 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board. And we're gonna start this afternoon's meeting with the Executive Director's Report, Susan Barrett. Thank you, Chair Mullen. I have a few announcements. First, I wanna announce a couple of public comments that are ongoing. One is a special public comment period for the Board's vital budget guidance and that is posted on our website. Those comments are due back by close of business April 9th. And then another public comment that has been open for quite some time and will continue to be open. Is any public comment regarding a subsequent all-pair model at the moment? As I've mentioned before, the Director of Healthcare Reform has presented to our general advisory as well as our primary care advisory group and the slides are listed on our website. And we ask that if anyone has any comments on that subsequent all-pair model agreement, we would love to hear from you. And of course, are sharing those comments with our partners at AHS who will be taking the lead on a subsequent all-pair model agreement. Then the other updates I have is just in terms of our schedule. So we're hearing today from our staff on a report that we submitted on section four of Act 159, Sustainability and Equitable Reimbursement for Providers in Vermont. Next week, we'll be hearing from a staff member, Alina Baraby on our sustainability planning update that we submitted to the legislature on April 1st. And that is section five of Act 159. And then in addition, we've invited the Director of Healthcare Reform to come and come in and back us, to come in and update all of the board and public on their progress on the AHS all-pair ACO model improvement plan. And that is all I have to report. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 31st. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, March 31st without any additions, deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. Let the record show that the minutes were approved unanimously. And now as our Executive Director just discussed, we're gonna turn to a discussion of section five of Act 159 of 2020. And I'm gonna turn the meeting over to Alina Baraby and Sarah Kensler. So whenever the two of you are ready, take it away. Thank you very much. And I will just share my screen right now. So hopefully you can all see the projected slides. And only the projected slides. Looks like you can. We're good. All right, fantastic. So for the record, this is Sarah Kensler, Director of Strategy and Operations at the Board. And Alina Baraby, Director of Health Systems Finance. I'm sorry, Health Systems Policy at the Board. And we are here to present on options for regulating provider reimbursement as required in Act 159 of 2020, section five. This report was submitted to the legislature on March 15th and is available on the Legislative Reports webpage. We've also included a link on the front page of this document. So, and I just also wanna mention that we've been into Senate Health and Welfare twice now to present the report contents and we'll be returning there tomorrow. So this is definitely a current conversation at the legislature. Before we jump into the report contents, I just wanna give a shout out to the whole team that worked with us to develop this report because this was definitely a major undertaking and a big group effort. So within the Green Mountain Care Board, that was Sarah Tewkesbury, Christina McLaughlin, Marissa Melamed, Board Member Lunge. And I also just wanna thank our partners at the Agency of Human Services at DEVA, at DFR, and the private sector stakeholders who weighed in on this report as well. We could not have done it without all of them. So we wanted to ground our discussion today in the statute that directed the Board to develop this report. And that's here on the screen, I won't read it for you, but as you know, there have been several reports on provider reimbursements relating to pay parity at cross-care settings or provider sites over the past five years or so. The idea behind this report is to take a look at the range of options for regulating provider reimbursement with pros, cons, implementation issues, and costs for standing up this type of regulation at the Green Mountain Care Board. And there are a couple of key points that we want to lead off with when we are presenting this to you. So this report presents regulatory options, not recommendations. We really strived to present a range of policy options for the legislature to consider and to present the pros and cons of each fairly. To date, we've worked hard to be neutral when we've discussed this report in the legislature as well in part because the Board has not yet had a chance to discuss the options or express an opinion or opinions. Secondly, while we worked to lay these options out in practical terms, including funding and staffing estimates for initial development and implementation as well as ongoing operations, all of the options that we are going to present to you today would require further study. We describe likely avenues for this in the full report, but we really want to highlight that none of these are fully baked yet, and they would all require significant investment in study. In addition, we want to note that the inclusion of public payers in any of these regulatory approaches would require federal permissions. That's another area to consider and investigate further. And finally, we identified a tension between the goals that are stated in the statute of provider sustainability and reimbursement equity, as well as other goals Vermont and the Board have previously stated, including cost containment, the shift value-based care, consumer affordability, and access to care. No single option can maximize all of these goals, and while the options can be combined and layered, this will add expense and complexity. So you'll see that we come back to this theme of tension, and we'll end the presentation today with a list of key questions we're asking when we're at the legislature. We need to make sure that we prioritize these goals before we can really refine our options. So while these options are likely consistent with provider-led delivery system reform, we also want to note that they may compete with provider-led payment reform and also could complement it in some instances. So we're aware of the variety of these tensions and are hoping to have a robust discussion there. So that's a very high-level summary of key points, and now we're gonna provide a little bit of background and context before we talk options. When approaching this report, we really started from the current context, specifically the federal and state commitment to moving toward value-based care. We also want to note that related to value-based care, this report only looks at the cost side of the equation, and it doesn't really get into quality or outcome measurement and regulation. These areas should be considered as next steps, should the legislature choose to move forward with funding these efforts, and we hope will be part of the ongoing conversation. So in terms of that context, the federal government across three administrations now has expressed support on a bipartisan basis for moving away from Piper Service Healthcare Payment and toward value-based care. While the Biden administration has not yet discussed their approach in depth, we don't expect that to change given some of their appointment choices. We have a federal HHS secretary confirmed recently and Elizabeth Fowler was appointed this month as the director of CMMI, which does not require Senate confirmation. So we'd expect to hear more in the coming weeks or months as their leadership gets up to speed. And then Vermont's moved toward value-based payment. As many of you know, Vermont has been, and it's the board certainly knows, Vermont has been on this path away from Piper Service and toward value-based care for many years in alignment with and often ahead of the federal government. And that includes programs like the Blueprint for Health and Community Health Teams, the state innovation model grant, and the all-payer model. We've really tried to drive home that a key policy consideration for the legislature will be to think about how implementation of provider reimbursement regulation will or could impact the move to value-based care, both in terms of timing and in terms of capacity for change at the provider and payer level and at the state level. Now I hand it over to Elena. Great, thank you, Tara. So just kind of at a high level, one of the goals of the state and directive of the Green Mac care board is to assist in controlling healthcare spending across the state. If you break down total healthcare spending, there's kind of two key components that we look at. One is the unit cost or price, and the other is utilization. Our all-payer model is really focused on tackling the second component, utilization, by changing the way that we pay and deliver healthcare. We hope to see fewer chronic conditions over time and more prevention and keeping people healthy. This report really focuses on unit costs. That doesn't mean that these options may not affect utilization. They may, and some of them actually do more than others. But the focus here is controlling healthcare spending through controlling the unit cost or price. Can you hear the next