 Turn it over to the executive director. Thank you. Well, welcome, everybody. We have most of our advisory members here. Oh, thank you. I would be talking on mute. This is why Josh was here to remind me of these things. Thank you. OK, welcome, everybody, to today's advisory committee meeting of the Green Mountain Care Board. We were here last in February when it was very much winter out there. It is spring now, and I see there are some buds on the trees, but it's still really cold. So I'm hoping that it'll feel like spring pretty soon. What I thought we would do first before I give you an overview of the agenda and some updates is to go around the room. We have some newer faces. Last time when we met, we talked about everyone introduced themselves and said why they were here and why they wanted to be on the advisory. I'll have you just go around and just introduce yourself and let folks know who you are affiliated with or if you're a private citizen. That's great, too. I know we have a member here that was not here last time. So when we get over to that side of the table, I'll have her talk a little bit about her background and if she can do that for us today. So I am Susan Barrett, as everyone knows. I am the executive director of the Green Mountain Care Board, and I'm delighted to see all of you today. Sarah Kinsler, I'm a director of strategy and operations at the Green Mountain Care Board. Rick Dooley, clinical network director for Health First, the Independent Practice Association. I'm Sam Liss, I'm chairperson of the Statewide Independent Living Council among other titles. I'm big CEO of the hospital. I'm Jason Garverine, I'm an assistant professor in the Department of Nursing at UVM. Andy Miller, pharmacist with Broadable Pharmacy. David Sickle, private citizen, but I recently retired after 30 years at Vermont League of Cities and Towns, working on health and other insurance programs. Margie Rietmone, I'm a social worker at the AIDS Project of Southern Vermont. I'm Jeff McKay, I'm the VP for community and behavioral health at Wellum Regional Medical Center. I'm Sharon Guttwin, a physical therapist and a business owner of the rehab gym. Jim Gullagher, I'm a family physician and VP at the University of Vermont Medical Group. Alison Ebrahimi-Golden, I'm a registered nurse at Kingdom Internal Medicine. I'm Kirsten Murphy from the Vermont Developmental Disabilities Council. I'm not a member, I'm here to support our member. Who will introduce yourself? I'm Terry Olden, I wear a lot of hats. I'm from Memorial County, which is north of Montmainsville. I have a son with developmental disability and he's also insulin-dependent, diabetic. I have a MMS, so I'm on a road that is going to be dependent on medical care and I'm a farmer with a valid farm and someday I'll have time enough to put it back on its feet and get going again. I'm Micah Demers, I work in Quality Improvement at Blue Cross. Mark Nellist, Family Physician, formerly of White River Family Practice. Josh Claven, Primary Care Physician, CMO at Blue Cross. Gail O'Claire, RN, and CEO of Little River Self-Care and Breakfast. Kevin Mullen from the board. Tom Palland from the board. Joseph Hansen from the board. Robin Lange, also from the board. And Eli on the phone, could you just introduce yourself? Sorry? And Walter, wait Eli, hold on a second in the room. Walter Carpenter of Vermont Health Care for All. Citizen Activist and Green Mountain Care Board Health Care Groupie. Kathy Mone, I'm the associate chief medical officer for Bay State Health in Massachusetts, but I live in, what, low Vermont. And my interests are in quality and patient safety and how those, the intersection of those things directly impact the cost of care that we provide our citizens. And Eli on the phone? Yeah, I'm Eli Lester Goldsmith. I'm a small business owner in South Burlington, Vermont. I'm on the advisory committee. And I'm just looking to be a helpful part of the committee. Thanks. Great. Well, welcome all. Today, we have a very busy agenda, so I will be very brief, but I wanted to walk you through our agenda and I have no idea which way to, ah, to get it out. So after I walk you through the agenda, I'll give you a brief update on the work that the board has been doing since February. So today, we are going to have my updates and then we're going to finalize the draft charter. We incorporated some of the changes that you asked from the last meeting. Then we'll hear an update and an overview on the all-payer model and ACO. We have staff from the Green Mountain Care Board who will give you that overview. Then we're going to break out into different groups. We sent you the information on the three different groups and I'm just going to briefly give you a little bit of background on that. I think it was David who brought up the open meeting law last meeting, thank you. Then our lawyers took that and ran with it. Here we are today. So you all, if you want to communicate outside of a public meeting, you cannot be in a group that's larger than seven. That would be considered a quorum. So in order for you to take a discussion offline or online, you need to be within that group of seven. So what we did is we, it's actually, it works out well because it serves twofold. One, it allows us to abide by the open meeting law, which is very important. And two, for today's meeting, what we're going to do is break you out into those groups. We've given some scenarios and some questions around some topics that I can go over in a minute. But we're going to ask you to give the board advice on those issues. And I think that's the primary goal for you guys is to advise the board. So it's actually a nice way to kill two birds with one stone. The three topics that we're looking at are actually the result of a doodle poll that we performed with the group. And they're also aligned really well with the top three priorities that the board has for this year. So they are the all-parent model and accountable care organization, healthcare workforce, and price transparency. Or actually, let me back up, it's transparency in general, including price transparency. So any questions before I move on to the updates? Great. And everyone got the packet of information beforehand. If you need hard copies, they're on the table behind me. So this is a bit of a busy slide and I don't have a pointer. So I'm actually going to go up here and point to you. So what has the board been up to since we met last and some updates? So this is a slide depicting rural hospitals. As many of you know, we've had some recent troubles here in Vermont, specifically around Springfield Hospital. And what the board has done, I believe it was in April, is among other things. We convened a panel to discuss challenges and opportunities for rural hospitals. We had an expert, a national expert, who just did a great presentation. I believe we sent that presentation in the link to you. I know everyone's busy, but if you do have time, take a look at it. It was very dynamic and very informative. Then we also had CEOs from a couple of our hospitals on the panel. And the takeaway from the panel was two things. The national expert said, obviously there are challenges, but what we're doing in Vermont around the all-payer model and moving away from fee-for-service towards population-based payments is the way to go. And that was heartening, but the thing he also said is that it's a really hard time for folks who are trying to do that because you're in the proverbial two canoes or is it the doc in the canoe? I can't remember what it is. And that's really where we are right now. It's a very challenging time. But we've also incorporated into our hospital budget guidance some additional measures related to oversight of hospitals and getting more information on their finances so that we can keep an eye on these hospitals and also find ways to support them. I don't know if board member lunch would like to add anything and put you on the spot, but she was actually integral in putting that panel together. Sure, I'll just chime in briefly. I think what was helpful for me was to really get more of a national perspective because I think it's very easy to be focused on what we're doing here and how's it going and all those sorts of things, but really understanding that the dynamics around payment reform are really national and they're being driven by Medicare. And so that's something that we all have to understand when thinking about moving forward here in Vermont. The other piece I think that's important to