presentation, is streamlining the ACO budget and oversight process. She's leading up the team that regulates the ACO and implements the all-hear model here at the board. So I just wanted to wrap her up by hearing. So I think it's also really important to follow Kevin's talk slide about the role of the board in terms of cost containment to just highlight what we see as what I see, and the board sees as our value proposition. So I like to bucket it into three different areas. We are holistic. We are transparent, and we are independent. And when you look at the holistic nature of the board, the board looks at a broad range of health care activities. We look at health care spending. We look at insurance rates. We look at health system, health care delivery system. And that allows the board to make decisions, both in its regulation and in its innovation and evaluation, across the entire, well, I shouldn't say the entire, a large part of the health care landscape. And that's quite a benefit. The board's transparent. I think this goes without saying, but I'll say it again. All of our meetings are held in a public setting. Most of the work we do is done in a public setting. We are allowed to deliberate both for certificate of need as well as for rate review. But that's a very small amount of our work. We accept comments from stakeholders, the health care advocate, I see they're here today. We have two robust advisory groups. We have the general advisory, and then we have the primary care advisory group. You heard from the primary care advisory group a couple of weeks ago on workforce issues, and they've been wonderful to work with. So transparency is key to our work. I would say if my job would certainly be a lot easier, if I didn't have to do everything publicly, working with the five board members in a public setting as opposed to doing it behind closed doors. But I do value that, and I think it's a huge advantage for promoters. And then, of course, we're independent. The board is appointed, board members are appointed by the governor with your approval, of course, and then we are an independent board from the administration. And then I'll just close by saying, as it relates to the all-pair model, the all-pair model that we have in Vermont would not be in existence without the Green Mountain Care Board. If you look at the all-pair models throughout the country, all of them in the states, who have them, have, and there's only three right now, so there's not a lot, but they have a strong three. They have a strong regulatory board. And they want that because they need that assurance that there's that regulation, regulatory board in effect that can actually either step in the shoes of Medicare, which we do when we set the benchmark rates for the ACO, or also if costs do go out of control, that we are here, the board is here to push back on those costs. So I wanted to highlight that too. What is the third state? Right now it's Maryland, Vermont, and Pennsylvania. Pennsylvania, we forgot Pennsylvania. They're doing a rural model. And I know they're- It's actually a pretty interesting model too, because I don't know if he's a member of a few years back when I was in this body, Senator Ash and I were trying to get through a pilot proposal. Rutland had agreed to do a global budget for the hospital. And it was actually a state Medicaid office that couldn't perform the necessary tasks in order to go live with that test project. So it would be interesting to see what they do come up with in Pennsylvania for results, because that's something that, at least I've always believed that global budget really- We have a lot of support in here for that. And I know in Pennsylvania, their board is not as robust as it is here. They're having some difficulties getting their legislature, has the authority to create a board, but they've been really slow doing that. So we'll have to see what happens there. And then we have a couple of slides on the ACOs. I- Yeah, I'm just gonna- Go over that very quickly, because really they want to get into 290. But just to remind everybody that there are multiple signers to the LPR model. It was the governor at the time, the chair at the time, and the secretary of AHS of the state level, besides the federal assembly. And this slide just gives you an idea of the different roles that are performed by the board and by AHS. And the next slide just gets into the regulation. And unless there's questions, I'll just come in. One question that is, I think, more of a clarification. So the benchmark setting that you do is written within the waiver itself. So the role that you play is how many of those old checks under the U are related to the waiver for all payer? Yeah, some of them are through state regulation too. All payer ACO model and ACO regulation, some of them. Yeah, so they're number four. Oh, thanks. We can add another column to differentiate, but I think for the all payer, I would say, one, two, three, four, maybe about, maybe like two thirds or over time. It would be helpful for us to know that. Yeah. That would be great. Thank you. Okay. And then, so we're now gonna get into the meat of S290. What we've done here has given you a high level overview of where we're coming from in the different sections. We've also shared with Jen some very detailed thoughts on what could happen, some rationale, and I think she's better suited to go through those when you're ready or if you're ready. But high level for sections one through three. The first, the criteria for the ACO oversight that are expected to measure ACO activity, we think would fit more appropriately in the budget section. And then any requirements due to any requirements that monitors the ACO efforts to collaborate with other entities, like for instance, the Department of Health, we would suggest that maybe that could go into the contract language between the different payers. And we have this all detailed out for Jen, but we just wanted to give you a high level. And then a lot of the annual reporting outlined in section two is already collected through the budget process. We gave Jen a very large spreadsheet of a crosswalk of what we collect in terms of certification and budget and under our rule. So that's very much detailed in those materials. And we already collect virtually all of the things that were listed there. And then the two year budget, we can continue to think about this at this juncture with our reporting requirements for the federal government. They ask for things every year. So that may be a challenge in our view. Anything else? I mean, the question I would have is how long does it take to get to a two year point? So the free maturity is doing it, but right, that's actually a good question. The key point, though, is that so much is in flocks. So for example, this year with the budget that came in, there was the anticipation that state employees and teachers would be involved, but they're not. And if you had gone through a two year budget process, you were using numbers that would be pretty far out of whack going forward. Obviously, any time you can extend the length and create some more long-term planning versus short-term, it's good. So we understand where you're coming from. It just may not be practical at this point in time. I didn't even realize you were finished with that. So basically- Are we at section four? Yes, pH. Okay. Slide seven, is it? Yes. So Susan already touched upon the fact that how transparent everything is. And actually, one thing that could be done that might actually help us do a better job would be to allow for a couple of things to be a little bit less transparent. And I'll give you an example. In the recent budget orders, six of the hospitals were required and are required to present to us sustainability plans. And why was that? Well, what we've seen, if you take a look at the environment in Vermont for healthcare with the hospitals in particular, if you do a five year caterer, eight of the 14 hospitals have a negative operating margin. So it is not a healthy environment that exists currently. And while the vast, vast majority of hospital boards are incredibly tuned in, we've seen at least one situation where people have become complacent as board numbers and weren't following things as closely as they should have been. They took the CFO and the CDO at their word for what the true picture was for that institution. You talked about the hospital board? Yes, yeah. And so a couple of things that in our efforts to try to make sure that doesn't happen again, we're actually working on two fronts. One is we're working with VAS to develop a board education where this really goes back to this, it was over 20 years ago now that it was on a school board. But back in those days, went in Goodrich from Vermont School Board Association would travel around and we would meet with all the boards in the state and basically go over with them what their obligations were. And it was very, very helpful because it gave everybody at the local level the tools to understand how important their job was. And so we're working with VAS on that education plan. But the second piece is the sustainability plan which has already been ordered in the budgets. And since that time it's become clear that hospitals are a little bit reticent to divulge some information because of the fact that what they deliver to us becomes a public effort. So if you're even considering the possible elimination of a service line at a hospital, you wouldn't want your employees to know that until you actually pulled the plug on that decision. Or if you were negotiating with another hospital or a group of hospitals to do something contractual in alliance, you also can't endanger that relationship. So it would be very, very helpful if there was something that could just be in session law that would allow for sustainability plans required by the 3D Mounted Care Board to be allowed to be kept confidential. Because the real fear is if we can't get that confidentiality, we're still gonna go forward and we're required to do a sustainability plan but one would have to beg the question if they were truly transparent in that plan or if they intentionally were a little bit opaque because they had to protect the interest of their institution. You never got the real picture, right? Right, so that's the case where it would be very, very helpful. And you talked in here I think about three specific, if there could be some flexibility on more than three, that would be helpful. Also, it might be helpful if you actually studied what the impact on the half of 1% increase might be because the administrative burden might be fairly high if you set it at that level. But it also brings up the question of something that would be truly helpful is that if during the hospital budget process we had statutory language that enabled us to pierce the veil of the contracts that are between carriers and hospitals as far as reimbursement rates. So in the hospital budget process we have two primary levers. One is to restrain the growth of overall expense through the net patient revenue side with the