slide? Okay, so to dig in a little deeper into the legislative language here. So it's really about identifying processes for improving provider sustainability and increasing equity and reimbursement. And then we thought most importantly, within the context of value-based care that has been such a major component of healthcare reform in this state and federally as well as they were just discussed. And that we also take into consideration care settings, Medicare payment methodologies, payer mix and other very important characteristics for flushing these objectives out. And the next slide. So we thought it would be helpful to define these components. So we have something to kind of anchor back to as we propose or kind of outline a series of options and think about how they could further these policy goals or not. So value-based care, we define broadly efficient and economic delivery of high-quality care. So does the option move us away from fee-for-service, address utilization issues and promote services that improve health as opposed to, you know, or avoiding spending that does not improve health? For provider financial sustainability, it's really about the provider's ability to consistently cover their expenditures with revenues. So does this option include a provider level look for solvency and consider payer mix and promote predictable and flexible revenues stream to providers? And so this is really important when thinking about whether or not, you know, it's not just your income statement but also thinking about capital expenditures over the long term. So thinking about sustainability needs to be over a long time horizon and not perhaps on an annual basis as we're used to thinking about. Reimbursement equity. Similarly, we took a pretty broad stroke at this without further guidance in the legislative language. So we defined it as equitable payment within and across provider types for care delivery. So does this option address underlying fee-for-service differentials within certain provider types or, you know, or move away from site-specific reimbursement or does it address kind of across provider type differential? So between different kind of service sectors, if you will, like for example, primary care and specialty care. Okay, can move to the next slide. So I think Sarah highlighted this a little bit but these tensions that exist. So there's, you know, not always but sometimes the tension between provider sustainability and reimbursement equity. So she mentioned no single option maximizes both of these and some of these could be addressed by layering on some of the proposed or the outlined policy options but that does add complexity and potentially regulatory burden. So, you know, this report contemplates the ability each option to address each of these statutory goals within the context of value-based care but could be refined further. So what we're presenting today is really the high level. There are even more nuanced options within these high level options that could vary on this part as well. Okay, go to the next slide. So we thought it also important to bring forward kind of two other policy goals that are always kind of circulating in the background and also very important to consider, though not called out in the legislative language explicitly and that's affordability and access. So while we didn't kind of focus on that for the purpose of this report, you know, it is important to remember that, you know, provider reimbursement methodologies will likely impact access and affordability. We did not dig into that but that is certainly work that could be done. So, you know, while provider reimbursement could have an impact, provider reimbursement alone probably is not likely to solve these really complex issues either. So that's another kind of element. So while intertwined, you know, it won't push it one way or the other. Okay, back to Sarah. So now before we get into the options, we wanted to kind of set the stage by providing some background on how we have been thinking about provider reimbursement. There are two much primary kind of bases that sit at the foundation of provider reimbursement on which payment bottles are built. The first is cost-based where reimbursement amounts are based on the provider's historical cost to provide a service or a set of services. Here prices are based on actual expenses, sometimes blended with that of a peer group or otherwise adjusted. But the biggest example here is Medicare reimbursement for critical access hospitals which is based on each hospital's historical costs because Medicare recognizes that these hospitals are serving a few patients and not enough to pay for ongoing infrastructure. And, excuse me. Secondly, the other kind of base for reimbursement is fee-for-service where reimbursement amounts are set based on negotiated amounts, whether those are based on market rates, historic amounts or reference pay or some other set of criteria. Fee-for-service rates are unrelated to the actual cost of providing services. So they could be more than the expenses associated with providing a particular service or they could be far less. Either can be rolled up into more complex payment models like per diem rates, episode-based payments or global budgets and these bases for reimbursement can also be layered with payment strategies with the goals of improving quality and or controlling spending growth. These include growth targets or CAPS which limit growth trends. It also could include value-based models which reward or penalize providers based on performance on cost and quality and or population-based payment models. So then how we're thinking about regulating provider reimbursement. We define this as government action to set provider reimbursement methodologies and amounts which can be implemented either via provider regulation at either the provider or the entity level or at the service level or through insurance regulation by setting parameters for payer or provider negotiations. Currently reimbursement amounts and methodologies are most commonly negotiated between commercial payers and providers and their networks or they're set by public payers for providers participating in their programs. Left to the market, negotiations can be influenced by relative bargaining power and market share and we also wanna note that where there's an ACO or ACOs that's an additional kind of set of negotiations to set methodologies and amounts. So to drill down a little bit further into those regulatory approaches, we're laying them out here. The first two columns are provider regulatory strategies and approach three is the insurance regulation-based strategy and I'm just gonna kind of walk us through this table so you can see how we have been thinking about this as we lay out the options and suboptions in the report. Approach one, entity or provider-based regulation sets reimbursement policy for the provider entity based on provider-specific characteristics. A great example of this is our current hospital budget review process which looks at expected revenue and expenses for each provider organization individually. The trade-offs here are that this individual view supports a really strong focus on sustainability and can also balance factors like pair mix when considering equity. However, if equity is defined as paying the same amount for the same service, it's hard to achieve because it's so provider-specific. Providers have different expenses and unique circumstances that are considered in this view. This can also be really hard to scale to provider types with large numbers of unique organizations. So in Vermont, we do this for 14 hospitals. If we were to do this for every practice in the state, that would be much more challenging because we'd be looking at hundreds of organizations, probably. In addition, this potentially captures a broad population since it's implemented through provider regulation which regulates how providers charge for their services rather than how payers pay. Secondly, approach number two is service-based regulation. A hypothetical example here might be that payments for primary care services have to increase by X percent in a particular year. The trade-offs here is that this approach is very compatible with a reimbursement equity focus because it sets reimbursement policy for a service type regardless of where it's delivered or what kind of provider organization delivers it. However, it can't consider sustainability in a particularly nuanced way because it doesn't look at individual organizations. And as we said, kind of the individual factors like pay remakes or populations served or size or anything like that. Like the entity or provider level approach we just walked through, it also has the potential to capture a broader population depending on the services that it's impacting. And finally, the third approach, insurer or payer-based regulation. Here we're setting policy through the insurance market. So the hypothetical example is requiring GMCB regulated commercial plans to increase payments for primary care services by X percent in a year. The trade-offs here is that it's a much smaller population, a subset of the commercial market which is limiting in Vermont because our insurance market is small about 94 or our insured market, excuse me, is small, about 94,000 people and it wouldn't reach