 Good afternoon and welcome to the Green Mountain Care Board meeting. My name is Kevin Mullen and we have an exciting board meeting planned for today and to start off I want to thank the members of the legislature who are in attendance and also the members of the congressional delegation staff that are in attendance and we always appreciate it when you come to one of our meetings. We thank you for spending your time with us this afternoon. The first thing that I wanted to do which is not on the agenda but the first thing I wanted to do was welcome our newest board member Tom Walsh and I thought maybe would be appropriate if Tom introduced himself to everyone. We're very grateful to have Tom as the newest member of the board. Tom? Thank you Chair Mullen. I'm thrilled to be here with you all. Just a little bit of a background. I grew up in a single parent home in a small rural part of Northern New York State. I'm a first generation college student. I'm also nervous talking in front of people. I went to school to become a physical therapist and became very interested in health outcomes and how to measure those. That eventually brought me to Dartmouth College where I received a master's degree in outcome research and eventually a PhD in health policy. After graduating from there I've continued to teach. I've taught at other universities across the country. I started a small consulting firm helping universities and states build education systems to help health care systems adapt to changes in health care. My most recent work has been with the Joint Commission where I've led a team designing ways to assess the reliability and safety of large systems and worked with the VA health care system and Navy medicine to develop the skills, principles and practices needed to adapt to changes in health policy. So that's enough to get started. Thank you Chair and I'll send it back to you. I'm thrilled to be with you all. Thank you Tom. We're thrilled to have you with us. The next item on the agenda is going to be the Executive Director's Report, Susan Barrett. Thank you Mr. Chair and welcome Tom to the Green Mountain Care Board. Just a couple of announcements. First as I've been announcing for nearly a year now, we are taking public comments for a potential next agreement, all peer model agreement with CMMI. We have a portal on our website. I encourage folks to share their comments if they have any and we do share those comments with our partners at AHS and the Governor's Office as they are leading the negotiations on a potential next agreement. I'd also encourage folks to check out our calendar for the month of January and by the way, happy new year. Welcome 2022. I don't want to steal Elena Barrett's thunder or introduction here but I will say that today is at the start of a series of meetings that we're going to be talking about balancing access, quality and cost to ensure sustainability for our hospitals as we move to a value-based healthcare payment system. In addition to these discussions on January 26, the Board will conduct a certificate of need hearing on the Collaborative Surgery Center. That starts at 9 a.m. on the 26th and that's conducted via Teams. That afternoon we'll come back and we'll at 1 p.m. and we'll hear a presentation from our partners at DFR, Department of Financial Regulation, on the proposed updates to the Essential Health Benefits Plan. And then after that we'll hear an update from our own hospital budget team on 2023 hospital budget guidance and hospital budget guidance beyond 2023. And that is all I have to announce. I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, December 22. Do I have a motion? So moved. Second. It's been moved by member Pelham and seconded by member Holmes to approve the minutes of Wednesday, December 22. Without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion, signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show that the minutes were passed unanimously. So we have a great agenda for this afternoon and I just want to say before we start that Vermont is facing a lot of things in the healthcare system right now. We have the highest number of hospitalizations we've seen in the last week. The good news is that no hospital has been overrun, although there are hospitals that are at full capacity and have no more room. And so fortunately everyone has been working very well together. And thank you to our hospital leaders for the outstanding job that they've done to make sure that Vermonters are still receiving care during this very difficult time in our healthcare history. With that being said, today's meeting is a way for us to talk about what the future might hold and actually to learn some lessons from the past. And so without giving too much away, I'm going to turn it over to Alayna Barabee who is our strategic health policy advisor and who has put together this outstanding panel for this afternoon. So Alayna, whenever you're ready you can take it away. Great. Thank you, Chair Mullen. I will share just two very brief slides. So first I want to underscore some of the comments that you just made and recognize the historic challenges facing hospitals at this moment in time. Work for challenges are real. They're getting worse every day as physicians, nurses, and health service staff are experiencing burnout at a rate they've never experienced before. So while COVID relief funds paid to providers have been instrumental in offsetting increased expenditures and revenue losses experienced by providers earlier in the pandemic, these financial challenges faced by hospitals are by no means fixed. So with most, if not all, of Vermont providers still largely operating in a volume-based fee-for-service paradigm. So while it's clear that many voices that we need here at the table today are unable to join us as they're on the front lines of the pandemic, we must continue this conversation and keep a seat for them to join us when they're able. Each day we kick the can down the road is another day that healthcare becomes more unaffordable and our healthcare system becomes more unstable. So now is the time to develop a plan for solving these serious challenges of hospital sustainability, healthcare affordability, and equity. So it's clear that those that will be harmed most by doing nothing are those Vermonters who live in the most rural communities and those that continue to be un- and underinsured. So with that said, we've invited this panel of great leaders in healthcare reform to speak with us today about their thoughts on these seminal challenges, lessons learned from the ongoing pandemic, and ideas for the state of Vermont to consider as we move forward and build a more resilient and equitable system. So we're thankful to our federal, state, and health system partners that were able to join us today and we look forward to discussions and hearing your thoughts on these important issues now and as the conversation continues. So the agenda for today. So taking care of the introduction, but I will go introduce each speaker in turn in more detail. I'll kick it off for a board conversation at the end and then public comment and introduce some homework for January 19th. But today we'll be hearing and hopefully spending most of our time with first Dr. David Goodman who will be discussing capacity, is capacity destiny, Elliot Fisher from Dartmouth Institute as well on healthcare reform, where do we want to go and how can we get there, Michael H. Baylett of Baylett Health who will be discussing a path to hospital sustainability, healthcare affordability in Vermont, and Dr. Bruce Hamery from Oliver Wyman, Vermont hospital sustainability and implementing value-based care. So with that I will introduce our first speaker, Dr. David Goodman. So Dr. David Goodman welcome. As I mentioned, Dr. Goodman is from the Dartmouth Institute for Health Policy and Clinical Practice. For the past 30 years, Dr. Goodman has studied the causes and consequences of healthcare variation. His current research is directed towards unwarranted variation in the use of neonatal intensive care services. He was a founding investigator of the Dartmouth Atlas of Healthcare and a co-principal investigator for over a decade. He has led multiple Atlas projects on such topics as the physician workforce, end-of-life cancer care, post-hospital discharge utilization, and care for infants and children. His studies have been published in the New England Journal of Medicine, JAMA, health affairs, pediatrics, and New York Times. He has also served on editorial boards of journals, health services research pediatrics, the journal pediatrics. His teaching focuses on advancing knowledge and methods in medical care epidemiology and in evaluating children's medical care. Dr. Goodman has been a member of numerous national and international advisory committees and was the recent chair of the U.S. Council on Graduate Medical Education. And with his colleague Professor Gwynne Bevin of London School of Economics co-founded the Wenberg International Collaboration in 2010 with the goal of accelerating population-based measurement of healthcare in OECD countries. So Dr. Goodman, I will pass the screen sharing over to you. Great. Well, thank you for this opportunity. And now let's see if I can make this magic work. Can you see that? We can. Yes. This is a miracle. Okay. So let me get started. Again, thank you for the introduction and for this opportunity to share some of my work and work of, I would say, many colleagues as well. So is capacity destiny? When I refer to capacity, for those who aren't familiar with that term, more specifically, you might think of it as supply. That is supply of clinicians, physicians, advanced practice nurses, PAs, and other healthcare workers. And then the bricks and mortar manifestation of capital investment, medical and surgical beds, ICU beds, NICU beds, and so forth. And the questions that I'm going to address today in a very short period of time is, number one, is how is capacity distributed? Is it distributed rationally? How does variation in capacity relate to healthcare use? And does this variation in capacity lead to unwarranted variation? That is, is the healthcare variation unrelated to patient needs and preferences? And then how is capacity associated with outcomes? So this is really a synopsis of many studies and many studies that I can't present today by myself and my colleagues, principally at Dartmouth. So how is capacity distributed? Well, I think it's no surprise, particularly when I put up a map of adult primary care physicians. This is now measured at the level of primary care service areas, which are obviously these very small markets of primary care. And we look at the map and we can see, yes, indeed, it varies. And your eye will be caught by the light yellow, the light tan here. And you'll be concerned that there is a possibility of underservice there. And that is true. And of course, there are many regions of the US where there's an under capacity of primary care physicians. But what I'd like to point out today is that most of the variation in primary care physician supply, and in fact, physician supply in general, is beyond the threshold of underservice. So this is a very important topic in terms of how to get to physicians into serving certain populations and into certain regions. But we need to keep in mind that that's a very specific issue. We'll talk about that a little bit, but that there is this tremendous variation above that. The distribution of capacity in general is not related to patient needs at a population level. It's easiest to measure physicians. I'm going to use that as my specific examples today. Let's take, for example, the example of cardiologists. So this is a per capita supply. This is now a number of cardiologists per thousand Medicare enrollees across 200 and rather 306 Dartmouth Atlas regions. And you can see that there are big differences in these regions. These are all, by the way, regions of tertiary care from rather low to relatively high, or I should say rather low to relatively high. On the X axis is the rate of acute myocardial infarction hospitalization per thousand Medicare enrollees. And the point is, is that there's really no relationship between the two. So that risk, cardiovascular risk, and disease varies a lot. The supply of cardiologists varies a lot, but they're not related to each other. Moving away from an elderly population now to the newborn population, this is a population where we can measure risk very, very precisely. And for example, this is now measuring low birth weight rates across 246 neonatal intensive care regions. And Vermont would be down here. Vermont has a very low rate of low birth rate burst. Places like Baltimore, Louisiana, are up here. Big differences across the country. Socioeconomic risk also varies a lot. This is low educational attainment and there are big differences across the country. And this is closely associated, by the way, with maternal and newborn outcomes. But if we look at capacity of NICU beds per birth, again, a lot of variation, but no relationship between needs. So the regions with higher perinatal risk, and not just risk, but higher perinatal specific needs in terms of illness levels, are not the places in this country where you find higher number of NICU beds or a higher number of neonatologists, I should say. And this is generally true. It's true for a medical specialist. We've looked at a variety of medical specialists. For primary care physicians, it is also true with the exception of family medicine where there's a weak association of family medicine, a positive association, I should say, of family medicine and socioeconomic risk, not health status, but socioeconomic risk. Advanced practice nurses tend to be distributed. Their distribution tends to correlate with physicians. Although there are obviously exceptions to this, it can be critically important in health profession shortage areas, medically underserved areas, but in general, most advanced practice nurses are not practicing in those areas, and they tend to distribute where physicians to. Hospital capital investments, this is beds of all types, and I'll show you some of this. These, again, don't distribute in accordance with need. Next question I'm going to address is does more capacity lead to more utilization? And the answer, you're not going to be surprised by this, is generally yes. I mean, generally capacity gets used up to the limits of its capacity. So for example, if we go back to the number of cardiologists across those regions and look at the number of visits for beneficiary, we see that there's a strong correlation places with more cardiologists, more visits, even though the cardiologists are not distributed in the regions, not preferentially distributed in regions with higher cardiovascular risk, as represented by acute myocardial infections, infarctions rather. Looking now at medical discharges, acute care beds per thousand. Again, we can see this wide distribution, correlation between that and all medical discharges. This is medical discharges for things like congestive heart failure, pneumonia, and other conditions where there's a lot of variation in the way that these patients are cared for and in the probability that they're admitted to a hospital in a particular market for conditions for which the diagnosis is certain that there's, you know, this consensus and what the diagnosis is like hip fracture and where there's a consensus that all of those patients or essentially all those patients ought to be admitted to the hospital. We find that there's no association with capacity. Patients for which there's a consensus they all need to be admitted, they definitely get into hospitals. Capacity operates across particularly medical admissions, which are generally seen as being discretionary in that some places are able to care for those patients in a way that they are less likely to come into the hospital and other places. The probability of coming to the hospital, even with the same on this level, is much higher. So now what about this notion that of utilization that may not be needed or wanted of what we term unwarranted variation? So I've already pointed out that capacity is associated with utilization and now I'm going to go back to the newborns. This is a study that we're doing in Texas, looking at Texas Medicaid newborns. And again, this is a unique population because we have these very, very precise measurements of all of health status and health risk in all 1.1 million newborns. This is now looking at the care they're receiving across the 50 largest hospitals in the state of Texas. This is very low birth weight newborns. These newborns are all sick. A lot of them are very, very sick. This is looking at the number of special care days that they receive. You can think of them as a number of NICU days. The average number of NICU days is 58. So they need and they do spend a lot of time in the hospital and that's very, very beneficial for them. These measures now, these sort of relative rates of the number of special care days are highly risk adjusted in a way that we can do, again, so much better than we can do with Medicare beneficiaries because of this precise individual level information that we have. And it shows that from hospital to hospital there are big differences in how many days these newborns spend in the hospital. Now you might ask if there's benefit in being here or if there's harm being here and I'm going to address that question in a couple of minutes. Before that I'm going to show you for a much less sick newborns, late preterm newborns. These are 34 to 36 weeks gestation. On average, they spend about four or five days in a NICU. But again, depending upon where they're admitted, there are these huge differences. Now, NICU care is a critically valuable, important service. It's also a very, very expensive service. It's a baby who's admitted to NICU for a commercial pair is a single most expensive hospital episode, more expensive than orthopedic care than cancer care. So this is a place of great concentration of resources that in general is quite beneficial for newborns. But you have to wonder what's going on here when you see this variation, whether there might be opportunities to reduce newborns exposure to time in NICUs and to save money. So when we think about this question or try to address it is more better we rely upon this theoretical construct, which is I think obvious. But I do want to give my thanks to Elliot Fisher and to other colleagues who worked with Elliot and really doing laying down the theoretical framework in healthcare for this discussion. And so bear with me, but you can see that obviously there's a point with capacity where if you add additional capacity, patients will benefit. This is a steep part of the curve. There's also at least theoretically a point where it begins to level off where additional capacity doesn't give quite as much benefit. And then one reaches a certain point where if it makes no difference to be this level of capacity, no advantage to be this level of capacity compared to this, then well this is the efficiency benchmark. I mean you're just wasting resources if you're over here. And one can certainly make the argument that like all good things in life like sunshine and food and fresh air that an exercise that there's a point where what is generally good can be quite harmful. And so we also have to consider that that too much capacity or healthcare can be harmful as well. So primary care and health profession shortage areas has been empirically demonstrated to be on this part of the slope of the curve. That is you add more resources to these sites and the population as a whole will benefit. And that's the basis of a number of really laudable public programs. Primary care outside of these regions are more along this part of the curve. So there's a little bit of detectable. David, I think you may have muted yourself. I could hear. Can you hear me now? Can anybody else hear him? Yes. Yes. Okay. Okay, let's let's try it again. Okay. Okay. No one is ever accusing me of being too quiet, but okay. Can you hear me okay? Yes. Okay. All right. If we look at neonatologist or hospital capacity is good evidence that that by and large, there are exceptions to this and particularly in some, I would say probably some regions in Vermont, but generally hospital capacity is operating in this realm of inefficiency. So does more care always benefit patients? The answer is no. And I'm going to return back to those newborns in those hospitals in the state of Texas. You recall that for very low birth weight babies, a number of special care days they spent in the hospitals varied a lot. So these are those hospitals. The bigger hospitals have bigger dots, the littler hospitals, little dots. And what we're looking at now is the association of the number of days on average that these babies are spending in the hospital with 30 day adverse events. These include mortality, readmission, and emergency room visit. So these are very sensitive indicators of things not going well for a baby or things not going well at home for a newborn. This is 30 days after discharge. And there is no evidence that the babies that are discharged from the hospitals, which on average they spend less time in the NICU, that they have more adverse events on average. Doesn't mean that there aren't some babies who get sent home too