 Good morning and welcome to the Green Mountain Care Board. My name is Kevin Mullin, chair of the board and we are going to start this morning meeting which will be recessed to an afternoon meeting as well. So the first item on the agenda are the minutes of Wednesday, November 25th. Do I have a motion? Some moved. Second. It's been moved and seconded to approve the minutes of Wednesday, November 25th without any additions deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show the motion carried unanimously. The next item on this morning's agenda is the executive director's report. Susan Barrett. Good morning everyone. Happy Wednesday. I just have a couple of comments. A reminder that our ACO FY21 one care budget period that public comment period is open until December 21st. But as a reminder that we're asking that public comments be submitted by December 2nd 2020 which is today to be considered for the December 9th presentation. We will be accepting public comments up until the 21st. In fact we accept public comments 365 days a year but wanted to make sure that if folks wanted to have those considered within this presentation for December 9th to get those in to our public comment portal. And all of the public comments posted to date are or received to date are posted on our website. And then I also just wanted to mention that yesterday we had our first meeting of the Green Mountain Care Board Prescription Technical Advisory Group. I want to thank Christina McLaughlin who is leading the effort from our team as well as Board Member Lunge for her expertise in that group. And we met yesterday for a couple of hours. It was a really informative discussion. I'm hopeful that this this group of experts in pharmaceuticals can help the board and the state address the high cost of prescription drugs. And I don't have anything else to report. Chair Mullin I'll just send it back to you. Thank you Susan. So the next item on the agenda is a further discussion on the hospital budget lessons learned and I'm going to turn it over to Patrick Aruni. Thank you Mr. Chair. Good morning board members hospital budget stakeholders and members of the public to build on what Kevin had said. We are here to discuss the continuance of the hospital budget debrief and let me know when you can see my screen. We can. Okay and I apologize for the barking dogs. Those are mine that may go on for a couple of minutes just to warn you. So we're here to continue this work about a month after our initial meeting in which the stakeholders that being the board the Green Mountain Hair Board staff the HCA and VOS got together in a public meeting to discuss the hospital budget processes opportunities and challenges etc. And then following that we were asked by the board to kind of digest all that was downloaded from those various parties. So we got five board members the staff the HCA and VOS representing 14 community hospitals. It's a lot of perspectives. There was a lot put forth that day so we spent a couple of weeks building this into a structure that we hope can serve the board to make some decisions on how best to move forward. So what we are looking at here is a structure that from this we hope that the board will provide the staff with some guidance on where you want us to begin to spend our energies and our our resources to improve this process. And that's the approach that we were going for. And what we arrived at was this list here and we'll go through this as we move through. So what we did was we we bucketed what we heard from everyone into some common themes. We figured the best approach here because we're all stakeholders in this process is to try to find some shared interests common ground etc. So we bucketed pretty broadly some common themes. We then took those and moved them into short term and long term considerations as in what can the board act on now and what might take some time third party involvement research etc. to achieve to return a value to this process. So we've got some items in here that we've tagged in certain areas where things like for example the hospital budget guidance if we want to shorten that. That's something the board can pretty much take unilateral action on whenever they so choose. And then there's other items as we'll go through what that could take some time to get at. We then decided that we'd try to peg these items on an implementation analysis. What's of importance. What really isn't. What is easy to implement. What really isn't. And so on. And we wrap up with some other comments of items that weren't explicitly stated as a common theme across parties but that we felt should be should be built into the process acknowledged or even continued throughout. So saying that I'll move into some of the common themes. And the three common three themes on the screen on slide three here are discussions around change and charge. We heard several parties discuss the potential to to arrive at some opportunities there or acknowledge challenges. What's the best measurement of growth currently. It's MPR. Are there alternatives that we want to explore. And then transparency in the decision making process. So those are kind of the big three and moving through that there were more detailed matters that were brought up that kind of build into the change in charge discussion. And on slide four here we've kind of we bucketed what we thought were some of those items. So more specific guidance around the components of change in charge. For example does the board want to acknowledge the inflationary factor and have the hospitals show that explicitly when discussing their charge if you ask for 4 percent. How much of that is is inflation is built into that. Does the board want to allow an allotment for cost shift. Does the board want to allow an allotment for a margin. Like what what do we want to go into that. And how explicit do we want to get. That's something that the staff felt we could probably get at sooner rather than later should the board want to move forward with it. The next one up that we had was the COVID component. Originally there were some temporary nature to that. It was then made permanent upon reconsideration. So what is it we need to do with that. And I believe the HCA had brought up concerns about that becoming