 Good afternoon and welcome to the Green Mountain Care Board. My name is Kevin Mullen, chair of the board and I'm gonna convene this meeting. First item on the agenda is gonna be the minutes of Wednesday, July 28th and Wednesday, August 4th. Is there a motion? So moved. Second. It's been moved and seconded to a few minutes of Wednesday, July 28th and Wednesday, August 4th without any additions, deletions or corrections. Is there any further discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Those opposed signify by saying nay. Thank you. Next I'm going to call on Michael Barber, our general counsel to announce a couple of rate decisions. Mike. Thank you, Mr. Chair. So I need to announce the board's recent decisions on the 2022 individual and small group rate filings and probably should just start with a little bit of background. So as a result of legislation that passed during the most recent legislative session the individual and small group health insurance markets in Vermont were unmerged for 2022. And this meant that Blue Cross and Blue Shield of Vermont and MVP health plan each submitted separate filings for their individual and small group plans. Unmerging the markets had the effect of lowering small group rates and increasing individual rates compared to what they otherwise would have been with individual rate increases being offset by expanded premium tax credits available as a result of the American Rescue Plan Act. So starting first with individual plans based on the filings, there are approximately 31,000 members covered by these plans with membership being split pretty evenly between the two carriers. Blue Cross requested a 7.9% average annual increase for its individual plans which it lowered to 5% based on the recommendations of the board's contracted actuary. And then they increased their request to 5.2% following the submission of hospital budgets. The board approved a 4.7% average annual increase for these Blue Cross plans. MVP requested a 17% average annual increase for its individual plans which the board reduced to 12.7%. Moving to the small group filings, according to the submissions, there are approximately 40,600 members in these plans with 21,858 members enrolled in MVP plans and 18,755 members in the Blue Cross plans. Blue Cross proposed a rate change of negative 7.8% which it increased to negative 6.4% based on the review conducted by the board's actuaries and then increased that again to negative 6.2% following the submission of hospital budgets. The board approved a rate of negative 6.7% for these Blue Cross plans. MVP meanwhile proposed an average annual rate increase of 5% for its plans which the board reduced to 0.8%. So I know that was a lot of words but it was a little complicated this year by the four separate filings. Thank you, Mike. So next on the agenda, I'm gonna turn it over to Executive Director Susan Barrett for an update and also I'm gonna ask Susan to introduce our presenter and presentation this afternoon. So Susan. Great, thank you, Mr. Chair. And thank you, Mike, Barbara for getting that announcement out. I'm glad you were doing it today and not me was very complicated. So I want to remind the public that next week the board will start our hospital budget hearings. They are all going to be accessible via teams and we do have a physical location at 144 State Street in Montpelier to comply with the open meeting law. I will mention that all board members, staff and presenters will be presenting via the teams remotely. We have a couple of ongoing special public comment periods. One is related to and is about the FY22 hospital budget submission. So on July 28th, 2021, we opened the special public comment period for the FY22 hospital budgets. This will go through September 1, 2021. As I mentioned, the hearings start next week and then the deliberations for these decisions start September 1, the board will make a decision on the hospital budgets no later than September 15th. So we ask that folks submit public comments prior to September 1st to be considered by the board in deliberations. The second ongoing public comment period is on a potential next agreement of the all-pair model with CMMI. We opened this comment period earlier this year and we continue to take these comments and we ask the public to please provide these comments. We are sharing anything on that potential next agreement with CMMI and any public comments with our partners at AHS and the governor's office as both AHS and the governor's office are taking the lead on the negotiations for a potential next agreement. So with that, I will move to introduce our speaker today and give you a little background. Today, we welcome Shuley Garovitch who is a senior fellow at Mathematica Policy Research Group. She'll be presenting to the board on avoidable utilization in rural hospitals. Before I share a little bit of background on Shuley, I wanted to mention that her presentation today adds to the ongoing work and discussions the board is undertaking on rural healthcare sustainability as the Centers for Medicare and Medicaid Services, the state of Vermont and by virtue of that, Vermont's hospitals transition to value-based care. And as such, these hospitals will be more increasingly accountable for cost and quality. We want to ensure their sustainability in this value-based world. I think the presentation today will talk about ways to do that. And I hope that it will inform both the board, the public and our stakeholders. So now I'll transition to introducing Shuley Garovitch. As I mentioned, she's a senior fellow at Mathematica Policy Research Group. She's a lengthy bio and I won't go through everything, but I think I'll pull out a couple of things that may, I think are very interesting for our discussion today. So Shuley manages the state health policy portfolio at Mathematica and she's an expert in healthcare payment policy alternative payment models, global budgets, all payer models and quality and performance measurement. She has a really extensive experience with state health policy in Maryland, Pennsylvania, here in Vermont, of course, in Massachusetts. Shuley, I actually met Shuley years ago, I don't know, maybe five or six years ago, when we were just really exploring the potential for an all payer model, Shuley worked at Maryland's and I know I'm going to get, maybe I'll get it right, the Maryland Health Services Cost Review Commission for many years and her expertise, both in data analysis, quality metrics and the work she did down in Maryland really informs her work that she does for states today. I will also mention that Shuley also has a clinical background having worked as a clinical nurse for six years in inpatient settings. She also has a PhD in public health from Bloomberg School of Public Health and an MPP, Masters in Public Policy. I hope I have that right from the same university. And there's more, but I'd encourage folks to look at her bio on the Mathematica Research Policy website to learn more about Shuley, but I think I will turn it over to you, Shuley, to share your presentation. Thank you for coming today. Thank you so much, Susan, and thank you for that introduction as well. Can you hear me okay? We can hear you. Great. Thank you for the invitation. Yeah, I think it was about six years ago. What I remember is you all came down to Maryland to talk with us and I had the terrible franchisee, so I ended up not being able to talk with you, but I'm glad we