soon. I mean this can always happen and there are some babies who are held back too long. But we can see that this practice style in these hospitals, there's no signal of adverse events. And if we look at the less sick cohort, the late preterm newborn cohorts, it's the same phenomenon, no evidence of harm. That's looking at the newborn. Let's go back and look at the elderly. So one way of addressing this question is more better is to standardize the outcome. So Lex, instead of looking at the relationship between, say, capacity of utilization and outcomes, let's fix the outcome and then see the different patterns of use or different patterns of capacity. And we have done this, and Elliott's going to, I know, refer to this study design as well. He's done much of the work in developing it, is to take a group of Medicare beneficiaries who have chronic illness and who have died, and then to look at their care in the last six months of life. These individuals can be assigned to hospitals on the basis of where they're receiving most of their inpatient care in the last six months of life. And we're able to measure, in this case, what we're measuring is clinical physician labor input. That is a clinical FTEs. This is measured through looking at professional claims, CPT codes associated with the work R views, knowing the number of average work R views per internist, per cardiac surgeon, per rheumatologist, and calculating the clinical FTEs. And we can see that NYU Medical Center, this cohort on average, they died about 82 years of age, and they receive 28 FTEs per thousand of these beneficiaries in the last six months of life. Primary care, 8.8, medical specialist, 15. Now I'll draw your attention to the Mayo Clinic in Rochester. The average age of death is just about the same. 8.9 FTEs, less primary care, so there's no substitution here, less primary care, less medical specialists. Health care systems health care systems unknowingly, typically, are very adaptable at using, you know, high amounts of capacity that's available to them in their environment. They're very adaptable in evolving health care systems. They're able to deliver very, very good care with low capacity as well. A different study that Dr. Fisher and I collaborated on looking at this issue from a patient's perspective. This now takes physicians per capita across the Dartmouth Atlas Hospital referral regions. We divide those regions into quintiles, the lowest quintile, the highest, you can see that the highest quintile on average now has 60% more physicians per capita. And this can be done, we have done it for both primary care and specialist. And by the way, the findings are quite similar. Looking at technical quality now, QMIs, congestive heart failure, pneumonia, is essentially no difference in technical quality related to physician per capita capacity. There are slight differences, but these are slight, particularly when you consider that, you know, rather light touch interventions in these places can definitely alter favorably these technical quality scores. Increasing physician capacity to like the highest quintile across the whole U.S., you couldn't think of any intervention that could be possibly more expensive or difficult to achieve and for not really any benefit. From the standpoint of the Medicare beneficiaries, ever had a problem and didn't see a doctor, do you have a particular place for medical care, satisfied with ease of getting to the doctor, satisfied with doctors concerned for overall health, satisfied with quality of medical care, capacity is not important. That's not to say what doctors do is not important. I think what this says is that what doctors do is very important. The number of doctors that happen to be in a region is much, much less important than the way the care is organized and it's delivered and the quality of that care. Now I'm going to give a cautionary note and then I'm going to end up with talking about some ways that different jurisdictions have tried to wrestle with this problem. This is a tough problem and to demonstrate that I'm going to go to the most centrally planned and organized healthcare system arguably in the world, which is an English NHS. And this shows measurements across these regions called primary care trusts. They were used during this time period as a way of both measuring and organizing and funding care, not just primary care, but also secondary and tertiary care. The BRITs have a long history of measuring what they call deprivation in small areas. One of the components of the deprivation index and it's one of the most important components is early mortality. So this is mortality rates in those under age 65. Obviously this is an age where one ought not to ought to die. England is like the US. I mean there are great disparities across regions in terms of socioeconomic risk as well as actual health outcomes. And what they do in the NHS is they fund in accordance with deprivation index. It's very intentional places with higher deprivation indices get more money. Now we're going to look at the supply of general practitioners, the primary care physicians. And we're doing this by looking at their patient list. So every patient has to register with a primary care doctor and list size can be seen as if you measure list size then you have a very precise way of measuring the number of physicians caring for a particular population in a region. And this is what primary care supply looks like in England. It's as irrational as it is in the US. So why is that? Well the GPs are not employed by the NHS. They are independent practices. They are contractors. They're vendors, if you will, for the NHS. They're contracts are negotiated by the British Medical Association but they have great flexibility in how they organize their practices and where they settle. So even in this very planned economy, healthcare economy, we have these problems. So what are some of the responses to under and over capacity? Well this is a really interesting report to look at from this New York State Commission on Healthcare Facilities in the 21st century. New York State looked at itself at a state level and concluded what health services researchers certainly concluded a long time ago which is that it was an overbeated state and that it was driving irrational care and very expensive care and they constructed a commission that they tried to devise so it would be relatively politically and lobbying immune for the decisions and the recommendations that they made that once this committee made the decisions that there would be action on the ground. And they identified regions of over where there was a high bed supply and facilities that they thought ought to be closed for a variety of reasons and this would help to reduce capacity. They were partially successful. You may recall that there was a hospital in lower Manhattan that on the basis of this commission, that hospital closed down. It caused a local commotion but it was closed down. On the other hand, Syracuse, New York where I went to medical school, Crow Serving Hospital is adjacent and connected to the University Hospital and Crow Serving long time after I graduated was identified as a hospital that was redundant in a service sense and in a capacity sense and they're still in business today. It's tough stuff taking away capacity which means it's even more important to be very wise and careful about adding capacity. Numerous states of course and the federal government but I want to point out states because I'm talking to a state now and there are states that have been very energetic and active in their incentives and subsidies for sustaining primary care both through funding training programs and also for subsidization of practices. Primary care and other marginalized services. These communities need directed investments. This is where the marketplace there's failure all over but this is where the worst failures are manifest. Now there are other countries who do this differently and that is that they ignore capacity but they don't ignore the effects of capacity and so one way of handling this is saying well at least we're not going to go bankrupt from this and so they use a uniform fee schedule simply to turn down price. So when over capacity or over enthusiasm in the part of the providers lead to high levels of utilization that's not in the public interest the price is decreased. Now you can say well that's going to increase volume and it does to some extent but by and large of course these countries have the percent of their GDP that goes to healthcare is a little bit over half of what is in the U.S. and they have much better outcomes and although you can say well Japan is a very homogeneous country no one can say that Germany is today with the immigrant population so these are in Germany in particular is becoming a diverse country with a lot of the same challenges that we have in the U.S. Numerous countries have this is not what they call them but they're essentially capacity commissions that provide not you know one snapshot but ongoing surveillance of the different dimensions of capacity monitoring their met their both their manifestation and their consequences and then promoting policies these commissions usually are not delegated the authority to intervene but their recommendations are taken very very seriously both in terms of who gets trained or where public funding goes through training and also how public funding is used for you know for shaping investments into into capacity and an organization of care. Capitation in theory if if capitation was linked with meaningful measurement based accountability then one could argue that that those firms or those regions would on their own they would rationalize capacity because it's very clear what the goals are in terms of outcomes they are measured by it they're incentivized by it and then that would lead to more appropriate investments and and you do you can see this in in prepaid group practices like Kaiser Permanente I mean Kaiser Permanente does not have excess capacity in NICU care and they have great outcomes risk adjusted outcomes and there are many many you know examples of that and it's hard to achieve but but it's good to keep that in mind so is capacity destiny well the way I think of it is that it's not destiny but levels of capacity are strong and typically invisible currents most healthcare systems don't know what their level of capacity is and yet those currents those health systems are unknowingly rowing with or against that current so you reduce readmission rates in a place where bed supply is high and what happens to that empty bed it doesn't it doesn't get closed it gets filled it gets filled and and with what patient and there is evidence that maybe not all those beds but a high proportion of those beds get filled with a discretionary admission the same admission that in another place with lower level capacity would be cared for outside the hospital just as well and then finally I'm going to leave you with this which is it's a reminder to myself not to you as someone who tries to ask questions is this continual struggle in healthcare are we asking the right questions and you can look at this here this I mean this could be in Vermont although it's in upstate New York but here you have this a tunnel scene this fellow who is a firefighter who's staring at the pumpkins here and and he is thinking about something but he sure isn't thinking about the right thing and this is a this is a challenge I think to all of us and I will leave it at that thank you very much thank you Dr Goodman and so we'll hold all substantive questions to the end and I'll present or I'll introduce our next speaker unless there are any clarifying questions from the board but we'll assume you will have asked those okay so next we'll have Dr Elliot Fisher so Elliot Fisher is a professor of health policy and medicine and community and family medicine at the Dartmouth Institute and the Geisel School of Medicine his research focuses on exploring the causes and consequences of regional and provider specific differences in spending and quality and we're recently on developing policy approaches to slowing the growth of spending while improving quality he was one of the originators of the concept of the Accountable Care Organization or ACOs led the research that demonstrated the feasibility of the approach and worked with Mark McClellan now of the Margolis Institute to achieve their inclusion in the Affordable Care Act his current research is focused on exploring the policy and organizational factors that influence health system performance in the US and what can be done to reduce costs improve health and improve care he received his undergraduate and medical degrees from Harvard his MPH from University of Washington and advanced training in negotiation at Harvard Law School he served on the board the Fannie E. Ripple Foundation and helped design and launch their first flagship initiative rethink health and he published over 200 research articles and commentaries and as a member of the National Academy of Medicine so welcome and thank you Dr. Fisher hey great can can you guys hear me at all or that's the first miracle now the second thing we'll try to do is see if I can share my screen appropriately and with any luck let's see I gotta bring you guys back up somehow can you see that screen by the way and yes let's see there we are all right now I can both see you and the screen and now I'll start the presentation and then lordy lordy will be on our way oh god don't you guys love the mirror love teaching in zoom or doing stuff in zoom first thank you so much for having me it's really an honor to be here you know see some former students and colleagues trying to make the world a better place for the people who live here um I also thrilled to be able to follow David who has done so much of the remarkable work about the importance of capacity so directly related to the sustainability challenge that the hospitals are facing um I'm gonna pivot a little bit um to try to think about where we might go from here but I'm gonna gonna I'm gonna both touch on some health services research um but also talk about you know what I've learned about negotiation for many years and some advanced study at Harvard Law School so here we go um here's your charge which I think I can I've summarized in the bold terms on the on the right you know better health lower cost better care a great workforce simpler um and I know you know given COVID-19 and what it's revealed about disparities equities for all of us also and a really important priority and whether it's in for various kinds of disadvantaged populations um the challenge of course is that it's really hard to do you know the biggest challenge facing American healthcare is rising health care costs um it doesn't help to increase somebody's deductible they're gonna have to pay it financial toxicity is one of the most broad you know more than half of the American public reports that they're harmed by the the costs of health care um directly upon them and yet it is almost impossible for us to make meaningful progress except in remarkable circumstances um so what I want to touch on is what I think are a few barriers to getting there you know why is it so hard first pessimism uh we feel you know it it's an extra role help rising health care costs is like the tides we're not going to do anything about it what about population health it's impossible so we tend to be fairly discouraged um a second reason is we ignore the weight where the waste is and David has pointed us in some of those directions um we have a fragmented system and all that's really what I think is the major barrier um to improving the value of care in our system and finally policy change is really hard it's like there are plenty of people who don't want to change so let's um look at what's possible you know I I've been privileged over the last 10 years to be involved with rethink health which is an the flagship initiative of the ripple foundation when we launched it one of the things we realized we needed to do was try to gain some insights into what is happening um in the healthcare system what are the factors that drive um better health better care lower cost one of the policy interventions that might make a difference working with you know some of the leading systems modelers in the country um we developed some simulations in 11 local places um and you know it's a complicated model there's lots of math behind this but the idea is based on the best possible evidence we could test interventions um in combination to see what would happen um if we um tweak the system over the next 20 to 30 years what would happen to cost what would happen to disadvantage uh and you know we we published one of the papers that showed what's potentially possible I suspect Robin if she's there I mean commit I'm supposed to say board member lunge what am I supposed to say um um has worked with the model when she was at mhcds um but what what we found was really you know in some ways exciting for those of us who want to be who are optimists about the healthcare system now uh the key elements of the strategy not surprisingly reduce modifiable health risks get people to you know what in another work with a team from the university Washington we showed that you know reducing modifiable health risks would increase American life expectancy by 10 years um adopt global payment models support and spread innovations and improvements in care delivery address the truly upstream health determinants like socioeconomic disadvantage and early childhood education and lack of labor force involvement and then the trick to the model is that you figure out a way to capture the savings so that you can reinvest the savings to fully fund the cost of those extraordinarily expensive initiatives which I just presented but the results are pretty impressive up so let's see if I can go backwards one you know when you when you implement the model you can reduce total per capita health care costs over the next 20 years 25 years by 15 percent you can reduce the prevalence of severe chronic illness by 20 percent you can increase the income of the employed population by 9 percent that's the biggest number what you've done is you've produced a healthy workforce if we think about Vermont and our efforts to recruit people from out of state well what if instead we decided we're or in addition perhaps not to criticize the governor in addition perhaps we decide we're going to invest in creating a healthy population so that they are able to work and finally we're concerned about equity and the disadvantaged portion of the population falls by 20 percent because they're they're now able to make a decent living the second reason we aren't making progress I believe is that we ignore where the waste is you know Don Burwick and oh I forget the first name of the second his second author in 2012 published an article estimating the magnitude of U.S. health a waste in U.S. healthcare a second more recent article by William Shrank came up to essentially with essentially the same conclusions there's huge amounts of waste in American healthcare some of them are obvious and I'll mention one of those but the ones I want to focus on are really the first three failures of care delivery failures of care coordination and overtreatment which together I think are a serious problem the mistake is that we especially those of us trained as doctors tend to have a narrow focus on specific treatments on biomedicine I was trained to think about how to treat blood pressure this is the focus of medical education and we need it it's how you deliver care that keeps people healthy and safe the challenge is that oh here's oh yes I forgot to tell you an example I love it how many of you are familiar with choosing wisely I see a couple of hands raised you know at least a few of you are nodding others if you were looking puzzled anyway it's it's a wonderful effort I was at the meeting of the ABI M foundation where we came up with this idea um let's get people to pay attention to low value tests procedures and drugs and that will reduce harm and cost and now over 80 specialty partners involved there are 520 recommendations everybody's buying into this so question how much money is on the table well a wonderful study you know from just about a year ago looked at this carefully in the Medicare population and you know they found that about 36% of enrollees were receiving some low value care well that's bad there's a lot of harm potential harm there from getting that done um but the spending on low value care there was 50 52 dollars per person now there's been a huge campaign and they saved six dollars per enrollee over the over the four years by reducing now there are all sorts of assumptions under there the key point is about that that dollar now 52 40 46 it's not much money who knows who that's a picture of I can make it bigger if you want he's famously said go where the money is I'm mute I want to hear he's a famous bank robber bank robber exactly so we we're not going where the money is and there are two places where the money is that I want us to pay attention to the first is this this notion of care delivery it's really the supply sensitive discretionary care that David already referred to it's not what treatment it's not what the biology is it's where by whom and how often treatment