permanent. So how do we want to get at that. That's something we will have to address in the short term going into the next guidance process or budget process in general. So therefore what do we how do we want to approach that that piece that we built in this year to deal with the COVID pandemic. Standardizing the measurement the measurement of change in charge. We came across an issue this year where there's been kind of an adoption of effective commercial rate for the UVM health network hospitals. And yet we've been doing change in overall charges for the the other hospitals. And we've found that we've been intermingling some of those stats really do have to arrive at one measurement for change in charge in general. And we've got to stick to that. The next one was capturing the impact of Medicare and Medicaid payment policies and changes. Someone had brought up well maybe we do this retroactively looking back at what like say Medicare had given for an increase and having that backed out. That could be a component of the change in charge. You back out payer increases from the prior year to mitigate some of that growth just an idea those are some of the things that we could probably get at sooner rather than later. And the price transparency matter. This one's probably long term. We'll get to that but that was another one that could impact how the board looks at change in charge amongst some of its other regulatory responsibilities. The next measurement of growth with some detail to it would be or the next sorry common theme would be the best measurement of growth. There was some ideas thrown out there about using the total cost of care per member per month in conjunction with NPR. The staff had thrown out using growth and operating expenses in conjunction with NPR as those expenses are what need to be covered by NPR and therefore the growth etc. And also we do need to work on improving comparison to other hospitals because that will help the board members see compared to their peers both in state regionally or nationally what type of growth are we looking at what is acceptable. So building that out improving that and investing in some of those were another item that was brought up. And the last of the common themes with the details would be grouping the hospitals around decision making grouping the hospitals into critical access perspective payment academic understanding the cost structures of those hospitals based on their designations there is certainly some pretty distinct differences there in regard to those designations and to better understand some of that stuff and how it impacts those hospitals perhaps could help guide the board better in their decision making and understanding how fixed some of those hospitals are in regard to their expense structure. And any way that we can try to get a better handle on that perhaps that would allow the board to pinpoint the dollars that they allocate through commercial change in charge in a way that's more valuable to the system and specifically hospitals in those designations. Reducing the administrative burden by streamlining the guidance requirements and delineating need versus want. I think that came from VOS at our last meeting and that is an important point. We don't want to dilute our process by adding and adding and adding and adding things to it. So is there a way we can reduce the burden both for the Green Mountain Care Board staff and the hospitals. We did a streamlined guidance this year. The hospitals exhibited appreciation for that. We felt as staff though that some board members needed some a little bit more. So we thought we had a pretty good pre-COVID guidance going into March of last year we then scaled that back so perhaps within those those confines there is the hyperscale back version and then the pre-COVID version is there a happy point in between that we can arrive at that reduces the burden but also gives the board members what they need to make a decision on MPR growth and change in charge growth. And then there was the topic of the non-financial reporting that was brought up that is usually built into the overall budget process and the deliverable is around mid-May. It was thrown out there that maybe this is not the right place for it. It seems it has kind of organically grown into that process. Is there a better spot where that can fit into the board's regulatory oversight that may not be hospital budgets. All things to be discussed and finally clarity into why the why behind the board's decision on hospitals and ease of understanding for subject matter experts as well as the public. We deal with some very complex matters in health care and in this process there's probably a limit to how dialed back it can get but there's always room for improvement and there's always room for us to explore how we can improve. So those are the three common themes and those are the three common themes with some of the feedback shared by the stakeholders that were put under those buckets. Now we'll move into each one of those for both a short term and long term consideration. So I won't repeat everything I've just gone over but you can see up on the screen here on slide 7 that under the short term considerations for the change in charge bucket more specific guidance around the components that's something we feel we can get at pretty quickly and the board can impact directly the COVID component and standardizing the met the measurement of change in charge whether gross or commercial effective rate or whatever and then capturing those Medicare and Medicaid payment policies. That seems like something that's within the grasp of the Green Mountain Care Board and board members and staff directly. There wouldn't have to be too much outside involvement there to get that done besides maybe some some back and forth with some of the hospitals to make sure that we are capturing exactly what we want to capture. Change in charge long term. The price transparency discussion it's due to come around on or take effect I should say on January 1st of 2021 that is less than a month away. We feel this is long term because this is going to be something that has never been done in health care before. There's going to be a lot of ripple effects following this a lot of uncertainty