had the opportunity to meet in person and I really enjoyed working with Vermont and thinking about these challenging issues. As a kind of person who worked with multiple states, maybe my perspective on Vermont, I'm gonna start there and then we'll go to the presentation. Vermont is one of the three states who are really at the trailblazing end looking at the reform, both from the delivery side and from the payment side. You have been in the long journey, you know, blueprint and before that medical home models. So you are far ahead in this journey compared to many other states. And the way that Vermont is dealing with sustainability and rural health is an advanced model and I'm hoping that it will help other states as well as you work through these tourney issues and create a sustainable healthcare finance for rural health. So with that, I'm going to see if I can share my screen and turn to the presentation mode. Okay, can you see my slides? Yes, we can, yep. All right. So I wanted to start with a little bit about Mathematica. As Susan mentioned, we've been working to support GMCB around all peer model monitoring reports, but Mathematica has been supporting public and private sector policy makers over 50 years and our strength is really bringing the data and the policy makers together to think about how we can use analytics to improve healthcare and social services. With this mission orientation to improve public well-being, we've been working in what we call a data lab. Data donation lab is aiming to bring the data to the decision makers and looking at variations in total cost, quality, and access, both from the payer perspective, provider perspective, and population perspectives to help with the healthcare reform that we are here to discuss a little bit today. We process the national Medicare and Medicaid claims and we are producing publicly available reports on our websites from our work. There is about 10 people who are working on the innovation lab with me. I won't go into the details, but I just wanted to acknowledge the team behind me who really worked hard to create this dashboard and published it on our website. The interactive dashboard is focusing on rural health. As you all are aware, we have tremendous challenges and disparities in rural health, both in terms of access, high burden of disease, as well as high quality of care that is provided to this population. So we focused on rural health for our dashboard and wanted to give information to help decision makers how to think about value-based payment models and create new models to bring the delivery reform and the payment reform together. Our goal and our audience is really hospital executives and hospital policy makers. So a lot of the information that you're gonna see today is thinking through the policy levers that we could use to improve the care and provide high quality care in rural areas. So I'm gonna go into a little bit details. So what we did in this dashboard is we measured avoidable hospitalization at rural hospitals. So what does that mean? So this is a concept that has been used in many states and it is defined as a unplanned care and it is a care that we think would be prevented if we have a better ambulatory care settings. So I wanted to give you a perspective with the other measures you may have heard as we are thinking about healthcare reform which is termed waste or unnecessary care. I wanted to make a distinction here. What we are looking at here is an avoidable utilization. It is really tied to population health. So it is not unnecessary once we arrive at the hospital door and from my experience with the inpatient care, this is very true to my heart. When you are at the hospital, you definitely need that care. So we are not talking about unneeded care or waste. What we are talking about here is a population health based utilization where really if you look at these measures we could design population health centric policies and reform to improve and reduce avoidable utilization at the hospitals. The measures are based on claims data. So these are the billing statements provided by hospitals to the payers. And we flag these claims into three categories. One is readmissions within 30 days. Second is ambulatory care sensitive admissions. So those are two inpatient measures we have. And the third one is looking at the emergency department visits and looking at avoidable emergency department visits that are not admitted into the inpatient setting. So I'm gonna go into detail a little bit what these measures are and how we modified it for this purpose. The first measure is a 30 day all cause readmission measure. You may have heard about this measure in other settings. Federal government as well as private payers have been using readmissions as a quality measure for hospitals and adjusting their payment rates based on whether they have high readmission rates or low readmission rates. The measure looks at whether the patient is readmitted to the hospital within a 30 day period of their initial discharge. The idea behind is that if there is a care coordination and support services for the patients following their discharge, they should not be coming back to the hospital and those admissions could be avoided. The measure is validated nationally by NCQA and it is also used in the HEDIS measure sets for the private plans. It excludes plan service lines such as pregnancy, prenatal care conditions, transplants, rehabs. It's really looking at the admissions where we think that with the care coordination and better primary care, these admissions could be prevented. For our purposes, since we are looking at hospital finance, we only count if the patient is coming back to the originating hospital. So this is a subset of the readmissions that the quality measures look at because in our terminology, we would like to give the hospital executives an idea of how many of their admissions could be prevented that are coming to their hospitals and originating from their hospital. So the idea is the patient is using a rural hospital as the main source of their hospitalizations. The next inpatient measure is ambulatory care sensitive conditions. This is again, another nationally used measure by ARC. It is also called as Prevention Quality Indicators, PQIs. As the name suggests, it is focused on prevention and ARC calculates these measures at the geographical level. So they do have reports looking at county level, PQIs, measuring all admissions for the residents of that rural county or urban county. The idea behind these measures are the, if you look at the conditional list that I listed here, these are all chronic conditions and with a better care management and prevention public health interventions, these admissions would reduce at the hospitals, diabetes, COPD, hypertension. So these are all chronic measures where we do have some evidence that with the prevention and public health, we could reduce these admissions at the hospital. So we took those two algorithms and created an inpatient measure for avoidable utilization and looking at the percent of revenue that are coming from these two measures in the inpatient side. Emergency department visits are in other places where we could look at this concept and look at avoidable utilization. And here we have a somewhat of an old algorithm developed by New York University about 20 years ago. We adapted this algorithm and updated with the new ICD codes. But in this basic