notice there is a bill going through the legislature to establish a rural health task force. And I think right now what we're doing is waiting to see kind of how that comes out of the legislature and then that would be the followup to our meeting and kind of the next step in looking at rural hospital issues and what's happening in that area. And it hasn't been signed by the governor but it has passed the chamber. So this is DC, if you can tell. And I'm gonna ask Chair Mullen if he could describe or update the committee on his recent trip to Washington. It really wasn't that recent. Really? Yeah, when you think about it. Time flies. Yeah. But Governor Scott, Secretary Gobay, Ina Bacchus and I traveled to Washington to meet with the new director at the Center for Innovation at the EHHS facility. It was really a fascinating discussion because what you continually hear about is how government is broken. And this was a case where we went to discuss an agreement that was signed under the Schumlitt administration with the Obama administration in Washington. And yet, here we are with the Trump administration and the Scott administration. Everybody's still working towards fulfilling what everyone sees as the future of Madison which is moving away from fee for service. And the good news was we felt home right away when Deputy Director Bowler talked about how we love Vermont and makes frequent ski trips up here. So that was a very good thing. And I think that the governor definitely walked away from there with a much better understanding. And as did our Washington partners. And it's nice to hear when the governor's out making speeches. I know I was in Rutland just two weeks ago for the groundbreaking of the Huebner building which they're calling the Hue. The governor was talking about the move to the Alpera model. So that's a very good thing. So I think that it was refreshing just to see that despite changes and administrations, everybody's still moving forward. Thank you very much for that update. I have a couple of more. The picture in the middle is the picture of a recent report that I believe was also sent to all of you. It is, I don't know how many pages, 180. It's a lot of pages. 600 or something. Oh, it's more than that. Okay, clearly I will say I did not read the whole thing. Executive summaries are wonderful. But this is a document that came out in April and it is a federal evaluation of the state innovation models. So the state innovation models was a program that Vermont participated in, gosh, four or five years ago. It was a $45 million grant that we received from the CMMI which is the Innovation Center of CMS. There are many people in this room who worked on SAM, either worked, like Sarah sitting next to me, I don't mean to embarrass you, Sarah, but she was working on the same team. I know there are others. But then there are many of you who actually worked tirelessly in the stakeholder groups and suffice it to say, and I don't like to read off slides, but I'm just gonna read what they said in this evaluation. They looked at the six round one states. First, Vermont yielded savings of $97 million in Medicaid over the three years in relative to saving in the comparison group. And Vermont had a statistically significant slower increase in total Medicaid expenditures. Vermont showed comparatively lower rates of ED visits and inpatient admissions. And then this is a quote from the report. Overall, Vermont's SIM initiative was a catalyst in terms of advancing alternative payment methods and innovative delivery models focused on paying for value and quality rather than volume. Many especially recognized the importance and influence of the SIM initiative for promoting alignment, coordination and communication across state agencies, delivering payment models, stakeholder communities and other state initiatives. While a solid foundation of health reform initiatives existed in the state, the SIM initiative was a valuable driver of funding major activities that accelerated the models forward. Strong stakeholder engagement and invested providers who were supported through innovation grants and learning collaborators were key to Vermont's success. Although still in its early implementation phase, Vermont's all-payer ACO model, which has developed under and informed by the SIM initiative is expected to continue the momentum of payment and delivery model reform across the state. So it was an excellent evaluation from the federal government. And I want to thank all of you who participated and then the folks also who worked tirelessly on that. The last thing I just want to mention to sum up and Robin talked a little bit about this earlier. We've been at the legislature for the last, since January, so five months, four months. I want to point out to you that this is actually Kevin in the witness chair. I don't know if you can see that on the bar. I am right here, you can see my hair. But we have been working with the legislature throughout the session and fingers crossed, I think they're going home on Saturday. But so there are bills that are still working their course through the legislature, but two bills I wanted to highlight that are pretty much done. Robin alluded to the healthcare task force bill that has not been signed by the governor yet, but the board as well as many other stakeholders will be involved in looking at the rural healthcare in the state of Vermont and then reporting that back to the legislature in January. And then another bill that is quite an accomplishment, I think, and I have a phone a friend here who may have a couple of highlights for you is the primary care spend bill. This is something that the board has been looking at on its own through the all payer model, but the legislature wants some reporting back to it for next year's session. Michelle Degree, I must have called you by your wrong name, Michelle Degree, who is a health policy advisor here at the board will be shepherding the work on this bill. And if you wanna have a high-level overview of the bill, you don't have to get into the weeds, right? Do you wanna sign this? Sure, I'll give it to you. Sorry, it's really bright. I will just, I had my eyes dilated this morning, so I might just put my sunglasses on at some point. So it's in concert with Diva. So it's the Dream on Care Board and the Department of Vermont Health Access. And so it's kind of directing us to report back to the legislature on January 15th of this coming year on a variety of things. Most importantly is sort of developing what we think is an appropriate primary care spend measure. And as Susan alluded to, we already have a few versions of that that the board already uses, but this directs us to kind of work with some more advisory groups and get some feedback on that. And then, so we're gonna look at the proportion that's spent across a variety of sectors and submit that to the legislature and then also determine sort of future implications. So if this, then what might happen? If we were to say all commercial insurers up to X percent, then what might those implications be down the road? So there's a lot of forecasting, but also a lot of current state. And that's what we'll be working on, I'll be working on. That will be Michelle Summer. Over the summer. But I also wanna highlight this too. There may be folks on this committee reach out to as we prepare the report for the legislature. I think there's a few primary care providers in this group. So thank you. Oh, I should, it's also Act 17 now. Oh, right. It has been signed by the governor. So it's Act 17. Thank you. So I am going to turn it over to Melissa Miles, who's a healthcare project director. At the board who came in a little late because she was getting a piece of material for me not because she was late. And then Sarah Kinzler who you met earlier to give you an overview of the all film model. And you know what I just realized? Why don't you guys go and then we'll do the charter afterwards because I didn't see the copy of the charter. So I don't think that makes sense. Sure. All right. Again, I'm Sarah Kinzler for strategy and operations report. Melissa Miles. Health policy project director. Thank you. All right. So just to, before we really dig into the all-care CO model, we want to put that in context. So to do that, I'm going to start with by reading a quote from the board's decision to sign the all-care model agreement in 2016. The rise in cost of healthcare imposes unsustainable financial burdens on Vermonters and their families, imputes equitable