self-insured employers. We also can't consider sustainability in a nuanced way with this strategy. And reimbursement equity is also limited, that kind of focus is also limited because the population is so small. And offsetting limitation would also have to be made in other services if we're kind of increasing payment in one area, if we wanna have cost neutrality for premiums. So in planar language, if you choose to increase one provider sector or type of service and don't decrease somewhere else premiums will rise which we know is an ongoing concern. So now I am going to hand it over to, oh actually nevermind, I'm not gonna hand it over to Elena. I'm gonna talk through the report development process and then we'll move on to the options. So before we dig into those policy options, this is a little bit of background on the report development process and scope. We developed the options by researching known examples and scanning the literature for regulatory approaches and state examples. And we really tried to capture a range as I said earlier, including adapting current GMCB regulatory processes and envisioning new regulatory approaches using or expanding on our current authorities. Act 159 directed the board to engage with the director of healthcare reform at the agency of human services, the department of Vermont health access and the department of financial regulation. And we did so multiple times as we developed the report including reviewing drafts with those state partners and we got incredibly helpful feedback throughout this process. We also took the opportunity to share the draft report with potentially regulated entities and advocates in early March and solicited comments and that included FOSS Health First, by state Blue Cross Blue Shield of Vermont, MVP, VMS, the office of the healthcare advocate as well as a member of the public who requested to join. And again, we got incredibly helpful feedback through that process. So moving on to the scope, this report could have easily doubled in size and complexity if we had had more time and resourcing to develop it. But in order to make it, I wouldn't call the full report digestible but in order to make it more digestible and hit our March 15th deadline, we had to establish kind of some boundaries related to provider type services and payers and we note in the report that we could dig in further to broaden or clarify the scope and subsequent analyses if we were directed to do so. The options discussed in this report really focus on regulating reimbursement for hospital inpatient, outpatient and professional services. So primary care and specialty care services. We have generally excluded providers for whom Medicaid is the dominant payer like designated agencies, for example, since the state already sets their payment rates and growth rates and there's already significant infrastructure and expertise at DEVA and other AHS departments that oversees these providers. The report also excludes pharmacy dental and vision. As we discussed last week, the federal laws around reimbursement for, oh, excuse me, that's my note for myself from Senate Health and Welfare. So we also wanted to note that the federal laws around reimbursement FQHCs really complicates inclusion of FQHCs in any of these regulatory models. That doesn't necessarily mean that these reimbursement models wouldn't work for FQHCs but that would require a lot more explanation, exploration and legal analysis to assess the potential. And on the payer side, we wanna note that we really focused on options that impact reimbursement from Medicare, Medicaid and fully insured commercial health plans in the individual small group and large group markets. We were not looking at other segments of the commercial market like Medicare Advantage, like Workers' Comp, Federal Employee Health Plan or TriCare and we need to do more research for each option to determine how it would impact these market segments. Now I will hand it over to Elena to discuss the options. Great. So there are three kind of primary options that we looked at, health systems budget, setting reimbursement parameters and fee-for-service rate setting. And then we layered those various regulatory approaches on top of these options to kind of think about more nuanced ways of how we would implement them or how they could be implemented. And we'll talk to those in more detail on the following slide. So we can go to the next slide. So the first one is health systems budgets. So this is a cap on spending for some portion of the healthcare system. So it could be a provider, organization, a facility or a network of providers. Generally these caps are set prospectively with a defined budget amount with enforcement mechanisms and usually a payment methodology. So budgets can be all payer or payer specific. And this is designed to impact total spending. And then there's some other kind of benefits or design options if you will depending on how you implement that. So two examples which we'll talk about in a moment are Maryland and Pennsylvania. So like I mentioned, there are these three regulatory approaches provider or ACO or insurer. So while Maryland is really focused on the provider lens, Pennsylvania kind of comes from the insurer lens. And I think you could kind of think about our ACO process or ACO structure right now is moving towards a global budget. It's not quite there, but it could be designed in a similar way. So what are some pros of this approach? So this approach could help you tackle unit costs and utilization while considering value-based payments. Conflict between sustainability and cost containment, affordability in the regulated sector is another potential benefit. And then impact of minimal reimbursement increases in the public payer sector. So you can think about how to balance across payers in this vein. So what are some issues that are hard to adjust with this approach? So the lack of market power for smaller or unregulated providers. So if you come from the provider perspective, as Sarah mentioned before, the greater number of providers you have, the harder this becomes because you're setting and regulating a budget of an individual provider. And the administrative burden might be higher for those that enter kind of a regulated process. The cost estimates are below. And so this is kind of one of the bigger ticket approaches because there's a lot of layering and design that needs to happen, both for implementation and then ongoing. Because you're not only looking at the aggregate but prescribing the enforcement and the rate setting methodology. But we can talk through some of the benefits as they're evident in the cons in the other two options. So we can go to the next slide or in the two examples rather. So Maryland. So Maryland was started from a fee for service rate setting. They evolved to a global budget model in 2014 and then to an all payer total cost of care model in 2019. So in this model, they have a similar to the board that Maryland Health Services Cost Review Commission and they set these budgets annually and then they set the rates for all payers and adjust those rates as utilization kind of occurs over the course of the year to adjust to that total budget. So as I mentioned, this is built on fee for service. So it's still in some sense relies on utilization but what they found helpful is during COVID they could adjust the prices in such a way that they could kind of help keep the hospital whole when they have lower utilization rates. One challenge they have seen with this though is precisely that fluctuation in prices. So if you go in one month, you could be paying 15, 20% more than if you went in for services in a subsequent month. And we've heard anecdotally, I won't speak for Maryland but that they are looking for ways to kind of fold in fixed payments into this methodology. They do have two waiver requirements as it relates to quality for Medicare hospital readmission rates and their potentially preventable diseases over the five years of the waiver. So they have seen a lot of success in this so far. So they've saved over 45 billion and lowered their growth rate from 25% above the US average to 3% above the US average. So that is quite remarkable. It is more cost focused than it is sustainability focused but I think COVID has shown or demonstrated that it has blended a sustainability element to their stay. Let's go to the next slide. So Pennsylvania on the other hand was aiming to solve a sustainability problem for rural hospitals and they set up their global budget and theirs is coming from the payer perspective first. And they do set, it is facility based but the budget is really set with the insurer side first. So this one, they still have this fee for service reconciliation to their fixed payment but it's really about setting those fixed payments for providers over, I shouldn't say reconciliation. They use fee for service to establish that initial budget and then they have these growth rates year over year but it is based on that fee for service historical look. One challenge they've had here is it's voluntary in nature. So they had I think difficulty getting their regulatory board off the ground but now that they have that up and going it is still voluntary. So it's taken a while to get moving but they have seen more progress in the earliest and more