 Okay, it's 10 a.m. I'll call to order the Green Mountain Care Boards meeting of February 21st, 2024. We have 2 meetings today. The 1st 1 will include a presentation on the hospital budget review. An overview of that process this year, and then 2nd. We'll have a presentation from Vermont legal aid regarding the implementation of act 1 19. We should end around 1130 ish, and then we'll be back. I think it's 1 p.m. So, first, I'll turn to Susan Barrett for the executive director's report. Thank you so much, Mr. Chair. A reminder on some public comment periods. First, we're going to open up a public comment period for the hospital budget guidance today. We're first going to accept any comments on director Barrett B's presentation this morning. And then as we move through the guidance process, we will post materials for folks to comment on and we'll keep that open until March 25th, and we plan to have a vote on the guidance by March 27th. Also, we have 2 ongoing public comment periods 1 on the act 1.67 community engagement and hospital sustainability work. So if you have any more comments on that process, please share those with us. And then more pression more more relevant for today is and this afternoon is any public comments on the all pair of model, the next all pair of model. We'll be hearing from Pat Jones this afternoon. So we would encourage folks to share any comments on the next potential all pair model. Any of the comments we receive, we share with our colleagues over at AHS and in the governor's office. I also want to remind folks that next week, we do not have a so I will turn this back to you, Chair Foster. Thank you. And we have meeting minutes from February 14th. Is there a motion to approve the minutes? I live approval. All those in favor, say aye. Aye. Aye. And the minutes are approved. I'll turn it over to Director Bearby for an overview of the hospital budget process for fiscal year 25. Great. Thank you. And thank you for having me. And bear with me. I am not feeling great. So I may have to stop and blow my nose. So here we go. Let me know when you can see the slides. They're up. Great. So I wanted to give you an overview of the hospital budget process and some goals that staff are proposing for 25 building on prior year work. And I'm, you know, please stop me and ask questions. And hopefully this will not, you know, no big surprises. So I want to start with some background, talk about goals, do budget guidance structure. So, you know, building on prior years, you know, the staff kind of went back and kind of looked at our budget guidance and saw some opportunities to just, you know, provide additional clarity and a clearer structure to map out kind of how we approach the guidance and the budget process. I want to start, I want to start conversations around benchmarks for 25 and then timelines and next steps. So I just, you know, I think it's important to remember where we're coming from, you know, nationally, healthcare is unaffordable. This is also the case in Vermont. We're really struggling to keep up with the rising costs of healthcare and this affects people in their everyday lives. Vermont has healthcare spending per capita that's grown beyond the national growth rate since 1991. Hospital spending is a major component of our spending. And, you know, for good reason, we need hospital care. But, you know, thinking about how we allocate our resources is really important and making sure it leads to higher quality outcomes for Vermonters. Vermont is the second highest in terms of growth in hospital spending compared to other states. So on the right, you can see a chart, you know, the national average of growth for New England states. Each of those New England states you'll see that Vermont is around 6.4 percent since 1991. The graph on the left shows kind of from 2010 to 2020 what that looks like. This is the latest available data from the national health expenditures. This doesn't control for, you know, our aging population and other factors, you know, our rural nature. But, you know, is an important kind of marker because this is what translates into growth and health care costs paid for by Vermonters. We also have the highest per capita or one of the highest per capita hospital spending compared to other states just behind South Dakota, West Virginia, and D.C. Again, you know, some of this may be because of our rural nature and their, you know, necessary inefficiencies to making sure that we have access in all of our communities. But this is, again, translating into real-cost experience by Vermonters. Ms. Berry, sorry. Would you go back to slide five real quick? I just didn't catch, I was just trying to look at all the other categories. So this is 2020 all revenue, Medicare, Medicaid, commercial, everything, right? Yes, this is everything. Okay. Okay. Thank you. And so, you know, hospital spending is necessarily, you know, a major part of our regulatory process in Vermont. This is not a new process. It's been around since 1983 in some shape or form, though it has kind of evolved through different agencies and evolved in its focus. As you know, in 2011, this came to the Green Mountain Care Board in an effort to kind of streamline some of the healthcare regulation in the state. I'm getting some feedback, so I don't know if someone needs to mute. So, but why should we regulate hospitals? I mean, I think as we mentioned, you know, hospital spending is a major contributor to unaffordable health insurance premiums and out-of-pocket costs. Higher spending in one sector can limit resources that could otherwise be allocated to other parts of the delivery system or even to other parts of the economy. We know this is a major struggle, you know, for our small businesses, for schools, even for hospitals themselves to employ clinicians and people who are critical to serving Vermonters. And we know that, you know, in rural states, there's less opportunity for efficient competition and regulation is really important when you have monopoly markets. That said, you know, I think it's important to view this process with the lens of continuous improvement. The board has established goals a number of years ago. I think these goals still remain quite important. It doesn't mean that, you know, that we're ever going to achieve them and our work is done. There's always room to do better. But some of these goals were about establishing objective metrics for evaluating hospitals, financial health and performance. I think we're, you know, have been doing that alignment of Greenmont Care Board regulatory processes to improve affordability, particularly between the hospital budget, the rate review process is important. So thinking about, you know, hospital spending as it relates to insurance is a really essential piece of our regulatory scope. Continue to look for opportunities to improve transparency, consistency and predictability of the regulatory process. I think, you know, clarifying our guidance is an effort to do that and I think is a good one. And then, of course, we should always look for opportunities to minimize administrative burden. And so, you know, on the left you have this cycle, you know, we can plan, then we execute the plan. Now we need to kind of look at what we did and see what worked, what didn't work and what we could do better and then we need to make changes. So I think this is kind of how envision every year and approaching every year. We're not going to have a brand new guidance, but there's always ways to improve and to build and to clarify shared understanding. So I think with that in mind, hopefully we can make some more improvements this year. So given last year's our starting place, I just wanted to kind of remind folks, you know, what we had accomplished. So decisions were made through two key lenses. One is hospital sustainability, sort of financial health. The other is healthcare affordability. The board established a two-year net patient revenue target of 8.6%. This was, you know, to balance kind of, you know, sustaining hospitals with some of the challenges that we had post COVID. And then we capped commercial rate increases by payer to create a more direct link between hospital budget and insurance rate review. We also increased evidence-based regulation through greater reliance on data and comparisons to hospital peers and national trends. The staff created the hospital budget review tool as an effort to start these conversations and some deliberation templates. And I'll talk about how we're kind