access to preventive care and threatens to cripple our state's economy. Left unchecked and uncontrolled, it will prevent Vermont from reaching its goal to ensure that all of its citizens have access to affordable high quality healthcare. So to couple this with data, this slide is really just showing, it's showing data from Vermont's healthcare expenditure analysis, which we've been doing since the mid 1990s to track Vermont's healthcare spending. And in 2017, the most recent year for which data is available, Vermont healthcare spending grew 1.7%. Healthcare is also growing faster than our economy in general. The healthcare share of Vermont's gross state product has risen precipitously over the past 20 years, as has healthcare as a percent of national GDP. So the blue line is Vermont, red line is national. There's actually some visions on that slide, because if you look at the most recent trend, it's the lowest spread between the two lines of recent history, so. Absolutely. And I should say, Kevin has presented similar versions of these slides. Chair Mellon has presented similar versions of these slides over the past few weeks and months. So if anyone's heard Kevin present on the all-pair model recently, you might be getting a little bit of a review. Kevin, you can chime in if you have additions for us. So despite our high-scunding, health outcomes must also improve, even though Vermont's consistently ranked one of the healthiest states in the nation. Chronic disease, suicide, and drug overdose take a huge toll on Vermont and Vermonters. Chronic diseases are the most common cause of death in Vermont. In 2014, the year for which, the most recent year for which data is available, 78% of Vermont deaths were caused by chronic diseases. And Vermont's death rates from suicide and drug overdose are higher than the national average. So to address the issues that Sarah has just laid out, the legislature gave Vermont permission to enter into an agreement with the federal government back in 2015, as long as it met specific terms, which were outlined by under the Golden Dome over there by House Health Care and Senate Health and Welfare. And the act is called Act 113. So the criteria that the legislature wanted in the agreement and can be found in the agreement includes things like predictable population-based payments and alignment of payer programs and population health outcome measures, utilization of local community collaborates. These were all priorities for both the community and the legislature at the time. So the all-pair model was signed in 2016, went into effect in 2017, and our performance period is 2018 to 2022, so we're in performance year one. But basically, the premise of the all-pair model as it's outlined up there is, if we move away from fee-for-service to value-based payments that are tied to quality and also increase investments in primary care, will we be able to accelerate the care delivery transformation and improve health outcomes while also slowing the growth of healthcare costs in Vermont? So that is our logic model that we are touched on that we go back to. So basically, how are we doing this? What is the all-pair model? It was built on the chassis of an accountable care organization, which was a program started by Medicare, Centers for Medicare and Medicaid Innovation, which provided a way for providers to contract with each other to work together to increase quality while decreasing the cost of care. So Medicare has grown their ACO model into something called the Next Generation Program, which over time, Medicare is looking for providers to take on more risk and be more accountable for the total cost of care for their patients. So the all-pair model uses the ACO to, it's given us the flexibility to design our own Next Generation ACO model and with Vermont-specific modifications that reflect our population and our healthcare delivery system. And it's also allowed closer alignment of commercial and Medicaid programs that are risk-based that the ACO has. It's also allowed us to continue funding from the federal government that was otherwise going to go away for community innovations like the blueprint per member per month payments for Medicare patients and also the SASH dollars. So this slide really gives you a high-level overview of Vermont's responsibilities under the all-pair model agreement. In the box on the left, you'll see that the agreement includes cost and quality targets. The cost targets require Vermont to limit spending growth for certain services, both for Medicare patients and then a separate target for all-pair beneficiaries and quotes there, which really includes most Vermonters. With respect to quality, the state is responsible for meeting targets 20 different quality measures, including three statewide population health goals, and we'll talk about that quite a bit more in the next slide. Moving to the box on the right, the state's also responsible for ensuring that ACO programs in Vermont are aligned on some key areas, including attribution, so how we know who is a member of the ACO, the services for which the ACO is held financially accountable, quality measures, and then the payment mechanisms and risk arrangements that are part of the ACO's financial arrangements. Finally, the all-pair model signatories are responsible for steadily increasing the scale of the model, so how many people in Vermont are ACO members, and that is something that will happen as more payers and providers decide to contract with the ACO. Both the scale and alignment pieces are aiming to maximize the benefits of the multi-pair aspects of this model, so by aligning Medicare, Medicaid, and commercial payers, and then ensuring that their programs are similar enough, we give providers some strong common incentives that are moving in one direction. You've been muted. Unmute yourself, Chris. Darn. Sick. The phone is not. You're no longer muted. The phone is, again, interested in this presentation. So multi-pair alignment on things like quality measurement also supports decreased provider burden, which is a significant increase with the Board of the Legislature in Act 113. So now, if there are questions on the quality framework, I'm hoping to pitch them over to Michelle DeGray, who's our quality queen, and getting a lot of shout-outs today, and I'm actually gonna start from the bottom of the pyramid here and work our way up. So as I briefly mentioned before, the all-pair model agreement is tied to these three population health outcome goals that were selected way back as the agreement was being negotiated based on Vermont's state health improvement plan. So these are statewide measures and targets related to the health of the population regardless of whether individuals seek care or not. The population generally includes all Vermonters, and these measures are part of what makes Vermont's all-pair model unique. Around the time that this agreement was being signed, we were not seeing other states sign on to improve chronic disease measures. For example, to reduce the prevalence of diabetes in their state. And here in our all-pair model, those are really not just part of the quality framework, but they provide the structure for the whole quality framework. So as we move kind of up the pyramid, I'll give examples of measures. Well, and I'll focus specifically on reducing deaths related to drug overdose. So healthcare delivery system quality measures and targets are measures and targets evaluating ACO performance and quality of care. And for these measures, the population is the ACO population. Measures can either be across payers or payer-specific. And an example here is initiation of alcohol and other drug dependence treatment. And then for the process milestones at the top of the pyramid, those are measures that ensure that the state and the ACO are striving to improve quality and population health. And an example there would be the rate of adults in Vermont who are accessing medication-assisted treatment for drug abuse. So now Melissa's gonna switch over to talking a little bit about the board's specific responsibilities under the model. You are no longer using it. I'm interested in that question. Okay, so this slide has the Greenmont Care Board's two main goals to reduce the rate of growth in healthcare expenditures and ensure and improve the quality of and access to care. As you'll see under that, there are a variety of regulatory levers that the board is able to use and is working toward integrating to meet these goals and to achieve the goals