following this. There's also the impact of there's a new administration taking office on the 20th of January. You may see things differently. So to buy at our time follow some of the the news coming out as this thing perhaps drops on January 1st and kind of studying it as it goes along. And then maybe a year from now or so if it seems like it's going to stay then we can begin to dig into that because price transparency could impact not just this process but also your regulatory oversight on insurance rates. So there would be a couple of teams on the Green Mountain Care Board side that would have to be looking into it and even maybe some outside parties. But we feel that that is a long term item that warrants some diligence but also let's see what happens as far as the impact on the industry as a whole. Short term best measurement of growth improving hospital benchmarks that's something we can begin to put research into now. We are statutory obligated to have some quality by quality I mean good financial benchmarks for peers and then exploring the use of total cost of care per member per month and exploring the growth of operating expenses in conjunction with NPR as options for bolstering that measurement of growth that we currently have as only NPR. It would probably take some time for us to work that through. So the long term considerations have that built in as well using total cost of care as opposed to short term exploration and using growth of operating expenses as opposed to exploring that item at first. So that kind of crosses both of those long term and short term considerations from our perspectives. The transparency and decision making short term we feel that we could group the hospitals into these prospective buckets based on designations and begin to work with those hospitals to understand what are the constraints you're under because of those designations and how much of your cost is fixed and where do you have the ability to make sure you're as efficient and efficient as possible and where do you do not. That's a very real thing in health care is efficiency is a very tricky thing to put your thumb on but we want to make sure if we're saying now you look like your cost structure is drawing a little too much that we actually have something to to back that up with and reducing the administrative burden by streamlining guidance. That's a pretty quick thing to do. We did it very quickly this past year and turning that around. We have a precedent for it now. We also have a work product that we can say okay if that was really dialed back let's build a little bit more into it by getting feedback on the board from the board members of what you absolutely need to see in this to make your decision and going from there and that's something we could turn around pretty quickly. Long term considerations on transparency. The clarity into why behind the board's budget decisions. Really everything we've talked about above should trickle down into this if the board decides to take action on some or all of those. It should help improve the why behind that. That's the idea. So this is long term because depending on what the board decides to adopt when and how it should help better inform as we make those adjustments to the process. So this isn't so much a work product as it is a culmination of the other work products that we would take under our wings in the coming months or years or however long it takes us to make some of these alterations. So as discussed earlier we then took all of that and we tried to peg it on a scale of importance and difficulty. What do we feel is higher importance and lower difficulty all the way all the way around the wheel to lower importance and lower difficulty. So trying to provide the board members with some insight around what do we think we can tackle now. And we'd like feedback from the board on whether or not you agree with some of this stuff or whether or not some of this may have to be moved. But trying to provide some sort of roadmap for making some of these adjustments should the board choose to adopt them because as the arbiters of what does and what does not occur in the guidance in the hospital budget process we really do need board feedback on where to spend our resources. And we'd also advise that maybe the board could also not we could have board members nominate themselves or other board members to help work on some of these products and be that proxy for their fellow board members as kind of the subject matter experts as we work through this and also be engaged in helping make these changes and potential opportunities come to fruition. Lastly as I discussed there are some other comments that were made that we feel are very important to this process. It may take some time to get some of these done. Others may happen. There wasn't explicitly a common ground amongst this. That doesn't mean it doesn't exist. But one of those was reconciling the hospital rates the rate review process. There's a lot that goes that would go in behind that. I think to some extent it's been explored before from what I understand but there's been some legal hurdles and that may change in the future. But it's something we feel we should keep on the front of our mind moving forward especially if price transparency does stick. Another one I think was brought by the HCA was addressing racial disparity in the process. This is certainly something that's probably long overdue to be honest and even though we're not the most diverse state it still warrants understanding what our health care organizations are doing to make sure that health care is being delivered in a way that promotes equality and that all persons regardless of any identifiers are are certainly being cared for in the way that any of us would hope to be cared for. So we think that certainly warrants continuation through this process. And then kind of a broader thing was we we all get dialed into our our perspectives here and our certain trenches sometimes. But I think it was Kevin to take a step back and look at the bigger picture here. And we're all working in this thing to make sure that from honors have access to high quality health care at the most affordable rate possible. So kind of keeping that in mind as we go through this and we you