algorithm, it is looking at the primary reason or diagnosis for the ED visits and creating a three different classifications for ED visits. The first one is non-emergent care. So those are the conditions where they really didn't need the emergency department but for various reasons, they showed up in our ED departments. The second one is emergent but primary care treatable conditions. So there was an urgency for the condition but if they had better access to primary setting, we hypothesized that they are not gonna be coming to the emergency department. So this is a good example is ear infections for kids, right? So those kind of urgent care conditions could be treated at the office setting rather than emergency department setting. And the third one is an emergent ED care needed. So this is the highest level of visits where we do know that the ED was the appropriate setting but again, with a long-term planning and effective care, those conditions could also be prevented. So those are the three measures that we have in our dashboard. And before I go into presenting some results for Vermont, a few other details as you're looking at the results. The first one is what we present here today is a results from Medicare few for service only. So this is the traditional Medicare plans. And when you look at other payers, Medicaid or commercial payers, what we see is the Medicare population has the highest utilization rates in avoidable utilization. And reasons are multitude, but as you know, the chronic conditions are more prevalent in the Medicare population. And in the few for service environment, the coordination activities are limited to manage these conditions in the ambulatory setting. The second information is we are really looking at revenues. So these measures are not a reflective of the hospital's performance. So I just wanna repeat that again. We are not looking at hospital performance in these measures. What we are looking at is the impact of the area that the hospital is serving on their revenues. So if you are a hospital or a policymaker and you're thinking about value-based purchasing and financial opportunities for these hospitals to improve population health, this is the revenue impact of those potential value-based purchasing that I'm gonna get into towards the end of my presentation. It is not risk adjusted. And when you compare hospital to hospital, we also need to be very careful to think about what other services hospitals are providing on the outpatient care. So the revenue percentages are impacted by the denominators as well as the actual counts from the avoidable utilization. We included hospitals located in rural areas. So this is defined by the Federal Office of Rural Health Policy. And some of these hospitals could be large hospitals serving not only the rural areas, but also the urban areas. So I wanted to point out that. So the rural definition is really based on the location of the hospital, not the people that they are serving. And finally, as there is an overlap between inpatient measures on the readmission and PQIs that preventive quality indicators, we counter them as a PQI to reduce the duplication and have an accurate percent on the revenue. So if you have other information around readmissions, you may think that our readmission rates might be low. And that's the reason why readmission rates might be lower than the PQI. So we can't really judge whether they have a higher readmission rate versus a higher PQI rate. So this slide is the hospitals that we flagged as rural hospitals in Vermont. And it is showing the percent of revenue in avoidable utilization on the inpatient side. We separated the readmissions from PQI. And as you see, there is a wide variation in both measures as a percent of revenue. Just to orient you to the results, the highest ambulatory sensitive admission percent is with Grace College Hospital with 33% of their inpatient revenue in avoidable utilization in PQIs. When we look at the pink columns, it's looking at the readmission counts. And here the range is between 7%, the lowest at Radleboro Memorial Hospital to 14% in several hospitals that are shown towards the end of this table. The second one is the emergency department. So here you have a much higher percents. And if you think about the ED and the ED utilization, this is not surprising to us that over 30% of the ED utilization is potentially avoidable. And when we bring together inpatient and ED, what we see is that the floor of this is around 20% and the highest are around 37%. As you're thinking about your hospitals and sustainability in the value-based purchasing, these are the potential opportunities depending on how you structure value-based purchasing with these hospitals for them to improve their community access and work with the community providers to reduce avoidable utilization. So you could think about it that way, as well as the utilization declines in these hospitals as a result of these value-based purchasing, it creates challenges for the financing of these hospitals and how to maintain access to care in rural hospitals. So from there, we could think about different policy applications of these results and how you can think about utilizing a data-driven approach. So as we talked about the value-based purchasing, we are witnessing a different models in alternative payment models. And they are different based on the specialty or the type of provider. I provided two examples based on the specialties for primary care. We have medical homes emerging in a lot of places and it's been a more over 10 years development of the medical homes models. We have accountable care organizations and you are all familiar with your old payer model how accountable care organization really bridges the gap between primary care and specialists and hospitals. And for specialists in hospitals, there are also episode-based models which look at hip or knee replacements, for example, and how we can create efficient and coordinated care focusing on special procedures or special episodes. What is common across all these models is our goal is to create incentives that are aligned to provide better coordinated care and high-quality care. And the cost savings from these models are usually coming from reduced hospitalization and better post-secure care utilization to avoid hospitalization. So a lot of the work and the literature up to date is looking at the savings from hospitalizations as well as post-secure care utilization. So if you think about what I presented earlier, I created this two fake examples. So if you have a model in aligning financial incentives and you are trying to coordinate care and reduce cost, we have two examples here. Hospital B is about 25% avoidable utilization in their revenue and hospital A has about less than 20%. So if we are trying to improve care, which hospital would you focus? Hospital B has more opportunities, but it could also present more challenges in terms of the social determinants of health, access to care, and the ambulatory setting. Hospital A has lower opportunities and it may also have similar challenges or that there may not be additional improvements that we could expect from hospital A, given their low utilization rate on indovoidable utilization. I copied the slide that I like a lot in terms of where we are and where the payment models are moving towards. As Susan mentioned, we are working towards creating new designs for the finance and move our system from