recent days. So you can go to the next slide. So the second option is setting reimbursement parameter. So this is when we set a growth rate or growth cap or paired with a growth floor for a particular service or provider type aligned with state it could be aligned with state policy goals. So it's similar to the hospital budget process which we'll talk about in just a minute and there are three regulatory approaches that could be adopted here. It could be provider, it could be service level or insurvates. So for example, payments for primary care services could be required to be increased by x% over a period of time. The thing to keep in mind here is that if we're thinking about affordability and the effect on premiums that for every increase to stay budget neutral we would have to think about a decrease somewhere else. So that is a concern I think in each of these options. What could this help us address is prioritizing growth for certain types of providers or services that we want to see. So primary care is one area that we've talked about extensively and perhaps learning growth in other types of care domain and it highlights winners and losers in certain provider sectors. So that's something to keep in mind. It could balance market power discrepancies to some degree over time but this would have to be kind of thought through and would be articulated in the kinds of rates you would set in expectancy or growth rates. What would this not help us address? It's total spending, it's not really, it does not have implications really for utilization and then the sustainability of unregulated providers that would not be helpful unless you were a regulated entity. And this is the most affordable of the three options and certainly there's variation in the design elements as they were to be further refined and perhaps the regulatory approach but this seems to be kind of the closest to what we're already doing the hospital budget process with some adjustments. We can go to the next slide. So as you probably know more about the hospital budget process than I can lay out here but we'll at a high level we'll go through the history for some of our other members of the public. So Vermont has reviewed and established hospital budgets since 1983. In that review the board is expected to consider local healthcare needs and resources, utilization and quality data, hospital administrative costs and lots of other data. This process came to the GMCB from Michigan in 2012. These budget reviews occur annually based on July one and it begins in October one that fiscal year. So there are two key regulatory levers. One is the growth in net patient revenue and fixed perspective payments. And the other is the change in charge to the increase or decrease in the average growth charges across all payers but because Medicare and Medicaid are essentially set outside of this process the impact here is really focused on commercial insurers. Okay, and so Rhode Island was another and I'll let Sarah chime in here. I'll just kind of give the highlights because I think you have some great insights on this one but they have these affordability standards which has evolved over the last couple of years that created a health insurance advisory council in 2004 and then they created these new criteria in 2009 on the criteria in which to have their premium rates approved so as expanding and improving primary care infrastructure spreading the adoption of patient-centered medical homes supporting the state's health information exchange and working towards comprehensive payment reform. And most recently they established these standards so at least 10.7% of their annual medical spend should be on primary care and then they tied hospital rate increases to CPI plus 1%. So I'll let Sarah if you wanna add anything on this slide. Not a ton to add here. I think you did a great job of summarizing it Alina but the only thing that I would say is that this like what one of the things that makes Rhode Island interesting to me is that they're using the insurance regulation both to impact kind of the provider payments and to set a floor across a whole service type of primary care. So it puts it in a larger context of kind of a unified approach to improving affordability and it's been a long running strategy with some interesting results. So Alina do you have more to say about option two or should I move us on to option three? I'll pass it to you. Alrighty, so the last high level option is fee for service rate setting where the regulator sets reimbursement amounts for each service or procedure at the code level. So for example, the example that we provide here is EM code X is paid at $100. Most often this uses an existing payers reimbursement scheme as the point of reference most commonly Medicare because Medicare is publicly that the reimbursement amounts and methodologies are publicly available. They're national, they're geographically adjusted. So it's significantly more transparent and we know that that it's fairly common from talking to partners and contractors as we developed the report. One of the things that we discuss in more detail in the report itself is the option to modify some of the details of Medicare's methodology. For example, site specific payments which is something that's come up in Vermont a number of times over the past few years. If we go back to that equation in the background slide that Elena had presented, this option is targeting unit costs but not utilization. Again, which limits its effectiveness in impacting total cost of providing care. This option would modify current unit costs but also targets that growth trend. There are two major implementation options here, implementation through provider regulation and through insurance regulation. So what issues could this approach highlight? The benefit of this approach is that it really sets an equal playing field across all providers of a service balancing out market power concerns that typically can drive fee for service rate setting now or excuse me, drive fee for service rate negotiations now. That said, there are also quite a few issues that this approach doesn't address. It really focuses on unit cost which we know from other states experience won't necessarily control total spending. It also can't take a nuanced look at sustainability since it does not consider individual provider organizations costs, populations, payor mix, et cetera. And it's not in line with Vermont and the federal government's moved toward value-based care and way for fee for service reimbursement. Finally, there are likely to be winners and losers in the provider sector as Elena mentioned with the previous approach and if we increase payment on one service type we'd have to reduce payment somewhere else or we'll see costs and premiums rise. Finally, I also wanna highlight that this is a fairly expensive option with costs of about 600,000 to over 2 million to implement in kind of the initial development and implementation stage and then ongoing costs estimated between 300,000 and nearly a million as well. And the example that we wanted to provide here as Elena mentioned, Maryland did fee for service rate setting for many years like since the 1970s prior to their global budget approach starting in 2014. Maryland was not alone in this approach for many years. Fee for service rate setting at the state level especially for hospitals was quite common until the 1990s but Maryland is the only state that was kind of the last date to move away from this. And it's the only state that's exempt from Maryland from Medicare's inpatient prospective payment system and outpatient prospective payment system. So the thing that I wanna highlight here is that there was decreased hospital spending per admission but hospital admissions rose far faster than the national average. So that gets back to that point of targeting price but not being able to control total spending which is why Maryland transitioned to the all-payer global budget model in 2014 and now to their total cost of care approach. I'm gonna hand it back to Elena now to talk about next steps and potential areas for study. All right, so depending on what comes next in the legislature, additional work mix-ups could include exploring these options further and digging into particular model design, particularly for health systems budgets which was kind of a very general concept but each implementation option could look very different and have very different implications for costs and kind of what pros and cons could be, so what we could affect across the system. And then establishing provider types that are in scope and any other policy objectives would be really important for understanding that further. As we mentioned, the number of providers, what level of detail and what kind of data inputs would affect all the operational design and costs that would go with that. Further study on implementation including robust stakeholder engagement to continue to understand implementation challenges. We really have to think about impact on premiums, additional operational costs on providers, insurers, data requirements, the impact on Medicaid budget and then a varied impact on depending on hospital designation. So critical access already has costs plus reimbursement so versus PPS or Academic Medical Center, these policy options might look