face-grain revenue cap. The second lever that we have is being able to set a cap on the increase in charges that a hospital can raise their prices on. And the problem with that is that we're not truly getting to the bottom of what the reimbursement rate is. So for example, you could say the hospital A charges 3,000 for a colonoscopy, hospital B charges 1,500 for a colonoscopy, but without knowing what the reimbursement rate is to each of those hospitals, those charges don't really mean anything. So you can't just automatically assume that hospital A is getting twice as much for that procedure when they get their reimbursement. And we've seen some pretty varying degrees of percentage off of charges that hospitals and carriers negotiate, and yet we can't have all that information right in front of us to make the truly best decisions. So that would be something that would be extremely helpful to us. We do have the language that we can share with Jen. That would be helpful. I mean, this is exactly the kind of thing, right? Yeah, good. The next section of your bill deals with designated agency budget review. And we will do whatever you ask us to do. That's perfectly clear. Wow. Wow. I do know that that section will change pretty significantly. I just want to point out, and I pointed this out in House appropriations, that I worry based on what transpired last year with our budget with the move to no longer fund pieces of the budget with global commitment dollars and a move to increase build back. But I'm worried that it may not be this legislature's intent to have designated agencies pay for this review, but could easily change in the future. Yeah. And I start to get nervous about doing that. And when you ask us to do designated agencies, if you ultimately decide to do that, you really have to decide how thorough of a review you're looking for. The hospital budget review is extremely thorough. And that will take at least two more positions at the Green Mountain Care Board. If it was a cursory review of the budgets, that would probably only take a half of a person to one person. And at the end of the day, you just have to ask yourself if there's enough value there to pay for that review. I'm assuming, and you know what happens when you assume, but I'm assuming that AHS is reviewing these budgets now. And I'm not sure if we would add that much more value to that process. At the same time, I understand how pressed the designated agencies are. And I look at, they can't compete as far as the workforce because a school can be higher, a hospital can be higher. So I understand all the challenges, but at the end of the day, we may come in with something that you can't afford to pay for. I think it just depends on what it is. Exactly. And we don't know what it is yet. I would see it more as a program review than a budget review to shed more light for the board as we're looking across health care systems. And it certainly, as Kevin said, we have to see how many levers we had on that. I think it would more likely form an option to have more transparency on the system as we are seeing with the Brown River Retreat and then as that language shifts and changes in the bill, it'd be important to have our feedback. Yes. Absolutely. Go ahead. Just one comment about that. As we take the new railways in to do more things that both traditionally human services like and they use surplus monies, where money is coming through that. I think the concern comes, who's looking at this in the open? And who should review it if you're not the place? Because we're using health care dollars to do that. So the value, as I see it, got dragged into seeing some value of us doing this. Representative Hoover said to me, because I didn't see that there was a lot of value in what we presented as a review of the three years of financial statements or the Brown River Retreat, but she found incredible value in that. So I think the value is for people making decisions on monetary expenditures. I don't know if anyone here, what we do in the traditional human services sense bumps up against what the direction that the ACOs move in and give in what our designated agencies are doing. And it definitely gives you a more holistic approach to the health care system. It may just be a lot of frustration on our end because we may see that holistic approach, but not be able to do much about it. But that's okay. We're frustrated a lot. But we're now in our clubs. We get frustrated, but we're not overwhelmed. We have a really dynamic team and great people. Okay, we should probably look at the people. Yep, so on section six, board membership, we've talked about this in the, or having a practitioner on the board. Oh, sorry, that's Kevin's. I'm stealing his thunder. We're neutral. Okay. We're neutral and... You said it so well. I publicly said that when I was invited to go to the Green Mountain Care Nominating Committee before the last nomination that I recommended that they send out names of providers at the same token. I do, I would love to have a provider on the board. I just worry if you're limiting it to the next person that you're tying the hands of somebody sending the best to absolute person. I did notice in the effective date section that we excluded someone. The next person that is, whose term is expiring is Dr. Holmes from Middlebury College. And if she wishes to keep doing the work, I would hate to have her pushed out. And it's clear from the effective date language that would not be the case. Right. So it's... We had that, yeah. Yeah, okay. But you're neutral, neutral. Neutral. Okay. So it's a blend. Yep. So provider rate setting as it was laid out in the bill it would be next to impossible to accomplish the what's laid out to have full rate setting in place by July 1st, effective January 1st with pricing. I can tell you that one of the most frustrating things for somebody going on to the board was my first year I tried to implement what I thought was rate setting ultra light. And quickly the staff pulled out a study that showed a $2.3 million cost for rate setting and without getting more help from other members of the board of the time to pursue what I thought could have been done very, very cheaply, I let it go. I still think there's ways to do this without full blown rate setting that could be very, very effective. And... Do you have suggestions for us or language? I think really what might be best on this section is a study. I would be speaking on my own if I gave you a suggestion because I'm not sure that I have. That's what we're recommending and replacing us with a study. Yeah. Yeah. Okay. Offline. Yeah. So for your contract standards, that's you. Neutral. Neutral on that, that with me. And then employee attribution. Oh, that's the... Public employee. That is a study. That is a study. It's AHS's study. I mean, that we'll let them speak to that but we do have a slide in our deck that looks at the attribution now. I mean, we feel that this is also very important. So it may not have to be a study. It may be a discussion. It may... But talking about it is very important. We agree with that. So we're neutral, but to be clear, the language in the bill, I think, could possibly delay attribution for a whole nother year. And that is not something that... We don't want to do that. That is what you intended. So I think that has to be looked at. So it's not that we're truly fully neutral. Okay. Send mine. I guess the question that we'll be asking folks when they come in to talk about this is, will attribution naturally detract from or cause a decrease in benefits? I mean, that's... That's a great question. For me, it's a silly question. But I think that's a great question to ask. And I think the ACO can talk about that. Right. Their concerns are more than just a decrease in benefits. What they're... At least as they were relayed to me when I met with them is the state employees have been very successful through wellness initiatives to keep the benefits from climbing. And in fact have actually received, I don't know if you would call it a repayment or a rebate basically for their initiatives. And they wanted to make sure that that wasn't taken away from them in this. I think that, and I'll try to say this politely, but it's gonna be difficult. If the state's true vision for trying to get health care reform as it stands now is enunciated in Act 113, which was passed by the legislature and signed by the governor, it's kind of embarrassing that the state's own employees aren't part of trying to make this effort successful. And the only way that you truly get to a determination of whether or not this would be successful is if you build enough scale to, so that when you, why? Why is that when you walk into your doctor's office, you want that doctor to be treating all the patients the same and treating them on value versus volume and you don't want them treating tick differently than they would treat me if we both walked in that same day. And it doesn't truly change their patterns if there's not a large enough part of the population that is attributed and participating in the model. So that's the why. We would welcome that discussion. I think it's great that you put this in here. I hope that we can have that conversation in here with the interested parties and see if we can put something in that helps them forward. We don't have anything else. We just have some appendices. Okay. And feel free to look at those at your leisure, but we do have the very detailed suggestions that we shared with Jen. And I think she's the best person to read that with you at the appropriate time. Okay. But you will, you speak. Yeah, there was actually one other thing that I was going to talk about. That was, and I'm sure that the ACL will speak for themselves, but a couple things. You had one provision that basically was hitched to a 15% administration. Their current budget is at 1.4%. No, we understand that. Yeah, that was just like, thank you. Great. I don't want people out there to think that they're getting these ridiculous administrative fees because they're not. And the other thing that you had in there was saying that nobody at the ACL could receive salary and that was demonstrated. Right. And I could understand where you may want to hold leadership accountable, but when you say nobody at the ACL, if you're hiring somebody into an injury level position, you would want them to be able to improve. And you wouldn't want them once you've got them up to being a very productive and efficient employee to be leaving to go elsewhere because they were unable to get to the position. That's a good suggestion. Thank you. I don't have anything else. Any questions for us? I do have one question, just to clarify. So you, as we had discussed earlier, you are sending some suggestions to Jen and then we'll be able to review those at some point. I do have a question about your preliminary scale estimates based on the 2020 budget submission. And I see some negatives in there on population. Those are approximations. I'm sorry. It's a squiggly one. It's an approximate. Oh, it's supposed to be. It's a sedia. Oh, yeah, okay. I