know we all share our different perspectives and everything that the that's the big picture here. We're all you know all these stakeholders are care about that right there on either side any side of this equation. So that we felt was something that deserves some reinforcing as we even work through this process. So that's why we put that in there. And with that that concludes our presentation. It's quick. It's pretty high level. But we hope we captured the thoughts of all the different parties involved and help provide the board with a little bit of guidance here for the discussion that's in front of us now. So Mr. Chair we'll turn it over to you. Thanks Patrick. I'll kick it off on behalf of the board and just say that for me there are two things that really jump out to the front of the list on what I think we should be focusing our initial time and resources on and that is having a common measurement for charges. And it should be across all hospitals. And so that's number one in my view. And number two is to expand the guidance so that we give specific guidance on for example change in charges. And I say that because what we've seen is a repeated effort by a number of the regulated entities to back into that based on putting together a budget and then figuring out what increase is needed to meet that budget. And I think more emphasis is placed on backing into that number than being placed on what is affordable for Vermonters and how do we adjust expenses to make it affordable for Vermonters. And so I really think those are my two highest priorities and with that I'll open it up to any board members for their thoughts. Who would like to go first. Well I have a couple that rise rise to mind readily. You know Patrick said that maybe in the budget process we should make an allowance for the cost shift. And I that's not something I would agree to. It would be that would be like enabling the cost shift. And to me the cost shift is a structural problem valued at hundreds of millions of dollars. And it's possibly a kind of a parasite on health care reform. Assuming that our health care reform efforts are successful and we are finding efficiencies and proving population health etc through the back door the cost shift kind of siphons money out of the system and sends it elsewhere in government. And so you know for me it would be a better course to admit that the cost shift is not a good thing. It is not a good thing for a certain population not to pay not some cost shift is fine. But it just keeps growing and growing and growing. And so and there are places that we could intervene or maybe BOS could intervene and one suggested I would have would be at the emergency board every year at the beginning of the legislative session the emergency board which is comprised of the governor and the heads of House Appropriations and Senate Appropriations and House Ways and Means and Senate Finance they go into a very detailed presentation with the JFO on the Medicaid budget. And I think you know if we could find some kind of access into that system to say you know let's be specific and clear and straightforward about the cost shift so that we know how that is affecting you know the systems that that we deal with as we learned in rate review from the Blue Cross Blue Shield actuary if there was no cost shift insurance premiums could be lowered by 35 percent. So that's that's one area I would want to make more transparent and to be more aggressive on because it is such a large force in our hospital budget system as we saw during the hearings every single hospital complains about the cost shift but the can keeps get getting kicked down the road. We keep whistling past past the graveyard in that regard. And I think that at some point we've got to raise it to a high priority. The other area for me is fixed prospective payments. If you look at the 2019 hospital budget actual fixed prospective payments as revenue it was about 10.2 percent of total NPR FFP. For the 2020 budget which is kind of by the board is given given the COVID problem it was at 14.5 percent and for 2021 budget it came in at 13.9 percent. And I'm not sure how those percentages equate to the leveraging of the reforms that we want to occur is a 13.9 percent FPP across hospitals. A metric that is going to leverage the capitation that we're looking for that will generate innovation and efficiencies and allow us to reinvest in population health. So that's one metric that I would look to see whether or not not just to kind of follow the number but to work to establish a target that we know that we're working for. Maybe that target is 30 percent maybe it's 45 percent. I don't know but I think that we need to spend some time to figure out what the target needs to be for FPP across hospitals such that we can leverage. It has the the capitation and leveraging effect of getting our health care reform efforts where we'd like them to be in the next two or three years. So those are two that jump out at me. Other board members. I'll go. Patrick and team first of all thank you for for that presentation and pulling together all these thoughts and all these conversations that we've had. I feel like some of these components of the presentation were also part of conversations we've had even last year. So you've really pulled in a lot. And I agree with all of the short term initiatives that you've put forth to improve our decision-making process and provide us with better data to be able to be better informed as we're making those decisions. I agree with Kevin in the sense that we really need to standardize the effective commercial rate so that really we're looking at apples to apples across hospitals. And that's really a top priority for me. And also the second component and really understanding the changes in those effective commercial rates. So your point about inflation is important. I want to really be able to unpack what is underneath that commercial rate change. So is it inflation driving it. Is it is it cost shift. I guess I'm going to guess it's both and margins. Right. So how do we start to unpack what's under the hood there and understand what is driving those commercial rate increases. What are the components. I think that's really important. If we are going to put guardrails around