fee for service to what the federal government and the private companies coordinate as the population-based payment models, which is category four. So in this models, what we have is a classification of financing from fee for service, which is the category one to category four, which is considered to be the most advanced payment models that really looks at population health and provide incentives for providers to coordinate care and removes the barriers of the fee for service, which is fragmentation and getting paid for doing more rather than preventing and improving population health. As you can imagine, fee for service creates this challenge for our provider community. On the one hand, finances are dependent on how many admissions you do or how many ED visits you have versus the medical community where they focus on patient needs and try to improve population health, which in turn may reduce hospitalization and admissions and impact the hospital's finances adversely. And we see that in the rural health very starkly. So this graph shows the hospital closures in rural areas and looks at the prior to 2010 versus 2010 and onward. As you see, we have a lot of yellow dots in our national map. So these issues are not unique to Vermont. So we are observing a national trend in rural hospital closures. And there are multiple reasons why we are seeing this trend increasing and we may see actually even more closures in the future. But there are very significant impact of rural health hospital closures to their community. And from there, our take on message is we really need to think about this collectively and merge the delivery reform with the payment reform and the PAUs could provide a data-driven approach for us to create some alternative models and work on sustainability. In these new models, we need to focus on community needs and improve access. And data in the PAUs has been providing a couple examples and how they structured their payment models using this data. So the models that are using PAUs from this perspective are three. The first one is in Maryland. That started as Susan mentioned when I was in Maryland and this is again a 10-year period for Maryland that we started working with the first rural hospitals to create global budgets with the rural hospitals in the state and later we created these budgets for urban hospitals as well. And in the latest stage of the Maryland PAUs, we are now focusing on improving total costs and trying to align payment levels between hospitals as well as physicians and ambulatory care setting. The other example is Pennsylvania Rural Health Model which started five years ago. And this model is really focusing on rural health and leveraging the state to coordinate the policies across commercial and public payers. And the most recent example is coming from CMS. CMS instituted a new model called Community Health Access and Rural Transformation Chart Model. And building on the experience from these two states, they created two tracks. One is a global budget for hospitals and providers in a community. And the second one is Accountable Care Model which takes some of the lessons learned from Vermont as well as some of the other rural health models that CMS ran in the past. In the CMS model, they are requiring the convenience to work with other payers and they are looking at, especially the Medicaid departments in the state to coordinate and recruit private payers and bring Medicare, Medicaid and commercial plans around global budget for rural areas. What is a global budget? And there could be different names but essentially global budgets are fixed revenue models. So you establish a revenue base for the hospitals. And in this revenue base, it's usually based on historical revenue. And you adjust the revenues, not only how many patients they treat, so you adjust the global budget based on quality efficiency and adjust for shared savings with the payers. So the fixed revenue really takes the equation to a new level and it is not a claims-based fee-for-service payment, but hospital receives a set guaranteed revenue for the full year and create transformation plans to improve population health in exchange. How the PEUs play in the fixed revenue? So I provided a very simple but complicated graphs in this example. Again, if you remember our hospital A and hospital B, we have a two scenarios. We have a 10% PEU in hospital A and in hospital B we have 20%. All hospitals under fixed global budget is going to receive $100 as a fixed revenue in this example. And based on their PEU levels, hospitals would save and create opportunities for population health improvements if they reduce their PEUs under global budgets. As they reduce their PEUs, which are the red arrows here, they get to keep the revenue because their revenue is set at $100. For from the payers perspective, how to ensure savings to population and reduce our rates? We would create shared savings looking at this targeted avoidable utilization reductions and gradually reduce the revenue percents from $100 in the first year to incremental changes to ensure that the savings are shared with payers and the population. So in both Maryland and Pennsylvania, potentially avoidable utilization have been very critical to help hospitals to create transformation plans, look at their data and understand where the community needs are. So they've been doing detailed analysis of the top conditions that their hospital is receiving in avoidable utilization and working with their communities to create new services if they are required or change their practices to ensure that the care is coordinated with the goal of reducing avoidable utilization over time. So with that, I will stop here and answer any questions you may have. Kevin, you're muted. You let me go on for quite a bit, Jess. And you gave me a heart attack. I'm like, oh my God, was I disconnected? Sorry about that. Thank you so much, Julie. That was a lot to digest in a short period of time. And I'm gonna open it up now to board questions and comments. And I'll go in reverse alphabetical order starting with Tom. Yes, a lot to digest. I mean, my mind is going between this presentation and the reality of how hospital budgets are staring me in the face every day these days. I don't quite know where to start with questions because there's so many. But first at a practical level, have you worked with any individual hospitals where these concepts have been applied and where the results are clear and can be pointed to? Because I find that this concept here of the two canoes with a foot and one canoe and a foot and the other that generally, whether it's insurers or providers, they prefer the bigger foot in the fee of service canoe. Everyone seems to genuflect to the concept of quality care and fixed payments of some sort, capitation of some sort. But it just seems to be in a small corner of the world and not getting a lot of momentum and growth. And I think it would help if there are specific hospitals that we can point to say to our hospitals and to our providers, look at here. Here are examples of where we can be. Wow, great question, Tom. So a couple of things. So I think the longest experiences with Maryland global budgets, you are right. So we talk about value-based purchasing and fixed payment, but until we fix this issue with getting paid on a fee for service versus having this marginal value base, right? At the end of the day, what we saw with the readmission quality