got it. I appreciate you changing that. Yeah, that's a great question you'll know about. And these, just so you know what I think that the ACO could talk more about this. Pro-virus. I know, really. This is part of your budget submission. So these are approximations and they can update that you on where they are with scale. Okay, yeah. Should point out in the different appendices that you have, there's resources that you can click on and so on. And before I get out of the chair, I did want to just highlight the fact that some people have asked about whether or not regulatory review has created any true effects on cost and demand. If you look at what was the case between 2000 and 2009 with the increases in hospital spending as opposed to this previous decade that's been cut in half with the increases. So we're, yeah, thank you. This is helpful to have available. And the hospital rates have gone down. It's compared to the nationally where we're lower. The concern is that the out-of-pocket co-pays and premiums that we're seeing haven't been commensurate, so yeah. They are, I think I've seen them in the past years. One thing that's not in this field but I'm assuming that there's some type of relationship going on between the House committee and here that somebody will be working on a drug bill. And- On which? On a drug bill, I hope. Prescription drugs, drugs, right. So what I did send to the committee yesterday and I'm not sure if it got distributed to everyone, but it was just to showing you the extremes that states have had to go to because of federal and action. And the state of Utah is actually paying for plane tickets for people to go down to get very expensive drugs in Mexico for a 90-day basis. And it is so much cheaper adding in the costs of the flight and they have someone that marshals them through the border. And they pick up the drugs and bring them back and it just, it's a real travesty. And if you take a look at Blue Cross Blue Shield this past year, 7.9% of that increase was specialty drugs, which are really expensive drugs. And then the hospital review as well, that was a large cost driver. The hospital, the- And as it stands now, there's nothing that they can do about that. Why is there nothing? Why is there nothing? Because of the farmers? Because, well, we want, the federal government doesn't want to do the same things that governments in other countries have done to keep drug costs low. Keep drug costs low. I mean, we're one of two countries that allows you to see Phil Meccalsen promoting emerald every other night as you turn on the TV. We're a country that still finances, even though it's not as much as it used to be through the National Institutes of Health, a lot of R&D costs. And yet, we allow a lot of those R&D costs, the remainder of them, to be amortized just over the U.S. market. Other countries are willing to negotiate for market share and if there's a group of drugs in the given class, pick statins, for example, they'll negotiate and they'll give the market to the one that gives them the best price. Trouble with us as Americans is, we want the lowest costs, but we want absolute choice. So we're not willing to give up anything to get those lower costs. And those are the type of things that have to occur. We can't just say that other countries and there are other countries that are getting better health outcomes that have the capital costs as the U.S. We can't just say that we're ever going to get to that point if we're not willing to make the same hard choices that they've made. So to answer your question, we are very concerned about drug costs, because there's no prescription drug costs in this room. And so we're going to continue to follow up on our importation law. So at least I have been staying connected with the administration as that work goes on. And you'll notice that when the current president talks about that program, he always references Governor Scott of Florida and the work that Florida is doing and I'm honest, kind of not in that discussion yet. We really, I believe, has started that. If we had a more assertive support at the federal level, that's what happened a long time ago. I mean, the rules are, I don't even know if the rules are finished being written yet. So that's a scare. And we're also working with Nashedby. We meet with them regularly to hear about what other states are doing and be informed on that work so we can keep Nashedby in again. We also have regular calls with the congressional delegation members of their staff. I can tell you it's not for a lack of trying by some. They're just as frustrated as everybody else. So. Can you give me that information? Is that the Utah stuff? Yeah, I don't think so. Yeah, what other states are doing? Because I think, and I can give you a list of all the stuff. Okay, I have a big story and she's going to go on here. I will just transfer it over. She said finances got a couple. We all have just limiting out-of-pocket expenses. But it, like the insulin bill, yeah. I can send you the link to Nashedby. I mean, we haven't made... Your biggest problem with some of those bills is gonna be that the way the federal law is established, you have an actuarial value to meet them. Yeah, no, we've already... Yeah, yes, we know this. It's frustrating. Yes. But I'm ready to start taking on the pharmaceutical companies. Well, go ahead. And it's been a few years, but we used to do a lot. And if nothing else, we can make enough noise. Well, our bill, we passed a few years ago and the importation bill and the transparency bill. And I've reported on both of those. A national Nashedby meeting a couple, two years ago. Those are still bills that are held out as the progressive drug prescriptions that are held. And so anything else that finance does, we'll be... Well, the healthcare advocate came in. I guess Thursday was the last day we met. About five o'clock at night suggested that we require hospitals to sell at the 420... 340. 340 with a B. We had that bill on the wall. 420, something else. Yeah. We're on the right direction, that's a long time. All right, so the list that I have is not in any order. So what I'm going to do is ask Devin Green and then Helen Layman, I've put an order to this. So Devin, Devin, Helen. And then we'll move on to the insurance companies and then we'll go to the ACO and then we'll go to Inevac and send them. So you know when you're up, that makes sense. So Devin, welcome. Oh, it's a treat. Sorry, the walls are kind of quiet right now. Why don't we leave the door open? Did you even want it open for air? Yeah. I don't know if I can catch the ones in here. Yeah, we have a real nice feeling to have air. Yeah, just to open that would be perfect. Thank you. Thank you. See you. Thank you so much. Thank you. Good. Devin Green, Vermont Association of Hospitals and Health Systems. Before I dive into S290, I just wanted to give a little bit of background on the current status of hospitals and of healthcare reform where we look nationally and internationally. So, it was great well done. It was worth it. It could yell maybe. So just a little background on Vermont's hospital system, as you know, where a completely non-profit hospital system. But what you may not know is that according to the US Census Bureau, Vermont is the second most rural state in the nation. So Maine is number one, Vermont is number two. We always think of places like Wyoming or North Dakota as more rural than here. But the reality is that in those places, a lot of their population is centralized in their cities. So what this does in Vermont is it creates a difficulty in providing access to care. We have to spread out our services a lot more. It's more difficult to be efficient. Critical access hospitals just by their very designation are supposed to be inefficient. They're more about access. They're not about big money savings. They're about making sure that care is there in the community. At the same time, you may be surprised to learn, you know, you had some national experts coming in, talking about the state of hospitals, how they build up and they build up and they buy each other and they jack up the prices and there's no Medicaid cost shift. That is not the case in Vermont with our non-profit hospitals. When you look at the number of beds per thousand individuals, we are 39th in the nation for the number of hospital beds that we have. Which is shocking to me because we are always number one when there's a per capita measurement, right? Like we always come in as number one. We are not only 39th in the nation, but when you look at DC and Wyoming, DC has a similar population to Vermont. They are more than double what Vermont has with beds. When you look at Wyoming, which is also a similar population to Vermont, they are many beds as well. And then if you look internationally, we're actually below the UK, Canada, Denmark and Sweden when it comes to the number of hospital beds in Vermont. So this is not a situation where we are building up tons of hospitals, tons of inpatient, inefficient. If there's any inefficiencies, it's just due to the very nature of our rural state. While we have that, Vermont's consistently ranked high as best in healthcare in the nation. So in the top five in Kaiser Health, number one for United Health Foundation. So hospitals really are doing a lot, it was very little. And I just want to make sure you get that perspective. We are different than the rest of the nation. And we're also different when it comes to our healthcare reform. And again, this is another situation where we're doing a whole lot with very little. So California is looking to do a very expansive social determinants of health, looking at housing, looking at all the social determinants of health and helping people in that way. Vermont is trying to do that as well with lawn care. The difference here is California has 1.5 billion in federal funds to apply to that effort. But how do we get that? I know. Well, we did have access to 209 million, and we haven't gotten that. Million. Yeah, 1.5 billion would be great. And you think, oh, it's California, that's why they get 1.5 billion, it's more people. But when you look at it, they're actually looking to help out 300,000 individuals. So not so different from Vermont. That's just the scope of what it takes to create this change in the social determinants of health. 