of building on that work from prior year. And I also just want to know, you know, we're making some improvements this year, but this work is ongoing. As you know, the board and many stakeholders are working diligently on Act 167. So thinking about potential participation in the AHEAD model and possibly global payments, as well as Act 167 community engagement and, you know, thinking about what hospital transformation could look like. So these things may have implications for, you know, the kinds of things that we look at, discuss, and hear about from hospitals in our hospital budget review process. So goals for this year in particular. So established benchmarks that, if met, give the board confidence that the hospital's budgets consider both these lenses of affordability and financial sustainability. So this year I'll talk more in upcoming slides. But instead of just having a benchmark for NPRs, thinking about like what are the suite of benchmarks that we would expect hospital budgets to hit to feel good about those. And then continue to refine the regulatory decision tree. So it's largely similar to last year. I just kind of added some more detail there to help our shared understanding of how the board makes its budget decisions. And it's in our intended use of comparative data. And I'll go again into more detail that this is really about the hospital budget review tool and how we kind of understand a hospital's position given all the different factors that contribute to its financial health and its ability to be able to recover our quality of affordable care. We're also going to continue to evolve towards a more person-centered monitoring framework. So incorporating a more robust understanding of community access, quality, and affordability of care. So it's not just kind of, you know, what the hospital is able to, like what the hospital situation is, but what the community is dealing with and what, you know, community needs are and what, you know, what are the other things that might affect what we see flowing through hospitals at the end of the day. We're also going to continue to improve our data collection and analytic processes, standardizing and automating where appropriate, but recognizing that, you know, each hospital and community may have unique needs and flexibilities maybe necessary in terms of how we approach those analytics. And then I just wanted to kind of underscore that this will be, you know, Act 167, community engagement recommendations will have just been coming out. So, you know, this will certainly, there's a lot of room to kind of continue the conversation, but this might be the first time that we engage with hospitals on what they learned and what they're thinking about in terms of that process. Okay, I'm not going to spend too much time going through the statute. I think if they're, you know, guys have all been through this before, but I just a reminder, you know, that the board establishes hospital budgets and that this is really about the good of the state and of remonters. We have to promote efficient economic operation of hospitals. We should consider prior years and, you know, we should be using data and thinking about trends relative to national regional or peer group norms. So this is really about I'm going to go ahead and go to the rule. So then we have the rule which flows from the statute. So the Greenmount Care Board, you know, establishes benchmarks for any indicators used by hospitals in developing and preparing their budgets for upcoming fiscal year. So we met with FOSS and HCA to start obtaining input on these benchmarks, and those benchmarks will be included in the guidance that the board will establish March 31st. So today is kind of the first time that we're going to discuss those for this year, but it's certainly not the last time and this will be ongoing until the guidance is issued on March 31st. And just a reminder that the benchmarks themselves will be used to determine whether or not to adjust a hospital's proposed budget, but there are, you know, a number of factors that may vary across hospitals as the board decides, you know, if after they decide what weather adjustment is needed, how to adjust it. And so that part is a little more complicated, but, you know, it's really about understanding the whole picture. And if you should you like, there's a list of potential categories of indicators the board could use in setting those benchmarks, and it is quite a broad list. So I want to kind of spend a little bit of time on the schedule and where we are in the process. So this is a cyclical regulatory process as you know. It feels like just as you're wrapping up, you're already starting to plan for the next year. So, you know, I think in November, after the conclusion of last year's budget process, we met with hospital CFOs to hear kind of their thoughts and debrief with them a little bit on the FY 24 process. In January, and this will continue through the end of March, staff have been meeting with VAWS and HCA to solicit input on benchmarks and other aspects of the process. And then as Executive Director Susan Barrett noted, we're opening a special comment period today and there will be multiple opportunities for the public to provide input and other interested parties on what this looks like. So February, March, as I mentioned, will continue collecting input on guidance from other interested parties. And then we'll issue the guidance at the end of March. April through July is when hospitals will continue to develop their budgets. You know, we've heard from hospitals that they're already starting this process. So, you know, they'll be prepared and can evaluate where they are relative to the budget guidance over that period of time. And then in July, hospital budgets are due from hospitals by July 1st, and that's when staff will immediately begin reviewing all the materials. We'll come back to the board with a summary. And then in August, we expect to have hospital budget hearings. We're currently working on, you know, scheduling those, at least holding those times, and then certainly the criteria with which a hospital should be expected to deliver hearing or not, or if there are exceptions to that rule. So that will be spelled out in detail and guidance and we can continue talking about that over the next couple of weeks and months. And then as a reminder, as mentioned in statute, so the board will then publicly deliberate, approve, modify, or deny budgets by September 15th. And then budget orders are delivered to hospitals by October 1st, which is the start of the fiscal year. Any questions on timeline before I start getting into the meet? Should be pretty straightforward. Okay. Is there any changes in the timeline this year compared to prior years? No, I think largely it's pretty consistent year to year. You know, this year, because I was coming into the role, I wanted to have that debrief and hear from folks what they had heard. My understanding is that that kind of thing has happened every year and these conversations on guidance have happened every year. Yeah, thank you. Thanks. Great question. So the structure of the guidance, so I think, you know, none of this is new. It's just kind of articulating, you know, how we're using certain measures, how we're pointing to certain data sources, and, you know, how it will be used in guidance. So bench marks, you know, establishing bench marks against which the hospital budget request will be reviewed and evaluated. So again, that's the whether budget adjustment may be needed, not whether it's needed period, but then it kind of triggers a whole host of other comparative analyses and trying to understand the broader picture. Section two will have a list of comparative metrics and data sources that staff will use to evaluate hospital budgets in greater detail to understand that story. And I'll get into kind of what we're thinking there and, you know, some exciting materials we have to make that more transparent. And then budget assumptions. Section three, I think historically we've collected budget assumptions in the narrative, but thought that it would be helpful to really articulate upfront, you know, what's included in this budget, what's not included in this budget, and this will help us understand if, even if a hospital meets budget, you know, section one benchmarks, if that makes, if that all adds up, makes sense. Community context. So this is going to offer an opportunity to kind of point to some contextual data for better