adjustments that CMS implemented, they were getting dinged by small percentage of their revenue. They couldn't afford to lose the readmissions from the finance perspective, right? And it is a reality and it is the rational thing to do if you are get paid on a per service. In Maryland, we have as a regulatory agency, we have collected a lot of information what hospitals that once we established global budgets. Setting the payment model is not enough. It is a culture change. What we experienced with Maryland in the initial years was even though we thought that the incentives were aligned, culture wasn't there yet, right? So it takes a while for hospitals to leave that canoe and jump fully into the value-based world where you look at your services from a very different perspective. There are very good examples in Maryland and I'll be happy to connect you with a few of them that implemented that strategy. They used data and they looked at their ED utilization and they start tracking which patients were coming for what purposes and they created additional services to support these hospitals. Some of them did social determinants of health and they are working with kind of reducing prescription drug cost or creating some food support for their patients to reduce again hospital utilization but they are guaranteed on the revenue side, right? So that's the big one that kind of changed the way that they implemented their services. I guess if a lot of provider community is hesitant on the value-based purchasing, I'll say even if they are not participating in those, it is coming as I pointed out, all other models are looking at hospital utilization as a cost savings. So if you don't implement value-based purchasing involving hospitals at the end, especially for the rural health community, we are gonna be in a place where hospitals would start closing and who's gonna provide services if the major employer and the infrastructure is gonna disappear without any sustainable model. So whether hospitals do it themselves or somebody else to do them is the conversation that you may wanna have with the hospitals to understand what their perspective is. Finally, one model that is kind of getting me into that direction is CMS started a new model called Drake Purchasing and the details are many, but the idea is to create contracts with external entities for them to start thinking about this providing services and purchasing them directly from the providers and that is gonna create additional financial pressure for the provider to negotiate and kind of do analysis like we did to create the per member, per month type of analysis to reduce cost. So whether hospitals are in or not will become irrelevant in a way because this is the field and it's going towards as I showed you in the graph towards the population-based models and it will come five to 10 years to everywhere. So based on just your observations, I think in the last year, the board has spent some time trying to nail down what the quote unquote tipping point is for value-based payments where these reforms begin to yield the kind of benefits that everybody hopes for. And so we put a condition on our ACO to get us a report in that regard and they've submitted a draft I think and staff is scrubbing it now. But do you and our hospitals we can see have been pretty flatlined for the last two or three years that around 14% in terms of their revenues being the broadly defined fixed prospect of payments. Capitation rates are much lower but broadly defined was some kind of rich sharing or something of that sort. It's in the 13 to 14% range. Do you have any sense about what a, as this thing unfolds, value-based payments unfold where the tipping point is, where hospitals or providers can begin to say, Eureka, this is working. Value-based payments is working. We do a lot of evaluations at Bathmark of the federal models. So I would kind of need to talk with them a little bit on the tipping point, but from my side, like one is about the impact of those models, right Tom? And it takes time. So it does take a few years for the implementation to get into the levels that we want them to be. It has to be at the patient point of contact. So it's a little bit of a time question than a tipping point for flipping the switch and declare that value-based purchasing is working. In a lot of the models, the expectations are set from the historical revenue base. So if you look at Maryland and Pennsylvania they worked on creating targets for avoidable utilization and that range 3% in Maryland to about 5% in Pennsylvania. So there is a lot of analytical work to look at this concept of avoidable utilization and how much reasonably we can reduce it over time. There are some studies on the care coordination and we see 30% reductions given the population that they targeted. But my experience with those studies are they really narrow it to a very high cost patients and then they show big gains like 30% over one or two years which when you apply it to the population level reduces the impact and reduces the numbers. So I'm happy to kind of take this offline and provide you a little bit of detail on the evaluation studies with that, if that will help. And then one final question, this might be totally mixing apples and oranges but as you know, last year, CMS required this price transparency information to be published by hospitals. And I think everyone here on the ground who's looked at it says it's a mess. You know, it's just, you can't compare apples to oranges apples to apples across hospitals. People have defined the coding that they've used differently, they've used different formats of presentation and so it's really not useful. But on the other hand, it could be useful. And I'm just wondering whether you folks have crossed paths with that and have some thoughts about, gee, you know, if this were just better organized or on a template that all hospitals would use there's valuable information here that would help us see into the realities of pricing across different providers. Tom, yeah, I think that reminded me when the EHR's electronic health medical records were rolled out to do the CMS, there were no standardization and we are after, I guess it's also with the ACA over 10 years, now we are trying to figure out how to standardize and use that data better, right? Transparency is another area where we could have impact if people have better knowledge of the prices that they're gonna pay, both the patient but also the purchasers, right? So comparative information. We've been thinking about that a lot actually at Mathematica, the initial reports are gonna be probably useful for people like me and like you who could understand the details and make sense of it, it's not gonna be useful for the patients unfortunately yet, but it is the first step in my view that now we are gonna have this data coming in and collectively we have to work with federal government and the providers to make it more useful. I agree with you currently, we were questioning, okay, what is this gonna show? And with all the experience we have collectively at Mathematica, we were puzzled in terms of like making sense of even the data that we got for our own hospitals. So there's a lot of work to be done there, but I think that that's a valuable, like you said, to get a better sense of what the prices are in the hospital sector. Thank you. Thanks, Tom. Next we'll go to Robin. Thank you. Thank you, Shulei. That was