1.5 billion to help people with housing, to help them with mental health services, to get them coordinated care. It's a staggering number. Meanwhile, in Pennsylvania, as you heard, they are doing a rural hospital program. Right now they have 13 hospitals in that program. Again, pretty similar to Vermont. They had 25 million available for their startup costs, which included overseeing the model, aggregate and analyze data, compile and submit reports, propose and administer the global budgets, and approve the rural hospital transformation plan. So those are all 25 million just to do those sort of arguably administrative things. It takes a lot to change over to this healthcare delivery system reform before you even get into the social determinants of health. Meanwhile, again, Vermont is doing a whole lot with very little. We received some startup funding from the federal government, not the same amount as the 25 million that Pennsylvania is getting. And as I mentioned, we did have 209 million available to us, but we have not been able to tap into that. So that leaves us with a healthcare reform that needs to be very efficient and streamlined. And when we started out with that healthcare reform, the legislature here laid out a very comprehensive framework to oversee the all payer model, ACOs, the agreement for the all payer model and ACO budgets. And that was found in Act 113. And usually this is the part in the testimony where I would say, oh, you have it in your slides, just take a look at it later. I'm not gonna do that today. I wanna go through this because it is comprehensive and it's worth looking at. So with the all payer model agreement in Act 113, required that the all payer model be consistent, the all payer model agreement. So this is just the agreement between the feds and Vermont. The agreement has to be consistent with Vermont's healthcare reform principles set out in Act 48. It has to preserve consumer protections under Medicare, including maintaining Medicare covered services, Medicare cost sharing and Medicare appeals process. Allow providers to choose, participate, give patient provider choice and include extra measures for population health. The Medicare payments go directly from the federal government to the ACO or providers, not through the state of Vermont. State of Vermont was very adamant when it set up this system that they did not want Medicare payments going through. Now the federal government is not going to say, yeah, we're gonna do deals with every provider in Vermont. That's why they want the ACO. The next piece of Act 113 pertains to the all payer model. So under these requirements, the all payer model must be consistent, again with Vermont's healthcare reform principles set out in Act 48. The Medicare payments have to go directly from the federal government to the ACO providers, not through the state of Vermont. You have to maximize alignment between payers, which is one thing you're trying to do here, strengthen and invest in primary care, incorporate the social determinants of health, adhere to mental health parity and integrate mental health and substance abuse treatment into the healthcare system and include a process for integration of existing community-based providers into a fully integrated care system that may include transportation and housing. Integrate approach to data collection and analysis, exchange and reporting, evaluate access to care, quality of care, patient outcomes and social determinants of health, arguably what you're trying to see happen in this legislation requires shared decision-making, support coordination of care and work with the healthcare advocate to ensure robust grievance and appeals process. So that's a lot of protections in there. Then there's ACO oversight at the Green Mountain Care Board. So we have our hospital budget oversight at the Green Mountain Care Board where hospitals provide detailed information on their budgets. This is ACO oversight of ACO, which includes the hospitals. So it's a little bit like double oversight. And in here, the ACO governing body has to have governance leadership and management that's transparent and represents ACO participants and providers. It has to have care coordination, including blueprint. It needs to have mechanisms for receiving and distributing payments to providers. It needs to have no discrimination against providers. Evidence-based healthcare, coordination of care, electronic health records and other technologies. Meaningful participation in health information exchanges, performance standards, which again we're talking about in this bill as well. No restrictions on information in provider-patient relationship, shared decision-making, outreach and hotline to consumers, shared de-identified complaint information to the healthcare advocate, collaborating with community providers, which I know is a big goal here. So that's already encompassed in statute. Patient choice, public sessions of the ACO meetings, no decrease in access to healthcare. Which again, I see that in the concern for the state employees and the teachers, my understanding is that their benefits will not change but I will let others speak to that. Public session of ACO meetings, no decrease in access to healthcare and financial guarantee to cover losses. So that's general ACO oversight. Within that, there's the ACO budget. So in the oversight for the ACO budget, the green amount of care board must receive information regarding the utilization of healthcare to ensure that there's no sort of restrictions on people having access to healthcare. The goals, they have to look at the goals of the health resources allocation plan, which again, it gets to what you're worried about in terms of where services are located. The soundness of the ACO and its principles, the report from professional review organizations, effort to prevent duplication of services, which I know gets to the community provider, worry about sort of buying, not building. So the ACO has been working on ensuring that efforts are not duplicated. Incentives for healthcare investments to strengthen primary care, which I know is an issue near and dear to the heart of this committee. Incentives to integrate community providers. Incentives for system healthcare investments and social determinants of health. Incentives for addressing adverse childhood experiences, public comment on all aspects of ACO costs and use on ACO proposed budget, information from meetings with ACO, information regarding ACO administrative costs, effect of Medicaid reimbursement rates, extent to which costs are transparent to make patients aware of costs of healthcare services. And then added in Act 52 was the extent to which the ACO provider's resource provides resources to primary care practices to ensure care coordination and community services, including mental health and substance use disorder counseling that are provided by community health teams that are available to patients. In addition, in Act 52, the Green Mountain Care Board needs to report on the manner and degree that social services are integrated into the ACO. The AHS must provide an interim status report and the AHS and the Green Mountain Care Board must submit a plan to coordinate the financing and delivery of Medicaid mental health services and Medicaid home and community based services as well as future plans for integrating long-term care in January 1st of 2021. So this is the framework that we're currently working under. So when I read through Act, or when I read through S290, I kind of wanted to cry because we are doing so much with so little right now and there's been a lot of questions of why are hospitals doing this? Why are hospitals sort of putting themselves out of business because instead of fee-for-service, they're doing these fixed payments? And I'll tell you that what our rural hospitals need now more than anything is predictability and stability. And I was reflecting on how I was in the seat I was in the seat two years ago on February 14th, arguing for the same thing when we were looking at universal primary care. I was in here last year on S7 when we were talking about S7 and having consistently these sort of proposals come in year after year of trying to change the framework of this program and require more reporting and more administrative burden is not giving our rural hospitals the predictability and the stability that they need. So what about the suggestion that Chair Mullen made about having global hospital budgeting? You know, can we, I would like to. You want to, I would like to. I would like to answer if you would, but that's, I think that's an important question. I think that's what one care is leading up to, right? Like that's when we get, let's get through this waiver. So then let's figure out how to do it is the other question. And so what steps need to be taken in order to ensure that we have a sustainable global budget, especially for the critical care hospitals. And this is the steps we need to take is to make this waiver a success. No video. We need to make this waiver a success. This conversation is happening on the national level. They want to move to Valley Base Care. If we're still under the Trump administration, gotta help us. They are not going to care about shifting funding to community providers. They are just gonna wanna cut costs. They are gonna use a bundle payments the way that they use Medicaid block grants and say we're limiting how much money you get. So let's do this right while we have it and set a good precedent going forward so that we can have a strong position going into our next negotiation with the federal government. Okay. Thank you. All right, why don't you keep, where are you going now? Because it's just a long list of things that I know are currently in statute and the things that are related to S290 that you shared concerns about. Well, the whole long list is what's currently in statute. I found that. The position on S290 is that we do not support this bill. We do not support anything that adds further administrative burden or unpredictability to this model. Do you think that the outcomes assessment and evaluation that's currently happening at the board is sufficient? Yes. Okay. And then in terms of decision making on any DSR investments, do you believe that those are being done adequately through the ACO process and governance structure? Yes, I do. And I think that the other reason that hospital got involved in this and that providers are really excited about is that this is provider led reform. It really shifts the focus to providers and patients making decisions about where healthcare resources should be. And I think we should retain that sort of provider led focus. Okay, any questions? So do you have specific suggestions for change as the board is gonna be making some suggestions for change in the bill? And however that might affect the sections that you're concerned about. I don't know at this point. I mean, I have an inkling, but it would be helpful to have your feedback on those changes or any changes that you might suggest as we go forward. Good to know. And our position again is not to support the bill at all and to not work forward with the bill at all. Great, okay. So healthcare reform, we don't wanna touch it. We're doing it now. And we need to put our resources there. And then in terms of contract transparency and in terms of rate, rate assessment, rate regulation and rates, you're okay with everything that's happening now. We are doing healthcare reform now. I think anything that opens up contracts or starts a rate setting process again is that unpredictability that will hurt our rural hospitals. Okay, well we'll have to talk about that. Okay, thank you. Thank you. It's very helpful. You love the bill. You don't like Trump, that's how it's done. Thank you. So I'm Helen Leven from Vice State Primary Care