understanding the needs of a community. It could also include kind of the outside hospital delivery system pressures, as we've been hearing about, that may affect a hospital's ability to meet those benchmarks. Section five includes measures that are important, but may not be directly tied to the hospital budget decision, but are important for monitoring over time. You know, we're kind of thinking about quality here, since we're kind of reinvigorating quality into the hospital budget process. And then section six is really the narrative. So it's where hospitals have an opportunity to provide qualitative justifications for the proposed budget and really explain some of the, you know, requests and data that we're seeing. So this is the hospital budget decision tree. So it's really largely similar to last year. I just kind of added additional detail. So do the budget requests meet the section one benchmarks? Historically again, that's been NPR. And this year we'll talk about some additions that we have to that section. And then if yes, then the next step is to evaluate the budget assumptions for reasonableness. So, you know, did you include all of the relevant payer increases that can be expected? You know, we understand that hospitals may not have all of the, you know, parameters figured out at the time of budget submission, but understanding what those assumptions are really important to understanding whether the budget is expected to be sound. You know, are you budgeting over estimating or underestimating utilization? Those are really key to making sure that what we're seeing is what we can, you know, that it's the best budget it can be. And then also that submissions are on time and complete. And then if everything looks good, then hopefully, you know, you get an approved budget. If not, then there may be like if your budget assumptions maybe are not totally reasonable, then there may be an adjustment to the budget. If a hospital doesn't meet the section one benchmark, it's not the end of the world. It doesn't mean it's not a warranted budget, but I think that's when we really try to understand in more detail kind of the nuances of that particular budget and the community context. So that's when the comparative analytics will come into play. And of course, if there's some community level factors, then we would consider those. And then the section three budget assumptions again are they reasonable? Are submissions complete? And then in either case, you know, it's not that we will only look at section two comparative analytics if hospitals don't meet the benchmarks. We will look at those for all hospitals, but we just want to tie that to the budget potential budget adjustment. So if we say you a hospital meets a section one benchmarks, but there's some kind of concerning trends in section two comparative analytics, this could lead to, you know, additional questions or reporting, you know, depending what it is. So I don't want to say that we're not looking at it, we're looking at it for all hospitals, because we think those measures are quite important to understand the whole picture, but that we wouldn't necessarily expect a budget adjustment. Any questions there before I move on? I feel like this is the lynchpin to the whole thing, but hopefully this isn't new. Okay. You know, I think the goal with this decision tree now and over time is really to both be predictable for hospitals, but also to be adaptable, right? So the benchmarks give some predictability of how we're going to evaluate budgets, but we also need to be adaptable for hospital specific challenges and then a dynamic industry and economic environment. So, you know, we're not going to have all the answers upfront. It's really important for I think for us, for the health of the system and for Vermonters to really make sure that we're able to respond to the changing needs, you know, as we've seen in COVID, rising inflation and there's just, you know, we don't know what's going to happen next year. And so I think we always need to be ready to adapt and make sure this is a robust and helpful process as possible. So the section one benchmarks, as I mentioned, these two lenses, I think these two lenses will kind of continue as we move forward is really about healthcare affordability and also hospital financial sustainability. And I just wanted to take a moment to kind of say out loud some of the things I heard from board members and, you know, this is a staff position as well. You know, we believe that hospitals provide essential care and services and economic opportunity to communities. Hospitals are critical component of our healthcare system. At the same time, unaffordable hospital prices do not create a sustainable system. And the loss of a hospital can, you know, can really be devastating for a community. I think this is where the hospital sustainability and Act 167 work really came from is kind of a fear that if, you know, left to market forces, this could, this could lead to, to have things for Vermonters. The relationship between healthcare affordability and hospital financial sustainability is really complicated and affected by a variety of factors. So this is not, there's no formula that's going to pump out the perfect budget. It's really important that we consider, you know, what are the opportunities for transformation? How, you know, are there opportunities to improve efficiency? You know, rural health requires some level of inefficiency to make sure that we can prioritize access, but what's the right amount? Local market factors, there are a lot of factors that are important and affect this relationship. And again, it's what makes it complicated. So section one proposed benchmark, so, you know, really to think about how hospital spending translates into premiums is really at the aggregate level. So more, more spending means higher premiums. So making sure that we have some kind of cap on total spending or cap on growth is really important. And this is why we've had the net patient revenue growth cap over time. And so continuing that is important and is why the state kind of started participating in its Vermont all payer model to begin with. So I think tying net patient revenue as we have in the last few years to that target makes a lot of sense to continue. So 3.5 to 4.3 is based on Vermont economic growth, historic economic growth. And so I think for consistency, particularly as we're contemplating next steps, it makes sense. I thought to continue with this target. In terms of prices of health care is another way that this affects affordability because government payers set prices directly. This is really a commercial price. So hospitals have control over what price they negotiate, but how much they need to cover their expenses is another question. So there may be heterogeneity and what's appropriate. But having a cap on hospital growth and commercial charges and commercial rates. So that's charges less than negotiated discounts at no more than some percent. So I think the question is what percent, an area that we've been focusing on, but could set a goal for hospitals at the beginning of the process. So how should we set a cap on growth in this process? What indices could we tie to? What level of analysis last year we capped price growth by payer? One thing that we've been thinking about and used to kind of capture more detail and is really by care setting. So should we really be looking at growth by inpatient, outpatient, professional services, if that's how making sure we have a tight connection between the rate review and the hospital budget process. So here are a list of potential price inflation indicators. I won't go into detail, but this is for you. There's certainly trade-offs in terms of how timely these data or forecasts are, whether or not they're focused on the hospital industry and how salient they are for Vermont as a state or for rural context. But I'm trying to narrow it down for you, but I thought it'd be helpful to know what other states are doing as well. So Rhode Island used to use Medicare Market Basket, but has recently shifted to CPI, so Consumer Price Index, for urban populations less food and energy plus one percent. They removed food and energy from that inflationary factor because it creates a more stable estimate over time. Delaware, through their insurance department, but it's actually, I think, codified in statute, also uses Consumer Price Index plus one percent and that they're kind of on ramping, so they started with plus