is given it's something we don't think about I was never trained when to see the next patient for high blood pressure but in some other studies we did we know that this how frequently the same patients are seen for high blood pressure across the country varies by a factor of 12 you have some doctors in Oregon when would you see the next patient with welcome your patient with well-controlled high blood pressure they say in six months or a year in Miami and McAllen Texas they say every month you know the site of care is similar by whom they're seen how often this is you know what David pointed us to that is there's lots of care that's not biologically driven it's driven by the way we think about delivering care and one insight we've learned from COVID the disaster that has been COVID is that innovations in care delivery can mean we can deliver care in all sorts of different ways we have ICUs built in parking lots and patients seen by telephone I was really lucky to have been given gazillion dollars by the Robert Wood Johnson Foundation to look at this at a national level in the Medicare population and this is a subset study because the initial studies were criticized because we looked at the whole population and found 20 or 30 savings because there's a lot of waste in the low spending regions compared to the high spending regions and then all the academic medical centers said no no no you're not looking at the best hospitals in the United States you're looking at everybody and maybe it's because there's lousy care so we did another study which looked at the subset of best hospitals in the America in the United States the top 300 members of the council of teaching hospitals and then they complained still and we looked at the top 100 academic medical centers all the same findings which I'll share with you now the first thing is we studied patients with heart attack hip fracturing colon cancer because they had similar baseline risk everywhere in the country it would provide insights into the quality and outcomes of care for three service lines um orthopedics cardiology and oncology and if we find patterns consistent across those service lines and diagnoses it'll reveal shared attributes of what the healthcare system is and they were measured root according to regional intensity and David's already showing you how they treat people at the end of life it's a travesty I had to I had to go give a talk at Langone after we did that study um and talk to them about how much they cost anyway what we found is if you look in the first six months where everyone's been hospitalized the spending differences are pretty substantial in the highest group in the highest intensity hospitals the differences for heart attack with about 600 bucks per person 600 bucks for colon cancer and about 730 per patient in those first six months but if you look at patients over the following six months to five years and they get all their care at these hospitals right there's loyalty to these hospitals we know that because we measured it um the differences per person are per year are incredible so you can reduce the this study the national study because we found that outcomes were no better quality was no better access to care was no better by any measures we have this was the these were the findings that ended up putting me on the road to talk about the possibility of saving 20 to 30 of us healthcare spending if we could learn how to adopt the the practice of the lower spending regions time wise not to add another place where waste is common and that's high prices and you all know that this is just a figure from Kaiser Family Foundation looking you know comparing the Baltimore region where the average in network charge is $23,000 for a joint replacement and it's $60,000 in New York pricing power is a clear problem states that decide they're going to do something about it such as Maryland can do better now turning to my more recent frustration with why I've made no progress after deciding that you know at age 23 to go into medicine to try to reduce the cost and improve care for disadvantaged populations um I think that the challenge is that we have an incredibly poor system if we try to control prices um on the public side and we know this providers can raise prices to private payers because they have market payers we do bundled payments providers will shift costs out of the bundle deliver more bundles oh this is my favorite acos for some patients so I thought this was going to be a nifty idea well that's great you can use the aco model to keep some of your patients in the aco out of the hospital and fill the beds as David was pointing out um with higher paying patients if you limit the profit of health plans they can raise premiums or lower provide lower value plans and my perhaps most egregious is think we're going to reduce costs by limiting increasing co-pays and deductibles and we just increase discretionary care for those who've met the deductible said no impact on health care costs the fact that we all are now in high deductible plans um so and you know in vermont I'm afraid our porous system is not helping with this you know if you've got multiple payment channels it is easy to shift from one payment channel to another in order to increase your maintain or increase your revenues so in a paper I wrote from the journal catalyst um a year ago I think we can overcome this if we think about a global budget for the state capitation to something I refer to there is population health organizations but if you can imagine every you know community in in vermont having a primary care focused population health organization that pays attention to both population health and great primary care to implement what rethink health says we could do you need good information to find the leaks and improve performance and you need administrative simplification you know that's a single system um and I don't care single payer regular multiplayer you just got to figure out how to put your hands around this thing and get rid of the all of the administrative waste and be able to constrain um what our providers providers are doing so that they now and our health plans are competing on value not competing by shifting risks for raising prices or shifting costs to others but can we so I'm coming coming down the home stretch here the underlying problem is that you know and I'm looking at Michael here you know it's really hard to change policy you know um but right now in vermont we have a process headed for failure a divergent stakeholder of perspectives many of whom could easily block block progress their current focus is on positions you know reading the letters that have been written to you guys it's like oh don't touch hospitals that's our position you shouldn't be interfering at all with the hospitals or a vermont medical association let's just increase the payments to primary care positions I'm not being completely fair there's lots of good to these proposals but let's increase the payments to primary care physicians without mentioning that maybe we have to figure out where we're going to find the money the decision making is structured this way stakeholders are largely asked to make concessions you know a representative will say or the chair of committee will say you know won't you take this behind the scenes and and why would you give anything up before you know it whether other interests are being met um and no one has the primary ongoing responsibility for inventing a creative and feasible solution well if those are the diagnoses I'm a doc you come up with some prescriptions you know engaged stakeholders in a process specifically designed to make them willing to support a final proposal explore interests and create solutions focused on the public good that meet the party's core interests you know in terms of decision making encourage criticism of a working draft with no commitment iteratively or fine but then present a final decision well it's this or nothing is this better than no progress this year or is this better than some progress this year and finally you can't do any of that without establishing a dedicated team to manage the reform process and develop proposals that could achieve broad support and overcome the technical challenges might this work well it has this was the method that was you know that was used by um president carter and cyvance um to you know through 23 different drafts uh adept camp david and led to the camp david accords and it's like almost funny uh oops uh much smaller scale but it's really what mark McClellan and i did when we tried went over a three-year time frame we tried to take this germinal idea that came from bluecrow in niceachusetts his own work with um at medicare for large groups and then our our work um to try to quarantine he came up with some money from brookings i came up with some money from the darwin's institute um to work over a three-year time frame to gradually refine a product refine a proposal and get it presented and you know it it was a pretty long process uh and you know it ended up being included in the affordable care act and the rest of you are suffering the consequences of our success um so next sunday if you were listening to christa tippett desmond tutu said about the truth and reconciliation commission reconciliation is a process it's not something that is just an event and i want us to sort of remember that as we think about health care reform it's not a product it's a process and so i think we should invest in the work in what we need to do um or i hope you will think about investing doing the work and what yeah we've got to get back to advance my screen might this work here well i think we should think about establishing such a process and it might look something like this you know there's a dedicated team uh that identifies interests invent options develop draft proposals review some of the refines and then present yes or opposition they're gonna have to do that with all of these content experts um and in consultation um with all of the stakeholders and decision makers what are their interests why are the you know what's not addressed in this draft how would and you don't have them tell you how to revise it you have them tell you why they don't like it which gives you insights into what they might better be able to like so to sum up we all know the challenges we face it's a total mess the barrier if the barriers pessimism create a shared vision of what's possible and perhaps do that by convening a multi-stake stakeholder group here in vermont using the rethink health model we facilitated um sessions all over the country we could do it again here we ignore where the waste is so we need to broaden our perspectives on the opportunities and improve and i think the model can help there as well in terms of a fragmented system i you know i'd do our best to think about moving toward a single system um that can improve health care and costs while eliminating costs just and that's going to require data i didn't talk much about data but i know that can you know you all are working at the board is worried about it um but we we're probably in as good a position as any place in the country with the hie and the all-payer data um if augmented to really be able to measure performance well with meaningful clinical data of population health risks and then if the underlying barriers of focus on solution with each party thinking they're right and pushing their ideas let's shift toward a reform process for the long haul that serves up the best feasible solutions and then seek some expert guidance so i want to wrap up there i apologize for something of a sermon my great grandfather um was a presbyterian lay preacher known throughout asia and the united states and roaring and robbie um so i i come by my um preacher the attitude legitimately anyway thank you i look forward to any questions and i'll figure out how to stop to stop sharing thank you great my lady oh you got work thank you thank you dr fischer um so now we'll hear from michael bailet who will focus more on the policy um approach um so michael bailet um mba president of bailout health founded bailout health in 1997 and has since worked with a wide array of state agencies and employer purchasing coalitions in over 30 states including vermont michael's professional interests focus on how purchasers and regulators can influence healthcare markets to operate as efficiently and effectively as possible michael's worked with clients on affordability strategies payment and delivery system reform including aco medical home and episode based payment strategy design and implementation performance measurement and value-based purchasing and multi stakeholder change process guidance and facilitation in addition to assisting state and multi stakeholder efforts michael has also authored many reports and briefs on payment reform prior to founding bailout health michael served as assistant commissioner for benefit plans in the massachusetts division of medical assistance in the state medicate agency his responsibilities include the management of all of the division's benefit plans including the hmo behavioral health primary care case management and senior care programs also while with massachusetts michael founded the massachusetts health care purchaser group and served as its chairman and president and previously michael worked for digital equipment corporation and was engaged in health and welfare benefit planning and management activities for digital 60 60 000 u.s employees michael earned a bachelor of arts degree from west lee and university and an mba from the keloch school of management at northwestern welcome thank you michael thank you um can you all see my slides yes great okay well uh good afternoon members of the board i'm pleased to have the opportunity to speak with you this afternoon my plan is to summarize findings from a pair of studies that you all had performed for you and then to offer to you recommendations to address your twin objectives of hospital sustainability and affordability for healthcare for monitors i am i think at times going to make comments that are going to resonate with both david and heliott's comments that you heard before me so first i want to briefly summarize two studies that you had commissioned one by the berkeley research group looking at hospital quality and capacity and one by health management associates on payment and cost coverage variation and i'm going to summarize just six observations from their studies first they observed and i want to note that everything that they did was pre-covid and and i want to note that vermont's hospitals right now are going through a particularly stressful period um due to the um omicron surge so all this data um or almost all of it uh is pre-covid so what they found was the financial health of vermont's hospitals as it says by operating margin had declined pretty consistently over six recent fiscal years um i do want to note that when viewing hospital finances i think it's important not only to look at operating margin but also a total margin given the significant revenue hospitals generate through non-operating sources but nonetheless um declining operating margins over time could lead to hospital closures as this happened with rural hospitals across united states and of course um this is also going to harm health equity particularly for people in rural communities um two um they observed that commercial reimbursement is significantly higher than payer public payer payment um and higher than the cost of delivering services and that's linked to number three um which is that um these higher commercial reimbursement rates create significant affordability problems for vermont employers and residents uh and uh a survey conducted by vermont the household health insurance survey reported that for 2018 40 percent of vermonters under 65 reported being under insured and i'm guessing that percentage is much higher now and so affordability is a problem it's especially affordability for people with lower wages fourth they observed that several vermont hospitals operated very low occupancy and some of them are located relatively close to another hospital and there are a few examples of hospitals with low occupancy rates uh further projections for the vermont population indicate that some of the hospitals are going to have even more excess capacity in the future although there will be a few that will need to add capacity and then finally um they observed that the prevention quality indicators which are measures uh created by the federal agency for health care research and quality um found uh the composite score uh found uh was found to be below optimal levels so that means that the rate of potentially avoidable admissions is higher than one would want it to be and that might indicate an opportunity for improved community services that would avoid those potentially avoidable admissions so those were six key findings that i pulled from their research um and and from there i want to share with you some recommendations as to where to go next so i've grouped them as short-term and long-term i struggle with this a little bit because i'm not i'm not sure that there's actually a sharp demarcation between them but certainly some of the short-term ones are are easier to do more quickly so the first one is to study how much commercial hospital prices are rising annually on a per capita basis and how they're contributing to overall trend. Connecticut did this recently uh and um and the findings are pretty compelling they found between 2015 and 2019 out-of-pocket commercial spending was growing 6.5 percent a year and they compared that to wage growth and average wage growth was 2.6 percent a year so that that's a it's a pretty you know gripping example of the impact on affordability when you got out-of-pocket spending growing six and a half percent a year and wages at about two and a half percent a year so um this is this is not all that difficult to do you've gotten all pair claims database and you can do it using that information and i think that provides some important contextualization for understanding the affordability problem i think um you can also fairly easily use the national academy for state health policies hospital cost tool uh to better understand the finances of vermont hospitals easily accessible so these are shorter term things that you can do um a little bit more substantive as a policy change and something that would directly address affordability in the commercial market uh is to begin to constrain price growth in the commercial market um the green mount care board um i recommend you should use its regulatory processes not only understand hospital prices but to restrict how much they can grow and this obviously would involve a more aggressive use of your regulatory authority but there are examples of other states that are doing this road island for several years now has constrained hospital price growth by linking um uh price growth to um uh inflation so they've got that cpi plus one percent i'm not saying that's right but that's how they've constrained price growth and uh an evaluation published in health affairs showed that road island health care spending has grown more slowly than the other new england states during the period since they implemented this um in the commercial market uh and i'll note that uh delaware recently borrowed uh pretty directly from road island road island is a set of what they call affordability standards that their health insurance commissioner administers through regulation and uh delaware has replicated them so this is a strategy that um i would suggest for your consideration i'll also note because this is relevant um giving the all payer aco model in the state that road island also set a cap on how much um commercial aco budgets can grow from year to year um and then um you know be uh you know harking back some of the the comments you heard earlier um because uh capacity um uh should be viewed both in across the service uh spectrum and because there's some indication that there are more avoidable hospitalizations in the state than are necessary you might want to consider um creating some requirements for increased investment in primary care capacity and maybe mental health if that's relevant uh and so this is a another concept there are about a half dozen states that have created primary care spend targets to increase um their primary care infrastructure and bias really i mean to um support and sustain it uh and of course vermont's done a lot through the blueprint for health around primary care but at least i offer for your consideration that if you believe that there's not sufficient capacity for primary care uh and and i don't just mean counts of clinicians but i mean uh primary care teams that can support all the needs of providers you might consider a primary care spend target some of the other states that have done this Rhode Island, Oregon, Connecticut, Colorado and Pennsylvania and i mentioned a mental health spend target because there are some states that are starting to think about this too so these are um some shorter term changes some more substantive ones that that you know honestly are going to be more difficult to do and and as Elliott noted making change happen is really hard uh but but it's it's necessary and it can have it can happen uh in stepwise fashion it doesn't