Association. You have testimony from me, I pre-submitted, it's written as if it's a script, I'm not gonna actually read it, that I'll just go through and roll out points and highlight the points we would like to make. And for this I'm speaking from the perspective of the federally qualified health centers, the FQHCs. And we, like Devin, we do oppose S290 constructively, we constructively oppose it. We oppose it. These are most concerned to FQHCs, so I'm not doing a line by line of every element of the bill for efficiency's sake. And what you have at the beginning here is a discussion of FQHCs are a little bit distinctive that we respond very heavily to federal regulation and it's a lot of federal, like they wanted me to bring in the manuals and the, but it would not fit in this room to bring in all the federal regulation. We do not need to belabor that point. So there's a hundred additional requirements, right? And so we feel particularly sensitive to added burden and discussion of setting up new state-based systems that are not just added to administrative room, but for us it has the potential of being, sometimes they don't sync up with the federal regulation either. So that's just a general concern that we haven't. And additionally, the FQHCs feel this in a day-to-day sort of ways. It's on top of general concerns around administrative burden. I mean, we know that our primary care providers are spending as much time on the paperwork related to their patient as they are with that particular patient. So it all gets built into that general atmosphere of concern. So that's just a starting point of where we're coming from. And for FQHCs, we feel it's very transparent. So we recognize the fact that it's not just whether or not people are looking at the FQHCs individually to know that they're doing okay or that the federal government is looking at it, that it matters that the state also has that holistic view of what's happening throughout the healthcare system. And FQHCs are not directly regulated by the Green Mountain Care Board, although they do participate in the ACO, so they're indirectly part of that. And we do talk with them frequently and are part of their advisory committees. I should say that that federal information that we have out there is generally available so we're happy to work with anyone at the station who wants to access that data or evaluate it or look at it for transparency's sake. So we feel overburdened in regulation and we feel like we're transparent. In this bill, I will say there's one very specific area where that comes into play, which is in the section, I believe it's section five, looking at the designated agencies, which includes that line about preferred provider organizations. And that includes some FQHCs. And so while they recognize that participating in that program at VDH, they would come under programmatic review. The idea of their entire organization can move a separate regulatory system because of that participation is just unreasonable and we would recommend striking that. I don't know if anyone has an issue with that. So which section, the whole section? The preferred provider organization line in that section. Oh, I got it. Okay. Yeah. And we also have a timing issue that I know Devin spoke to and this is sort of a two part, or even a three part timing issue. So we have FQHCs that have, nine and 11 of them have joined the ACO. Some of them were recently, some of them are expanding the pair mix that they're participating for. It's a time of transition and building up to scale and all the uncertainty and running multiple books of business that come with that. So it feels like a time of working through that progress with the ACO. At the same time, HRSA, the Health Resources and Services Association which administration, which is our federal folks are moving FQHCs towards value-based care as well. And they have new programs that are going into place, different ways of evaluating and funding us. So we're also helping our members work through that period of transition. We know that the first phase of this work at the state level in the LPR model is ending at the end of 2022. That's roughly equate, as much as the federal government is on time for anything that roughly equates with what's happening federally. So when we talk about changes, we're looking towards 2023. And the idea of changing midstream to a new system feels a lot like having the rug pulled out from under us. It's disheartening as Devin expressed. So we do have concerns about the timing in that regard. I also wanted to talk about the contracting division of this. And in this, so it's not as if our members think that all of contracting is perfect, right? I often hear from my members about the contracts. And when we hear about it, sort of comes into one of two categories. They either have a specific problem with a specific contract that they're looking at that they don't feel is fair. And that's kind of the upside of all the regulations around FQHCs, right? It's really, there's a lot saying how you have to pay them, what you have to pay them for. So when we have a dispute like that, we will review it and we'll bring it to DFR for their review and assessment of an individual contract. At the same time, we also know that there are questions about new types of contracts. So when our members are looking at joining in next generation ACO, they said, you know, this is new territory for us. We don't know what this contract should look like. What should we be doing? So in that instance, we brought in a national firm that specializes in this area to answer the question of what should a contract for FQHCs in a rural area participating in a next generation ACO look like? What would that tell them would be the broad recommendations? And remember something, those contracts are quite transparent. You can look at those at any time. There are other contracts that are not transparent. You can't. So just... Which contract... Right, carriers. And those would be the individual ones that we would bring to DFR. So that's right. So that's another way of looking at the two different classes that we look at. Yeah. And so we understand that there's, right, there's that individual regulatory and then there's the idea of bringing in some expertise around a type of contract and certainly we would anticipate that second area of contract to be one that will come up again as we go through healthcare reform. So it's not that we think that contracting is perfect. It's just a question of what is the problem statement that S290 is trying to solve and are there tools in place that we have experience with that we could use to solve that problem? So that's another issue we have. And then, so there's a bigger theme and this is, I think, why advising is generally opposed to S290 and I think it came out a little bit in Vaz's testimony as well, which is sort of like a force for the trees question. So Vermont is a leader in healthcare reform, but it is something that's happening nationally. We are out ahead for various reasons, including our all-payer model that brings repairs into alignment. And it feels like a lot of the questions that I hear coming up around the regulatory issue is in fact related not to something that's happening specifically in Vermont, but into a sort of symptomatic of bigger questions of how do we regulate a different way of doing business in healthcare. So we look at the primary care investment report and how do you look at primary care investments in value-based environment. We would look at the preventive care issue that's come up previously, right? So we're trying to make generational change. We're trying to measure it on a one or two year return cycle. That's a problem. And it came up today, the question of, we have this reform model that's tried to reduce the growth and total cost of care, but how and when does that translate into consumers paying less for their healthcare, right? And these are all very valid questions, but they're also national questions. They're not just Vermont questions. And so our overall concern with S290 is that we really need to engage nationally in this conversation and stand back and take a look at healthcare reform and how that interacts with regulatory reform. And to spend time right now going line by line through S290 and making small changes, it sucks resources and energy and time out of the system while meeting those more fundamental questions unanswered. And that feels very disappointing. It feels like a missed opportunity. So that is why we are speaking in opposition to S290, but as I said, constructively. Yeah, in opposition to S290. So, and will you do this for us as language appears and changes are made? Will you also keep an eye on those changes and any constructive criticism that you could give would be extremely helpful? Knowing that as we have said in this room and as others have said, it wouldn't be great to have a lot of the issues that are in S290 taken outside for a broader conversation with folks who can work on those things in a little group. We certainly happen to. I feel like I need to say with respect for me and for my colleagues, we're smart people, but there are national experts out there. We might need some outside help from folks at Johns Hopkins at the different states that are looking at this in detail. I am not an actuary, nor have I built global budgeting systems, right? But there are folks who have done that and it would be wonderful to have a way to call upon their expertise as we discuss this. Sure, we get that. And Atrock was fortunate to have some national experts come in and talk to us. Thank you. That's for some of us that's coming in. Anyway, thank you. That's good. Another person who loves. I'm sorry. All right, so I think we're going next to Sarah and Susan. So I don't know which order it's in this time. Who goes first? I'll go first. All right. I think you went first last time. But thank you for coming here. I think we need to score board, huh? Yeah. Okay, so Susan Grickowski, MVP Healthcare. I'm going to limit my comments to the health insurance section, which starts, we don't have a global response. No. So it starts on page 17. And obviously there's a lot of existing language there. And so my first comment is going to be line 21 at the bottom of page 17. I'm telling you, we don't have the bill on the page. Okay. Page 17, in the very last slide, line 21. Yeah, so what the language says, any proposed rate increase that we would file with the Payment Care Board shall be considered if the proportion, shall be considered unjust. If the proportion of the rate attributable to administrative expenses exceeds the cumulative CPI rate of inflation for the applicable period. What page is that on? And that right here. It's not coming up on my, I need your page again before you go ahead. It's 17 into 18. It's under Jennifer Carby on our agenda today. We'll talk to you later. Health care contractor review. Okay, so this is talking about when we do a rate filing, obviously one component is administrative expenses, what we're putting in for that. And this would limit our administrative