three percent, you know, starting from a greater or condition. And then in Maryland, they do have all-payer rate setting, but so it's a little different, but they use the Medicare Market Basket plus some capital growth estimate to allow price increases over time. Okay, so I think what we're doing, what we're planning to do next is kind of take these estimates and some of these indices apply them historically and then kind of make some projections about what that would look like and talk about the theoretical trade-offs. I think this is an area we love some feedback, but next time we come before the board, we expect to have some more quantitative analysis for your consideration. Okay, and then the third section one benchmark is not such a benchmark, but kind of an aspirin, but we would expect that for a hospital that is able to meet the previous two benchmarks that is also efficient to achieve an operating margin greater than zero. So, you know, there are many important measures and indicators for evaluating financial health, but this is kind of like the starting point. It's kind of a basic one that you should be able to cover your operating expenses with your revenues, but I do want to recognize that it's not just about getting more revenue, but also making sure that our expenses are fiscally responsible and efficient. So, just to reiterate, you know, if you meet all three benchmarks, that's great, then you move on to, you know, the staff will then evaluate the section three budget assumptions to make sure that we believe that those can hold, and if not, it's again not the end of the world and it may be completely warranted, but then we'll be kind of looking at, you know, again, the assumptions, but also some of those comparative analytics to understand the specific context of a hospital in a community. So, the section two comparative analytics are really to capture the operating factors that might play a role in the hospital's ability to meet the benchmarks in section one, and it explains how Vermont hospital is compared to national regional trends within peer groups. There are no specific performance benchmarks established here. These measures really need to be considered collectively. I, you know, we're kind of taking last year's list, looking at this list and thinking about what else needs to be included and what other states are doing, but there's no, again, there's no formula, there's no one size fits all. We have very different hospitals, even different types of hospitals. Again, that's where the peer groups come into play. So, you know, this is about being able to understand holistically what's happening in a hospital and in a community. So, the types of measures that are in here, so refresher, you can go look at the hospital budget review tool. I imagine this will look very different next year as we kind of try to make a one-stop shop for all of our hospital budget data. That's our aspiration, but it will include kind of revenue trends, operating efficiency, financial health and more. So, this is really going to be where we go to kind of triangulate across a variety of measures to understand a hospital situation. So, this is, as I mentioned, work in progress. We're reviewing the FY24 tool and some of the metrics that were used in the process. And we're creating a measure specification document with the focal measures that we hope to reference in this section. And we're going to be working on kind of thinking about the best way to visualize these data in these analyses. So, but we think this specification document, our goal is to have it kind of include, you know, the measure, how it's calculated, what the intended inferences are, you know, what does this measure mean? What are the other measures that we should be looking at relative to this key measure? What are the limitations of these measures? And then, you know, there should be some information on the peer group. But the goal really here is to make sure that anyone can pick up this list and they can replicate what we did. And that it's as transparent as possible. So, that's, that is my hope for this tool. In guidance, we also plan to establish peer group methodology. So, building on last year, but kind of thinking about what are the factors that, you know, certainly designation and kind of hospitals role in a community across our Vermont communities is important, but there may be other factors that we should consider when establishing a peer, a peer group. Section three, as I mentioned, is going to be about budget, how do we capture systematically what, what budget assumptions are underlying each hospital's budget. So, for example, government reimbursement changes, payer mix, service mix, patient acuity. So, case mix index was a topic of conversation last year, utilization or market share shifts, anticipated future capital investments, and certainly more. So, this isn't as a, again, work in progress, but think that it's, it will only help provide transparency into the budget, but also a shared understanding of what we're looking at and what we can expect. Section four, as I mentioned, community context, here's some examples. You know, what are health outcomes across communities, how do those differ? Population demographics and trends, economic and social needs, access to non-hospital services, for example, long-term care, may have some information that community health needs assessment, drive time to services. So, these are just some examples. We're going to see how far we can get this section this year, but certainly these are really important to understanding the broader pressures on a hospital and what they're dealing with. Section five, as I mentioned before, will focus on monitoring measures. Again, so changes in utilization, as you know, some of these show up, but they may show the particular kind of measure may look a little different. Hospital quality, quality improvement activities, history of regulatory compliance, payment and delivery system reform participation, uncompensated care, and other things like that. And then the narrative. So, we'll continue to have a narrative, but I think streamlining what's in narrative versus what we're collecting quantitatively is important. So, a lot of the content areas will still be there, but I think it's, you know, we're going to kind of think about how do we streamline this. We still need an executive summary, some background information, service line changes, for example. But then there will certainly be budget questions, you know, help us understand how you budgeted this year and how you kind of make the link from prior year to projections to this current budget. What are some budget risks? How do we understand patient experience or strategies you have to increase patient experience, group patient experience, performance improvement strategies? Or if ordered by the board, you know, are there updates on performance improvement plans, et cetera. And this is where we'll kind of begin conversations on that Act 167, community engagement. And I think it's also important to recognize kind of the health equity work and other related work that hospitals are engaging in. So, I'll just end with a timeline as we move forward. So, you know, we're going to come back to in a few weeks and staff will provide an update on FY23 Actuals. And then we will share a draft of the guidance along with the Section 2 measure specifications that I mentioned earlier. We'll have the special public comment period as Executive Director Barrett mentioned opening today, but then, you know, series of deliverables to respond to by March 25th. And again, you can certainly provide feedback after that point, but, you know, that will give us, hopefully, enough time to kind of incorporate any last minute suggestions. And then, you know, hopefully we will have a vote somewhere between March 20th and 27th, and then issue the guidance on March 31st. And that is what I have for you today. I'm going to exit my full screen. Stop sharing. Answer any questions. Well, thank you. I know this has been a lot of work for you and your team when you guys are busy with a lot of other things on your plate. So, I know there's been some long weekends and nights in this. So, thank you very much for doing that for us. I have one observation that seems pretty consistent with how we performed the evaluations last year, generally. I'd be interested in seeing those potential indicators that you put up, the CPI, PPI wage growth, those and what those sort of actually would look