have to be everything all at once um i want to run through these uh slightly longer term or heavier lift recommendations i want to start also with the assumption that long-term sustainability of vermont's hospitals is intrinsically linked to long-term affordable quality care for vermonters so i i think you need to think about two of them at once and i'm i'm breaking down my recommendations into three categories delivery system reform payment reform and public accountability and at the end i want to comment a little bit on waste which Elliott gave a lot of focus to and especially the care delivery element of waste so even though these are longer term clearly to to take these actions that requires nearer term steps but but these actions would take place over multiple years so i think the Berkeley research group analysis in pretty compelling fashion identifies an opportunity if not a need to think about redeployment of hospital resources and and linking resources to community need and while COVID-19 has showed the need for standby inpatient capacity it's probably not prudent or efficient to maintain capacity for maximum pandemic need so i think some of the ideas to better leverage the hospital assets and some of these were identified in Berkeley research groups report are to consolidate geographically redundant inpatient capacity because there appears to be some of this within the state and then supporting alternative services certainly the hospital at home concept is is growing that's not the only alternative to inpatient facility capacity but it certainly is one worthy of consideration i think maintaining existing and needed outpatient capacity at facilities is important even if their inpatient capacity is drawn down and some of those services might be freestanding eds and observation beds and outpatient mental health and substance abuse treatment and then creating new and expanding services in place of the inpatient capacity where there's unmet need and i'm thinking not just of clinical services but also of social services as well because there probably is a better way to provide services in some of the communities than to maintain excessive inpatient capacity there are a lot as i said there are lots of alternative configurations for for where there is access inpatient capacity some of those are listed here i think the decision of how to do this needs to and this connects to some of the elliott's process recommendations but needs to be heavily community driven i think that resonates very much with the culture of the state and so i think the community should identify what their future needs are in terms of services if resources and are going to be redeployed at the same time i don't think it can be just can be decisions made individually by communities because many of vermont's hospitals are in relatively close geographic proximity so a decision made in one community is going to impact surrounding communities so this can't be community by community even if it's heavily community informed if not driven second category of recommendations have to do with payment reform as elena said at the very outset of this meeting hospitals continue to be paid largely on a fee for service basis in vermont it that creates a financial imperative to maintain or increase service volume because it's the only way that you stay in business but but that that's inherently inflationary and it's not really aligned with maximizing population health population health needs are not linked to filled hospital beds there has been some movement in the state to prospective budget-based hospital payment models and i would say frankly a lot more than in most states but it simply has not been enough vermont's hospitals are receiving too small a percentage of their payments through prospective budgets and sometimes they're reconciled to costs which means they're they're not really true prospective budgets and little progress has been made in the commercial market so i don't think that hospitals right now are well served by the current payment model and i don't think that employers and consumers are well served by it either so with all that is context i think a better way of paying for hospitals would be to provide hospitals with an all-payer global budget this was this concept of a global budget was one of the ideas that elliott introduced i think under such a budget hospitals would know their revenue for a 12 month period in advance for all of their major payers they could then focus on meeting community need and managing their expenses and not on filling beds and and generating revenue again i i think that there have been some steps taken in that direction using the payment models that one care is introduced with some of its hospitals but it's just not been enough this would provide hospitals with financial accountability i'm sorry financial accountability but also rewards for improved performance and quality and community health i think it needs to be coupled with regular reasonable increases in payment rates from both medicare and medicaid i think that's a necessary quid pro quo here and i know that mariland's had some successful experience with all-payer hospital global budgets they've been evaluated and published i'll also note that rhodi island is currently considering a modified and more flexible approach to that of mariland and and seriously considering it and finally my third set of recommendations have to do with public accountability i think a sustainable hospital system has to be an accountable one and and i think that there are a few things that can be done for accountability public reporting of how hospital performance incentives are structured what their measures and targets are and incentives is important public reporting of performance on a broad range of measures including improving community health especially if um if vermont is to move to uh true um hospital global budgets and then perhaps annual public hearings to talk about performance results and how to generate improvements so um so last i uh i just want to share a few comments on the topic of waste which resonates for me very much the shrink article that elliot referenced and and described in the slide from the berwick hack barth study defines waste quite broadly and and it includes within waste prices so i think i've talked about prices particularly in the commercial market because that's where the waste is in the commercial market but there's also as elliot highlighted tremendous amount of waste in clinical care um and i didn't focus on this in my recommendations because i've not been able to find any state that's found a way to reduce waste in clinical care as maddening as that is uh and including states uh states and i should say um non-profit community organizations that have taken on choosing wisely um i haven't found one compelling example of a broad-based effort to do this um i still though have hope that that's possible i have long thought that um that standardization of healthcare delivery and creation of the type of single system that elliot talked about might be through um might be possible through one care vermont i don't think that's happened yet um i'd like to think that the green mountain care board through its oversight function might be able to help push towards greater standardization of healthcare delivery that that drives down waste and and creating a more efficient single system is possible um but uh i want to note that that is probably the most difficult challenge of everything that i've just presented and i just put some really big boulders in front of you as policy objectives so um i i am um inherently optimistic uh and that pessimism that elliot talked about it does not reside in me but i just want to know that that's a really hard change thank you michael um that was excellent and now we will move to dr bruce hammery who's last but certainly not least um dr bruce hammery is a partner and the chief medical officer for the health and life sciences practice alvin wyman he assists hospitals health systems in large practices to redesign and reorient themselves to patient centered and population based care in prior times he was an executive vice president and chief medical officer for geisinger having responsibility for the clinical operations which you so brilliantly set up um michael thank you um research and educational activities of the four billion dollar organization so he was a professor and associate dean at penn state and served as an executive director of the university hospitals and he currently serves on the board of the bozeman health in montana excuse me and has previously served on the boards of several health insurers and other hospital systems welcome dr bruce hammery and and thank you for joining us well thank you and uh thanks to the green mountain board uh care board for the invitation uh my assignment to follow this uh esteemed lineup of people who have spent entire careers trying to solve this um is uh daunting and i have to thank all three of you for um you know sort of economics is the dismal science right um so what i'd like to talk about is how um places have have tried to um support community based care and rural care with the caveats that you just heard from mr bailet and from dr fischer and that is that a lot of a lot of the current inpatient facilities have been repurposed so uh if if we could go to the next slide please and then the one after that that's just a okay so the problem i think folks have outlined i've put some another slide here if you go to the next one you've seen this operating revenue is terrible proportion of hospital revenue even for that terrible operating revenue about a third of it probably shouldn't need to be in the hospital if you had if adequate access to appropriate community level services was available um average daily census is low lower in some places and others need to reduce beds has been um commented on and i would agree clearly that one of the things the current outbreak of covid has shown is that this that the system can adapt right we don't have to have keep 153 beds or 300 beds in operation pay for all the maintenance costs and the upkeep costs and in a time when the resources are constrained just because in some period we might need them just in the same way we do not keep a major hospital like uvm with empty beds in cases 747 crashes in burlington um okay so let's go to the next slide please okay now there are some national stressors to this number one is a nursing shortage and you've probably seen things in the news in the last several days about hospitals being short staffed because people are calling out sick but it's more than that it's because nurses are retiring or leaving the profession and the projected needs for a number of years have been in excess of the number of nursing people who can be trained this has gotten to the point where because of the extreme shortages during covid these folks that are hired in as quote traveling nurses are are being hired in at a cost sometimes of 300 an hour rather than the $34 an hour that was the national average two years ago they're also increasing salaries and shortages for all the other professional people that hospitals need to run shortage of workers and entry-level jobs housekeeping and dietary physician shortages in a number of areas and those getting worse as well because physicians are aging out we talked about reducing elective surgery the other thing which is interesting is that um dr fischer and i and some others trained in a time when doctors expected to work about 60 hours a week plus the current average in the us according to the bureau of labor statistics is 51 hours and the new graduates at least the ones we're trying to hire in montana and i live in boston by the way so but the ones we're trying to hire in montana are expecting a 40 hour work week no more than one night in four to five on call and most prefer one in six uh and of course um you know lifestyle which for the is important for everybody so so the point is that you know having a doc practice in a small community like the grandfather did where he was on call 24 hours a day 365 days a year and going to show up if somebody got sick those days are pretty well over and it needs to be taken into account when we think about about personnel issues man if you will manpower issues physicians apns and so okay and then third bullet from the bottom is a key one and it has been mentioned and that is that in a number of areas there is an association between the number of times you do something and how good you are at it between volume and outcomes and so as you think about things like obstetrics and you know at the high end everybody thinks about neurosurgery you need to have people at a place where they can do enough so that they maintain their skills you do not want you know somebody doing 20 a year and hoping that the outcomes are good last two issues are that other things that are beginning to drive price although hospitals are clearly the the hemath here are pharmaceutical costs are going up and we are currently experiencing supply chain shortages including including generic meds next slide please so what i want to do is show an example of an integrated organization that i led for a number of years as a way to think about regionalizing healthcare could we go to the next slide please okay so this compares the state of vermont with geisinger and i want you to see the population geisinger serves is about the same as vermont surface area is about three times greater number of employed docs at geisinger is about the same this number for vermont does not include physicians who are non-residents physicians who are providing telehealth services or those working less than four hour a week the number docs pretty comparable number of hospitals pretty comparable the geisinger service area has twice at least twice this many hospitals that are not geisinger owned or controlled some of them medium size some quite small number of critical access hospitals geisinger has one hospital beds about the same counties medical school etc etc just point out to you that down in the lower right there is an alcohol and chemical dependency unit there is a universal electronic health record which is key now you can do that with the regional health information exchange but part of the part of the secret to reducing duplicative care and inappropriate care is the ability of the doc who's seeing the patient to know what happened right and then the next is that we had a and have a centralized telehealth hub and you i think have an an addition of this at the university hospital but just drives telestroke heart attacks emergency room oversight and so and home health for that matter next slide okay these are just the three major groups of geisinger the provider facility is the physician group and then it does own its own health plan which since i've gone has is also become a Medicaid managed care group in as well as a Medicare Advantage program and commercial in short next slide geisinger medical center just a quick shot this is a 530 bed hospital which elliot came by 10 years ago and told us was already too big before that bed tower was added 530 bed hospital in a town of 3500 of 5000 people okay we employ almost 9000 people at that site now as i showed you the service area is huge but this is level one trauma bone marrow transplants kidney transplants so forth and so on women's hospital children's hospital so forth major academic center now bought a medical school four years ago elliot and so but had in in previous times 25 approved residencies 35 fellowships and so forth so big place very small town density of docs to population in the county is higher than mayo clinics because mayo's in a big and for elliot's information this and darkmouth are the only two federally approved rural academic health centers in the us and we can talk about what that means next slide okay so this is the service area of pennsylvania the dark blue is geisinger's primary service area the lighter blue secondary service area and the outline in gold is the area served by geisinger health plan and what i want to point out is right in the dead middle of that of blue area is a tiny little county called montour county that's where geisinger is and geisinger has a air transport system that involves five helicopters the service area in the blue in the light blue and dark blue is roughly 25 000 square miles it's mountains the biggest industry in that area is logging and timber geisinger is the largest employer with about 20 000 folk but the biggest industry is logging so mountainous rural tioga county up there at the top is said to have more people more dear than people so in that sense similar to what the issues that you face with you know a lot of small towns next slide this just shows the district the population this is old old data you see down the lower right it's about 1.3 million managed either by the health system or in conjunction with the health plan and then by the health plan and by the so the quality metrics and so forth are lined up between those two although the way that the care is influenced is different next slide this shows uh and i'm going to sort of skip through the next two slides but this just shows the multi-year journey that this takes i think it's several of the speakers have commented on nothing happens quickly and this is just as true in a totally um not i won't say controlled system i'm not sure anybody controls physicians or nurses or any of that because you still have to get consensus you have to get consensus with the communities about the care that you are able to provide that in their location and what care you are able to provide that meets their needs elsewhere next slide and i'm going to just skip this one and the next one this is detail next slide thank you okay so let's think about regionalizing health care and i'm going to talk about some of the things geisinger has done and also a number of other health systems and large hospitals have done and you know elliot has has i think spoken very um eloquently about dr hammeray i think you're on mute i'm sorry so i i'm sorry didn't so what we're going to talk about is regionalizing health care and ways to think about how you can support health care in smaller communities that may not have the population or economic needs sufficient to um to uh preserve a full-time inpatient facility next slide okay so we think about tiering health care both in um the ambulatory arena primary care secondary level specialty care and then higher end specialty care as well as in facilities and i think mr ballot commented on the primary care center and so the you know the classic of this the thing don berwick another started 25 years ago patient centered medical home with a staff that is that is team-based and has additional support depending on the number of patients so staffing with a physician an advanced practice person um you know you can care for 2000 to 2500 people you can add specialists in mental health a pharmacist the diatrous some you know for a um federally qualified health center you may have a dentist and so forth um they provide simple diagnostic services so some rate radiology ekg that sort of thing and importantly some simple treatment services so for example they can do inhalation therapy for somebody with an acute asthma attack so they don't have to go to ed they have the capability of providing an infusion so they can treat a person who has a skin infection of the leg um or you know in in some instances like huntsman cancer center perhaps do chemotherapy under supervision and then secondly you have other the what i call the primary level of specialists the folks that when the primary care doc thinks he or she needs help they go to the mental health folks the cardiologists the general surgeon and so forth and those people can be aggregated in reasonably close by centers with more enhanced diagnostic facilities perhaps linked to you you know using a hospital as a base that had operating rooms so that they can do ambulatory surgery and remember that more and more surgery um has been approved by medicare to be done on an ambulatory basis so knees for example total knees um and you know this is changing very rapidly have to tell you i graduated from medical school 50 years ago and the amount of change in the last 10 years has been absolutely phenomenal next slide okay tearing facilities again we've heard about the mention of a freestanding ed which you can combine with an ambulatory surgery unit you can have observation beds there a couple just you know to to make sure somebody's stable you know with the with diagnostic facilities medium-sized hospital a little higher care and these bed sizes are you know very approximate tertiary hospital you'd think about the university the really high-end stuff and then the quaternary hospital now it turns out and we've done these analytics for a number of academic health systems that quaternary university hospital stuff is three percent of all of their business three percent okay the rest of it is community level stuff and that gets to dr fischer's point about why is it costs so much now having run one of those places we can talk about that but okay now the the bottom here again just to repeat at any level of care the person delivering that care doctor nurse whoever needs to see enough to be competent if they're not then that is not