commercial rate or effective commercial rate was what I hope that we're really looking at as an effective commercial rate versus just changes in the charge master which we know are not really a true you know showing the true impact of those commercial rate changes. We really want to look at effective commercial rate. How is that changing at the hospital level. I think we need an understanding of the base price. And so where hospitals are now in their pricing and so then we can really understand what are we building on top of that. So one of my questions to you Patrick was the price transparency. You had bucketed that in low importance high difficulty and I'm just wondering I I would have thought it would be high importance lower difficulty given that the hospitals are going to be required to report their prices in January. So the data is is is going to be available. It's just a question of unpacking that data and analyzing that data but we've never had access to that data before. So that's where to me it moves from you know high difficulty to low difficulty simply because of the reporting requirements. So maybe I'll finish up and then maybe you can just answer that question if you have an answer for that. The benchmarks I think are really important. I think we need to factor in when we're looking at each hospital factoring in the size and the type of the hospital and comparing our hospitals and how they're performing outside the state. Right. It's similarly sized and similarly designated hospitals. I think it's really important and like the idea of looking at per member per month growth rates per member per month total cost of care growth rates is a measure of hospital performance. It factors in migrations factors in the patient flows that we're seeing across HSA boundaries and it fundamentally is looking at the total cost of care which is what we are held accountable for with the federal government. So it's it's another look at that really important component. But it also does it's important because it's per capita. So it is recognizing that some hospital service areas are seeing out migration and some are seeing in migration. So as soon as you make it per capita you're accounting for that which I think is really important. And again we're reducing the burden wherever we can I think is is key ensuring that we have the data that we need. But where we can pull in data that's already being reported in other venues and using that data I think would be really helpful. So those are some of my thoughts. I thank you for the presentation. I thank you for thinking about this and I'm excited about moving forward and improving our hospital budget process. But again I would question I want to ask you a little bit about that price transparency difficulty and importance piece. Yeah so the reason that we put it down there was there's still even though it is set for January 1st at least on our end because we've never seen it before we don't know what we're looking at. And it's going to take a lot of time to digest and understand what we're looking at and develop a strategy as to how we're going to use that. And we did not see that dropping on January 1st and being a reality for the upcoming budget cycle. And there's also the fact that because it hasn't been viewed before there's going to be a lot of upheaval that goes into the wake of that coming out. And to to make sure we're knowledgeable and understanding of what we're looking at to incorporate it into your decision making and make a well informed decision it's on the lower importance higher difficulty piece because of that. It doesn't seem like something that we would be able to achieve with confidence and competence going into the next hospital budget cycle. So that's why it's on the higher difficulty lower importance scale right now. That could change several months from now once we understand what we're looking at and and what this means and what it could mean for other hospitals in our region as well. I mean we're certainly going to want to compare UVM with probably Albany and Dartmouth and things like that. So once we see what they're charging we're going to have to dig into that and develop a strategy. Do we want to focus on all of these different charges that they're putting out there or are there are is there a markup that we're looking at like a grouping that we'd want to look at and say OK well this is where they make their biggest markup. How much do we want to really allow for them. So there's a lot out there that we've never seen and don't know yet. So that's why it's down where it is right now. Doesn't mean it's not of importance but it's it's just down on that scale from the staff's perspective. Okay let me ask a quick question that I realized about the non-financial reporting. You had mentioned moving that around some thinking differently about the non-financial reporting. Can you just elaborate a little bit about what you mean by is there a better time. Is there a better way to do it. What were you thinking there. I really don't have any thoughts. I've never heard anyone on the hospital side say that is a burden. It was brought up by one of the board members in our last meeting. So that seemed to fit into that more detailed bucket of is there any way we can through the budget process eliminate some of the administration straight of burden on them developing and reporting a budget to us. So I'm not sure from what I understand as I said it's kind of it kind of ended up there and so it probably warrants us looking at well is that the right place for it. Does does it really inform the budget process around rate and NPR. If it doesn't perhaps there's a different time during the year which we can request that. But again I've never heard any of the hospitals mention that that's a that's an issue for them. Okay. Thank you. Certainly. Thanks Jess. Robin. Thank you. I agree with what folks have said around spending some time improving the change in charge data information and guidance. I do think that that's an area where we can add transparency to both the process and our decision making. And and obvious. So Robin we may be having a problem receiving your signal. Perhaps you could turn off your video and then we might be able to hear you on audio. Can you hear