like in reality. My sense is that they're probably all fairly close, but I don't really know. So, maybe at some point we can get a look at that. And other than that, thank you very much. Nice job. I'll jump in. So, Elena, it sounds like you're expecting on March 13th to have, obviously, the draft guidance, but also the measure specification. That's really awesome. Yeah, I'm hoping that deadline. We have a draft right now. We're just kind of iterating it. And then I want to certainly share that with the hospitals and get their feedback. Make sure that we can clarify anything that needs clarifying. But we hope to publish that with the guidance. And it will kind of be a companion document. Yes. Great. Thank you. And then just to follow up on Owen's comment on the modeling related to the targets. Are you thinking that's a March 13th? I'm just curious when you were expecting to come back to us with that modeling. Yeah, I think March, I'm hoping March, and I'm saying March 13th. It might be, I guess it's 13th or 20th. Let's just hold those two dates for both of those things. But I think certainly the 13th is the goal. And then if we have to push it definitely by March 20th. Yeah. Great. Yeah. Well, thank you very much. I think it's a good start. And I look forward to seeing more of the details. Thank you. Great. I don't have anything more to add. I appreciate the timeline. And I know how much work is going into this. And I really appreciate the data driven, you know, momentum forward on these hospital budgets. So thanks for all the hard work to you and the team. Likewise, Elena. This is Tom. Thanks for all the hard work and continuing our forward progress. Similar comments for me. Thank you so much. And I guess the one question that I had watching the presentation that I that I wanted to bring up, which you mentioned reinvigorating quality within the hospital budget process. And I was just curious your thoughts on how you envision that being used in the hospital budget process. Yeah. I mean, I think the board used to have something called non-financial reporting where we looked at a whole host of other things. And I think COVID happened and, you know, lots of stuff happened. But quality is really important. And I think, you know, we also need to celebrate what hospitals are doing and quality improvement programs they're investing in. And I think if, you know, having a holistic understanding of what hospitals are working on and is really important when thinking about what the budget represents. So I think to the extent that we can know that and understand that. And if there are quality concerns, I mean, I think we have a high, pretty high quality system that we're just aware of that. So I think we should celebrate wins and look for opportunities to improve. And, you know, so I think we'll continue to work through that. I think bringing our partners at VPQHC to the table to understand kind of what they're working on. And, you know, is also important. So connecting these dots is going to be an ongoing area. Yeah. Okay. Thank you. If I could, this is Tom again, if I could just jump in there for a moment. Considering quality, I think is crucial, right? Because we, societally in Vermonters, we may be willing to pay quite a lot for healthcare that's safe, reliable, and of high quality. On the other hand, healthcare that isn't safe, reliable, or as poor quality ends up being really expensive. So if we're thinking about how to manage costs, improving safety, reliability, and outcomes is a key strategy for improving the cost of doing care. That's a great point. And I think just, you know, not that the board is in the business of doing quality improvement, but to the extent that we're a body that can provide transparency to quality and quality improvement efforts, I think is really important for Vermonters. Great. I will hold public comment for the end of both presentations today. And thank you very much, Ms. Bairby, and your team for your presentation. Next, we have Vermont Legal Aid, which will present information relating to implementation of Act 119 and moving to a statewide minimum standard for hospital free care policies. And Emma Zavez and Eric Schulteis will present. And thank you both for being here. Thanks for having us. Can you hear me all right? Loud and clear. Perfect. Great. All right. Well, yeah, I'm Emma Zavez. I'm the consumer research and health policy analyst here at the Office of the Healthcare Advocate. And you all know Eric Schulteis, my colleague. So we'll be presenting today. And thank you, Kristen, for projecting the slides. All right. So let's go to the next slide. Okay. So let's see. Today, we're going to start by talking a little bit about the background and legislative history of Act 119. And then we're going to dive into the detailed requirements for hospitals. After that, we'll talk a little bit about the work that our office is doing to support hospitals and the timely implementation of Act 119 and then how we think about measuring success. And then we'll have time for discussion and questions. Next slide. Oh, so this is me. Can folks hear me? So this was just history-wise. It was a collaboration between our office and VAWS. It was a bit of an oddity how it all played out. House Healthcare asked us in VAWS to negotiate something that worked for both parties and come back to them. That is exactly what we did. From our office's perspective, there were a few things we were trying to solve. And it was mainly complaints that we were hearing from our helpline. It was variation in how hospitals were interpreting their given FAP policy, both between hospitals and within a given hospital, so varying by patient type, by patient. There was a pretty wide variation between the hospitals for what aid you were income eligible for. So for instance, someone at X-income might be eligible at GMC for 100% financial aid and at this imaginary hospital, they would only be eligible for 50% aid. From my perspective, there was a having FAPs limited to a given hospital's health service area created a mismatch between how people actually behaved and their eligibility for a given program. So especially at the edge of the counties or the HSA, someone might travel to another HSA for work, but if they got hurt there and needed financial assistance at the hospital they were taken to, they couldn't get it because they weren't a resident of that HSA. So we wanted across the board state eligibility, UVMMC and RRMC already had state eligibility and we wanted to bring everyone in line with that. And I guess the last thing to point out is there was a we wanted to standardize how income was calculated. I think the least for me the best example of the variation was that you know some hospitals use your taxable income and other hospitals were counted your roommates for instance income in the household even though you wouldn't they didn't share expenses you just found someone on Craigslist. So we can go ahead to the next slide and I'll hand it off to Emma. All right so we're going to dive into the detailed requirements. Next slide. So this slide is for your reference we're not going to spend any time here really this is just direct links to the different sections of the relevant statutes you can use this later if you need. Next slide. Okay so rather than move section by section through the statute I'm going to present thematically because I think that makes more logical sense. We're going to start with household income and size. So as Eric noted Act 119 is going to bring much needed consistency to how Vermont hospitals determine and applicants eligibility for financial assistance. Currently there is wide variation in what counts as income resources and who is considered to be part of your household. So Act 119 requires hospitals to calculate the household income and size using the advanced premium tax credit APTC methodology. APTC is based on modified adjusted gross income or MAGI as it's popularly known and defined at length in the Code of Federal Regulations. It's summarized hopefully here in a Q&A by the IRS it's essentially the adjusted gross income on your federal income tax return plus any excluded foreign income non-taxable social security benefits and tax exempt interest does not include SSI payments. And so for practical purposes you know somebody asks you about a specific source of income does it count. I have included this popular cheat sheet that was developed by UC Berkeley Labor Center as sisters and navigators the folks who enroll people