high quality care and for me high quality care is the first threshold right if it's not high quality go somewhere else and so I think another question that the board could consider and I have not seen in any of the stuff I've been sent to review is what proportion of people are voting with their feet and bypassing and an available facility in order to go somewhere else that is something that when we assist health systems to look at their needs and futures that we look at next slide this is just an example of tearing and it shows taking the duplication shown in the top level of this slide particularly in the secondary care and moving and then redistributing that next slide okay so what do you need to do in order to accomplish this well the first thing is you've got to have good information transfer systems broadband at least between the provider sites the second and very important is you need transportation you've got to have ways to get people from a to b quickly and I'll give as an example what are called the STEMI programs which is the the American heart other approved programs for taking care of people with acute myocardial infarcts and that standard is basically time from pick up to balloon in the coronary artery at 90 minutes geisinger could get that done in 60 minutes from 200 miles away faster than New York City because we used helicopters and they couldn't networks published so some system of helicopters ground transport and don't forget patient transport to available services which is a problem in the disadvantaged some sort of central mechanism for finding you know getting people from place to place and knowing where beds are right because we hear every day I don't know about Vermont in particular but we hear every day of somebody spending hours on the phone trying to find a bed for a patient now a lot of aggravated by COVID but winding up states away so examples of of region and a centralized way to share the health data again it can be regional information exchange examples trauma system I've been around long time as I at least as I was able to find out Vermont does not have a recognized trauma system STEMI program we've talked about geisinger most other large health systems telestroke program geisinger had roughly 10 hospitals two or three we did not own in that partners has 30 hospitals that they manage out of Boston electronic ICU provides the ability to monitor intensive care beds and step down units and other sorts of beds at any location at any distance a lot of folks use that require standardized treatment protocols can support as I've said here STEMI telestroke and so forth number of hospital systems tele radiology people these systems have what are called nighthawk services where they don't have a radiologist on call to the emergency room they ship those films the electronic means to a group in Idaho telepathology you can read slides for for surgical procedures if that you have a technician at the site that can produce it tele telemedicine military have been doing that for many years and with COVID many many people have had experience with this um the patients generally view it as positive little less so among older folks and it obviously depends on whether you have access to broadband there are groups of sanford health in north and south dakota of vera health in north and south dakota that do provide tele oversight of pharmacy services in smaller hospitals so next slide please this is a slide of the network that of vera health provides services to and so you see it's uh six states very rural small hospitals they provide um not only pharmacy services but also emergency room oversight and what they say is that you know with the average response time of a doc to who's at home to an emergency room be in half an hour or thereabouts they can get somebody online in 15 minutes to help the nurse or the PA who's in need deep they can also do consults for infectious disease and endocrine and whatever and with the EICU capability support that they have just been bringing up the capability to do um oversee nursing homes now again all this has to deal with regulation and payment mechanisms and so forth next slide okay what are some other things that folks are doing next slide okay one program that has not been mentioned is pace a program of all inclusive care for the elderly this is a federal program been around at least 20 years now really being used like an insurance program it takes people who are duly eligible eligible for medicare and medicaid combines those dollars and gives them to a designated program that has a community oversight board and so forth there was no program like this that i could find registered in vermont uh we have done this at geisinger in two locations one in a city scranton the other in a very small town called shamoken which has a very high proportion of elderly people one of my epidemiologists told me once that the quickest way to get out of pennsylvania was to die because it is such an elderly group in the rural rural areas and what these services provide is adult daycare with a doc primary care there dental services care at home when the folks come in they can get meals they get their meds they can be counseled by a pharmacist or a social worker they can get occupational therapy uh in in effect is a capitated program it takes about 60 people 60 patients per site to keep this going because people die off right if you're sick enough to need a nursing home this will support you for a while to keep you out of hospital keep you out of nursing home but um you know you have to have a constant influx of new people next slide hospital at home has been mentioned and i think this is an important thought uh this originated at hopkins 10 15 years ago it has been widely used as a way to shorten inpatient length of state to get people out of the hospital when they can't you know if you're nursing home capacities constrained whatever it's been used as a way to avoid quote social admissions from the ed where you know you can't arrange for an ivy or something um um at home uh and a way to reduce dependence on chronic care i would note that there is now a commercial company that just within the last couple weeks got 110 million dollars invested by Kaiser Permanente and Mayo that does this that has protocols supports it electronically and so forth and so on uh so it's not something any longer that people need to have the internal capability to develop uh it's used to shorten while we've talked about that reduces risk of hospital associated complications some of those things and and i spent 25 years of my life trying to reduce hospital infections and falls requires careful patient selection good broadband connections reliable electricity okay if you're on a respirator or whatever you need reliable electricity uh and availability clinical staff to go out and see the patient usually nurses if folks are quite sick this may be a physician but again those things can be supported with uh telehealth uh means and this has been uh generally a patient satifier because the bed softer the food's better nobody's waking you up at 3 a.m to take your blood pressure next slide okay now i'm going to take you way far down the road and that is home as hospital because we still think in terms of healthcare delivery many people as an inpatient operation it needs to be thought of more as a home based thing and so the concept would be do everything you can at home unless it takes major surgery or a machine an imaging machine you can't put in a truck again you have to have broadband service electrical service adequate water and sewage and transportation it needs staffing it needs home services but look at the diagnostic services that are currently done with electronic needs vital signs weight e k g e e g arterial oxygen levels uh electronic stethoscopes otoscopes and there are managed care companies that send these out to families so that they can look in the kids here see it on the screen the doc can see it and they can avoid a visit um diagnostic services potentially available but used in hospitals portable handheld ultrasound you can diagnose appendicitis you can diagnose gallbladder disease with a certain degree of accuracy um mgh's and mit reported they've got a portable MRI unit now that's very experimental we currently have breathalyzers approved for diagnosis of flu one was just approved by FDA for approval of covid diagnosis and as you may have seen california has just begun to make available self-test kits for sexually transmitted infections because their public health capacity is not high and these are relatively easily administered and very accurate there are a number of treatments that have been given in the home for many years uh for example acute and chronic dialysis has been given uh has been can be home-based and i you know help get people home on these since the 90s um but you know i'll just point out that even in elvin an external this was an externally um powered pump for somebody's heart people have been sent home on that you actually have a lower risk of hospital associated infection with it okay next slide okay so where do we wind up next slide number one um as the greek philosopher heraclitus said you cannot step twice into the same river because the river is not the same and you are not the same so please think about redesigning your health delivery system as well as your insurance system right you cannot keep what you've got not sustainable and you know i think eliot and his colleague have spoken very well to the capacity issues with hospitals and physicians and so forth and so on and the way that you have to deal with that is you have to help people rethink how and where they're going to get health care and you need to rethink okay so you you can think about maximizing some of these delivery systems on a statewide basis and i frankly am not familiar enough with vermont to know how widespread your stem a and heart attack your telescope programs or i know the university has set some up in their network but i don't know how widely they extend around the state i'm pretty confident you have some good arrangements with dart month at the southern end but i don't have a good sense of the metal just does not imply that you have done everything what it does say is that you've got to be coordinated you've got to have good contracts and you've got to have common expectations of what's going to happen so a lot of that process that eliot mentioned um and others needs to be gone through in a thoughtful way but the point being guys the old days are over right we cannot sustain this telehealth has acceptance has been accelerated by covid both by patients and physicians and by payers out of necessity supporting these structures as everybody ahead of me has said needs payment methods other than fee for service global budget capitation whatever but remember and this is something often forgotten that under those payment mechanisms hospitals are cost centers they are not profit centers and right now everybody's run the hospital is a profit center right gotta make money and the more the better keeps you know the bond rating people have but that had again that's changing you're going to need to really think about different types of health care professionals so for example if you think about home based care um you know you may not need a four-year degree trained back back you're at level nurse to do that not if there's good support available from an iphone okay for a question uh you're going to need people in it to go out and make sure the connections work you're going to need you're going perhaps if some people have done use the available emergency medicine technician people in the community who are not always making a house call you can train them in someone's they know how to start an ivy they can learn how to use a handheld ultrasound machine you may need changes to state law and regulation we heard this i'm working with some of your folks on another project about access to care and some of the things we heard from the mental health community sorry the mental health community uh were about licensure issues and that may also be the case for the way that your physician assistants and uh nurse practitioners but you know i think one of the things i'd leave you with is to really think hard about what services need to be provided in a bricks and mortar structure that you build to purpose whether that's a primary care site specialty site a freestanding ed or university hospital what services do you really need to provide there and to a point earlier made this all has to interface with the social needs of the people so if you can't get access to a pharmacy you can't afford to med you can't get good food uh you know reasonably healthy food you know we're we're talking about dealing with a train wreck instead of preventing the train wreck i will point out geisinger began a program about three years ago of food as a prescription where they actually have a pharmacy that with a doctor's order will dispense healthy food to a diabetic patient and that that has helped there are also a number of health systems that have now announced that they're going to spend dollars on low-income housing because they've identified that they've got people that don't they're sleeping in a car or under a bridge and you can't manage health in that situation so you know i i think these are other pieces that will need to be integrated so at any rate um happy to take uh with my colleagues questions later i think that's the last slide thank you dr bruce hammery um so i had a couple questions teed up but in the interest of time i want to make sure we we get all board questions and get to public comment um i will turn it back to you chair mullen and maybe squeeze my question at the end thank you alayna and uh thank you to the panel there's a lot to digest and dr hammery i'd like to talk to you at some point about some of the creative things that have been done here in vermont like the the veggie get van go program when you talk about prescribing foods to diabetics as a healthy alternative we've been doing some of those creative things through our accountable care organization here in the state of vermont now and um we also um i want to give credit to some hardworking people at our sash program here in the state of vermont the uh it's been the one program that the federal government has actually seen a positive return on investment for um and uh we'd like to be able to take lessons learned in vermont uh to elsewhere in the country but what i wanted to do to throw out the first question to the panel is much has been said already about the workforce and as we know healthcare is a people business and it's taking care of people uh primarily by other people who are the providers and um we are facing a historic shortage of providers one that uh we've struggled with um even pre-pandemic but it's been exacerbated it's not just a vermont problem but a us problem and i'm just curious if any of the the panelists have thoughts on um what some of their um ideas could do for this workforce crisis and um possible other solutions so i'll i'll throw it out to any one of the panelists who might want to put some input into that ellie your lips are moving but we can't hear you well it's hard did you can you hear me now we can so so first i i think bruce has given us the answer which is innovate and redesign um i'm skeptical that there's actually a shortage uh one of the um i'm sure there are shortages in some areas but one of the thought experiments i would encourage us all to make um is to to think about when you see the next patient so every the most expensive decision any physician makes besides hospitalizing a patient or maybe even more expensive is when do you see them again right and we tried to get the v8 or on a randomized trial if every just this is your thought experiment if every physician in the country just said i'm going to take whatever i would have put before a week two weeks two months three months and simply doubled it for all of their routine patients what would happen to the effective supply of physicians in the united states bruce obviously knows the answer we've actually done some of that but no you're right i want to remember our our wonderful board to tell you know when you when you look at for example um went to a place number years ago where you know they had a hospital good hospital and the hospital director could not get his um employed people that he was self-insured for in with diabetes into his own uh employed endocrinology office and it turns out when you looked at it what elliott said was exactly right the problem was the endocrinology guy had a group of people that he was just seeing every two or three months and they were stable they could have gone back to their primary care doc so you got rid of that and suddenly he had massive capacity we've seen this all this at geisinger where we had a a former chief of neurology great diagnostician couldn't get in to see him because his clinic was filled with returned patients they'd come back they'd exchange tomatoes talk about grandchildren and all that and so what we did was put a pa in front of him and everybody that he had been seen for longer than a year the pa turned around and sent back to their primary care doc so fine so you got access to a guy with really world-class diagnostic care which is what you needed and those people who didn't need to be seen by that specialist sent back to where they should be so elliott's exactly right um and i think you know and the other question is the level of person right if you're a stable diabetic and your hemoglobin anway and sees control the audiota you do not necessarily need to be seen at doc you could see a very good nurse practitioner or physician's assistant uh add much less frequent interval i i will um i'd like to just add to this i think that this is um really important way to be thinking about this i think that you know the examples that i think the most sort of um the graphic example these days is the felt nursing shortage uh and uh and you know with that you know the price of nursing care and the you know has skyrocketed for you know for for providers and in some markets and you know we we don't it's hard i mean and elliott it's hard to know how things will sugar out you know a year from now it's really really hard to know we so what we do know is this we do know that um that nursing is fundamental uh in terms of the delivery system it's a flexible workforce it's one that is you know very much patient centered uh and it is one that for which there's a much shorter lag in training than there is for many other any other providers or clinicians uh and and we certainly have seen you know i think great benefit from the increased you know sort of professional stature of nursing uh and then being able to practice up to their their you know the qualifications uh and uh at the same time there is a lag so you know expanding you know nursing training programs and you know vermont has them okay i mean darkness doesn't have one right i mean we have sort of a you know a relationship with a with a college nearby but so expanding nursing training is you know i i would guess because you have to guess that it's in the public interest however it doesn't speak to the immediate need or even the medium-term need i mean and and we don't know if you train more nurses you know where they're going to settle either so it may not help from on so delivery innovation is absolutely critical you know and and it is the only thing that we can do that can be done in the short term and it may very well be what we're what is going to save the system both in terms of being able to provide care and quality care and in terms of costs in the longer term so i would um you know i would i think i just agree that the focusing on this those sort of innovative ideas is terrifically important right now one other idea too because i think it's a critically important question which is better data um i think the crisis in access to um specialist specialist care would be well served by doing the kinds of analyses um that dr hamry uh proposed which is understand how the current workforce is being utilized so there may well be physicians who are working you know incredibly efficiently um and there may be others who are seeing their patients every three months um regardless of need so i think data could also be an important early step in providing insights about where the shortages are and how you might reduce them right i no i i agree i think another thing to think about is you know we have tended to think about um i agree nurses are incredibly important nothing happens in healthcare without good nurses period but we have tended to think of that group as monolithic there has been a real effort i think appropriately for hospital-based folk to get every all nurses to a bsn level a baccalaureate level it may be the case that for certain things that are might be done in the home given a bath for example you do not need a nurse uh it may be the case that in order to give an im injection you do not need a nurse now you may need one for an iv but i think these are things that that folks need to re-examine right i was told a long time ago the reason the nurse needed to give a bed bath was because she needed to be able or he needed to be able to check the condition of the skin and the vital signs and see if the person