expenses to the cumulative consumer price index rate of inflation for the applicable period. So our folks expressed concern about this. And if I can just read what I got from them. MVP manages its administrative expenses on an enterprise wide basis. So across New York, across Vermont, across all product lines, not market by market. So we don't have a separate Vermont versus a separate New York. So it says we have been growing in Vermont recently, but we are contracting in New York, which is resulting in that membership reduction. So due to our overall membership shrinking, we've had to push our fixed admin cost onto a lower membership base, which is gonna make this number look inflated. So it's not actually that our administrative costs are going up. It's just that insurers can expand and contract and expand and contract. And you can't, there are some admin costs that you can do things with, but there are fixed costs that we can't. So that's our concern about that. So it says this could result in rates having to be filed that do not produce a rate that is actually rarely sound. So, and again, what I've seen over the years is if you have a year or two or three of rates that are not actually rarely sounding it catches up with you at some point. So you're gonna end up having to have a much higher rate later on. So that's our concern with that section. So now I'm gonna go on that section continuing on page 18 is fair contracts, standards, again, most of that is all existing language. And when you get to page 20, starting at line eight, these are new proposed fair contracting standard language that is being proposed here. So the contracting entity shall provide at least 120 days for a provider's consideration of a proposed contract and for negotiation of terms. Healthcare contracts must be for a minimum of two years and include reimbursement amounts that are consistent with the rate parameter set by the Green Mountain Care Board pursuant to the Green Mountain Care Board section of this bill. And then this is the one that I really wanted to point out number three on line 14. Prior to a healthcare contract taking effect it shall be reviewed and approved by the Green Mountain Care Board for fairness adherence to parameters, blah, blah, blah. So I guess my question is when we looked at this is what exact, what problem exactly are you trying to solve here, number one? So that's the first one. And then the two year contract might make sense in a number of situations, but there may be situations where it doesn't. So to have to be locked into a two year contract there may be situations where it is not a good thing. And then finally that the subsection three where the board has to review every single contract that we enter into. I was actually surprised that the Green Mountain Care Board said they were neutral on this because when you look at the number of providers across the state, not just hospitals, not just the ACO, not even just large physician practices but again the way this is written this is absolutely everybody. So I can't imagine how many staff, the Green Mountain Care Boards going to need to do this. If there were specific items to be reviewed such as in the case of fee for service any discrepancies between independent and clinically or hospital affiliated providers consideration for facilities fees in place. But some of the concerns that we hear about these contracts are the fairness of reimbursement and then we hear about fairness around liability and I know there's a bill in finance on that. I'm saying this is really getting into health insurance. It does get into health insurance, right? So there are some things that we'll have to talk about that split off to finance but there have been concerns expressed about the equitable nature of contracts across provider types and categories that are negotiated and granted everyone has a right to negotiate these contracts and the best negotiator wins but having those contracts evaluated for fairness at some point and equitable reimbursement at some point I think that's what this is trying to get at. So we'll leave it there for now. Okay, and so again would these contracts then remain confidential between the insurer and the board? Or do they become a public record at the board that anybody could walk in? Well that's a question, yeah we've heard that that's an issue, right? Yeah, so those are our concerns with that section as well. Just in closing, I would just like to echo Devin Green's concerns that we have been far down a road of healthcare reform and this is like adding a whole new layer on top of that and should we give what we have in place right now a little more time to mature and go from there. So you could look at it that way or you could look at it in some other step in the reform process to ensure that we have all the little pieces in place. So but obviously we're not ready to jump into this. We need to take a little longer look. We get that, we get that, that's why it's our favorite. Okay, okay, thank you. Okay, thank you, and Sarah, thanks for being here. And the other thing I would say, well Sarah's coming up is we understand the commitments that the carriers have made to our reform efforts and we're very appreciative of those commitments. Seriously. Sarah, teach out with the New Cross and Blue Shield of Vermont. I will start out by saying that we do oppose S290 and I have some sort of overarching thoughts and then I'm happy to walk through certain sections that we particularly oppose. So we don't believe that the state of Vermont is going to regulate itself to help care reform or affordability. That those things need to be achieved through the all payer model and the efforts with payers, providers and government all working together. But that this additional administrative focus is not gonna get us there. The second thing that I have to say overarching is that this legislation is still focused on the old model. This legislation is focused on fee for service, rape review and all the things that we've been doing since the dawn of time I guess. We need to be focused on value based healthcare reform and this drags us back into the old fights, the old discussions and the old way of thinking and we really need to move forward. And then the last thing I wanted to say but originally and I appreciate your introduction is that we think that Blue Cross Blue Shield of Vermont and our efforts that we've done this year were a huge step forward. That we enabled every single one of our customers to join the all payer model. Whether or not they chose to is a different story but we have come up with a way and it took us a while to make that happen and we want to move forward with that effort. So I can talk specifically about some of the sections of the bill. I'm gonna focus mostly on the ones to do with health insurance. The pieces on page eight that have to do with the three specific healthcare services that were subject to the largest increases in commercial rates. I don't know if this is gonna get you what you want. Again, it's looking at fee for service. It's just looking at it could be three healthcare services that five people in the state used that had a large rate increase. There's just not enough fear to really give you information. I don't believe. So I think the board is gonna have some comments on that changes. Yeah. And when I see the board's recommendations I'll comment on those specifically. And I think part of this goes to look at the next step. The next step and all payer reform is to try and sort out what happens to specialists. Anyway, we're not there yet, but. On the board membership, you know, the Green Mountain Care Board is looking at value-based healthcare reform. We actually believe that an actuary or a health insurance regulator would be helpful in looking at that picture. Would so, so would that be defining board membership in a new way overall? I would just think about it. It's not right. I mean, it's quite true. Figuring out the right person at the right time and picking the most qualified candidate is probably the most important thing. And all of these efforts lock it into this yay, very fine process. On page 13 where you're talking about review and approved proposed healthcare contracts between a health plan and a contracting entity, we have over 2,000 individual contracts with independent providers, plus the hospitals. We believe that this would be an enormous task for the Green Mountain Care Board and it would also be quite costly. Will you hear my comment earlier? And we already have sometimes difficulties getting the contracts executed on time. It's frequent that we don't execute a contract until after the first of the year and then we have to retroactively change the way we're paying. I think this would just add to that problem. I think I won't get into much of the things with rate setting. I think the Green Mountain Care Board spoke eloquently about the issues associated with rate setting. When you're looking at healthcare contract review, I did have some questions. I'm not sure that the Green Mountain Care Board would have regulatory oversight over our Dartmouth-Hitchcock contracts or out of state. So Blue Cross, our network contracts with providers all across the country, they obviously wouldn't get into those. And also our non-participated providers. So anyone who refuses to contract with Blue Cross and charges whatever they want is excluded from this. So it's just a very narrow set of contracts that you'd be looking at, even though they're thousands of contracts. I don't believe you're gonna get the information that you need. And I also think that you will put Blue Cross Blue Shield of Vermont as a significant disadvantage with our compatriots. If you can't look at Cygnus contracts and United's contracts and all the other non-regulated health insurance in the state of Vermont, you put Blue Cross at a disadvantage. So then specific to the administrative rate increase section, this is starting on page 17, you're in health insurance rate review, and you're looking at the component. I would have, if you really wanted to go forward with this, I think the language needs some improvement, but comparing administrative rate increases to the CPI. A couple thoughts here. I can give you information about our administrative rate increases going back the last five years. They've never been as high as the CPI, so we believe this is a solution looking for the problem. Included are rate increases. The administrative pieces are state and federal taxes and fees that includes the costs of the Green Mountain care board, of which the legislature has continually shifted away from the general fund to health insurer payment or rate review. That's all reflected in our administrative costs, and so that the more that the state shifts those costs onto insurers, the more our administrative costs go up. The second thing is that pieces like our agreement to take over Vermont Health Connect Billing, which is a substantial operational cost, go into administrative costs. So that's another piece where state government is shifting to healthcare insurers and