in Medicaid and health insurance through Vermont Health Connect and in the marketplace all over the country oftentimes use this cheat sheet it's listed on Vermont Health Connect's website and is a nice list of what counts what doesn't count in terms of sources. All right next slide. All right so with regards to household size Act 119 stipulates that hospitals have to use the APTC methodology but Act 119 has included a few modifications and these are listed here. I'm not going to read through them all but I will just say at a high level these essentially aim to fix some of the issues that are commonly associated with equating an individual's household for financial aid purposes with their tax household. You know one major issue that comes to mind is that not everyone has a tax filing requirement. So there are many issues that have cropped up over the years. All right next slide. Okay so Act 119 requires minimum discounts at specific income levels based on one's household size. So for example it will require hospitals to provide a 100% discount to households with income at or below 250% of the federal poverty level. So hospitals could of course provide a 100% discount to an even higher FPL level but at the very least they need to extend it to 250. Hospitals must also provide a minimum of 40% discount to households with income between 251 and 400% of the federal poverty level. So again while 40% is the minimum hospitals of course are welcome to provide a higher discount amount and many hospitals do. So I'll call your attention to the green box. This is sort of the current landscape today. Five out of 15 hospitals currently meet or exceed the free care requirement and seven out of 15 hospitals meet or exceed that low-cost or discounted care requirement. Okay next slide. All right so for patients with income over 400% of the federal poverty level there is a safety net and it's called catastrophic assistance. So in Act 119 to qualify for catastrophic assistance it stipulates that your household must have income at or below 600% of the federal poverty level and the total owed to the hospital must be more than 20% of your annual household income. So for those who are approved for catastrophic assistance the hospital must lower your total owed to 20% of your household income. This is kind of confusing and I had to sketch out an example for myself and for hospitals to understand how this works. So here's an example in the green box we've got a household. The household size is three it's Shelly her spouse and child. Their income their household income is $129,100 that's the equivalent of 500% FPL. So she so they are over income for the free or the low-cost care discount but she would qualify for catastrophic assistance because her household income is less than that 600% FPL and she owes the hospital in this example $37,000. Someone in her family had an accident they were in a coverage gap they didn't have insurance. So that percentage of the total owed is currently 28.7% so upon qualifying for catastrophic assistance it would need to be lowered to $25,820 in this example which is 20% of her income. All right next slide. Okay so Act 118 provides hospitals with the option of using a resource test to assess eligibility for financial assistance. If a hospital wishes to take up this option the law prescribes certain parameters so they can only consider liquid assets and certain types of liquid assets do not count against the applicant such as their primary home their retirement funds etc. Additionally liquid assets totaling less than 400% FPL for your household size would not count against you. So again what does this mean in practice here's an example household size of four the liquid asset limit for that household size is $124,800 that's 400% FPL for household size of four. Juan and his spouse have $50,000 in combined checking and savings account that means his liquid assets are less than that 400% amount so the hospital cannot deny financial assistance on the basis of resources. Next slide. Okay so under Act 119 hospitals can require that an applicant for financial assistance be a Vermont resident but for the first time this definition will be standardized and applied equally across all hospitals. The definition also includes students, people who are employed in Vermont, undocumented immigrants, and people living in Vermont but who lack stable housing. So this will be a significant departure for some hospitals that currently restrict eligibility based on the hospital service area, county, town, and sometimes the duration of residency. So for example some hospitals right now currently require an applicant to have been a resident for at least six months or longer. So Act 119 prohibits hospitals from the durational resident residency requirements. All right next slide. Thank you. So Act 119 will also standardize the list of classes who are protected from discrimination in the implementation of hospital financial assistance programs. Next slide. And Act 119 will standardize what types of documentation hospitals can ask applicants to provide. So hospitals can ask an applicant to provide a tax return but they cannot require it and they must allow applicants the option to submit alternative forms of documentation which is crucial because as I mentioned before not everybody files taxes. So with respect to residency, Act 119 is actually silent on proof of residency. We recommend that hospitals follow the example that's set by Vermont Health Connect and Medicaid on the 205 ALMED application. That's the applicant's signature is considered sufficient attestation that they meet the residency requirement. Next slide. Okay. So Act 119 clarifies that financial assistance must apply at a minimum to all emergency and medically necessary care. I've included these definitions here for your reference if you want to go back but I'm not going to read them. The IRS also requires transparency regarding which providers do not accept financial assistance. So those providers need to be listed in the financial assistance policy or a website needs to be listed into the policy where someone can go and access that list. All right. Next slide. All right. Act 119 outlines required elements for financial assistance policy notably an appeals process which is very important and definitely not all hospitals have that right now as well as a plain language summary. Next slide. We're going to spend a little bit of time here on the plain language summary because I think it's an incredibly important tool in conveying the existence of a hospital's financial assistance policy to the public. So at my office we often hear from Vermonters who call us about a hospital bill that they can't afford to pay and they have no idea that their hospital has a financial assistance policy. And when we check we realize that many of these people would actually qualify if they apply. So we of course encourage them to apply. So section 2 of Act 119 requires that hospitals submit their plain language summary to you, the Green Mountain Care Board, as part of the fiscal year 2025 hospital budget review process. So these will be coming your way shortly and we think that there is no excuse for hospitals not to have a good plain language summary. So as part of our effort to support hospitals with implementation we developed a plain language summary template that hospitals can use if they don't have time or they don't have the expertise on staff to develop their own. This is a screenshot of the first page. It's back in front. We sent this out to hospitals last month. The reading grade level for the template is 8.4. Ideally plain language summaries should be between the sixth and eighth grade reading level. That can be tough based on some of the terminology you have to include. But I'll note that when we reviewed hospitals plain language summaries two years ago we found grade levels of 17.1, 31.8, 20, 17.2. So pretty high, high levels. And as I said it's easy to get to a high grade level with the terminology. But it is absolutely possible to explain financial assistance and what's out there to patients in a way that is readable and manageable for everybody. So we hope to see a lot of improvement there. Next slide. All right. So this leads us nicely into public education and information requirements. So Act 119 requires that the financial assistance policy and application be easily accessible online through the website and the patient portal. Paper copies must be available free of charge. Translations must