was awake we now have electronic ways to do that so i i'd think this this whole idea of who's doing what to and for whom is also something in terms of innovation that in light of new technology and these advances could be rethought now i don't know whether the green mountain health board wants to take that on but uh but certainly you know it it should be thought about okay i'm going to call on board members in alphabetical order for questions so that means we'll start with board member Jessica Holmes okay great thank you so much uh a sincere thank you a lot of intellectual capital and collective experience on this on this panel and i appreciate the insights uh i also just want to say i appreciate i think what's much needed optimism in terms of Vermont maybe the state where we can get this right uh if we you know engage stakeholders and policymakers and we're willing to to work towards building a more optimal system um i wanted to ask a couple questions one is a lot of discussion about efficiency of the system or inefficiency of the system and over capacity and under capacity and i'm wondering if you could speak a little bit more specifically about how we actually measure what are the you know metrics that we use what is the data that we actually should collect to measure efficiency of the system or to identify that we are at over capacity or under capacity um in a particular area just can anybody speak a little bit to that if we're about to engage in you know data collection and some of these exercises what do we need to be collecting well i'll jump in since i'm a i've been a data geek for you know 50 odd years um and just quickly i think you know the kinds of data systems that bruce has pointed out would allow you to do to track you know define cohorts of patients by every condition a primary care population to find them by specialty whether it's rheumatoid arthritis or multiple sclerosis or joint pain and then compare um outcomes ideally but even without outcomes just comparing the efficiency of utilization over the next three months or six months or year um you can reveal incredible variations both across the state and across providers within a given practice and that will give you insights into the opportunities to improve the efficiency with which care is delivered when mass general did that for their primary care physicians whether it's ordering high cost imaging or the frequency of visits they found four fold variation within a single group you know with a single 25 member group practice and then started the discussion about how can we change care so i think data will help you um measure it at the at the clinical levels that will give feedback to each specialty yeah and i would add you know ideally you'd like to be able to benchmark the best practice nationally but at least be able to look at variation within the state because that's going to drive you towards systematizing care delivery in a way that typically doesn't exist and you'll drive out the unnecessary variation and get to better efficiency totally agree right and i you know i think another thing just to add on to these two points is that for example access to cancer care or screening look at the proportion of your new cancer diagnoses that are stage one or two right and how that compares nationally because if you have a lot of folks being caught late what that's saying is you can't get them in for their screening or they're not getting screening so i think there's some of these other populations sort of measures that might help as well that's really helpful and and you know one of the things that we've asked for in our aco budget process was for the aco to report in april when they come back to us on their data and variations in care across the hsa so um some of that will be happening um hopefully we'll be able to to learn more from that process um um so i want to ask a little bit about so several of the panelists you've advocated for global budgets and capitated payment systems um and in fact might be an answer to reducing some of the waste in some of those categories that dr fischer outlined in that slide and i'm just wondering so global payment you know might help us remove some of that waste i'm wondering if the panelists might speak to what role the legislature or medicaid private insurers the aco the green mountain care board other stakeholders might play in reducing some of that care delivery waste you know aside from just looking at the data analyzing it and hoping that you know sharing the data might move the needle on some of reducing some of the you know unnecessary delivery are there any other roles for other the sort of the state stakeholders here so i think you need to compel multi payer alignment on this because it doesn't work unless everyone's doing the same thing and your biggest problem has been the commercial market where you've got the least adoption of it and so clearly i think that there is a potential role for the legislature and the board to play there in giving a nudge um i i think medicaid's been a leader in doing this in the state and i think in your in your next um agreement negotiation with medicare i would ask them to go a little further than what they've been doing which i would think they would be a willing partner to do i totally agree on all payer alignment yeah okay helpful uh and important i i agree um so i i guess my last question is really a two-fold question and you know it seems reasonable to say that we need care delivery reform or redeployment potentially of hospital resources that we might need to consolidate rationalize regionalize the delivery system maybe convert think differently about what hospitals are freestanding eds and whatnot unlike the idea of incentivizing hospital at home done well i recognize this will you know potentially preserve access lower costs improve outcomes but i you know i'm thinking about in practice operationally politically you know and you've all mentioned alluded to this this difficult process that you know to get to a truly optimized delivery system obviously we're going to need robust community and multi stakeholder engagement and dr fisher i appreciate that's going to be key and i'd love to hear maybe a little bit more about rethink health's process but i guess my same question goes to my last question is what role you know beyond a stakeholder engagement which is really really important we need to do are there other avenues that the legislature that the green mountain care board that payers of the aco hospital leaders and boards i mean what other things could parallel that process um you know or do we ultimately are we ultimately relying kind of on a stakeholder process and a move to a different payment system there are other you know avenues to get us there faster uh you know with more consensus things like that well i do i mean the the process that led to the camp david accords um that was used for the base close federal base closing commission and the new york commission although with the distinct difference um the first two had a strong team actually facilitating a long you know a long process that invented solutions to closing a base which was one of the most politically difficult things to do in the world um where the community and the congressman who represented them um ended up supporting the proposal so i think the way you get the multi stakeholder process most successfully to work is have someone facilitating that um who can draw the information and then come back and say did i understand you correctly um so i think the the process that i outlined in that slide um and in the slides more generally is one that i think can can pull people together and along enthusiastically um bruce spoke to the importance of bringing communities along absolutely um this is about developing a picture of what could happen that everybody could could get behind um and you know the first step i think is to maybe you ask the legislature for enough money to hire the consultant that could design and implement such a process that's how the legislature could help yeah i you know i i guess the for me the a big piece of this is getting people together to envision what they really want and how they want their healthcare to be provided right um you know i well no point in going into personal story but but you know it just seems to me that there's a lot of pressure on this it's not just on the global stuff but for example some of the big national payers have acquired companies that are doing primary health care centrally with telehealth and some of these things i mentioned so that has i don't know if i doubt that's hit vermont yet but that is beginning to hit some other areas of the country and because and it's driven in part because the difficulty they have contracting with people right but the intent is to in effect disintermediate the primary care doc in part there's a shortage in part they want too much money all that stuff so some of this is really going ahead and um and and because of distance and travel times and all that it may you know show up in your neck of the woods so i i like to add two thoughts on top of those of ellie and bruce because i agree with what they've shared i think the legislature can help by making this discussion more about how than what um and then two i think it's very important for the communities that are going to be affected that um they get something that they don't have right now that addresses a community need that inpatient beds are not addressing for really really helpful and my my last question i guess really addresses sort of the elephant in the room and the timing of this conversation in the sense that we are living in covid right our hospitals are you know at or near capacity bursting at the seams our health care workforce you know is spread then i recognize we might be thinking about better ways to deploy that health care workforce but i just want to ask and some of you alluded to this too but how do we plan for that ideal capacity that ideal distribution of our uh you know thin workforce uh in a way that factors in the pandemic that we're in right now and the recognition that maybe this is a hundred-year pandemic maybe it isn't how do we ensure that our hospital system our health care system has the flexibility to pivot when there is a pandemic or there is some you know acute need so how do we factor that into any kind of long-term optimization well i'm i'm your infectious disease guy and epidemiologist in this group and i'll just say it's going to take time right as you work the process as nobody knows right the current predictions okay it's going to become endemic and but you know we have problems with flu every year hospitals get overwhelmed in january february icu's fill up more people die that kind of thing so i think part of the answer is you can't probably sit down and calculate it right now but what you can say is maintaining the resource to expand let's say a 15 bed hospital to a 30 bed hospital is not going to help you right and i think the other thing is that one of the things that's been learned in covid is not everybody needs to be admitted to the hospital and a lot of people that were admitted you know two years ago would not be admitted now there are actually better predictive models for if you're admitted and you need to go to an icu are you going to get out okay so i think those kind of things help but i think at the end of the day one just has to plan that the need for surge capacity may not be in quote the classical four walls of a hospital and i think people have shown that all over uh you know that you can put stuff up in a parking garage if you need to you need a roof you got to run plumbing and that kind of stuff but you can get that done hugely helpful thank you chair millen i'm done thank you for your comments thank you jess next we'll turn to board member robin lunch robin hi and i just wanted to echo jess's thank yous um to the panel very much appreciate you being here today and sharing your expertise um so i think one of the challenges um i think about as a policy person and now regulator particularly around care delivery is that at least in vermont uh our government entities are not particularly well set up in terms of staffing and resources to do the kind of analysis um that we've been talking about here today and so um one of the things i struggle with not to not to land in the pessimistic category but i'm kind of there uh is that i think this kind of long term multi-year uh project that needs to be well resourced in order to be done well is not something that i think we as a state has have done particularly well in the past um so that's really more i guess comments um and to to michael's point i think there are things that government at least in the united states and in vermont do well and things that uh we don't do as well and so what i'm sort of struggling with is um how we can move forward um because i do think and i said this when we heard from our previous consultants in october this is bigger than the board the board alone is not going to pull this off particularly not with our current levels of staff and resources this need and we shouldn't this should be a much larger discussion it should involve communities it should involve the legislature um and so i think that uh that we really have to start to think about this as a longer and bigger project that's really more of a comment and reaction than than a question i guess um although i would welcome any reactions if people would like to comment on my comment well you know i certainly you know god i certainly agree um it's not going to happen instantly uh i think you know if we look at the continued trajectory of both hospital vulnerability though um and rising costs together uh that's a pretty serious crisis that we're facing um we are at a moment where the governor might be talking about tax cuts it sounds like there may be some resources and i don't know how many years it would take us to earn back uh you know a couple hundred thousand five hundred thousand dollar a year investment um if we actually got global budgets and deflected health care spending i bet we pay i bet it would pay for it um out of the various pension funds very quickly so that my my source of flipping the problem um also we have a one year to negotiate um the all-payer model which is a tremendous opportunity for us to think about what that should look like and how might it be better now well and to i guess just to i agree with your your comments miss lunch i i think you're right on and it does take a sustained effort it will take assignment of the responsibility with resource to a particular group and some legislative oversight uh and obviously a budget uh but i would warn and i you know i'll defer to the health economist in the group and others that you know at the rate the smaller hospitals are going you may not have more than four or five years unless somebody's prepared to throw millions at them which i don't think anyone is so you know so to some degree this is a question of getting things organized and planned and and having plans or just just being faced with a crisis Thank you i appreciate that because i think we you know we had our first um meeting panel presentation around hospital sustainability issues in the spring of 2019 um and part of what we spent the rest of me in particular spent the rest of the year doing was working with a group of folks with the called the rural health services task force to bring forward some recommendations to the legislature many of which have been acted on but then of course covid hit so um i appreciate your comments and i do feel like if we just pause um by the time the pandemic has finally fingers crossed when we're on the other side of it it will become a crisis and we won't have enough time to react so i really appreciate that i really appreciate that um i think uh i also wanted to uh just make a comment on sort of our hospital budget process and uh some of the recommendations michael that you provided um i i thought that some of your recommendations were really aligned with some of the work that we've start our staff has started to do internally to look at the hospital budget process and um see how we can refine that process so that it's more effective as a as um not just cost containment but also a sustainability tool like the hospital budget process frequently during at some point i usually say during deliberations it's acts as a sledgehammer not a scalpel in terms of cost containment and so um i i do think that that is an area where we can refine our regulatory approach to look at price growth in particular which we do set caps on but it's at a very high aggregate level and probably not particularly effective in a nuanced way so i appreciated that um i guess that's really all i i had to say right now but thank you again i really appreciate everyone's thoughts just i guess a quick question are any of the hospitals doing um activity-based costing or is this still all the old cost to charge ratio stuff um it i think that there's some variation across the hospitals certainly critical access hospitals are focused very much on the medicare cost report type of accounting um but i think that's an area that we could certainly delve in more deeply now when you think about a scalpel um that would be helpful thank you rob and next we'll go to board member tom pelham tom well thank you and uh thank the panel very much for all these um insightful and data driven ideas um and uh you know hopefully we can take advantage of them i i i just have one question that bothers me and it's kind of a willy sudden question um in that uh you know that uh i i worry that what let me let me start it by this way i do agree that the commercial sector is kind of late to reform in vermont to a great a great degree um and um i uh and i do agree that medicare i think has been a leader in terms of fixed perspective payments and putting that in place but there's one element of that relationship between commercial and and the uh and medicare that i worry is a stopper kind of a show stopper and that is the cost shift and so here's here here's some numbers um vermont numbers uh 2013 to 2019 the medicaid cost shift increased from $106 million to $243 million these are numbers that will be in our annual report which comes out later this week and that's an average annual growth rate of 13.9 percent over in medicare which we have less influence over um their average annual growth shift growth um of cost shift onto commercial is a 10.4 percent and the overall is 10.3 percent so i kind of look that and think if i'm sitting on the board of a provider or i'm sitting on a board of a hospital you know if i'm a hospital do i really want to change my utilization patterns etc when there's this cost shift out there that can eat it up um and if i am a commercial person similarly do i want to kind of change the way i do business um because the cost shift is there and and it's kind of a silent partner in vermont to me unfortunately so i guess my question is is that in the face of those kind of real growth rates 13.9 percent for medicaid which is an arena that we have some control over um and and the the annual average is 23 million dollars in medicaid cost shift as a former estate finance commissioner you know i know that that that's not an easy number to solve but it can be it can be solved um but is it is it your sense that that relationship with with the growth rate that's 13 14 percent uh is one that can be worked around or is that growth rate going to have to change yeah let me um haven't run a couple of hospitals i mean your your point is exactly correct right i mean hospital needs to make enough money to support its capital and keep the bond you know the bond rating people happy and all that so they're going to cost shift now what you have to remember is the data from dr fischer and colleagues and others is that a lot of that care that's being given for medicare and medicaid does not need to be done in the hospital right so those costs wouldn't have to be shifted if the care was delivered or at least not that to that level would not have to be shifted if the care were given appropriately at a different place or by a different person or with less uh unnecessary technology okay so i i think that's where we get back to the issue that uh elliott and others have raised of a global budget but you need to give people the ability to spend the money in different ways right now just give you an example uh my my wife who's a lawyer wrote the letter to the medicare people that got them to approve providing transportation from small towns into larger places where we had group practices without this thing uh well you're unduly influencing people to come to your institution and we're gonna find you a bunch of millions okay uh there were some things you couldn't advertise it and this and that but the point is there had to be a change in the way the the payment policy was thought about in order to make that transportation to an outpatient facility to get care that would uh obviate the need for inpatient care done it was a policy thing right and i certainly can't speak to all those similar things that you might have in vermont but certainly there are a bunch of them in medicaid and some in medicare that if they could be identified discreetly and elliott and others may well know what these uh you know discrete things