me now. We can. Thank you. Okay. Sorry about that. I'm having all sorts of technical difficulties. My laptop died so I'm trying to do this on the phone. So sorry about that. So what I was saying was that I agree with what folks have been talking about in terms of change in charge and the importance of that part of the process and improving the data and information that we have available given that it is a lever connected to rate review and affordability. And I I think that it makes sense to continue to look at areas in the process where data and information that we're perhaps not using. For me the non-financial reporting is important. It is I don't know how to look at the financial aspects without some concept of the totality of what the hospital is doing including around quality. And so that is something which I routinely have used and missed this past year. We did move that reporting to the spring and I think a lot of it quite frankly is compiled by our staff which is why it may not be perceived as a burden. So all for looking at that but do think we need to in some way continue to try to incorporate quality as well as access measures which I think are sort of the point of those. Yeah and I think otherwise the short-term initiatives did make sense to me as a place to start. I would just make note of a couple things in terms of the total cost of care per member per month. That's something which Sarah Lindberg has looked at a couple of different times I think and there are challenges with doing that which we have been exploring in the regulatory integration. So I would encourage our staff to connect with each other on that piece and also specifically on the rate review and hospital budget component there is a section of that in the regulatory integration paper that I would encourage people to read. So that's that's what I have to say. Thank you Robin. Next we'll move to Maureen. Thanks and thanks for the presentation. I had I want to go on the same line as Jess was going on on the price transparency and you know looking at that chart I also thought that should be higher importance even now I mean we may not have the requirements that they have to file by January but the hospitals themselves know what their prices are. We just haven't always had the transparency of getting the information on prices for services. So I do think that's important and where that kind of piggybacks on is to the change in charge because one of the things we we know is that all the hospitals aren't starting at the same starting place and you know we when we treat everyone the same and say we're going to have a uniform change in charge that that's where I have a little bit of a hesitation. I do think we should give guidance on change in charge. The concern is that those that may be already at higher cost are going to continue to grow at that higher cost and those that have been lower cost and more efficient you know may have more challenges living within those means. So there's just an issue there on you know how do we work that and part of it is we don't really know the starting place and we try to treat everyone all the same which which is the challenge all the 14 hospitals are not the same. So if we were to come out with a change in charge you know as a uniform one rate that might be a challenge but but there may be ways we can come up with some guidance there. You know a couple of the couple of other things that maybe are more in for the long term which we didn't really talk about would be the sustainability plan and how that impacts the hospital budget process and in particular when we talk about talk about services because hospitals may be making a small margin or no margin and part of that may be related to the mix of services that are being provided and are they the right mix of services and all the hospitals. And that brings me to another thing on the chart you had where where you had positioned the ability for I think can you flip to that chart because there are a few things on that chart I think that was good good way to look at it. But when we talk about higher importance lower difficulty understanding the cost structures of the hospitals a challenge that that's lower difficulty and and the reason why is when we look at it on a on a total perspective yes we can understand kind of you know what the cost structures are of the hospitals but really being able to dig in and understand if we were to look at where they make margin where they don't make margin by payer type by services and things like that I mean that's the way you would look at a business right to determine maybe where some changes could be made obviously we can't just look at hospitals and say OK this is a business like that and we cut those things out but but there may be some learnings from that to be able to make hospitals have the ability to be more efficient. So I think that you know it's at what level of understanding cost structures of hospitals so I think that's higher importance higher difficulty because because from what I've seen we we don't really have an understanding of the cost structure of hospitals and when we try to dig into it we don't get clear answers about that you know when we talk about you know cost savings and things like how do we gain efficiencies and cost savings you know that that's really one of the key drivers here to ultimately what the top line will be needs to be in order to create a margin. So so I think we need to do I would move that to a different spot and you know I think the other thing which we didn't completely touch on Tom talked about a little bit and fixed perspective payment but you know just ACO participation and as we move more into that and that becomes a larger piece of the pie how does that then relate to change in charge and things like that. So you know I think I think this has been helpful and it'll be interesting to hear you know some of the public comments you know that we get at this point. Thanks. Okay anything else from the board. Any questions from staff to the board before I open it up to public comment. No not on my end and I'll open that up to Kate and Laurie if they have anything. Hearing none we're good. I'll open it up to public comment now. Does any member of the public wish to comment. Hi Kevin this