very different. And then assess other regulatory intersections would be key to ensuring regulatory alignment moving forward. Certainly with GMCB's hospital sustainability efforts and a companion report due to the legislature this fall, some of this will kind of be picked up and dug into in more detail anyway in that report but there's certainly a lot of work to do there to connect the dots. And then implications for all-pair model total cost of care is another area that would be really important to understand and then ACO oversight and certainly health resource allocation planning. We'll pause there and see if we have any questions. Oh, just kidding. One more slide. But these are, I'll just summarize quick. So these are kind of key questions back to the legislature that we wanted to pose that are, we thought it's a very important question that they're asking, but there are some additional kind of considerations that need to be taken into account, which is why we kind of did not feel comfortable making any recommendations and why we kind of laid out some policy options, cost containment and value-based care have been central to every month health reform strategy, but how should we prioritize, particularly when there might be tensions between sustainability reimbursement equity, while balancing affordability and access, like we mentioned earlier, and then how should we define sustainability and reimbursement equity? So we took a pretty general approach but there could be some priority setting or particular ways that equity would want to be defined that we could take into consideration and further defining some of these options. And then how should Vermont balance provider-led reform with mandatory regulation? So I think this is really important to think about that today we have really been adopting a provider-led reform model, including payment reform in many sense through the ACO. So we want to recognize that that's our starting point and some of these policy options may deviate a little bit depending on how they're designed or a lot from where we are currently. All right, now I'll pass it back to you, Chair Mullen, apology. Thank you, Elena. Could you go back to the slide in the early 20s that showed the results or outcomes for the Maryland model? So on this last bullet point on this slide, you have so far Maryland has saved over $45 billion and lowered the rate of cost growth from 25% above the U.S. average to 3% above the average. Is there something wrong with the grammar here? Because the way I read it is they were growing much faster than the rest of the country, so therefore more expensive and they're still growing above the national average despite the decades of work that they've done. What am I missing here? I think, yes, but I think the value for them at least is that they've reduced it from 25% to 3%. So they're growing less than they would have been if they didn't have this model. So certainly their work is not finished and actually they were talking with our team to learn more about how they can think about population health and fixed payments as I mentioned before, but I think their work is not done. They did see great results with their hospital readmission rates. And so, I think it shows that they've moved the needle but there's still certainly work to do in Maryland. Well, and Elena, this is Robin. If I'm, I may be wrong about this, but isn't this their results since 2014? So it doesn't reflect the rate setting approach prior to that? Yes, thank you. Sorry, Robin, I missed that. Yeah, so I think it was over the last five years. It was over, we can double check on the time period but it was a much shorter time span. It wasn't since over the, you know, since the 70s it was more recent than that. In the report itself, we included kind of references and further reading for all of these examples so that we can dig into it a little bit more. Readers can dig into it a little bit more. So we can definitely go back in and make sure that that's accurate and provide some more information. My memory is that that came from the evaluation of the original hospital global budget model. So pre, you know, pre-total cost of care model. It'd be interesting to see what their per capita spend is and things like that to better understand because it's still, if you're selling an apple for $10 and somebody else is selling it for $1, even if you're growing at only 3% above the average, you're still, the cost of that is still growing at an expensive rate in comparison. So it's- Right, and I think, oh, sorry. Go ahead. I was just gonna say, I think one theme to keep in mind here too is there's a difference between growth rates and absolute value, right? Or your base, where you're growing from. So I think one thing that's not always clear or comparable is that base rate. So, you know, are you an expensive state or facility to begin with and then what you know might be, right? It's like many years ago when the federal government locked in rates for reimbursement for the V&As and Louisiana was like $10,000 higher per capita than the others and they got locked in at that rate and how is that fair? You know, so just something to consider. Members of the board, questions or comments? Yes, Maureen, a couple of comments. I mean, first, thank you for doing this, very complex. And, you know, I think a couple of things. One, you know, what Kevin was just talking about, I mean, some of these base off of a cost plus and we don't know if the costs we're starting at, you know, if they're the most efficient place to begin with. So I think that's always something to factor. You know, I'm not sure how we factor it is the way we do the hospital budgets to spend a challenge. But, you know, when we talk about cost plus, you know, even for all types of providers, we don't know what their costs are and that's always been a challenge. I think another thing when you talk about the cost estimates and ranges and some of them are more expensive than others. I think the thing there to look at too though is what's the, you know, is there more opportunity with some of the others? So, you know, we may end up costing a lot more to implement, but is there potential for a larger savings or more quality? I don't wanna say it's all savings, but just, you know, is there potential for a larger amount there? And, you know, I don't know if there's any way to estimate how long it would take to implement these things. You know, so when we talk about the implementation costs and the ongoing operations is, or some of them shorter term to implement, others longer, you know, that might be a factor, but again, we're looking, you know, we wanna be in for the long game, so what's the best thing to look at there? And I think, you know, one other thing it doesn't really seem to be addressing is what's the right level of services throughout the state and, you know, are we doing too much or too little in certain areas, right? We talk about some of the things that maybe hospitals are doing where they're only doing a few of those services and maybe they shouldn't be doing those and they should be centered at other hospitals, but, you know, really to look at the whole system collectively and not sure how we factor that in, but a big project here all the way around. So, thank you, you know, but those are just a few comments. Thank you, Maureen. Other members of the board? Sure, I'll pick up on a little bit of what Maureen was saying. I agree. It would be helpful to understand the time horizon, the time horizon of the impact, the ROI, all of those things. I know this was just a first pass on a very, very complicated question, so I thank the entire team for doing this. I think there's so much work to consider here. I think it's slide 30. Can you go to slide 30 for a second, Sarah? Yeah, to me, that second bullet point, how should Vermont define sustainability and reimbursement equity? I think you were right to put this on here as, you know, putting it back to the legislature to help us think about how we define that. You know, I think sustainability generally implies generating enough revenue to cover costs, right? And maintain a margin for capital investment in rainy days. But I think we really need to dig deeper on what we mean by sustainability and in particular, what we mean by costs. So, you know, it may not be the current costs that we're seeing right now if the system has fee-for-service driven and efficiencies embedded within it, right? If there's an abundance of, there's excess capacity in places or if there's care that's being delivered at high cost and low quality, right? So to me, I think about sustainability as meaning generating enough revenue to ensure that there's access in our communities to high value cost-effective care delivered in a timely way in an appropriate setting. And when we think about that definition of sustainability, that's going to require a much deeper analysis to ensure that we have that sustainability because then we have to figure out what are those essential services? What does access mean? What is cost-effective care? All of that. So really complicated makes that whole calculus much more complicated. And I think the same thing true when I think about reimbursement equity, equity, you know, generally implies fairness. So what is fair? I think you raised some of these important