of the all-pair model. So I'm gonna do a deep dive into the regulatory duties under Act 113 of the ACO certification, ACO budget review, and I'll touch on the ACO program design. But as you also see, we have the hospital budget review, the health insurance rate review, and the certificate of need. In absence of time, I will keep moving on to stay on ACO-specific staff. So the ACO certification in Act 113 of 2016, there were about 10 areas of focus for the board to look at. And so they are all listed on the left-hand side there. So composition of governing body, leadership and management, solvency, the provider network. And so in the beginning of 2018, the board did a very detailed review of this to examine the areas of the ACO. We looked at their governance structure, their population health management and care coordination program, their patient protections, performance evaluation, and so on. It was quite a detailed review. And so within each area, then we looked for additional criteria. And I thought an example might be helpful here. ACOs have a large focus on care coordination and enhancing community provider communication to ensure that patients are getting the right care in the right place. So we looked to see how this is being performed in collaboration with the Blueprint for Health, as was required by Act 113, and the local community collaboratives and community health teams. So this is a vehicle that the legislature has thus far used to add additional certification requirements. And so in 2018, the legislature added the review of mental health programs and childhood adversity and how the ACO is addressing those and wanted us to take an additional look at provider payments. So we reviewed those at the end of 2018. So we had quite a bit of certification review in 2018. And now we're receiving and reviewing on an ongoing basis any updated policies and procedures that OneCare has. And do that through a quarterly monitoring process. So secondly, Act 113 gave us the authority to review the ACO's budget. And this is an annual budget review. And it includes a look at their budget and their planned revenue. We also look at their payer contracts. We look at how they're mitigating risk among the different programs and how their different payer programs with commercial Medicare and Medicaid align according to the requirements of the agreement. We also look at scale and if the ACO is growing and in what lines of business or what areas of the state they're growing in. And so as it says up there, so for the 2019 performance year, the ACO provided the board with an estimated budget of about $850 million with a projection of 196,000 lives. Those are still being settled and they're coming in to present to us in June to give us the final numbers because attribution takes a while to run. But it should also be recognized that a majority of those dollars are passed through from the ACO to the providers and they're turning them into prospective payments for our population health programs and care coordination payments. So the board writes a budget order every year with conditions that the ACO needs to meet and those can be found on our website from 2018 and 2019. I think I do the next one too. I think you do. So this is where we have the flexibility with Medicare to design our own next generation ACO program and simply put it allows us to set the financial target for the ACO for their Medicare attributed lives and also allows us to make any operational changes that would align the Medicare program closely to the state and the state's priorities for Medicaid and commercial. So for example, the board worked last year to set the 2019 quality framework for Medicare in the Medicare program. So I'm gonna give you a quick overview and it doesn't look that quick I guess. I think to staff at least on the reporting that we're required to do under the all panel. So that in signing the agreement, CMMI did not just say and we trust you to improve quality and control costs. We're doing a very significant amount of reporting to help them understand what we're doing and how we're performing over the course of the model. So you'll notice that year two, which we're early in year two right now, it's a big year for our reporting and particularly for the recurring reports and analytics that we're starting to produce. So we've only listed those once but the recurring reports include our quarterly total cost of care reporting which began earlier this year and we'll continue quarterly for the duration of the agreement. So these reports come out about nine months after the quarter during which an individual might receive care. So our first report, including a full year of data won't be produced until September for the 2018 performance here I should say. In addition, we did our first annual payer differential report which measures the percent of ACO benchmarks, or sorry, the percent ACO benchmarks increased by payer and we'll be doing that annually as well. And then we'll also report annually on scale and alignment, so the number of Vermonters participating in the model and how the different payers models are different or similar to one another annually and doing annual quality reporting. In addition to this, Vermont's gonna produce a handful of more one-off reports on particular topics including additional reports on various aspects of the payer differential, a public health system accountability framework which will be led by the Agency of Human Services and a plan to integrate Medicaid and mental health substance use disorder and home community-based services within the all-payer financial targets that are included in the model and again, that will be led by the Agency of Human Services. So we have a lot of work to do on analytics and reporting over the next few years. So this is progress to date. Where are we? As we head into performance year two of the model. So the ACO is one care of Vermont. We have one ACO operating in Vermont and they have contracts with Medicare, Medicaid, Laplace, Lucio, the Vermont QHP program and they have a contract for their self-insured employees at UVMMC. So we have found that these contracts are largely aligned and this intention once again is to reduce burden for providers and just hopefully streamline things. In these risk-based programs. So I will say that we're starting to see and hear that the payment changes are providing some flexibility for providers to develop local transformations in their clinics or in their communities. We had reports from the field presentation board meeting back in February and providers were saying, yeah, I was able to hire more care coordinators or I was able to embed a mental health clinicians in my practice with some of this increased funding and flexibility. So that is a hopeful sign toward progress in my plan. So we have 12 of Vermont's 14 hospitals participating in at least one payer program and we're still, as I said, settling out the final attribution for 2019. These maps just show performance year zero. One care had a contract with Medicaid for a next generation program and they were in four communities in Vermont. So then performance year one was 2018 and that included an addition of Medicare contract and Blue Cross and Blue Shield, Vermont contract and the UVMMC contract. And then performance year two shows where there is at least one, where the community is participating in at least one risk-based program. Medicaid has been the leader for communities to jump into that's what we've seen this far. And then at the bottom are all the different types of participating providers. That's it, great. So I'm looking at the time. It's 2.40 and I just wanna make sure we have enough time to do our breakout groups and we wanna finalize the charter, which should be, but I can open it up to questions either Melissa or Sarah or for the board. Does anyone have questions? That's great. Maybe, I think that's a good sign, I hope. Is there a strategy towards achieving the scale model targets? Oh, that's a good question. Well, I've got a little, a little cheat sheet with who in terms of then self-funded of course is the area we chip away at. Yes, we are working on that. We have a scale report due at the end of June to the federal government. I don't know if the board members wanna add anything else? One of the things I would add is in the ACO budget process, one of the areas that we often explore with them is their strategy for scale. And so that we can kind of get a sense of how they're looking at it, because there's a number of