is Mark Stanislaus from the University of for my Health Network. Hey Mark go ahead. So you know just a couple things. I had shared this with Patrick but you know the University of Vermont Health Network has been fairly silent through the last few discussions and I just wanted to share that we're focusing our priority in other areas right now you know given what we're dealing with. So I just wanted to share that out there and then I was taking some notes as I was listening to the conversation. I think these are more items just to be aware of well from my perspective that I just wanted to share. I mean Patrick's summary was a very good summary. I should say Patrick and the staff summary was a very good summary but and so I will just punch down through this list. It's in no particular order. I was kind of making notes as they came to me but I think I think when we focus on growth rates we really need to focus on industry standards and comparisons. They need to be fair and they need to be specific to our industry you know. I think in the past what we've heard we know we should try to keep it health care growth will be low GDP you know that's not a comparable industry standard because you show me how many other states have been able to do that. So I think we need to be very clear on you know what we would like to get closer to and what's are reasonable expectations and you know the focus needs to be on industry standards and fair compare groups. I think as we think about the cost shift the cost shift is real. It is impacting the hospitals considerably and the burden is growing more and more where it has a material impact on the hospital's financial results each year. So you know we can talk about the individual components of that but I just don't know how the cost shift can't be part of the conversation given the significant impact on the hospitals. As we think about affordability I think that we just need to remind ourselves that the hospital process is just one part of the cost structure that all of the Vermonters are engaging in. So you know the more we can transition to total cost of care and those relationships I think that's a better place to be. And you know this kind of gets back to the cost shift component but you know we need to remember that when a patient comes to any healthcare provider they don't think about the cost shift they don't think about the problem. What the what the profitability of that service may or may not be. They focus on what is the best best care that that patient needs to get them healthy again. And so the providers are bearing the cost of that care up front even before any payment is processed. So you know I think that we just need to remember that of you know just saying that and you know this gets back to the cost shift conversation is you know just saying that that you know that needs to be a focus here because you know with the providers that are providing the care they don't think about it that way. And you know if the providers start to think about that way I worry about the downstream impacts that that it could have on our healthcare system. There was no conversation about understanding other revenue. I think we've had some conversations in the past and I think it I think that it you know was said the hospitals wouldn't have a margin if it wasn't for 340B. So we know I think a better understanding of other revenue and the relationship of everything else needs to be there just needs to be more emphasis on that than there has been in the past. I think it makes sense to do the crosswalk on the commercial charge you know we'll talk to all of the areas that are driving that so that makes sense. You know what we didn't talk about at all or you know what I didn't hear and understanding where the components of the math might lead into this. But you know what is an appropriate margin. You know hospitals need to have a margin to continue to invest to meet the needs of the patients. And you know as you just think about the hospitals and the margin and the deterioration of those margins and the number of hospitals that are growing that are in the red I do think there needs to be some aspect of that injected into the process. Let me see. I'm trying to understand this. No Kevin so so yeah. So as it relates to inpatient and many outpatient services we need to remind ourselves that the health care system is complicated and it is complicated. But the hospitals and other providers for inpatient services and many many outpatient services are not paid at the line item level. So that complicates things as we I mean they're simply not paid that way. The inpatient is DRG outpatient many of the services are on episodes of care now. So you know I think that we need to find ways to do a better job than we're doing today candidly. But you know you know that piece of this is going to be an evolution. And you know as we think about the impacts of the decisions that we make and when I say the decisions that we make is it could be the Green Mountain Care Board decisions. It could be decisions that individual hospitals choose to make. But we really need to break that down into what that does to access what that does to cost what that does to commercial rates because you know if say a hospital stops doing a critical service but another provider is going to continue that critical service that isn't the isn't under the regulatory oversight of the Green Mountain Care Board you know while it might appear that the hospital has lower cost it really hasn't lowered the cost of care. And you know at what cost any decisions impact on access. So you know I think you know there's a lot of difficult decisions to come. This is not an easy process. Well the board's role is not an easy role in the process. But you know I believe that we're coming to a breaking point where decisions are going to be made on cutting costs which is going to have a direct correlation on access and we just need to keep that conversation open so everyone fully understands the impacts of those decisions. And I thank you for this time and opportunity to share those thoughts. Thank you Mark. It was really good comments and I sympathize with you on the not being able to read your notes. I have the same problem. I don't know where my penmanship went