really interesting. And I especially liked your clarifications around that this type of a dashboard is really the way I would say it which might be a little bit different than the way you said it is that it's measuring potentially avoidable care at what we would call the HSA level. So really looking at the community level and it's not all obviously on the hospital to fix that that would have to be a joint effort of the community as a whole. So I liked that perspective because I think it aligns well with Vermont's history and the blueprint in our efforts in healthcare reform in general. I was wondering if you had any plans or thoughts about including commercial data at some point using APCDs in the dashboard. Robin, I'd love to do that. I think for a specific state, we were able to do that in Pennsylvania and to a certain extent Maryland has been working on that as well. So we could do that with your APCD, right? You guys have the APCD. Other pieces like try to benchmark and try to see, we don't expect them to be zero, right? So the other piece about this is, we'll never get to zero. That's not the goal. But what is the reasonable level that we could target that will require commercial claims. And we are kind of thinking about whether we could use commercial claims databases to create a commercial component as well as using the Medicaid claims that we have access to currently and add those two payers into our dashboards. Yeah, yeah. Because from the other thing that we didn't discuss is value-based purchasing for providers to invest. So reducing this is gonna require investment. And if you do it payer by payer, and this is my all payer, I guess my all payer slant and preference, what we observe is if you do it payer by payer, you are not creating enough incentive for hospitals providers to make major investments, right? So the more we could think about from an all payer or multi payer perspective, the stronger incentives would be and the alignment will be there as well if you are using the same concepts and same definitions. Thank you. I didn't have any other questions. Thanks very much for the presentation. Thank you, Rob. And next we're gonna go to Jessica, Jess. Great, thanks. And thanks, Shuley. This is really helpful. And I think it's gonna inform some of the work that we're doing around hospital sustainability and preparedness for value-based payment, which I'm gathering from what you said in the presentation, value-based payments are coming. That's really not debatable. I mean, coming in a comprehensive way, that'd be the primary form of payment. I guess it's not really debatable what maybe is debatable or what we have to think about is are our hospitals and our providers prepared for that transition? And so this is really helpful in that regard. So I'm wondering if you've done research or Mathematica's done research into what are the factors that are really the biggest drivers contributing to avoidable utilization, whether it's lack of primary care access or lack of access to the wraparound services and community support systems, or is it ineffective care management, or is it poor discharge care plans, poor follow-up? In some ways, I'm wondering what are the big drivers because then that would help us figure out what factors could be addressed, what would have the biggest impact on reducing avoidable utilization if we understood what are the biggest drivers? Yeah, it's a great question. I think there are some studies in terms of like looking at readmissions, what factors impact lower readmissions than how providers implemented certain interventions, right? But from like we've been working a little bit looking at the associations between certain population health indicators if you have a higher prevalence of certain conditions, does that have impact on the avoidable utilization? So we are trying to look at it from the area level perspective to see associations to help with that decision. There is a vast literature on the readmissions and avoidable utilization on impact, but I don't think I haven't read any article or any study addressing exactly what you are, like comparatively, right? Like comparatively where it needs to focus. Yep. Got it. And actually with respect to the readmissions, I know you pointed out that the measure that you used was readmissions only to the original hospital. And I understand that because your audience is the hospital itself in terms of their financing and preparedness or value-based payment. But in some sense then that actually means that this is probably an underestimate of truly avoidable utilization because there could be readmissions to other hospitals that could have been avoided that aren't captured in your data. So at the very least this is, you know, probably an underestimate. Definitely. Definitely. Definitely. Yeah. Especially if you think about rural hospitals, right? You know, a lot of the readmissions could be happening to other centers not coming back to the originating hospital. And in general, we had done some cities when I was in Maryland, 50% in general, like average, 50% of readmissions are happening back to the hospital and 50% is going to another hospital in Maryland. So if you run this algorithm, you know, we could measure those as well to measure the overall avoidable utilization. Right, which would be really helpful to understand. Yeah. And then you broke down the categories of avoidable ED visits. And if I'm remembering correctly, it was like non-emergent, primary care, treatable, and then emergent, but could have been prevented, right? And I'm wondering if any of the work that's done here breaks it down by those categories by hospital because to some degree, understanding, you know, whether this is, what percentage of the avoidable ED is non-emergent might have a different solution than emergent but preventable. Or, you know, I mean, I'm just thinking that it actually might matter what the breakdown is. Yep, yep. Is that something easy to do or has been done or is easily pulled out of the data? It could be pulled from the data. What we did with the Pennsylvania hospitals once we created these reports, first they were shocked. With that 30% on the Medicare side, they just kind of, it took a while for them to believe in that number. And once we did that, then we provided detailed reports and break it down into those three categories as well as giving them some diagnosis information for them to really focus on what kind of conditions, like detailed conditions are drawing the avoidable utilization to ED. And they took that reports and they are working to create some interventions, working with their ED. They put the care coordinators in their EDs to start addressing some of those individual diagnoses or conditions that they've seen in the data. Do you remember off the top of your head which of those three buckets seem to be the biggest bucket in Pennsylvania? And I recognize Pennsylvania is different than Vermont. But I'm just wondering, is it more than non-emergent or is it more the emergent but preventable? I need to go back, sorry. I don't have that in my head. Yeah, no worries, understandable. I just was curious. And then I guess my last question is, when you look at the data for Vermont, and I guess I can go back and look on this pretty comprehensive website. But I'm just wondering your first pass at it, looking at how does Vermont compare to other similar states? Where do you think we are? I mean, it's similar. I