are but if they could be identified and changed within the context of your operations as a state that you could uh markedly decrease the use of hospital-centered expensive resources by medicare and medicaid patients and commercial patients and take the need or at least dramatically reduce the need for some of this cost shift um i'd like to add something that's going to be a little more controversial um so i i i think it's fair to expect that medicare and medicaid increase their payments with a with inflationary adjustment i'm not going to say anything about the base level of payments the lower for public payers we know that um but i do want to note that there is resounding um research findings on this issue of the cost shift that finds that it doesn't exist there's lots and lots of research in fact i just read and i have it in front of me because i just read this morning so ran published uh a document titled nationwide evaluation of healthcare prices paid by private health plans in 2020 and i quote um in our analysis we find a very weak relationship between hospital prices and the share of patients treated by that hospital who are covered by either medicaid or medicare so it's really a price shift more than it is a cost shift because hospitals um are generally using their market power to extract higher prices from commercial payers um they legitimately have concerns about their public payers not increasing their prices but the prices are going up to the commercial payers not as a cost shift but because the hospitals are able to receive higher prices from the commercial payers can i can i frame that in a slightly different way i completely agree with michael this is this is raising prices is a choice you can decide to cut costs keep things efficient you know not you know not expand a b c or d um and not raise your prices and in competitive markets hospitals do make that choice because they have to survive to keep their prices down so i think i'm with michael sorry so i would like you to apply that to the hospital budget process and then come back and talk to me about that because i think the problem with the research that's out there is it's not done in a regulated system where we cap net patient revenue and increase increase in commercial price so i think that's that's i think uh why we don't see it the same way as the research because the research has not looked at vermont or maryland yeah i you know i guess to to the point made by my two colleagues that you know the other thing the piece of this is deciding what you're not going to do right so are there certain services i'll just make something up um you know really high-end pediatric nerve surgery for stuff at the back of the brain right there maybe two or three people in the country that do that well you don't need to provide that service you need to make sure you can get people to it and so without knowing how in detail how your system is set up you know are there services at any hospital that are low enough volume or require enough other specialized support the team the equipment or whatever that you just ought to figure you know maybe you're sending them to dartmouth maybe you're sending them to new york or boston or wherever but you might want to take another cut of that because people do tend to want particularly academic centers tend to want to say we can do it all well thank you for that i i i do think that as rovin was alluding to during our hospital budget process we spent a lot of time for example with the uvm network hospitals where i think 20 to 25 percent of their their charge increase was they say driven by the cost shift so it's out there as a as a kind of a negotiating item i do know for example that for 2021 the state made a decision once it became clear that about the how deep the the pandemic was was that they were not going to raise reimbursement rates in Medicaid except for those that are federally mandated so to me it's an issue that needs to get somehow resolved and off the table before people can focus on some of the things that are made that that that and and opportunities and uh that that the ideas that the gentlemen are presenting offer and with that i will pass it along to the other tom thank you tom tom walsh do you have some questions or do you want to take a pass on your initial board meeting tom if you're speaking we cannot hear you thank you um i'll take a pass on questions or comments other than thanking everyone for um sharing their knowledge and experience with us thank you tom so at this point i'm going to open it up for public comment and please uh members of the public please direct any of your comments towards me as the chair um so with that um if anyone has any public comment please raise your hand and i'm going to start with walter carpenter thanks kevin uh just more comment really nothing on question i all of the presenters have pretty much said what i wanted to say about how the system needs to change we've reached the end point and i speak as a patient and an activist and quite frankly as i was listening to dr fischer talk about a the thought hit me that for the past 40 years we've been living under the doctrines of neoliberalism more or less and in a generic sense and the the idea of neoliberalism has failed in not just healthcare but it's failed in all aspects of american life and another thing when dr fischer had his lists of pessimisms pessimisms and we don't start the real big elephant in the room or probably not even an elephant but more of an avalanche is one reason why we don't do an equitable healthcare system is america's racism and maybe that should be on his list i don't know but it's one it's a huge reason why we don't do an equitable health system strong in my memories uh tom hartman's the hidden history of american healthcare for the reason that we have to medicare only covers 80 percent and we're stuck with the rest 20 percent is that legislators in those days north and south east and west didn't want black people to access healthcare and i think that's a huge problem today in all 50 states but that's when i took away from the presentations of all the people here you know another one especially about the waste everyone here who mentioned it was correct and i agree with them we should also remember that our health system again in all 50 states nationally etc is basically a welfare program for ceo's and shareholders and various various profit for company for profit companies you know in vermont we have executives starting at four to five six seven hundred thousand dollars a year and it's our healthcare dollars that pay for that another thing is when we talk about payers we need to remember that insurance companies etc are not payers we are the payers they are the middle people who distribute it and there's an interesting thing where the ceo of uh oh signa i forget his name edward hammering somewhere woke up one day and said that his biggest fear was that american people will wake up and realize they don't need insurance companies anymore but essentially those are my thoughts it just comments no questions they pretty much covered everything elaney did a great job in putting this all together kudos to her i hope she gets a raise from it well walter i'm not sure if i would be uh um keeping a good watch on your taxpayer dollars if i gave people raises that quickly but um i will say mind if you did kevin i will say this that we're very fortunate to have elena as part of the team and walter your points are very well taken and uh i did want to throw one question back to the panel because you you raised an important issue that everyone has been grappling with for the last few years and that's equity and it's not just racial equity but also rorality and whether or not uh there's equity between um rural and urban and so finney the the panelists wish to weigh in on the uh point on equity we'd greatly appreciate it go ahead eliot um first thank you for the comments i think um i agree with many of them i think one of the challenges is that we we have essentially separate systems and they are inherently unequal so medicaid patients get less access to care than medicare patients um and you know in the article that i referred to the single system solution i suggested that if we if we can get to the level all where all payers are paying similarly which would be one way to eliminate the cost shift by gradual equalization as as other states have done then we would not be asking physicians to discriminate against the uninsured if it uncovered everybody we wouldn't be asking physicians to discriminate on the basis of ability to pay which is what we are doing now they would be making decisions based on who needs what care so i strongly support the concern about inequity um and i think our opinion delivery system reinforces the inequity that we see in the us health care system that was the neoliberalism pirate ellie i i certainly agree and i you know i also really appreciate your comment that you know we use the term payer as sort of synonymous within short but it's coming at everybody's wallet taxes and we forget that yep you know i think nobody you know we just got to keep that front and center but i think you know the other point is that i think there are ways to directly address the morality issue and certainly should i think there are ways to address some of the others but but it's going to require a lot of um let's say political will and sustained effort so that was the neoliberalism part too but thanks for that appreciate it okay next i'm going to call on jeff teamon jeff can you hear me we can okay great thank you chair mullen i'm jeff teamon i'm the ceo of the vermont association of hospitals um i'm not there's not time for me to respond to everything we've heard today would need a lot more time for that so i'm just going to comment on a few key points i i do want to take issue with the notion that vermont is on a path to failure in health reform i i just don't view that as a fair observation given the work being done and the investments being made by hospitals um few other states have such a widespread voluntary commitment to value-based care um even in the midst of a global pandemic i also want to push back on the comment that was made that hospitals have advised the green mountain care board to simply do nothing what we've advised over the last two years is to make sure that hospitals which have been at the center of the pandemic for minute one have the resources in bandwidth to take care of their patients during a major public health crisis that does not relent and on that note i think it's important to recognize the situation hospitals face today our workforce is in crisis with rapidly growing and deeply troubling numbers of staff out with covid or with sick family members doctors nurses administrators support staff exhausted burned out and stressed hospitals are assigning leaders as we speak to work at the bedside clinical leaders they're deploying staff to the highest areas of need they're postponing elective procedures in some cases and of course paying skyrocketing amounts for increasingly scarce travelers needed to meet the patient demand in terms of vital transports we're short on paramedics and medical transport teams and hospitals are routinely calling 20 to 40 other hospitals as far away as Connecticut to place patients in the proper level of care people are therefore waiting hours or days for transfers that would have happened rapidly before the pandemic on the testing side we have need that exceeds supply and availability which causes anxiety and disruption in our hospitals but of course also in schools and workplaces and even our homes we're also working to provide the very best and most compassionate care for those with mental health needs on any given day our eds have people waiting for placement which which also places a burden on those patients and their caregivers so with all of this it is disturbing to hear continued talk of reducing bed capacity and the hospital association will push back on that early and often to make sure that Vermonters can receive the hospital level care they need today and into the future if you think reducing hospital capacity system is a good thing whether from a workforce standpoint or a physical capacity standpoint just look around right now in our hospitals and tell me if you think we should strive for fewer beds I could not agree more on the need to make sure our system is affordable and that Vermonters can access the care where they need it at a fair price we just also have to make sure we balance that with the need to make sure that our medical system is strong stable and ready if we've learned nothing else from the pandemic let's please learn that and if hospitals are to continue their commitment to reform and value based care they also need to know and have confidence that the regulatory body is not going to attempt to make those decisions itself or ordain where and how care is delivered that is not the goal of reform and it should worry Vermonters if the Green Mountain Care Board is making decisions about their care that should be made by health care providers so to close I appreciate everyone's awareness of our hospital status the need that we face and the future potential given where we are today at what I would say is by far the most challenging moment so far in the pandemic thanks Kevin thanks Jeff valid points but I do want to push back on one thing the Green Mountain Care Board is not going to be making decisions on the the care that is given to Vermonters other than trying to facilitate a discussion where everyone can come together similar to the format that was laid out by Elliott Fisher with the peace talks but this is the beginning of a very long conversation and I don't want anyone listening today that's tuned in to think that we're going to unilaterally say there's going to be fewer ICU beds in this location or this is going to happen it's just not true and I don't want anyone to walk away from today's conversation with that as their outcome next I'm going to call on Taylor Han hello so hi everyone my name is Taylor and I am right now currently a middle grade school student and just based on your presentation which are really wonderful and I have just two questions the first one is about when you are talking about the value-based care in my perspective I understand it as to evaluate the results of the care evaluate the quality and the result of the care instead of just the volume of the care and so I have a specific question about the practical issues about how to actually to put it into effect because I think when we are just thinking about the quality people different people have different perspectives and they will have just the different standards upon that point so I think it may just constitute some kind of like complex issues and my second question is actually about the price control and when I heard about this kind of the proposal of having a global budget plan I think it means that it will just different all of the insurers all of the providers of the insurers how about just agree on a standard price of the insurance and they will just pay beforehand before a fiscal year so that the hospitals can just have a better use of their money so I think there might be some problem with that because if we just fix the insurance at a specific amount well that caused the problem of insufficient competition which will lead to inefficiency later on so that's all about my questions thank you so much. Taylor I just want to say that you give us great hope for the future and they're great questions and by any chance are you a student of Dr. Holmes? Yes I'm currently a student of Dr. Holmes and Professor Long. Thank you so much for tuning in this afternoon and thank you for your great questions. At this point does any member of the panel wish to jump on one of those questions or should I just continue with public comment? Well I want to just explain what a hospital global budget is. It's not intended to reduce compensation but rather it's intended to set a budget for a hospital for all of its operations for a year so that the hospital knows how much it will receive in revenue and be able to manage to deliver services to meet community need within that budget and so the hospital has some incentives to find ways to become more efficient and thereby generate some savings that accrue back to the hospital. And if that takes out some of the internal competition within a hospital and within coordinating organizations with that hospital if everybody is working on the same page to just make the care the most efficient they're not competing to show that one department brought in X amount of dollars or you know the visiting nurses did this or what have you if everyone's working together there's better coordination and probably better outcomes for the patient. Dr. Hemory did you? Yeah just I think to pick up on a point you made a minute ago which I think is extraordinarily important. This whole process depends on the people in the community leading the way to decide what services they need and how they are to be delivered in the future not in the past. So you know I serve on the board of a community hospital and we do a community survey and this and that but the voice of the community front and center in that in public meetings not just in a survey that somebody has a consultant do and then checks off is essential and it will be absolutely critical to the success of any of this so I mean I think the views of the hospital association medical association all of that are important but they come from particular viewpoints and interests and I say that having been a hospital director and a member of a hospital association and an AMA member so but this community view that that I think is going to have to really be taken into account. The other thing I would mention is that I do not know the degree of cooperation between hospitals in Vermont. I do know that in western Montana my group is having a very good conversation with a hospital moderate distance away about what services could we share. I mean not antitrust none of that stuff but you know somebody has more specialist in one area than another and why duplicate that. So I think all those need to happen but community led. Thank you. Next I'm going to call on Rick Dooley. Rick. Hi thanks Kevin. I want to first just say thank you to all three speakers because I think that was helpful in illuminating these are many of the issues that you know Health First has been pushing for a long time. I especially want to say with the comments on the price shift versus the cost shift we frequently hear and I've heard for six or seven years now anytime we start having conversations about what's happening other places in the country we hear well well that's not Vermont that's not Vermont that's not Vermont and that's true however I think things like market forces lack of competition market dominance you know single single players in the ball field all those things are you know market concepts that are you know in existence and and do indeed apply in Vermont and so I I think that it's easy to say you know Vermont has this different system set up but we also are not immune to those forces and they have not done well for us in the past and that's it. Thank you very much for your time. Thank you Rick. Next I'm going to go to Robert Hoffman. Thank you Chair Mullen. It's great to see my former mentor Tom Walsh joining all of you on the board to see Elliot and Dr. Goodman and Dr. Fisher both of you touching after a couple years I'm not seeing and hearing your voices. I want to start with the question and then follow it with a couple comments if that's okay. Chair Mullen could you say or answer the hospital that controls 66 percent of health care spending in Vermont specifically the medical center is 52 percent market share what is their value-based payment per capita in 21? Well this is a period of public comment and we're not going to go into a series of interrogatories Robert. Okay well I'll answer it for you. It's a 25 percent premium over Geisinger where I happen to live now. Geisinger very dissimilar to Vermont has University of Pittsburgh, Penn State Medical, Lehigh Valley Hospital Network, St. Luke's all competing in its yard and so they're not capable of commanding the cost shift that Tom likes to talk about because they're not able to charge three to four times the Medicaid rate of their neighbors. So the value-based payment per capita from University of Vermont Medical Center is 8,000 versus two to three thousand for its neighbors and its Medicare is 12,005 which is two to three times its neighbors. So I think most of the conversation today focused on a DRG and utilization level and we're all really looking past the gorilla in the room and that is a single player controlling two-thirds of health care spending has successfully gained the health reform efforts of the last decade to its advantage and that can account for things such as worker shortage when we talk about a system that's unwilling to negotiate with its nurses over a 10% raise unless they accept breaking up their right to organize. When we talk about a system that's willing to cancel leases with landlords if they rent to independent practices we're talking about a system that is lacking competition and is pushing higher premium costs out in the health service areas where the commercial