questions. Is it paying providers the same price for the same service? You have to consider other factors there. Is it paying providers based on the cost of delivery? We don't know the cost of delivery. In many cases, the providers themselves don't know the cost of delivery. We've heard from many hospitals that they don't even have cost accounting systems. Certainly independent providers don't. So it gets tricky and costs can vary for a whole host of reasons, right? So would we want to have higher payments to compensate for higher quality or greater patient acuity, right? That might work, but then we have to be able to measure that. And when we think about, you know, higher reimbursements based on costs, is that rewarding and efficiency? I don't know. It's going to be very challenging to tell that. And I even think about Paramix being so important. Would you pay two providers the same amount if one, you know, it was open to all comers, including Medicaid patients and another one says I'm not going to accept Medicaid patients, right? Do they get reimbursed the same amount? And I think those are all such important things to consider. So this is only to say that I think how we define sustainability and how we define equity here is going to be so important for how we move forward with designing policies that will improve both. So really, really good work and so much work to be done here. And I appreciate all the, you know, nuances here that you've raised because I think it's complicated. Yeah, I'd like to follow up on that, that this, as I was reviewing these slides and reading the report before that, this all remind me a little bit about all the moving parts that were in education and property tax reform, you know, back in the 90s and that never, you know, everybody always had their little kind of marginal plan until the Amanda Brigham decision came along and it was Brigham versus State Board of Education. And all of a sudden there was a Supreme Court ruling that basically upended the state's system of educating its children. And the key phrase in that Supreme Court decision was equal access to educational opportunity. And so when I was reading the page that Jess has called up here, I just substituted the words equal access to preventive and remedial care. You know, if we could just get a Supreme Court to kind of mandate that, then a lot of these interacting forces would be, would get resolved in a short period of time. I mean, back then the court decision came out February 15th and by June we had a Act 60, which was imperfect, but it started the bowl rolling to long-term reform. I was kind of struck between a sentence or a phrase on page, slide 29, that said, depending on legislative direction, and then going to this slide, the next page, where it says cost containment and value-based care are central to Vermont's health reform strategy. And there's a gap between those two statements. And I'm just wondering if there are things that we and Diva can do to kind of move this you know, in important ways from a narrative presentation, which is very complex and very well done, but to one that is, for example, addressing the issue that Jess raised, like the payer mix. It is striking, so striking to me always that in the 2020 report that the budget people presented to us earlier this year for the five-year trends, we see that for over that five-year period from 2016 through 2020, that the total net operating margin across all hospitals was $221.2 million. And that of that, $216.2 million was accrued by UVM Medical Center, not the network, just the medical center, which is 97.7% of all net operating margin. I mean, to me, that's a fantastic statistic that strikes at the issue of payer mix, given that UVM Medical Center has the best payer mix, and you compare that to someone like Springfield that has the worst, and one is complaining about their margin, but the other went bankrupt. So, you know, I'm just wondering if there are things that we can do, like doing some analysis on the payer mix to kind of give it more granularity in terms of its impact so we can inform the legislature and ourselves in that regard. Can we do more in terms of price transparency? We have two bodies of information out there now. One is our own in terms of our A-team doing work on price transparency, but also this federally mandated CMS data, which some reporters are using now in the news media, we're getting letters from individual citizens that are using that data. So we have Auditor Hoffer out there saying, this is an issue of scale and monopoly and bargaining power. Is that true or is that not? And can we kind of give some more detail to that by looking at the price transparency data? Or FPP, are there pieces of this that we can reduce the narrative to actual analysis that will help us? Even maybe going through this year's rate review process and hospital budget process. So that's, you know, this narrative presentation is wonderful, it's a great job and incredibly hard to write, I would think, because it is a narrative. And but there's gotta be some things that we can do, you know, on an analytical level to kind of give these options kind of better shape. And certainly if we had a Supreme Court decision, like the Amanda Brigham decision, we'd get to it a lot faster, but that decision was incredibly complicated too. You had incomes by school district, you had different grand list, you had rural versus urban schools, you know, I learned that up in the Northeast Kingdom, they spent 1,700 bucks per child to get them to just to get them to school and in Burlington it was 50 dude bucks per child. So there's all these moving parts that aren't always obvious that we're, you know, in analytical for a while, but great job and thank you very much for this. And I was gonna go next, Kevin, unless you would like. Go ahead, Robin. Yeah, so thank you to Sarah and Elena and the team who worked on the report. I've been in the legislature with them, but I was happy to see them take the lead today. So I had a couple of things that I've been thinking about as we approach, as we've been having the legislative conversation, obviously, you know, due to the nature of the legislation and we did take a neutral approach in terms of presenting all of the options, but I do think that there are some low hanging fruit for improving the existing regulatory processes. These things would not necessarily result in kind of the big shifts that people have been talking about and certainly wouldn't fix all the problems that are out there. As we said, there are a lot of trade-offs and in contradictions, but I think if the board wanted to heighten its affordability viewpoint and framework, there are ways to do that using the provider reimbursement setting, the provider reimbursement policy option, so option two. Particularly, I think we could look at how that might get, how we could refine our current process around hospital charges to think about how to make that more nuanced and to points that people have already raised, think about the base better, think about what the price is for each individual hospital and have a more nuanced understanding of that. And I think that could be a way to do that. And while it certainly does not impact a ton of people when you're thinking about the whole system, looking at what Rhode Island has done around reimbursement policy, I think could enhance the affordability considerations that we currently look at in rate review, which I think are, at least for me, are somewhat frustrating because we have this very narrow kind of window to look at affordability within the context of the actuarial parameters. So while that doesn't change the world, it could enhance, I think, the rate review process. Similarly, I think looking at how to move forward with fixed payments, to me, that's a bigger issue because it's a conversation around, are we still all in with provider-led reform, which then lends itself to a lighter regulatory touch and more of a review and not a directive? Or do we feel like we as a state need to move forward with more of a directive? And if that's the case, then I think our existing processes could be used to kind of look at how that FPP implementation could move forward in a more state-led way, I would say. So I just wanted to highlight, I haven't made up my mind in terms of what the right or the wrong way to move forward should the legislature want to or should we wanna promote an option. But to me, those are the areas that I think would be baby steps and would both improve the existing processes, not have a price tag that probably kills it at the legislature and could also move a little bit into considering these issues more broadly than we currently are able to do with our regulatory framework. Thank you, Robin. And I too wanna thank Elena and Sarah for their hard work, but I especially wanna give a shout out on behalf of the other members of the board to Robin who tirelessly worked on this project and has accompanied the team to the legislative presentations and has really owned this work. So thank you, Robin, and thank you, Sarah and Elena. At this point, I'm gonna open it up for public commenter questions. And I see Walter Carpenter has his hand up, Walter. So I still don't hear you, Walter. So I'm gonna move to the next person but come back to you afterwards. So, Rick