be provided upon request. And notice and information about the policy must be conspicuously displayed in areas that patients frequent. So patient reception, patient billing, those types of areas. Next slide. All right. And Act 118 requires hospitals to inform community members about financial assistance program in a manner reasonably calculated to reach the members of the community who are most likely to need financial assistance, including members who are non-native English speakers. So that's the public education outreach requirement. Hospitals must also directly notify patients at their first visit during intake and discharge if it's a hospital admission and include conspicuous written notice on billing statements. And all written and oral debt collection attempts must include notice of financial assistance. Thanks. Next slide. We won't go through these, but Act 119 lays out procedural requirements that hospitals have to follow, including timely eligibility decisions and, you know, response to appeals, that type of thing. Next slide. All right. Act 119 requires hospitals to offer help to those who would like to apply for insurance. Although I will note, hospitals cannot deny financial assistance on the basis that an undocumented immigrant refuses to apply for public insurance. And they cannot deny on the basis that someone refuses to apply for private insurance. Next slide. All right. Medical debt. So Act 119 prohibits hospitals from selling medical debt. And it says that if a patient qualifies for financial assistance and still has a balance owed after the discount, then hospitals cannot require payments in access of 5% of someone's monthly income. And there's an example here, but I don't think I'll walk through it. It's there if you want it later. Okay. Next slide. Patients can direct their complaints about hospital financial assistance policies to the Vermont attorney general's office. We have met with the staff there a couple of times so far to make sure that they know about this new responsibility and to make sure that they're setting up channels to accept those complaints and process them in a timely fashion and will continue to communicate with them up until the implementation date. And I don't think I've mentioned the implementation effective date. It's July 1st, 2024. So it's coming up in a few months. Next slide. Okay. All right. So that's it for the detailed requirements. I wanted to just briefly talk a little bit about some of the work that our office has been doing to help ensure that Vermont hospitals have all of the resources and support that they need to implement by July 2024. So we have been engaged in sort of a one-year resources implementation push. We sent a letter to hospitals in July 2023 introducing the new law, giving them links to where they could read more about it and describing some of the resources we'd be rolling out and offering assistance. And since then, we have been rolling out resources every couple of months. So an Act 119 requirements checklist, sort of a plain language description of the different areas of the law and where that fits into their financial assistance policy. We also provided a model financial assistance policy template that complies with Act 119 and indicates what's legally required, what would be best practices that we recommend if the Act is silent and is sort of plug and play. They can update it as needed if they would like. We've also delivered public education requirements checklist, ideas for implementation, and recently the plain language summary template. And we'll be sending out more resources in April. So more to come. Okay. Next slide. And Eric, if you'd like to do this slide, I might hand it back over to you. Oh, God, this is unexpected. So I think how you measure whether this is being implemented in an effective way, it hasn't been determined yet how our office is going to do it, or if the board is going to think about doing it too. And even I think we've had some discussions around enforcement with the AG's office. So I think they might do it to some extent. I think I try to come up with a few ways that I might look at the issue. So I'm not going to go through these. I think I would, at least on some of them, I would expect to see it on their, it would be a lagging indicator, but on their, the amount of free care provided at cost on their 990s. As I've mentioned before, there's some difficulty in crosswalking board reported data with the cost report with the 990. So hopefully as we move towards standardizing metrics, perhaps we can get into the world of two different sources, two different sources of definitions for data rather than some unknown amount, which is our current state. And I think the important one here to think about is the ratio of free care to bad debt. I think we've tried to explore this for several years and have yet to get a cogent response of why a hospital would benefit from booking something as bad debt rather than free care. Of course, our approach to measuring it and looking at this ratio should some cogent reason arise. We would reevaluate that. I think what's interesting in the limited cases where we've heard from CFOs, it's been, well, in either case, we're not getting paid. They're the same thing. And from our perspective, of course, it's not the same thing to a consumer. So the consumer never knows that the bad debt has been written off. Their credit history is ruined when it's bad debt. They might not have even known they could get free care. So I think from a consumer perspective, there is a profound difference between free care and bad debt. And hopefully we can slowly shift to a system that recognizes that impact on Vermonters. Thank you, Emma. Thanks, Eric. The next slide is just opening things up for questions, discussion. We'll be back to the board. Thank you both very much. A couple kind of high-level ones. Just an observation. This is incredibly laudable and will be very helpful to a large number of people. So thank you for looking into it and evaluating it and sharing it with us. I had a question about the financial impact to hospitals. And if there's any sort of assessment or evaluation done of what this would cost hospitals, because a lot have financial challenges and some many actually have negative margins still. So I think, Chair Foster, from our perspective, and this connects back to the kind of cogent explanation of why free care or why bad debt instead of free care is that this will effectuate a shifting of that ratio, but not a change in that aggregate amount of write-off. Of course, that could change, and we might need to monitor that. And we can get from the cost report or the 990, the cost of bad debt in free care and see if we have seen a change in the level of the combination of those two over some period of years. I see. So the financial impact is expected or hoped to be zero to hospitals, but it's really a classification issue, which would in your to the benefit of the consumer. Near negligible. Of course, I suppose if the PFA, the FAP standards somehow incent more people to use services given general awareness of FAP standards and this, you know, I don't think that's a plausible expectation. And then from the hospital's perspective in terms of whether or not it's bad debt or free care, I don't understand all the nuances to tax write-offs and implicate financial implications, but from the hospital's financial perspective, there's no difference in terms of the benefit of how it's classified. We are unaware of any with the caveat that they do get some reimbursement of the cost of Medicare, bad debt, but those amounts at least reported on the cost report, which would drive that partial reimbursement are so small that they're essentially rounding errors. Yeah, in my opinion. And then to track whether or not these changes have a financial impact negatively on the hospitals, we would the best way for us to kind of look at it as a board is the aggregate total of bad debt and free care over time. I think so. I mean, this creates odd challenges that bring us back to the data standardization issue. If you look what that sum is over time, you're going to get a and the percent change, you're going to get a different picture if you're using board reported numbers, 990 reported numbers and cost report numbers and sometimes in strange ways the sometimes a cost report directionality of the change can conflict with the 990 and sometimes hospitals don't follow the instruction. So you're not supposed to report cost as a