different ways that reasonable people could approach it, of course. You could do a payer approach, you could do a provider approach. Probably wanna do a little mix of both. And as you mentioned for self-insured employers where we have no regulatory levers, that really has to be a private sector approach. So we certainly, that's a question that we've been asking and promoting as well as certainly doing our own internal thinking about. And I don't know if you have anything to add to that? I guess I would just say that there's a small group of us trying to think about strategy in respect to a lot of these folks who may or may not be already in the model on how do we change attribution methodologies, how do we reach some of the self-insured populations. So I think it's an ongoing process and I think we're trying, and we welcome feedback from anybody here who can help us think through what are some of the mechanisms and levers and ways that we can encourage people who wanna be a part of this model. So. What has been successful has been the Medicaid population. It's the other two populations that are a little bit more elusive. That's the commercial and the Medicare. And so we definitely, the good news is it doesn't seem to be any panic from Washington at this point because the take up between performance year one and two is very good. But we're still behind. That's because we started way behind. Yeah, and Medicaid got a year start on the other head start on the other programs. Was there a question? Can you just add a quick question about the number? As you had mentioned the self-insured population, what percentage of Vermonters would that apply to? Oh, a big percentage actually. It's the majority of the commercially insured or consured population. It's about a third of Vermonters, maybe a little bit more. And we don't have authority over them. Sam? How closely aligned is our, the strategy that targets with the Medicaid pathway project and sort of dissipated, but like the mental health and the substance abuse targets and strategies. So how closely aligned is what's rolling out now with that dissolved Medicaid pathway project? I'll start and I think there are folks who can add. As I understand it, that is not dissolved. It just has a new name which escapes me at this point. But I do know that our partners at AHS are working. As Sarah mentioned in 2021, 2020, there needs to be a plan for integration of those other services. So the goal of this program is to have alignment. So I think that they are just, they're starting that plan right now. You'll hear more, I believe in the legislature, they're asking for some reports out at the beginning of next year. So you'll hear more from them, but I don't know. Do you wanna add? What I would add about that is there was a, from the, as one of the people who negotiated the agreement with the federal government, we've made a conscious decision to push, to not include certain services in the financial target because the financial target is meant to be a cost containment device. And we thought that these are the types of services that we may need to invest more money in to improve outcomes and populations. And so if it's an area where investing more money is desirable, you actually don't want it to be under the financial cap. You want the efforts to be aligned programmatically. The federal government, however, they are obviously very far away from people delivering care on the ground in Vermont. And so one of their major tools in their federal programs are these financial targets as a way of basically getting people to play ball on the ground. But it's a pretty blunt instrument to be frank. And I haven't been involved obviously in the AHS work since I moved over to the board. But I think that's something that I'm sure that they're really thinking hard about is how to balance those two interests. And we are, we will be working, the board will be working in consultation with AHS on this. Any other questions? As you think about the, one of the two primary charges reducing the total cost of care for remote areas. Is there a sense that there is any low hanging fruit places to start? I have a turn. The analytics is just now starting to be produced because as Sarah mentioned, it's nine months of claims and so the analytics team is going to be able to start to dig into that and do some decomposition analysis. So I think, I can't speak to anything specifically right now, but I know the ACO is looking at their data and identifying clinical priorities where they do feel like there could be areas of low hanging fruit to reduce the total cost of care. But in general, we are a very low cost date. In general, New England, healthcare is lower cost than in other parts of the country, so. And I think really this model is, it's a dispersed model because it's built off of the blueprint for health. So the decision making on which areas to tackle is really pushed down to the community level. The concept being like people in Montpelier who sit on a regulatory board don't necessarily know the right clinical priority for a particular local area and really putting that decision making in the data and information in the hands of that local group of people will result in better outcomes and just better thinking around the clinical piece. Now there are challenges to that of course because a dispersed model means that you'll have different priorities in different areas. You'll have different talents in different areas. And so you could get some, I think as we've seen in the blueprint, there are some very strong blueprint communities and there's some others that are less strong. So that's kind of the downside of that approach, but I think because we as a stated, proceeded that way with the blueprint, the legislature basically said, we don't wanna undo that. So ACO, you need to go work with the blueprint. You can use your analytics and your data and your tools to pass on, but you need to be able to work through the communities and through the blueprint as well. So I think it's hard for us to answer that question because it is this kind of dispersed model, but we did hear some good stuff at our panel on lessons from the field and some of the examples people were talking about were reducing emergency room utilization and getting people more closely tied into their primary care and looking at ways to support people with mental health needs by embedding either primary care in mental health or primary care. So I think there's a lot of good stuff happening and we certainly heard some of that. Yeah, I was just gonna answer that. I think in some ways the benefit of having it be dispersed is that you can actually, it's like every little community is almost like a little Petri dish and there's some experimentation happening to the extent that we learn from those across communities, which has the best ROI or return for investments as communities are varying those healthcare reform investments, I would say there's a lot to be learned. I think that we're also trying to understand the variation in cost of care across communities and understanding is it the delivery system, is it underlying health of that community, is it, you know, so how do we start to unpack some of that is what we're starting to do in our data analytics team is doing and I know that the ACO is doing as well. So, and to your point about our lessons from the field, I don't know if folks are able to, you can go back in time, any of our board meetings are actually archived on our website and that's fun to listen to if you're really curious to see how this is actually manifesting, how some changes are manifesting themselves throughout Vermont. I mean, I was struck by, you can start to see how the services are changing in hospitals as the payment system is changing. You're starting to see hospitals, here's an example that I often use and think about palliative care. When I was on the board at Porter Hospital five or six years ago, palliative care was a service area that we were, the board was being challenged with thinking about whether it's something we should keep, right? Because it's actually a revenue loser for a hospital. Now, under the all-parent model and fixed payments, it's actually exactly what you want. You want, you know, palliative care keeps, in some sense, care out of the hospital, but it keeps people patients healthier and their quality of care higher at lower cost. And so, now that that hospital is expanding their palliative care. So that was an example of, you know, care delivery