Dooley. I thanks so much for the presentation, the information. And as I'm sure everyone is aware, Health First has been trumpeting these issues in terms of reimbursement and sustainability for several years now, going back even before certainly the formation of the ACO. I just wanna say that in the, I think it was option two, there were a couple of times that you just referenced increases in primary care spending. One of the detriments of the plan was that that would have to come from somewhere else, that there would have to be an offset. And I just wanna point out that's exactly the point. That's what we're trying to do. That's what all the studies show that we should do. That's what the, some of the Rhode Island program does. It is exactly that shifting into primary care to reduce costs in other places. So I don't see that as a detriment or as a problem with a particular model. And again, we're not endorsing any particular model. Like Robin, this is incredibly dense with a lot of information. And it's impossible really to point to one and say, this is the, you know, this is Eureka the solution that solves it all. But I think it is important to remember that primary care was the basis of the all-payer model, the basis of the ACO and it's the basis of healthcare reform. So I think we need to keep that in mind that increased spending is gonna come from someplace else and that's okay. That's the goal. Thank you. Thanks, Rick. I'll try again with Walter, Walter Carpenter. All right, Kevin. It was a mute issue as usual. Hey, I was born in the age of record players and phones with chords on them. I'm still trying to get this stuff down. You're not the only one. Yeah. I wanna kind of back up what Jen and Tom said and I like Tom's idea of a court resolution or court decision on a lot of this stuff. I think he's more or less got it there. And I remember when he brought up education, I remember that I had emigrated to Vermont from New Hampshire around that time and New Hampshire's towns were going bankrupt because of the education funding down there and suing the state. And I remember I was astonished that people were complaining about what was going on with education in those days. But anyway, I wanna know that with all this dense complexity that we're going and sustainability and accountability, how we can do this or something because the people that pay for this are us and we're the ones that don't understand. If you're not involved in it, don't understand how this stuff really works. And I just ask that when we think of this, when we do this and look at this, we think of the people that pay for it. And I know that the board is stuck between that rock and a hard place, but I just wanted to re-emphasize that. Thank you, Walter. And just as a reminder to everyone, simplicity of the system was a major driver of Act 48. Yeah, I'm not so sure that it's gotten any simpler. It hasn't, I mean. With that, I'm gonna go to Ham Davis. Ham. Thank you, Kevin. I've got a couple of questions that I'll start out with this one. I'm curious, I'd ask Sarah. The, I'm very interested in Maryland. I think Maryland and Vermont, the yin and the yang of trying to figure out how to do all of this. And one of the things that if I had to stand Maryland correctly is that they've aligned the payment levels for various things across all payers. What I wonder about that is, and I wonder because even though they've done that, the state cost is still very high. Have they, were they able to do that? In other words, I think that means that they eliminated the cost shift. And if that's the case, they would have had to eliminate it by possibly by getting more money for things like Medicaid from the state legislature and possibly more money from Medicare from the federal government. Is that how they did it? In other words, and we've already found out, Kevin found this out a couple of years ago and he politely suggested the legislature they should make payable for Medicaid payments and it didn't get a friendly reception. I'm just wondering, is that the engine that is driving Maryland? I can, this is the link. I think they never had a cost shift problem. So they kept up with it. And then as they implemented these various evolutions of their fee-for-service rate setting into global budget, that parity in payment was carried forward. So that is one difference is we in many other states are starting from a very different place. When we do in fact have a cost shift, if we made it a policy goal to have some equity across payers, that would have to be, certainly, funding would have to come from somewhere and be structured over a period of time. Thanks for that, Elena. I'm curious, I don't think that that cost shift was, I think that cost shift in Maryland was present back in what for me anyway is just recent history, which is to say 1990s. Now that may be not recent for you, but it's recent for me. Anyway, but that may be right. So I thank you for that. I'd like to just check that out. I don't think that there was anybody in the 1980s and the 1990s that had no cost shift at all. At least I didn't know that. I think that Maryland is, the modern Maryland is different. Anyway. Can I just have them in hand to talk about that? So they do technically have a small cost shift because they discount the fee for service rates that they were setting for both Medicare and Medicaid by, I think it's like somewhere between five and 10%. So there is a small cost shift. And we can certainly look into that, but my recollection from our last conversation with Maryland is that because they did it kind of all payer starting in the 70s, they didn't have a big catch up, but we can certainly, you could certainly look at the resources or we could take another look at that. Well, thanks, Robert. But I don't think it needs a lot of work to be done here. I just curious about that because, because the cost shift is a huge irritant for all kinds of reasons. Kevin tried to take a crack at it with that letter the legislature a couple of years ago. So anyway, I just think that that's, if you build a solution that requires a big, whatever your solution you build, if you build something that is going to require the legislature to do something affirmatively and spend a lot of money, then the chances of it happening are not good. I have one other question that, can I have one more question, Kevin? Go ahead, Ann. One of the things that strikes me in all of this discussion, and we've been doing this now for many years and so forth. But one of the things that strikes me is that the whole enterprise, everybody, the legislature, the regulatory structure, the law, so forth, all is aimed at, it looks at the Vermont delivery system, although as though it was a fairly uniform thing. And I think it isn't. I mean, I think that the way that the University of Vermont works is just the University Hospital itself. I'm not talking about the rest of the network, just the University Hospital. But for forever, I mean, for all my experience, beginning back in the 80s, the way that the University of Vermont deals with money is that they pay their doctors a salary and they pay their doctors a salary. They do not essentially function on a fee-for-service basis within the hospital. They don't do that, okay? That's very different from, I believe all the other hospitals were the exception of Dartmouth, but they're not willing to play anyway. So what makes no sense to me is that you can, that the reality is, the reality is if you treat, if you wanna treat a system, if you wanna treat a hospital, two hospitals you have, you basically have two hospital systems. One, 50% of it is UVM. And the 13 others, the other half, and those other hospitals really are functioning on a fee-for-service basis internally. UVM is not focusing on it internally. And so when you try and compare them and they, you know, Senate Health and Welfare, I mean, Senate Finance in 2018 spent half a session trying to figure out how they could make Blue Cross pay the same fee-for-service rate for a doctor's office, doctor's office visit between the two things. And it just doesn't work because the University of Vermont doesn't pay people that way. So if you wanna get, you say, we have to have equity across all sites. So we wanna pay everybody the same, irrespective of the site. The site's different. Burlington is very different from North Country. And if you wanna, and so it seems to me that it makes no sense to try and treat them exactly the same. That's just my opinion. Thank you. Thank you, Ham. Next, I'm gonna go to Mort Wasserman. Mort? Thanks. I am totally in awe of the team that put this report together because the situation is so complex. I was just trying to muse about some overarching principles that could be applied here and then question those very overarching principles. In healthcare, there's this principle, first, do no harm. So the thing I would first consider is doing nothing an option. And I would probably answer that by saying, no, it's not an option because sustaining the current system that is so poorly put together and so distorted is just not an option. The second thing that occurred to me was using the principles of value-based care while leaving quality completely out of the value equation strikes me as dangerous so that if you have to leave quality out, you'd better try to