didn't see Vermont as an outlier. So I think the ranges are similar. You see some variation in the hospital. So it is really difficult to do a comparison, right? Because your denominators are different type of hospitals you have. So if you're interested in that type of analysis, then we may wanna control certain things to see where we're not compared to other states, right? So it's really hard judge in a way, whether you have a high or not, yeah. Okay, I was wondering if it jumped out of you in any direction. No, no. It sounds like we're right in there with the masses. Okay, those are my questions, Julie, and this has really, really been helpful. Thank you so very much. Thank you. One thing to add, we did historical analysis in the past. It's like in the past 17, 18, 19, they are stable. So those trends are not jumping up and down, which is interesting to me to think about that nothing really changed in the last three years. Do you mean that nationally or do you mean that for Vermont? We didn't run this historically, so maybe that's another one. In the other data that I've seen in Maryland and in Pennsylvania, we'd run historical data and percents were similar until of course Maryland started their program. So then things started changing a little bit. Great, thank you. Thanks, Jess. Julie, on slide eight, you have the list of the conditions, and I'm just wondering in your research if you did any rank ordering by frequency or costs so that there's some type of order to what is costing the system the most in these conditions that can be avoidable? Yeah, we didn't look at that one. That's another good one. So I'm taking notes on in terms of our next iteration of the dashboard to add a little bit more detail. What I can tell is like from our work, U2Is, urinary attract infections are kind of the low hanging fruit, so to speak, that the provider seeing a quick, good interventions can prevent U2Is much more so than some of the other like diabetes or COPD. But we didn't run that with the national data to see what that order is. Okay, thank you, Julie. At this point, unless there's a board member that has additional questions, I'm gonna open it up to the public. Does any board member have any additional questions? Hearing none, I'm gonna open it up to the public for public comment or questions and please address anything through me. And I'm going to start with Jeff Thiemann. Thank you, Mr. Chairman. Good afternoon. And thank you for the presentation, Shule. Really, really good work and interesting. As board members said though, there's a lot to digest here and I think we're just seeing the slides and hearing your remarks about them. So for the board's purposes, Kevin, we may submit a letter responding to some of what we heard and trying to further contextualize a little bit of what Shule had to say. So that may be coming. I do wanna make a couple of quick comments, I think, though, since this presentation and topic is focused on utilization. And I think given where we are in the pandemic, it's really important at the moment to take at least a second to look at utilization through a current today lens. And one note on readmissions before I do that is that I think it's important to recognize that there are a lot of factors outside providers control, outside the hospitals control that dictate whether someone is readmitted and that can include whether they follow a care plan and are adhering to discharge instructions and all of those kinds of things. So that's just some of the context we may provide. But when we get back to utilization through a current lens, what I can tell you is that right now Vermont's hospitals are very busy, they're very full. There's a lot of volume and utilization right now. They're busy in the emergency department. They're busy in medical surgical wards and psych units, outpatient clinics and surgical sites. You name it, people are coming back to the hospital. This represents, to some extent at least, if not to a large extent, care that was delayed or deferred during the pandemic for various reasons. And it is filling up our hospital beds and in the mental health space, having patients who really need care, seeking that care in the emergency room, often with few options for where we can properly place those people for the treatment they need and deserve. So that volume only continues to intensify. And I think you're seeing that in headlines, not just here in Vermont, but across the country. And then when you combine those factors with our ongoing workforce shortage and the challenge we face there, and which adds to our daily costs on a kind of rapidly increasing basis, it just sort of fuels the notion that hospitals are doing a lot more with a lot less as the uncertainty only grows. And couldn't agree more with Shule that at the same time, we continue to make the right steps and be a trailblazer in Vermont towards moving to the value-based payments. We all know the system, you know, probably would function better with if we could do it on a broader basis. So I think in the upcoming budget hearings, you will hear a lot more detail about the utilization issues I just described, probably some responses to the slides that Shule shared. And also, you know, we'll gain a fuller appreciation, I think, for some of what's going on right now. But we may follow up with additional comments. And until then, Shule, thank you for your work and presentation. And thank you, Mr. Chairman. Thank you, Jeff. Next, I'll call on Ham Davis. Thank you, Kevin. I don't know if you could ask for your consultant question. I'd just like to read, just like to know whether in her work, whether you get a metric like either readmission to the hospital or, and I totally agree with Jessica, that the much more important is the revision surgery. It's certainly in Vermont, which happens all the time. I'm just curious whether the public knows anything about that in Pennsylvania or Maryland. And let's say that you have, did they publish hospital data about revision surgery, about readmission to the hospital? So basically, Shule, Ham has asked whether or not there's any public transparency on readmissions. Yeah, great question. I think we talked about the price transparency and the quality transparency has been a focus as well. As you may know, CMS publishes the readmission rates in their website for the Medicare population. And in Maryland, they also publish complication rates. So this is the complications happening during the surgery or during the visit as well as rate mission rates. I think public transparency is a complicated and a different perspective. So you really need to work hard to make them understand what it is. And a lot of the payment policy work is happening at the regulatory level and it's not their primary goals. So I think there is a lot of work to be done to take some of this work and create the transparency for the patients to understand what they are receiving. And at the end of the day, Maryland did a focus group with the patients back in the day when we were trying to prepare for the second phase. And patients as well as the providers at the hospital, they didn't connect, they didn't know about this payment, whether you are paid on a fixed revenue or a fee for service, what they knew what was changing for them, right? So we kind of have to have that lens as we're looking at this data and do more public reporting in a targeted and a different way. So what I presented to you as I