payers as they've told you repeatedly when you've asked why will they not sign up the providers are not going to take this higher price risk from Burlington that's been pushed out into their HSA and accept that responsibility and risk when they feel they have little power to effect change back in a higher premium cost center. So it's it's opportune that Clover is coming before you all today you have an opportunity to open up lower cost care settings to provide procedures that currently are being built at much higher rates in high cost centers. I would challenge you all as I have frequently to consider the role that this single player in its consolidation efforts is having in a small state. Thank you. Thank you for your comments Robert. Next I'm going to go to Aaron Tobias and then to Mike Fischer and then we're going to take a bio break before we move on the conversation to Clover Health. Aaron. Thank you. Hey everyone thanks for your time today I really appreciate all the insights. I'm relatively new to all this. I'm also a member of Professor Holmes's class. No I thought it was very interesting hearing about the push to move away from the fee for service structure and that many hospitals currently have and I remember it was an interesting point brought up that you know you can reduce the amount of people within a hospital by increasing the emergence of electronic ICUs. But I'm just wondering how the emergence of those capitalistic companies like Teladoc or American Well or Intuitive Search Goal who can potentially improve the productivity of these hospitals. How that would coincide with an effort to move away from the fee for service structure because it seems like those companies basically gain money and profit through service and through production. So I'm wondering how like trying to grow those companies would potentially impact or potentially deter the ability to move away from fee for service. Thank you. So it's a great question and it's one that we've been hearing a lot about over the last couple of years and kudos to Dartmouth Hitchcock for the advances that they made quickly so that we hear from example doctors at Southwestern Vermont Medical Center in Bennington where they can have a consult from the patient's room with a specialist and have the cameras on the patient and some amazing things are happening. So I think that really it could be hospitals themselves that become the main players in providing those telehealth services. But it could be external competition. An external competition could be what keeps the hospitals honest in this whole thing moving forward. So a great question. So again I'm going to Mike Fisher and then we're going to go to a bio break because I did get a few texts about an hour and a half ago asking for one and I've dragged this out for about as long as I can without having a few board members. So Mike Fisher you were the last person in public comment. Thank you Mr. Chair and thank you board and thank you everyone who's participated and the presenters. I guess I want to I'm Mike Fisher I'm the healthcare advocate and I want to start by recognizing the passion that the hospital association expressed a few minutes ago and to I'm not going to pull it off but I would like to match that passion on behalf of Vermonters who are struggling to afford care. And so on that and thank you for Elliot Fisher for citing the household survey number of 40% are underinsured and we have been spending a great deal of time talking to people who are have medical debt or who are afraid of medical debt and to understand the dynamic that they face when when they are forced to make a financial decision instead of a healthcare decision. And and so I really just wanted to sort of bring that voice to this table. I think a number of the presenters gave a real shout out to that dynamic and so I thank you for doing that and and I appreciate that presentation. Thank you Mike. So at this time I did see a couple more hands that popped up but we do have a business to conduct on clover health and I would ask if anybody has any further public comment if they could email it to the board and we'll make sure that it gets posted on our website. So at this time I'm going to thank the panel for an excellent afternoon discussion and giving us your valuable time and really creating a lot of food for thought. So we're going to put the meeting in recess until 320 and we'll be back for discussion on clover health. Thank you everyone. Welcome back everyone. Before we start with the discussion on clover health I understand Elena that you wanted to give us a homework assignment and that you were trying to raise your hand as I was going to the bio break. So go ahead. That's okay. Thank you so much and I will be very quick because I know it's been a long day. So here is your homework assignment as soon as I can find the right screen. And Elena it's the homework assignment for the board members correct? Yes and I'm just not sure why it's not oh here it is okay. Elena is getting ready to be a professor. Okay so it's quickly just two slides. So you know based on what we've observed through the hospital budget reviews over the last five plus years as well as various analyses insights from thought leaders on hospital sustainability affordability and healthcare reform. So largely today's conversation and I've listed here for you a lot of relevant recent kind of speakers we've had or different kind of resources that would be helpful for thinking about this. And I will be sharing with you a draft of the key findings for the legislative report but which I think have implications for our ongoing work at the board. And so I'd like you to take a look at those and kind of identify where do you agree, where are your priorities, and what do you think I've missed. So what are the key findings that you think are most important? So that's the first piece. And the second piece is this is a little preview. The long-term recommendations that I will hopefully flesh out in this report to the legislature I think will mirror a lot of what we heard today about process for the obvious reasons that we haven't been able to bring hospitals to the table given the pandemic and we want to allow space for them to weigh in and to shape what that looks like. So this will allow providers to continue partnering with the state and developing the shared vision. And then this process map would also or a process-oriented approach would allow us to map out connections to the next agreement potentially with our federal partners as well as any legislative changes based on that shared vision that should be required. So I would like to get your thoughts on this process approach and kind of are there guardrails that you think we should include? Is this the right approach? And then you know thinking about what we can do you know inside internally and I think there were some conversations today and some recommendations from some of the speakers about how we can evolve our regulatory processes in the interim to you know move from a sledgehammer to more of a scalpel even though we might not be quite there. And so you know what what is your vision for hospital budgets particularly but also a CO budget review certification insurance rate review you know our CON process and you know thinking about I think we've talked about the next agreement already but are there other things that we could do right now given our current authority to help tackle some of these challenges? So just some food for thought and if you'd like to kind of brainstorm together I'm happy to meet one-on-one but look forward to hearing your wish for this direction. Thank you and Chair Mullen I'll turn it back to you now. I just got a text that Chair Mullen has lost power temporarily so I think what I'll do is I will shift it over to Russ is that right and Russ maybe you can start and Chair Mullen will be here in momentarily hopefully probably be up on. Okay I'm happy to go ahead I'm for record Russ McCracken staff attorney with the board I'm here presenting what is a procedural procedural question really from for interlaced in regards to Clover Health Partners which is a direct contracting entity operating in Vermont. Clover Health submitted their FY 22 budget to the board in accordance with the guidance that the board had promulgated along with that budget or with the budget Clover Health included a request that the board declined to hold a hearing concerning the concerning Clover Health FY 22 budget which the board is allowed to do under rule 5404 for ACOs that have fewer than 10,000 attributed lives in the state in that year in support of its request Clover Health notes that they're expected to have under 2,000 attributed lives in Vermont and they also cite that their budget submission includes confidential or non-public financial information company trade secrets and other proprietary information for which they've requested confidentiality we're still working through the we're still working through that confidentiality request rule 5404 does say that the board may decline to hold a hearing concerning a proposed budget submitted by an ACO that's expected to have fewer than 10,000 attributed lives in Vermont during the next budget year or or that would not be assuming the risk the rule doesn't give us criteria for when or why the board should decline to hold the hearing so it's really in the discretion of the board and so the request having been made by Clover who wanted to present it to the board for consideration the board could hold a hearing hold a separate hearing with Clover Health to present its FY 22 budget or alternatively what staff had been thinking about and wanted to offer for the board was that we could move directly to the staff review of the budget presentation of recommendations board review and deliberation in a regular public scheduled public board meeting I say that in light of both the small size of Clover and the fact that Clover was before the board not too many months ago giving a presentation that did cover a lot of Clover's operations in the state so with that I would turn the question over to Chair Mullen I know that Clover's attorney has also joined us here. Thank you Ross and my apologies to everyone we had a quick power outage here and so I missed the beginning but I'm sure that Jess had it under good control for that and I have in my notes for us that you had mentioned that the healthcare advocate wish to address this issue as well is that is this the appropriate time for him to do so? I know that the healthcare advocate's office does want to make a public comment regarding the request so I think if it's okay with you Mr. Chair it might be an appropriate time for him to do that. Okay so Sam are you doing the speaking? I am yeah good afternoon everyone actually more of a clarification question because I wasn't sure what the recommendation from the staff would be about this I mean we're in support of a public hearing but Ross would you mind clarifying what you meant by having a public meeting and a staff recommendation? Sure if we look at the process for one care from odd for example we have that spread out over multiple meetings one meeting would be dedicated to the ACO coming in before the board and presenting its budget and fielding questions about it and then at a sub and subsequent to that hearing at a meeting we would have staff present an analysis and recommendation for the board with respect to the ACO's budget. In this case what I was suggesting was perhaps if the board were comfortable with it we would move directly to that second step where the staff presents an analysis and recommendation with respect to the ACO's budget and we would do that at a you know a normal public board meeting and I do think in it you know candidly I haven't been carefully through all of the budget submission but if there are questions that arise in the course of review I think staff would feel comfortable presenting those to Clover and writing and getting responses that way similar to what we do for one care from odd. Okay may I respond chairman? Certainly. Thanks Russ I appreciate that yeah I mean I think the healthcare advocate would support any kind of public setting that would allow for the general public and the board to ask questions specific I think if I'm understanding this correctly this forum wouldn't require Clover to answer questions in a public setting so I'm wondering if that's a possibility because I do on behalf of the ACO we have concerns about the business model and practices that Clover has that we documented previously in our remarks when the board was considering waiving the oversight regulations in summer so just wondering if you're sorry to respond with another clarification question but it's an important issue to us. I don't know if that was a question for me Mr. Chair but I'm happy to go ahead Russ try to parse it out I had in thinking through it I had assumed that Clover or their representatives would be at the meeting in which staff presented um analysis and recommendations um I hadn't considered whether that would be whether their attendance would be required or not so could leave that as a point for consideration by the board. So Russ and again my apologies I missed the beginning of the conversation is there a request for the board to make a decision today on on what type of hearing would be held is that what the board is looking at? Essentially yes the Clover Health in there along with their budget submission requested that the board as it's permitted to do by rule declined to hold a hearing um concerning the their FY 22 budget submission so that that's the question that's being presented to the board. So board members do you have questions of Russ? I don't have a question this is Robin but I'll just jump in with my thoughts in case it's helpful for anyone else. I personally um am fine not doing the type of hearing that we typically do with one care one care submission is um quite voluminous as is necessary to understand their program in this case it's an off-the-shelf national Medicare program that Clover is participating in um and so I feel like uh at least the the payment parameters and those sorts of things are pretty well laid out in the participation agreement etc um I do like I do think it is important for Clover to be at the meeting where we have the staff recommendation to respond to that recommendation potentially if if they have issues on the other hand it's their you know the burdens on them to prove their case so if they don't show up you know that will that is what it is um and I do think it is important that we do get questions answered but I I think those likely can be done in writing at least the questions that I've sort of identified that I have so that's my thinking on it given the size and scope of um the budget and and the attribution and those sorts of things. Other questions or thoughts from board members? In the interest of time I'll just say that I completely concur with what Robin just said. Chair Mullen this is Tom Walsh and a question for Russ if possible. Go ahead. With this the smaller size and scope of this application if we treat this one applicant this way is there a risk of other entities entering into the state of Vermont staying below the 10,000 lives covered threshold and kind of taking advantage of that as a loophole is there anything we should be worried about there? Broadly speaking the way that we prepared the guidance that Clover responded to with the budget submission it was done generically it was not specific to Clover Health so any entity that kind of falls into the same classification of being Medicare only and under that 10,000 life threshold would respond to the same the same guidance. They are the only entity that meets that criteria that has submitted an FY22 budget so I don't think so I think to answer your your question are we if we set up this procedure of not having them come in and do a presentation of the budget does that prevent the board from having presentations from other ACOs in future years and so I would say no to that it doesn't you know it may if there were other ACOs this year we would treat them all the same and I think in future years we'll treat all ACOs the same but the board isn't committing to that particular procedure for future years. Thank you you answered more clearly than I asked. Yeah my take on this is there might be some marginal value in holding a hearing but only marginal because this is a very small application it is significantly different you know than the other kind of Medicare plans and and so that coming into our community is something that you know I think over time people need to become aware of you know Robin is you know clearly laid out that a lot of this is kind of predetermined it's not as flexible you know as it might be with say one care I also worry about staff burden you know putting together a hearing it you know does take some effort. So I think if I so I think the budget discussion is open enough allowable enough for folks to get their questions asked and answered in a public way that I feel comfortable going in that direction. Okay any questions or further discussion from the board? The only other thing I would chime in with is I do think it's important for the healthcare advocate's concerns to be addressed and asked so but I do think that that could be a written process. Okay Robin are you prepared to make a motion before I go to public comment? Sure I move that we approve Clover Health's request to wave a presentation of their budget and proceed with the processes outlined by Russ. Is there a second? I'll second. It's been moved and seconded. Is there a further board discussion before I open it up for public comment? The only thing I'll just also just clarify is that as I'm sure people are aware in the ACO process all of our deliberations are in public so there's still lots of public process left to go. Okay so I'll open it up for public comment at this time. Does any member of the public wish to offer comment at this time? And I'm going to call on Walter Carpenter first and then David Alt. Thanks Kevin. I just want to back up the healthcare advocate and Robin on the public hearing. We should have it however marginal or non-marginal it is and open up more as much public as possible because it's important for us Medicare recipients to understand what this is about and what these CECs are going to do to us. Thank you Walter. David. Thank you. So yeah I appreciate the comments so far with respect to the healthcare advocate absolutely. First of all I'm David Alt counsel for Clover. You know absolutely would want and be willing to answer and respond to any questions that the healthcare advocate has. I think one thing that is particularly useful and helpful in this instance is that as I understand it the healthcare advocate's office is under the same confidentiality rules as the Green Mountain Care Board and so that is open and if we do that by a written question and answer process you know it allows for hopefully a the kind of discussion and responses that the healthcare advocate's office would like and I'd hope would be helpful to their office. So I think that the process that's been laid out would address that and again Clover's happy to answer not just you know the board's questions but healthcare advocate questions as well and Robin to your point about Clover attending the upcoming meeting I know they for me they're not I can't ask them on the call but I know they'd be more than happy to to be present. I guess one one question that I'd have and that we've asked in the past is with respect to submission of the of the requirements set forth in the guidance you know it hasn't been clear to us you know what is the the review standard or the review process so I know you said the the burden is on Clover to prove their case I'm not sure what that burden is or what is meant to be proved I know there's a submission requirement and they have met those requirements and are happy to meet requirements they they appreciate the opportunity to be in Vermont but to the extent there is something that must be proven or if there is a burden whatever those parameters for review are or standards for approval it would be helpful to know what those are in advance of any meeting thank you thank you David is there any other public comment seeing and hearing none I'll throw it back to the board for any further discussion prior to a vote hearing none we'll call the question all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay so Russ will task you with following up with the healthcare advocate and with David to make sure that everything is being coordinated and have you got an idea on a proposed date yet or not I don't have an exact date yet and I'll have to I think coordinate with the rest of the team as well but it was we had been talking about late January early February well late January is coming off of fast so I'll leave it up to you to see if everything can be handled that quickly but just stay in touch thank you Ross we'll do so is there any old business to come before the board hearing none is there any new business to come before the board hearing none is there motion to adjourn some moved second it's been moved and seconded to adjourn all those in favor of the motion please signify by saying aye aye any opposed signify by saying nay thank you everyone have a great rest of the day