imagine what distortions will be introduced that will in fact affect quality. It would be nice to move from anything based on fee-for-service and yet I see service type and current fees, unit costs being the basis for many of the possible ways to alter things. That seems to be moving away from population health goals. The notion of provider type is so broad, the way we use it, a provider, as far as I can tell, is any one or thing that sends a bill which encompasses the small, solo and three-person practices going all the way from that to the health network. So maybe that notion itself should be questioned. So finally, I would just say whatever decisions are made or whatever is put into place if the legislatures chooses to put something into place will result in distortions and will create harm and it would be good to anticipate those harms as much as can be possible so that one can consider how to address the damage that is done when you reform the system. That's all. I will just, oh, sorry, Mark. I just wanted to comment. Those are very helpful comments and we did think about quality in a robust sense but for the purposes of our timeline we're unable to kind of weave it in here as explicitly as we wanted but it was definitely feedback we gave to the legislature that if you are really going to dig into value-based care that is absolutely something that needs to be layered into each of these options and I don't, in the actual report if you look in the full report we do talk about that a little bit. Like some of these options are more amenable to kind of a value-based care or quality focus and some of them it's not at odds with but it wouldn't have the same kind of complimentary aspect as, for example, like global budgets are trying to really set up to have those quality components particularly in the Maryland and the Pennsylvania models but that's certainly an area that warrants further research and then as for the provider type that's something that we tried to call out in the whole body of the report that that certainly needs further refinement if we're really going to understand how to design and implement any of these strategies. Could I also add to that or Robin it looked like you were about to jump into? You go ahead Sarah. Okay, I was just going to say that from my perspective I think quality could potentially be layered onto any of these models whether that looks like something like health system budget as Elena mentioned where it's really kind of like part of the fabric or whether it's something that's built on top like a pay for performance or quality withhold or something like that. There are things that we can do to layer different models on top and as we said the report itself is like 100 slides because there's so much complexity that we did dig into and that we could dig into. The other thing that I want to highlight is when we talk about those potential distortions in the report itself which goes deeply into the eight kind of suboptions that I'm projecting up on the screen right now we do include pros and cons for each of those options. So we've tried to kind of highlight some of those distortions where we can already see them but one of the things that we are thinking about as we propose areas for further study and as we kind of ask the legislature for direction on where to go next is making sure that we would be identifying those distortions in advance and doing the analytic work prior to and doing the policy work prior to to think about how changing the incentives will or how changing payment will change the incentives and could impact quality. Okay, is there other public comment? Ham is your hand up again? Yes, sir. I'd just like to ask whether you're gonna make a recommendation among these options, Kevin. At this point we haven't been asked to make a recommendation, Ham. Okay. I mean, okay. Thank you. Other public comment? Well, Kevin, this is Mark. Go ahead, Mark. So, you know, these are just some thoughts to share as you think about this but if we are truly talking about how do we make healthcare costs affordable in the state of former monitors that has to have some component tied to the total cost of care? It really, really does. And I'm obviously just sharing my opinion here. So, you know, and in that spirit, there are some topics, there are two topics in particular that I didn't hear discuss that has that is gonna have a big impact on cost of care to remoders. Our aging population, you know, that's gonna have an impact on the cost of care. So like, once again, I go back to the total cost of care. If we're serious about this, you know, we really need to look at the total cost of care. And then the other thing that Vermont exports a lot of care to. So once again, that comes back to the total cost of care and how do we balance those? And then the fourth point, you know, there's been some, you know, throughout this conversation, you know, in these examples, there's been some reference to we need to take dollars from one to take, well, to give to the other to balance out. And, you know, at least I think if we have an effective reform process, there's probably gonna be a higher cost that first candidly. And the reward comes from lowering utilization, lowering unit cost. And that reward is later down the road in the cost curve is much less. So, you know, I would just kind of share that because, you know, I mean, I can't speak to how good our system is today or how imperfect it is today. But, you know, if you're just moving around the dollars that makes it seem like you're transferring, you know, you're just changing, you know, one challenge for another challenge. And if, and if reform, and I mean, health reform, not regulatory reform, health reform is done well. It comes from lowering utilization down the road. So, you know, so I would just put that out there as we think about these things. And it's obviously a complicated issue, but you know, you know, so, you know, those are just, you know, some thoughts when that hit me as I was listening to the presentation. And I would just, you know, share for a very complicated discussion. I thought the staff went through it very well too. Thank you, Mark. Next is Eric Shultes. Eric. Hi, Kevin. I just have two comments. I guess they're not really about this report. One is if the board has seen more, a substantial number of comments about the hospital procedure price transparency disclosures. I think it might be worth asking the board and the HCA and the hospitals to work together to try to figure out how to best tell consumers what you can and cannot do with it. So I think having talked with the board about this and I guess three hospitals, I think we're in a rather surprising amount of agreement about what Ken and Kenopi said with this data. And I think, you know, if the hospital's approach to the disclaimers isn't working, it is something that needs to be addressed so that we can try to head off the worst confusion because it could be misused. And then the other item is I would like to introduce Sam. He's took over Julia's role. He is a graduate of Middlebury College in Polisai, recently graduated with his MPH from the T.F. Chan School of Public Health, both roughly three years before then and then during his time at Harvard, he was working at the Harvard Center for Health and Human Rights. And I'm sure everyone will be seeing a fair amount of them in the upcoming years. Can Sam go on camera so we can see who he is? Nice to meet everyone. Thanks so much, Eric. There he is. Okay, other public comment. Walter. Hey, Kevin, I just wanted to make a comment here when we talk about utilization. I thought the purpose of the healthcare system was utilization and not lower utilization. Lower utilization translates into claim denials, translates into deductibles, which are made to stop people from using the healthcare system. So I asked us to think about that. I'm a victim of claim denials. I know very well what they're like. I just had to fight one this year and I'm even on Medicare now. It's a good point, Walter, but there are a number of studies that point to unnecessary utilization as well. So you have both problems. You have people being denied proper utilization, but you also have improper utilization that doesn't result in better results. So it's about getting the right care at the right time in the right setting and making sure that that care is coordinated and making sure that it's early enough so that it doesn't become the more expensive care. So it's a very complex situation when it comes to utilization. Nobody's trying to deny utilization because that goes against our aims of quality and access, but at the same time you have to recognize that there is room for improvement in the system. Other public comment? Hearing none, once again, I want to thank the team for a great discussion this afternoon and a lot of interesting points were raised and hopefully the legislature is digesting what you presented to them and we'll move forward from there. Oh, did I miss someone? No, I guess somebody just wasn't muted. With that I'm going to go to 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 a motion to adjourn? Some moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion signify by saying aye. Aye. Aye. Those opposed signify by saying nay. Thank you everyone. Have a great rest of the day.