south but now it's like deciphering whatever I wrote. So with that I'm going to go to Mike Del Treco and the next on deck will be Mike Fisher. Thanks Chairman Mullen. Thank you very much. I don't have as many words as Mark. I never do. So just to be brief I think Patrick the outline that you put together and the efficiency of the conversation that just took place is really important in this time. So I want to comment on a couple of things that I think the change in charge is critically important. I think the board our members really need to be careful not to portray that we have multiple charge structures. Often when we talk about change in charge and we have a commercial rate that's really not true. We have one rate and they have different effects on how payments work. I know you're having a reimbursement discussion next week and there'll be a lot of information shared there. So we just need to be cognizant of potential odd compliance issues where public hears this and they think they might have a different charge than some other individual with a different with a different commercial with a different insurance carrier. Secondly I think transparency I've heard a couple or times not during not just this meeting but the prior meeting and I think from my perspective things are very transparent and it's maybe things that are missing elements and I would like to sort of move into exacting what those missing elements are. And if they're available what can we produce them. And if they're available that's one thing. And if they're if it's thought to be available and there's difficulty and there's reasons why they can't produce we need to recognize those those as well. And then finally I think a streamlined budget guidance or with that always in mind whether it's during this time of pandemic or not I think is important making sure that all parties and entities get what they need to make the decisions must must be part of that equation too. So those are the three areas of comment that I have and certainly happy to talk to anybody in Patrick more in detail but but but thanks for the efficiency of the conversation and the clarity. Mike can I just ask you a follow up question to what you said. Sure can. So you said that people shouldn't think that there's different charges on commercial rates but if one insurer is reimbursing a hospital at 80 percent of charges and another one is reimbursing a hospital at 75 percent of charges isn't that really a difference in charge. Actually you you answered your the question it's reimbursement the payment is different the charge to charge to the patient and payer payers the same. And then what impacts that charge is the insurance program that you might be enrolled in as an individual and then the contractual relationship that that insurance carrier has with any one provider. So the charge is the same those two elements make either out of pocket change or the payment to the provider change. So whether you're Medicare Medicaid commercial self pay if you and I had the identical service at the identical location and I was Medicaid and you were self pay we would get or commercial we would get the same identical charge and the payment for that service and the out of pocket for that service would change depending on the product that you're enrolled in and the contractual arrangement that the provider has with the insurer. Thanks Mike. Next Mike Fisher. Good morning. Thank you Mr. Chair and members of the committee. And thank you board staff. I will echo what's been said. I think that was a great presentation with a lot of important questions. And I also want to just echo I think well this last conversation that was just going on the the the question for me is a common measurement of charge across hospitals. You know is the methodology of determining charge done similarly across hospitals is the way I understood the chair's original comment. And I also want to appreciate the chair's original comment around just understanding what the affordability impacts are about what happens when rates go up. About cost shift I just want to bring it home for a second. The administration is developing a budget at this moment. I would be tremendously surprised if there was any kind of proposal to have Medicaid reimbursement rates keep pace with inflation let alone make up some of the lost ground and also recognized the constraints that they're under they probably can't given the global commitment caps that we live under. But it's a decision happening right now right in front of us and and it's real. And then under the category of other data available I we've spent a little bit of time looking at the Medicare cost report and and attempting and it may be that there is some information in the Medicare cost report or in the IRS 990 that is is close enough to some of the data that the board asks for or at least on a surface level should be that there may be some improved efficiency that the board could ask for you know Medicare cost report at you know S10 line 23 column 3 you know in place of how much do you spend on free care. And I'm going into the weeds for a second for just to make the point I can't recommend such a move because when we compare what the hospitals report on what should be very similar measures to what they report to the Green Mountain Care Board we can't make a lot of sense about the variation that we see. So my real comment is that it would take some work to understand why the numbers show up so differently. But there may be some efficiencies available in those reports to make reporting easier for the hospitals. And that's my comment. Thank you. Thank you very much Mike. Is there any other member of the public that wishes to offer comment. Hearing none Patrick is there anything else that you need to guide you in your efforts to keep this process moving to make the necessary changes. I don't believe so at this time. We will get together as a staff here and digest the discussion today and provide the board with some updates on what we've heard and then probably reach out to some board members to start moving some of these initiatives forward. Super. Thank you. And thank you everyone for the feedback this morning and we are going to go into recess until 1 o'clock this afternoon. Thank you everyone.