system reform changes and as Robin was saying, we're also seeing hospitals change the folks that they're hiring. So more social workers embedded in emergency rooms, more integration across community services, your integration with the hospital and the community care providers. Psych nurse practitioners now embedded in primary care practices. Really fascinating ways and the different ways in which each community is tackling. Some of the challenges in the community using the resources they have at their disposal differently and we can learn a lot from all that. So I think it was a good presentation and folks want to go back and look at it. We'll make sure we send it out to the group. Yeah, interesting. I know we sent the rural panel out to the group, but we'll actually send both of them and shout out to Orca Media, who is the volunteers and tapes our program. So, okay, I am going to transition to the charter. Did everyone receive the April 2019 charter in their email? And if you, I'm seeing some nodding heads, I'm seeing some not nodding heads. You know what we can do is I'm gonna have this sent out to you again and in the interest of time, I think we'll put this to the next meeting because I want to make sure that everyone sees it and is okay with it before we finalize it. We just, what we did is we took some of the comments that we heard from the last meeting and we incorporated it into this new draft. So, does that work for everyone instead of trying to rush through that and see some folks haven't had a chance to look at it so I'd rather do that. And this way we have enough time to do our breakout sessions. So, you all should have received in your packet a chart with the three groups. So we have group A, group B, and group C. Group A is going to have a question about the all-care model and the ACO. Group B has work on questions on healthcare workforce and group C on price transparency. Does anyone need a copy of this or does everyone have their questions? No, I had the question. My question is for group C, that is sort of the title is price transparency, which is a hot topic everyone's interested in. The question is about the amount of care for transparency, which I think is not as robust a conversation or something like this. It's not a hot topic. It's not a hot topic. I guess we're really curious here. So, how wedded are you just really discussing? Could you stop something outside? That's great. We're about wedded on price transparency. Yeah, no, please expand and provide your input. We're very much open to that. That's a great clarifying question. So what I'm going to do is everyone's clear of their groups. So, Sarah's on her way back. She just had to take a bathroom break. Michelle, can I just name that Michelle? Michelle is going to be helping out with group B, the healthcare workforce group. And this room is not great for right now. How are we doing this? I was actually going to, do you think we'd be too loud in the hallway probably? Maybe we'll have one group, Michelle's group over here in this kind of entrance area. So that's group B, healthcare workforce. James O'Lager, Eli, who's on the phone, will be participating. Terry Golden, Jason, Gabriela Nino, Allison, everything, Gold, Trey, who's not here today and Bob Beck. So that's workforce. And then group A, group C is Sarah Kinsler. So, Sarah, why don't you take your group over in that corner? Marguerite Monet, Andrew Miller, Kathy Mahoney, Samless, Sharon Gutland, Rick Dooley, and Walter Campenter. And while you're out, just so you know, there was a question on whether the topic could be if it expanded a bit to talk about high transparency. And then for the all pair model with Melissa Miles, I'm trying to think, I just don't like to be so loud. Why doesn't that group go over there where the chair and Tom are? Did you say we were going to take a quick break? Yeah, yeah, if you want to take a quick break, please do. So we'll meet back, convene back at 3.30. Work that you did today, like this is not the transparency group. This is group, I think it was C. And group A is not always the all pair model group. I want to clarify that because I think it was a little confusing. So we'll have different topics for each meeting. And certainly, please send me a note or folks, let us know if there's something in particular you would like to bring up. As a breakout group, we are all ears. We're very transparent. The second clarification piece related to these groups is I had a consultation with our associate general counsel, Ann Marin, and she just wanted to stress to everybody two things that when you're communicating within your group, you have to understand that you can't, whatever, say you come up with an idea that you want the board to hear, you need to bring the idea here to a full board meeting and have and talk about it here as opposed to emailing the board. Is that, did I get that right? And then the second part of the groups, the subgroups, is that just be aware that any communication that you have is open to being FOIAed or it is open to open meeting law. So if you have any questions regarding that, just let me know. But I wanted to clarify those two points. So can I just ask, so just logistically, so someone in our group of seven has this issue that they're, oh, this is really a burning issue. They, it shouldn't be something that the seven of us are talking about, something that goes to you presumably for the next advisory committee to become a group about. Yeah, sure, if you have a burning, like you're like, can we talk about this? You could send it to me and I could talk with the chair and the board to see if we want to talk about it in another meeting. But if there's something, you know, say you talked about, you had a great idea on transparency, you want to continue that conversation on your own within those seven people. You can do that, or any other topic. Does that make sense? Yeah. Okay, great. So I'm going to give you each six minutes to report out. I just want to make sure we get everybody in for the last time of 20 minutes we have left. So why don't I start with group A the all pair model ACO. Okay. And do you want to meet the question just so folks know? Well, do you want me to just distill it? Yeah, distill it would be great. We're charged with determining the ideal state of health care and who the partnerships and stakeholders should be asking for that. So, and please the rest of the group jump in because I'm quite sure I missed a lot of it. Distilling it down to in terms of the elements of the ideal state would be basically accessible health care for all regardless of without any barriers at all which would include, you know, in addition to transportation and cost, things like social determinants of health, behavioral health issues, mental health issues. So access to care without barriers, patient engagement, community involvement, aligned incentives for all participants, not just the payers or the providers. Infrastructure that supports the health care system and stable funding. So, and then in terms of the second question about who the partnerships and stakeholders should be, we look to the larger community even going as far as state and national but in addition to provide care, which obviously those are stakeholders, municipalities, schools, employers and the patients themselves. And one comment that Dr. Nunlust made was in terms of getting those stakeholders to number one, see themselves as stakeholders and then participate is the fundamental piece to that is to get people to commit to a goal larger than themselves because they're, for short term, if we were always looking at short term return or very narrow line item returns, we're not going to get there. We need to look at the longer view and much bigger picture in terms of looking towards safer communities, savings in terms of special ed and corrections, looking way beyond the health care narrow budget. I left out a lot of details. You have about four minutes left, so you have time? Oh, okay. Just to focus on the people who are the value that's derived by patients from honors is one of the focus and particularly outcomes that are important to them rather than important to the payer and the provider. So that was one kind of theme that I think I heard. I mean, one of the ways, a sort of shorthand way to think about what the health care ought to be like is how many of us feel that we get the care we want and need exactly when to how we want to need it. And that seems like an unattainable goal, but it's not really if you