ultimately to healthcare payers for the cost of the system. I think you would need to look at what's defined as administrative costs. I think currently I've done different ways by different companies. I attached the L&E, which is the actuarial firm for the Green Mountain care board. I attached their review of our rates. They found that in 2020, our administrative costs were negative 0.1%. They also compare us to health insurers, and I can pull it up. They compare us to health insurers nationally and across the blue system. We are among the lowest on administrative costs. So we believe this is unfairly penalizing. Those of us who've worked very hard to keep our administrative costs low. And lastly. Yeah, you could go up. We don't want our rates to go up any more than they have. I can guarantee you. And the last piece is the word unjust in this language. Unjust is kind of an odd usage of an actuarial term. We use unfairly discriminatory in the actuarially. And that's a definition that actuaries use. I mean, maybe just unaffordable would be more direct, but unjust is a little bit odd. And that is unaffordable for me. I would note that you are repealing the contractor confidentiality language on page 20 and 21 that Susan asked about. I won't get into this again, but we think that puts Blue Cross in an unfair disadvantage against our competitors. And then I think I'll let the state employees and the ACO talk about the study. We don't believe there's going to be enough data available to do this report and that anything you do to delay enrollment in the ACO is problematic. We know, I think everyone knows that we need to get more enrollment in the ACO in order to have a good position to negotiate with CMS in the upcoming year. Okay, I'm reassuring the test. Thank you, thank you. And as I said to others, any improvements, especially to the last section would be helpful because we do need to demonstrate to the state employees and others that this is the all payer is the right direction to be going. So that piece. Welcome. Hello, how are you? Good, so for the record, it's not flowing. It's not flowing. No, no, yeah, go home fast. I will, I will, our distance is temporary. Strange quote. So for the record, Vicki Loner, CEO of OneCare Vermont and if I could just have a moment of levity here, I think that the temperature in this room is just a strategy to have me stay on goal. I'm gonna move through it. I think that a lot of the provider associations did a really nice job talking through Act 113 and additionally Act 52 and just for context, I'm gonna keep my comments strictly to those related to the additional administrative requirements for the ACO on regulation, but I'm happy to answer any questions about anything else in the bill that I'm fit to answer, I should say. I feel like we had set up a really nice regulatory framework with Act 113 and additionally really looking at Act 52, which does the integration of the social services work. We actually were on a phone call the other day with a reporter from the Valley News talking through all the work that Vermont has indeed done to really integrate social services into the ACO. This is indeed a very unique model in that sense that it does bring primary care hospital and the social services entities together to have a more holistic look. When we first went through this process with the Green Mountain Care Board in 2017 as our test run for our budgeting and certification requirements, I think we were still learning our ways in terms of what the requirements meant and having a lot of back and forth. I have to say that over the years, the requirements and questions have grown significantly to the ACO, which has resulted in almost a doubling projected in our billback rates and I have to remind the committee that the ACO's administration is funded for the hospital associations as well as the preponderance of the delivery system reform efforts. So to date, the hospitals had funded about $44 million, about half of which has gone directly to primary care to fund these efforts. So this takes away from the ability to use money that could be delivered to primary care and other innovations and shifts it to administration. So I just want us to be thoughtful before we add additional administration to this. This is one layer of administration for the ACO that we currently have. Not only is the ACO regulated by the Green Mountain Care Board, we do our own internal regulation too. Every year we have an audit by PWC, which is a national financial auditing firm to look at our accounting principles. We have undergone an internal assessment on our overall compliance plan because ACOs are relatively unique so the compliance requirements are different for ACOs and they are for hospital associations. We also have responsibility to the payers where we have to get them quarterly deliverables on how we are administering the program so that again takes administrative time from the staff at One Care Vermont. And I would say lastly, the state has put in a framework with the federal government that every year there's an annual evaluation of the ACO and the all payer model. So that's kind of a fourth level of oversight that the staff undertakes at One Care. I know you can imagine this is timely and costly and we have a very short time to really be able to deliver on our premises of delivery system reform. I think we have talked a lot about this as payment system reform. We can change the payment system but if the delivery system doesn't make any changes then it doesn't matter. And this is really hard work that our providers are trying to undertake on a statewide level where you don't have systems that are primarily owned by one large healthcare. I mean we had contracts with hundreds of providers that are trying to coordinate care across the state. So it's a fairly large undertaking. I would say that when we did the analysis of S290 and the additional requirements they were already covered under Act 113. And they were said in a different way but I worry that having requirements that are similar but inconsistent don't add a lot of value and could really kind of lead us down a bad path as a system of care. I would also say I'm sure you're not surprised by this but we could not support making our workforce raises contingent upon shared savings within the ACO and that includes our leaders. We need to be able to recruit leaders to the state of Vermont. And if you look at the unfair model as well as our overall objective as the ACO it's not to save money. It is really to keep the growth of healthcare costs at 3.5 to 4.3. It's not to have shared savings in the model. So I just wanna point that out is that's not one of our overall goals. And as we look in the ACO that's what the actual review does. That's how we take risk corridors is to assure that there's a sustainability and predictability for those inside the ACO. I cannot talk about outside of the ACO but that's our goal within the ACO. And we've been very successful at that. I think even in looking at the Medicaid budget last year we had a $1.5 million variance and the state didn't have to come back and ask the legislature for $1.5 million because that was covered by the provider group. So it's sticking with that sustainability and predictability. So in terms of my overall recommendations for this particular bill I would really encourage this committee and others to take a look at the regulations that already exist. Have an evaluation framework for it to make sure that it does make sense in our current value-based system. And are we actually measuring things that get us closer to our goals or are we are measuring for the sake of measuring? My concern is you add additional things without taking a good look at what already exists. And I don't even know what already exists is perhaps even too much because that hasn't been done because we're just in the start-up years. So I think that would be my overall recommendation is to take a good look at the current standards. We have budget, we have certification requirements to develop some sort of standardized evaluation framework for taking a look at that. And I certainly would encourage us to look at the feasibility of having a two-year budget process. I think that there's ways that the ACO has to go back accordingly to the Green Mountain Care Board to discuss any budget variances that we had. We have over 20 budget orders from the Green Mountain Care Board. So I think there could be a step-wise process in evaluating ACO budget year over year. Okay, and we haven't gotten the quality metrics which we'll do another time because under the outcomes I think that are so critical that they haven't been paid attention to. So our change is being made in the provider community with patients as a result of those quality metrics that you're putting in place. We'll talk about that next time. Yeah, I think the answer to that is yes. And as has been mentioned in this committee by various people, I think you really have to start thinking about getting to scale because scale is really important for this date. Because remember, that's their commitment to the federal government to get more people under that model. Scale is also important to the ACO as well because if you don't have scale then you'll have providers operating in multiple systems right now and they're not going to radically change their overall practices if we continue to just gradually increase over time. And I don't think that you'll be able to see this system being able to continuously be able to invest in these innovations if we're not really going to look at this as a 2.0 situation. And I think there's serious concern from a provider's perspective right now that we aren't going to meet our goals overall as a system. And I put that on us as a system and not just one care remop. We're obviously a part of it. And that we really do need to be able to show success under this model. Thank you. I'm sorry, we're in short now. We have to hear from Ina and we have a couple folks here from Recovery Day. Thank you. Thank you. I know that we'll be talking again. Yes. And before we get into Recovery Day I am going to have to- Yes, you will. Because that's perfectly fine. Cut 15 minutes out of money chairs. So the other thing that might be useful to us while even sitting down is Sarah mentioned how they're bringing in more food and supplies to these under the posts in your organization. And so it would be helpful to understand how that's happening and how many we're seeing. Welcome. Thank you. Ina Bacchus, Director of Healthcare Reform at the Agency of Human Services. AHS appreciates the themes that have been discussed this morning related to S290. In particular, the theme that components of this proposed legislation are at odds with a state that is looking to set an integrated total cost of care budget for the healthcare system. And that work is happening now and there is a rate setting at an aggregate level that is happening now across a spectrum of services that we want to see more integrated to be more effective in maintaining and improving the health and well-being of