negative. So a negative indicates profit, but we are in the situation where we could just ask the Vermont hospitals. Of course, that's not possible when you're looking at a national data set and trying to benchmark. Okay. Okay. Thank you guys very much. Other board members. This is Tom. Thank you, Eric and Emma. It's great work and thank you for walking us through it. I've been aware of the issue as you guys have spoke of it, but there was a recent Kaiser Family Foundation report from earlier this month where the data really struck me about how big a problem medical debt is in our state. Out of the 50 states, we're one of the seven with the highest rates. Mississippi and South Dakota are at 15 and 17 percent of all households. We're at 12, along with about five others. Those include places like Louisiana, Kentucky, Tennessee. Vermont's at 12.2 or roughly 60,000 people out in Vermont. Meanwhile, in New England, where the highest in New England, Massachusetts is at five percent, New York is at six. So this is a big problem in Vermont relative to other states. And I wasn't fully aware of how big a problem it is. And the Kaiser Family Foundation has developed a tracker to help watch this over time. And that may help us and you with monitoring this. So I just wanted to say thanks for bringing me up to speed on Act 119. Thank you. I think this is just a huge success for Vermonters. I'm really just impressed and blown away by it. I think because you have mentioned, I don't know if Emma, you know, but I work as a clinical emergency physician. And these are issues that come up frequently in conversations with patients. And this really seems like a significant move that can make a huge improvement in so many people's lives. I have a few questions that just came up through the presentation and they're not necessarily related to each other. But so if a hospital can't sell that, if a hospital can't sell debt, can they not sell debt to a debt collector? Then does that eliminate collections or is that a different process? Sure. So it's a bit complicated. Board Member Merman, I think it's unclear whether Vermont hospitals sell the medical debt, but they'll have. So for instance, CVMC, and I bring that example up not to suggest it's bad, but only because you work there, is has an internal debt collection part of the hospital. So it's a little, and they don't sell the debt, but they have them collect the debt. The debt no longer is sitting on the hospital's books. But at least from a national standpoint, the most egregious consumer harms were caused by hospitals selling the debt for pennies on the dollar to third party debt collectors. And then those debt collectors using practices that aren't in line with the Fair Debt Collection Act. So from our opinion, and I think VOS is too, is these practices of selling to third parties wasn't happening. And we had the most chance to intervene in a positive way within the hospital's debt collection practice, even if the hospital owned debt collection practices separate from the hospital budget that you see. And then, so say some cities and private foundations, NGOs, nonprofits have been buying hospital debt for pennies on the dollar with this, eliminate that possibility for homeowners? Well, I mean, I don't. So in those instances, you have those debt collection agencies, those NGOs, let's say, paying the third party, and they may or may not be buying the debt or just paying the money. I mean, it's a question of whether that transaction constitutes a payment of the debt or a sale of the debt followed by forgiveness. So I mean, I don't, you know, I think whether or not that would be allowed is somewhat up in the air. I'm relatively confident that the transaction could be structured in such a way that you wouldn't trigger the prohibition against the sale of medical debt. Okay, unrelated question. So what if a patient is from out of state and they get care in Vermont, say transferred to a Vermont hospital? I mean, I think of this most likely, the scenario I'm thinking of is most likely someone from a state in New York being transferred to UVM for tertiary care and critical situation. Does this, I assume UVM has policies that would apply to those patients, but does this a policy applied or not? So, oh, go ahead, Emma. No, no, please. My reading of the Act 119 is that a patient in that situation would not qualify for patient financial assistance. But Eric, if your reading is different, please chime in. Well, I mean, so I think one is it has to be measured against the baseline. And I'm sure individual hospitals, they have broad discretion, there's always this catch all, so they may find it in that. And I think certain hospitals are much more interested in that than others. The one exception to that would be that a Vermont resident is someone who, as it's defined in statute, is someone who lives, works, or goes to school. So, for some of those Edge counties, let's say someone lives in New Hampshire, but works in St. Jay, they are a Vermont resident under the statute and would be entitled to get free care. So it deals with the Edge cases. Oh, no, I was just going to say also that I mean, I think Act 119 is setting a like a minimum floor. And so I think a hospital could, of course, be more generous. And so I guess when I was saying that like if this person truly lives in New York and they get transferred to a Vermont hospital for this type of care, it doesn't mean that minimum, but the hospital, of course, could have a more generous definition that would allow for somebody in that situation to get financially. On the chart you showed earlier, with five of 15 Vermonters being at the level of where they could receive free care, seven of 15 low cost, those are additive. So 12 of 15 would get one or the other, could receive one or the other. And then the question that I had on that actually is on the low cost care, does that apply to co-insurance? So people who have bronze plans, who have high deductibles, does the patient financial assistance, do the patient financial assistance threat fold apply for people who have co-insurance that they have to pay for the hospital care? Yes. Yeah. So the uninsured patients, the discounts taken off the amount generally billed for insured patients, it's taken off their out-of-pocket costs. So that could be the deductible, that could be a cost sharing or co-pay is that type of thing. Could you explain, Board Member Merman, about the first part of your question about the okay. There was a chart that had five of 15 Vermonters would qualify out of the FPL limits for free care. And then seven of 15 would qualify in the FPL limits for low cost care. And I was just curious if those were additive. So is it 12 of 15? That would the free care or low cost care minimums would apply to them? So I think it's five of 15 hospitals. So it's not patient. So it's explaining what the current landscape is. Yep. I misinterpreted that. Thank you. That's okay. Thanks. Thank you. That's all. Thank you so much. And I will say, I guess just adding on to that point, many more hospitals are very close to meeting the requirements or exceeding them. So sometimes they're above 40% minimum, all the way to 350% FPL. But under Act 119, they need to be at 400% FPL. So many hospitals are close. And I don't think we know. I mean, a lot of hospitals retain discretion to approve or not. So even though their formal standard may be stricter, they could still exercise discretion. The IRS regs are exceedingly open-ended. It's essentially just you have to have a policy. Our concern with discretion in the exercise of it was that it makes it exceedingly challenging to challenge a given determination when the standards that are applied are unknown. It also, in our opinion, opens the door for unintentional discrimination. So that's why it's that way. I just wanted to say thank you for the presentation. It was very informative and very clear. So I appreciate it. I don't have any other questions. Great. I usually turn to the health care advocate, but you are the health care advocate. So I will open it up to public comment on either of the presentations today. Here, thank you both for your time in the presentation. Is there any new business to come for the board or old business? And I don't know if we need to adjourn because we have a second hearing. Yeah, okay. We don't need to adjourn. So we will take a break and we'll be back at Susan. Is it one o'clock? One o'clock. Okay, great. So we'll see everyone at one o'clock. Thank you.