break it down and start to work away at the edges. And that's really what would seem to be a superb health care system. And if we achieve that, I think the total cost of care would go down. And along the lines of access, we also talked about things, not only hours of availability and cost and transportation, but also some people just psychologically can't leave the home or Vermont roads and home visits. Sometimes it might take something like that, keeping in touch with patients in between visits and always having that lifeline and accessibility that way. So we had also talked about the need to have a defined mechanism for transferring dollars into to adjust the social determinants of health and just general community wellness that we talk about this dollar shift from inpatient expensive care, back into the community and the savings that will accrue in other parts of our AHS system, for example. But we haven't really defined any ways to move those dollars from one place where they currently exist, where people have ownership of them back into the community into these other types of investment opportunities. So we need to do more work on that. That speaks to Dr. Nummel's comment about that common goal and bigger than ourselves. And then, I'm sorry. Dave, we also talked a little bit about wellness and the fact that the benefits of that really are far broader than just the health care system. Yet it's the health care system that is associated with my insurance or whatever when a lot of the benefits from the, for example, for an employer are having productive employees being a desirable place to work, retaining employees. Those all have great value to employers, but it's the health system that's doing it, which often isn't very good at recognizing those things or even letting employers know that that's a value in this ad. I think that, I'm not sure about data and predict events. Oh, data and savings and just being a way of getting toward those goals. I'm also going to let folks know that we are taking notes on this and then we'll send this out to all of you. And there might be other interested parties like the ACO who might want to read the notes. And of course, our board is here listening to us, so. Okay. Am I allowed to contribute just an idea? Sure, please. As a consumer, twice over, myself and my classically autistic is one thing that we desperately, desperately need to navigate the maze of healthcare and developmental services. We need a social worker to talk about quality of life, just to help us connect the dots so we don't waste so much time running down the wrong path in the maze, only to find out it wasn't the right thing to do, the right place to end up. And I don't know any other profession that could do that, other than the social worker who connects the family to the community, to the health and keeps the community. Hallelujah, as a social worker, I have to admit I have a huge bias there. And no, I think that there's studies that have proven over and over and over again. If you have case management, you have social workers connecting the people in the community to all the different to the primary care, to specialty care and looking at things like insurance, housing, nutrition and all of those things. You get a much better outcome picture overall for a lot cheaper too, by the way. Did everybody have a chance to take a look at the video link that was sent out? The one on the car? The analogy to getting your car fixed? So those, I thought that was wonderful. And I look at many people, which are about social work, but they're one of those folks that coordinates the care. And so what we need is to make sure all of those folks are represented, right? Exactly, but we really need to see social wear and case management services embedded into the healthcare system across the board. Great, thank you so much. Thank you all for your honorable ACO discussion. So now I'm going to turn it over to the workforce. Oh, yes, all the workforce is up here, okay. Great, so I'm going to echo your comments that group members, please chime in for the pieces that I forget. Our task was to talk about workforce shortages in Vermont. We focused a lot about nursing with the current workforce. We're going to be short about 3,900 nurses in the next few years. That said, and I don't want to forget, we also had some conversation about other professions. Howard Center included that's really struggling with getting the staff to fill their vacancies. So some of the problems we talked about that we think lead or cause the problem of nurse shortage, our reentry program could see some improvement. We only have one reentry program in the state. And when I speak of reentry, I'm referring to professional nurses who leave the field, who leave the profession and then want to rejoin the nursing profession and have to do some things to get their licensure up in place again. And that can be a struggle for nurses in our state. We find that there is not a lot of nursing nurses in the state. We have a lot of our nursing workforce entering retirement and we don't have a young nursing workforce to replace those nurses. We recently had a closure of one of our nursing programs in the state in Southern Vermont. Fortunately, there's efforts to get the current students in place. I know at UVM where I teach, we're taking some of their students to help them finish their final years, but that's certainly a driver of getting some nurses in the Southern part of our state available for employment. We find that not just nurses, but all healthcare professionals who move to the state, their spouses or their partners who maybe aren't in healthcare. And correct me if I'm wrong in what you were saying. This is how I understood it, that their spouses are having trouble finding jobs. So there might be a nurse job or a physician job, but there's not jobs for their spouses in other fields. We had some conversation about paid disparity, a lot of nurses find that they will make more money going out of state. A lot of my nursing students are interested in large metropolitan areas for a variety of reasons, but paid disparity is certainly one that's hard to fix, but is real. I mentioned the topic of mentorship. In my years as a nurse, the patient's census and acuity is just staggeringly going up, so nurses are experiencing burnout. Young nurses are experiencing burnout, and we have to come up with some solutions to help them work through that. We talked about work environment, kind of goes along with that, but physical injuries, mental health concerns of nurses and other healthcare professionals needs to be addressed. Nursing has the advantage of having a traveler system where we can get travelers in place, but many of our travelers don't have buy-in to the facilities and the organizations they work for, so that's one of the main drawbacks that we've talked about with travelers, along with the cost. We mentioned it can be two to three times more expensive to have a traveler than to have a staff nurse. So some of the solutions that we talked about, we talked about increasing educational opportunities for nurses, that could be degree programs, that could also be continuing education. We talked about how the all-payer model might help with that. New facilities in the state, the UVM Medical Center's opening in Miller Building, we think that could have some positive implications towards nursing environment and practice. We also talked about shared governance of nurses, so getting them involved in making key decisions for institutions I think is really important. And I think the final thing I have written here is we talked about the advantages of programs like AHEC that can provide loan reimbursement for healthcare providers to work in rural areas and areas where it's hard to recruit nurses, such as mental health nursing, so yeah. Awesome. Great, so there's two minutes 18 seconds left of your clock questions or comments or thank you for that input. Yeah, it's a bit peripheral, but it isn't, isn't, because not only is there a nursing issue in the state, but I know, I hear all the time, there's a terrible shortage of psychiatrists in the state, and it's not only Vermont, it tends to be in all rural states, but nevertheless, and this is what I teach and I hear all the time, one possible way to alleviate at least some aspects of that and there've been bills in the last two sessions in the legislature is to follow a few states which have already done it, but bestow prescriptive privileges upon psychologists and it's just something