the monitors. Particularly for AHS, there are two components of the legislation that we'd like to share our concerns about. And those components of the legislation put the agency into a particular conflict when it comes to our responsibilities and our requirements as the single state Medicaid agency for setting the Medicaid rates for providers contracting with the agency, as well as overseeing the budgets and engaging in the regulation necessary for designated agencies, specialized services, service agencies and preferred provider organizations. As is contemplated now in this legislation, we see a variety of conflicts for us in those regulatory activities. Again, the most important to highlight the potential that our authority as the single state Medicaid agency, which is a federal requirement that the agency be the entity that sets these provider rates. That is a concern, a particular concern at AHS. Okay, we get it. And so, but as we move forward, this will continue to be the stress and strain that goes on and the tension between having a Green Mac care board setting rates with private insurers and then having Medicaid setting rates over here and integrating those things and how that can happen smoothly and in alignment. So we'll go back to that word that we love. So, thank you. Thank you. That's great. At least that you're here. We know that today is your Friday day is a very important gap to us. So why don't we introduce ourselves first and then we could introduce yourself and I'm doing a corner that represents the New Japan Senate District. Denny Berman from District of New Cali. Judy Lyons, District of New Cali. My name is Jeff Bother. I supervise the recovery program out of the company in the community. And I'm the executive director of our central home recovery center. Go with some of your words. Cool. Thank you very much. Thank you for having us before the Senate Committee on Health and Welfare, Senator Lyons and Senator Westman and all of you. We are very grateful to be here on Recovery Day at the State House, the early event where we share that recovery from addictions and in this case, substance use disorders is possible. And that Vermont has one of the most vibrant, holistic and successful peer-based recovery communities in America. We're blessed to have a community of recovery supports and services and people who serve as powerful beacons of hope in a dark time with dangers and loss and challenges for our citizens, our families and our communities. I'm here today with my colleague, Jeff Butler, who serves as the central from our recovery center's emergency department recovery coaching program supervisor. Jeff oversees a remarkable team of peer recovery coaches who provide recovery coaching 24 hours a day every day of the year at Copley Hospital. Our program along with the ED coaching programs at some other hospitals and recovery centers around the state are funded for now through the state targeted response and state opioid response grants from SAMHSA through the Vermont Department of Health and administered by ADAP. We're here to talk about the program in particular because it was one that has transformed our recovery center and in some ways has begun to transform our community. It's a program that exemplifies the critical role of Vermont's 12 recovery centers play in our community as well standing at the nexus of recovery, prevention, treatment and intervention. And it's a program that's relevant to this committee because the service within Vermont's hospitals is and will be a critical part of helping to reduce health care costs, make one care's model successful and help make our hospitals financially viable in addition to most importantly helping to change the trajectory of many patient's lives. Before I turn this over to Jeff, I wanna use a few minutes to share some thoughts with you about recovery and our challenges and opportunities. I do some knowing that there are several of us in this room who have first-hand experience with addiction and many of us who have had relatives who have suffered or even died as a result of substance use. And I do some believing that we're at a critical juncture in our state's approach to helping people with substance use disorders and that you as legislators will be among the people who will have to make choices in the months and years to come about where our precious limited resources are spent. It is you who will have to have the courage and foresight to act and invest. If we're going to turn the tide in our fight against the opioid epidemic and the epidemic of addictions old and new and still to come. Substance misuse affects tens of thousands of Vermonters, tens of thousands of families but really in the end it affects us all. Addiction is linked as both cause and effect to everything else that we care about, everything we're trying to address and mitigate and improve upon. It is the ubiquitous, pervasive and sometimes unseen force holding us all back. Now just the people who are suffering from addiction directly. Substance use and misuse is connected to mass incarceration, adverse childhood experiences, domestic and sexual violence, human trafficking, poverty, hunger, homelessness and suicide. It's linked to the destruction of families. It's linked to work for shortages. It's a disproportionate killer of our citizens. Substance misuse is one of if not the greatest hindrance to the health and wellness and prosperity of our state and its people. It's cost and lives and money is largely unmeasurable and unchecked. And if you want to, but if you want to find hope, if you want to find solutions, if you want to find cost-effective evidence-based ways to address what's holding our communities and our people back, you actually don't have to look very hard. Recovery centers and other recovery organizations are doing good work but need your support to be able to do more of what works to help save and change lives. We need to be empowered to do more and do better. And with that, I'm gonna turn it over to Jeff to share with you how ED coaching is among the programs and services that saves lives, makes our communities better and mitigate costs to society. Great, thank you, Daniel. So our role as recovery coaches in the emergency department is to come and sit down with individuals that are being brought into the EV for substance use disorder. Our team is all called 24-7, 365 days a year. When we're called, we are checking in with the hospital staff, doctors, riders, and other individuals that are working at the hospital. I call the hospital so far since the start of our program, we've seen 181 individuals through the course of this first year that we are running. Numerous people, we've helped find their way into various treatment modalities, detox, inpatient, IOP, MAT, also recovery services that we offer at the recovery centers, as far as regular recovery coaching, our support group meetings, 12-step meetings, just a fantastic recovery community that we have over at the recovery center at the Lawrence School. State-wide, the program has seen over 1,500 people, that's unique individuals, so that does not include three visits. So one of the things that we hear is how sort of tenuous recovery is for patients and how critically important it is. In just in terms of the work that you're doing with folks, are you seeing a success rate in keeping people from committing suicide or any relapse? How do you keep track of your success, I guess? We are using a data platform called Recovery Data Platform from Faces and Voices of Recovery, so it's RDP, so we have intakes that are in there, each encounter that we have, each phone call that we make. So the program, after we meet with the individual in the ED, we would do at least a 10-day follow-up from the calls with them. The level of engagement has been very high. If the individual isn't willing to go, or doesn't want to go into treatment or any type of treatment modality right off the bat, we're off into the on 10 days, 20 days, 30 days later, they'll reach back out and say, hey, actually, I would like to try something different because what I'm doing right now is working for me. And there's some other redundancies, for example, probably the first way that we'll be able to see in monetary terms and otherwise have what effect this has had. And again, we're kind of talking about Cochle, but this is statewide at nine centers and nine hospitals right now, but soon to be more. At Cochle, it kind of started with social workers doing case management around high utilizers to help reduce costs within med-surge and the emergency department. So that was a starting point before this program began. We were already doing calls up there with the social workers to try to intervene in processes to help people change the trajectory of their lives on a limited basis. This will help, you know, basically they're able to identify people who are coming back again and again and again. And, you know, there's people that are coming in who have just experienced an overdose and it's been reversed. There are people that are in withdrawal and many other conditions that are going on or health conditions where a screening process identifies that actually part of what's going on is the substance use. And so then they're able to call us in. So there's a lot of redundancies within our own tracking of information, but also within the healthcare world of them seeing where are people being connected? Are we keeping them from constantly revisiting the emergency department due to recurrences or continued overdoses or things like that? We also, one of the transformative effects and I know we're kind of putting up against time here, one of the transformative effects is that we have been able to instill a culture of harm reduction within the hospital. One of the things that has happened is we've been able to get Narcan out to many of the EMS services and we're actually providing it through VDH within the hospital. We know that at least four people have been saved by Narcan that we gave out through the emergency department. We've given out which over 300 doses and actually Krishna, Louis and Dover Recovery Day just said that they know of 29 that have been saved through Narcan given out by recovery centers in the last year. So there's some real concrete results and ones that are still to come. And so what's really good about that is that you're reinforcing the work that we're doing here because we have invested the money to provide Narcan and now you're handing out a saving lie. So it's great to hear that feedback. We are so fortunate in Vermont that we are investing in that. It's a negligible cost to save people's lives and I have to tell you, I wish I could show you these people, but we get to engage with them over a long period of time. We build relationships. We see what they become, who they become. And I can tell you that it has allowed people, we say where there's life, there's hope. We have seen people as a result of that investment who have gone on to be incredibly valuable members of our community. So we're really grateful for that. Thank you. Thank you so much.