mentioned, the audience is really hospital executives and the policy makers. It is not intended for patients to use. Can I have one more question, Kevin? Sure, go ahead, Ham. I'm curious about, one of the things I'm curious about that really has never been a major factor in Vermont, but certainly could be, which is the whole idea of global hospital budgets. I mean, in the hospital, in the small hospital, small rural hospital world, all over the country, small hospitals are, he is going out of business, so they are affiliating with much bigger, much bigger systems. Would global budgets, if we had global budgets, do you think it's any kind of a problem that you could take a hospital that just can't really function as a full service hospital in any effective way? Would a hospital, would a global budget get in the way of a natural solution to that problem? So Ham, I think what your question is, and correct me before I pass it over to Shule if I've got it completely wrong, but is there something inherent in going to global budgets that would not create the same type of fix as for example, if a hospital wasn't doing things properly, I think what your natural fix is a closure, is that correct? Well, yes, I mean, certainly, I mean, we've had that, we've had that, I mean, we had a hospital in Rockingham in Bellow Falls, exactly like Springfield just went away. Same thing at Fannie Allen in Chittenden County, same thing at Curbs Memorial in St. Alvin, same thing at Barrie City in Barrie, and so my question is, you know, my question is- And Proctor. I'm sorry. And also Proctor, that was six years ago. But I believe you that the question is, the question is that, the question is whether, you know, what to do about hospitals that are very marginal. We've got one in Springfield out there that has just emerged from bankruptcy and Fletcher Allen and UBM rescued Porter from bankruptcy. So the question is whether, the question is whether global budgets would change all of that kind of dynamic altogether. Julie, you want to try to take a stab at that? Oh, I will, but yeah, that's great question again. How to protect this, right? First of all, global budget is not a silver bullet, right? So it's not going to fix the problem of what kind of services our communities need. And the hospital acute bed concept comes from a, 100 years of the, you know, the population needs that originally we need acute beds and we needed to be treated at the hospital. That's no longer the case given where we are in our life expectancy and the burden, right? So it's all about the chronic conditions and management. To me, you know, you may call the hospital closure a solution. What is left behind is the problem most likely, right? So global budgets could give you a glide path to transform the hospitals in the community to whatever they need. And whatever need is still to be determined and I don't see a lot of work. There I think American Hospital Association published something recently about essential and you guys are working on that as well, essential health services. The finance is a small puzzle. I think the bigger problem is the delivery reform. What kind of infrastructure we need in the rural communities and how we can get there. Global budgets fixes one small problem that they don't need to chase after admissions and EVs to keep their bed open, their doors open. And I think prior comment mentioned COVID and I think that was a little bit of a wake up call for a lot of people nationally about sustainability. You've been thinking about this all along but others didn't pay a lot of attention about the capacity and creating sustainable health system. If you let these hospitals close abruptly, especially then we are gonna be kind of dealing with the problems rather than solution of the problem of the rural hospitals. And one thing, one else to add. Yes, there are some individual issues with the management but you saw that national charge, right? So 108 rural hospitals are closing. That tells me a systemic problem rather than a individual management problem. So I think we really have to think about it from the system perspective and the population health and what we need. I hope that kind of starts scratching some of the answers and maybe we can discuss more if needed. Thank you very much for that. And I appreciate my question I think was badly framed. I think that you do not have to necessarily just close a hospital. You could shift its focus from a full service hospital with surgical lines with very low volumes, therefore very high unit costs and then a quality question coming out of that. So the question, what I meant my question to be was what the hospital needed to be a clinic of some dimension rather than a full service hospital. But you don't have to go in there, Kevin, I got it. That was very helpful for me, thank you. Yeah, one more thing to add. Sorry, Kevin, if I can, right. I think that's the problem, right? The fixed cost in the hospital and traditionally our payment system provides more resources if they keep their inpatient beds open, right? And until we solve that problem, we won't be able to transform them into whatever we want them to be. To me, global budget could give that revenue stream and help them to glide back to that next stage. The important thing is what are they gonna do, right? We know what the challenges are. The question is if you were to give them fixed revenue, what would you expect them to do and what kind of services you would kind of collectively think about hospitals providing in their communities? Yeah, I think the point that Ham's trying to make was the question, thank you. Yeah, and just to follow up, Pam, I take your point to be and you can tell me if I'm taking it wrong, but I take your point very seriously because what I hear you saying and what I agree with, but maybe you're not really saying this and I just want you to say it, is that if you were to move towards global capitation that the first discussion is where the hard decisions are being made because you're determining what is the right care at that institution. So. That's exactly right. Ma'am, you can just answer Kevin's question. That's my question. I think she already has him. So. I'm completely happy with it, Kevin. Thank you. You get coffee, Kevin, at real time. Thanks. So I did see a hand raised earlier, but it's been lowered. Mike Deltrack, did you have a question or has it been answered or? I'm all set. It's been addressed. Thank you. Thank you so much, Mike. Any other member of the public who wishes to offer public comment? I'm not seeing any hands raised, but if anybody's joining us by phone, if you would just speak up, that would be fine. So hearing none. Shule, you sparked a lot of good conversation and a lot to digest. We look forward to hearing back from our hospitals on the conversation that was started today. And thank you so much. We know that you're very busy and we appreciate the amount of time that you've put into this. So thank you so much. Thank you so much. It was my pleasure. And I'm looking forward to what you guys are gonna come up with and work through these. And I'm happy to help any way I can. Thank you, Shule. So next item on the agenda, 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? So moved. Second. It's been moved and seconded to adjourn. All those in favor, please signify by saying aye. Aye. Aye. Those opposed, signify by saying nay. Thank you everyone and have a great rest of the day.