to think about to alleviate because in some cases, there are year-long waits for psychiatrists and so this might, is it a perfect solution? No, but it does give prescriptive privileges to only doctoral level psychologists with considerable advanced training in psychopharmacology. So that might be something to consider to alleviate which is a very real issue. Thank you for that and I know Brattleboro Retreat has had success with telemedicine and recruiting psychiatrists who live in Brooklyn and work at Brattleboro, so that's pretty cool stuff. I think in my area, I know one of the concerns for the nurses is a lack of support staff, like LNAs, because the pay is so low and we're on the border, I mean it can mean a difference of four or $5 an hour. So they just go to Greenfield or wherever and they work there and so the stress that that puts on the nursing staff is extreme and so you lose nurses. So we're in a big hole with that. Absolutely, it's been my experience with them. Thank you, thank you for that great feedback and so, yes. Sir, I was gonna add that the other group is primary care providers in terms of trying to get workforce issues, trying to get people to go into primary care, which is routinely under-reimbursed and with high workload. But hopefully with the primary care study, that shows how much money goes on the primary care if it's actually a target that makes sense after that, that will hopefully improve reimbursement and improve, hopefully, recruitment. Great, thank you. Okay, so last but not least, we have our Group C and they are given the topic of transparency, but I think you may have expanded it a bit, so go ahead. We originally decided we spent the first couple of minutes saying how much we didn't need to talk about transparency of the Green Mountain Care Board, but then actually we did talk a lot about it and we did expand a little bit from that to messaging and then we did very briefly in the end touch on price transparency. And I think the latter topic is gonna need a lot more conversation, but I can sum up what we did. We spent a while talking about perception of the Green Mountain Care Board, both from the outward-facing image to physicians, other provider groups, hospitals, and most importantly to the Vermont public really, was we talked about how there is a disconnect between what we think the Board wants to be doing and what maybe it's messaging and what the average person, and we struggled a couple of times to describe what's the average person. I think a better term is probably the citizens of Vermont. And so what is the image that the Board projects and how is that projected? There was pretty strong agreement that as far as transparency is concerned, most of us felt that the website was actually excellent and I liked your comment about the boards, every board is always told they need to be more transparent. And so maybe the reason that that perception exists is because maybe folks aren't accessing the website, maybe that's not the medium that they use to be educated, oh, I'm looking for you, yes. Maybe that's not the medium they use, maybe they're used to something else and in-person visit or television or maybe a website and reading documents isn't the way that they would learn. We also talked about what's the message of the Green Mountain Care Board, is it cost, is it quality, is it improvement, is it safety, is it, you know, what is it, is it targeting, is it clear, is the message clear? And we had a lot of input on that conversation. We didn't really come up with a strong answer except we all realized that most of us really want to see as you articulated care to ourselves and to our families and that really is what would resonate with most folks rather than targeting cost. Although we are all in this room because we understand that cost is important as well but how do we message that this is about improvement of life for all Vermonters as opposed to a cost initiative? We talked about the appearance of the Green Mountain Care Board as being a big government and maybe it doesn't trickle down to the folks at the front line of healthcare and patients and their families. We talked about the historical development of the Green Mountain Care Board and how there's been some angst over it does the board actually represent the populations that are stakeholders in the conversations and is what is said at the meetings or expressed in various forums. Does that actually get to the board and then get acted upon? We talked about that for quite a while actually. We realized that this group is a stepping stone to closing some of those gaps, particularly around the lack of healthcare participants and patients and families informing the conversation. We talked also about social services, preventive therapy and pharmacy and behavioral health as participants in that. We talked a little bit about cost and what does that mean? Does cost create better, when you look at cost, does that negatively or positively impact care? I think that it's tough to message that accurately and we struggled with that as well. Reducing cost, we know we need to because it's not sustainable and ultimately high cost will negatively impact access to care. We talked about that and so we have to be careful about how it's message that if the board is about reducing cost, most of us if we put our individual hat on would wonder how is that going to impact my own personal care or the care of a sick loved one or you mentioned someone, your family member with autism of yourself. So there's a complexity of healthcare that is difficult to weave through. We talked about some of the advocacy groups. I thought you made great points about certain populations. You mentioned HIV when it comes to transparency. How transparent do we really want to be and are there confidentiality concerns when we're transparent about sensitive topics? One of the things that's the goals is to reduce suicide and substance abuse issues and how I thought of those populations as you were talking about HIV, how do we manage that? How transparent should we be and where's the line between confidentiality and transparency? The other thing that we talked about was the board's role as far as does the board perceive it has less power than it needs? Does the public and do the healthcare members perceive that they have the right power, not enough too much that we talked about every different iteration of that conversation? Lastly, we talked a little bit about price transparency and we didn't get very far in the conversation because we only spent about two minutes doing that, honestly, but I think the general thing that I can sum that up was that there is some need for consumers, whether that's prescribers or users of healthcare to understand what the costs or prices are, of what they might pay, but how to operationalize that is very difficult. There are some legal barriers. Sharing of price information is not encouraged. In fact, it's prohibited in certain contracts and maybe there'll need to be some legislative ways around that. Did I miss anything? You got it, yeah. No, I think you did a great job. The one thing in talking about getting the general public interested and involved was language. I think we all forget when we're in our little professional worlds how specialized our language often is and that we're already at a level where we've been working in our particular field for many years and have a much greater understanding than the people that we're trying to talk to and transmit information to and that we really need to take language and how we use it very seriously in our communications with the public. That's a good reminder. There's a lot of acronyms we use. Thank you. Well, that was wonderful. Thank you very much. I'm looking at the time. So I have one, we should open it up to public comment. I don't know if there's any members from the public who would like to comment. I don't, I see a couple, okay. We will send these notes to you. I also realized we wanna share the emails of the groups with you. So you just expect those so that you can have a follow up conversation within your group. And our next meeting of the general advisory group is September 9th. So that is already, should be already on your calendars and it's on our website as well. We will be here in this room again. And please follow up if you have any questions, comments, thoughts, please direct them right to me. And I believe we can adjourn, Mr. Chair, if you are ready. All in favor? Hi. Hi. Thank you all. Thank you all. Thanks.