 Well, after once, I'll call to order the Green Mountain Care Board's hearing of April 5th, 2023. Today we have a number of agenda items. First, we're going to hear from Christine Smith and Laura Bellovo. Ms. Smith is with MVP Health Care. And there's a potential vote relating to MVP's non-standard QHP plan review and potential approval. Then we have a round table discussion. We have Zach Cooper, who's a professor at Yale University and director of health policy at Yale's institution for social and policy studies. And then general counsel of the Green Mountain Care Board, Mike Barber will present potential revisions to the certificate of need monetary thresholds. And with that, I'll turn it to our executive director, Ms. Susan Barrett. Thank you, Chair Foster. We do have a new public comment period that is on the One Care Vermont's revised budget submission. We received that on March 31st, and we're accepting public comments on that until April 28th and have a hearing on, we'll have a meeting on that starting on April 3rd. Probably have several meetings on that or sorry, May 3rd. When I start throwing out dates, it's dangerous. The other public comment is ongoing, as I've mentioned previously. We are accepting any public comments regarding a next potential all-payer model. We share all of those comments with the Agency of Human Services and the Governor's Office as they are leading the negotiations on the next potential model and the current implementation of the current model. I also just wanted to alert the public and others that we did post our schedule for April earlier this week and we have several, we will continue with some roundtable discussions and also we're going to have a primary care sustainability roundtable discussion on April 19th. Also, in that same day, we have a primary care advisory group, so that will be our all things primary care day. And please just take a look at that schedule. If you have any questions, reach out to Kristin or me. And then in closing, I just wanted to thank Brattleboro Retreat for hosting Dr. Merman and I this morning. We had a really informative conversation with Linda Rossi, their CEO, and heard about the incredible things that they're doing down at the retreat. And as the CEO, Linda said, it's not her, it's the workers at that hospital and the staff who are doing the incredible things every day. So I just wanted to have a shout out to Brattleboro Retreat and had a really informative discussion with them this morning. And with that, I will turn it back to you, Chair Foster. Thank you. I'll turn to our minutes from March 29th, 2023, last Wednesday, when we reviewed the hospital actuals and hospital budget guidance. Is there a motion to approve the minutes from March 29th? I'll move approval. Second. Is there any board discussion? Hearing none, is those in favor of approval of the minutes from March 29th, please say aye. Aye. Aye. Aye. And the vote is unanimous and the minutes are approved. And with that, I'll turn it to Laura Bellowo, who is a staff attorney here at the care board, and she can introduce Ms. Christine Smith from MVP. Laura? Yes, good afternoon. Today, Christine Smith from MVP Healthcare will be presenting MVP's proposed changes to the rate designs for three non-standard plans. In accordance with the board's established process for non-standard qualified health plan proposal review, earlier this year MVP notified Diva and DFR of proposed changes to its non-standard plan designs. DFR determined that changes to the three plans being discussed today contain what are called significant changes requiring board review. The board has established criteria to approve proposals for new plan designs and significant changes to existing plan designs that add value to the Vermont marketplace. And a vote has been noticed for this matter. And with that, I introduce Christine Smith, Product Manager, Commercial Product and Strategy and Design at MVP Healthcare. Thank you, Laura. So let me share my screen. So as Laura mentioned today, I'm going to be speaking about our proposed 2024 non-standard qualified health plan designs and some changes that we have. I'm going to give you an overview and give you a little bit of information about what's going on with our members in our market and why we're proposing these changes, give you an outline of the plan designs, and then open it up for any comments or questions. So with an overview, this is our non-standard plan design portfolio that we have today and what our membership was in these plans as of February 2023. MVP is going to continue to offer all standard plans and the catastrophic plan, as well as two non-standard high deductible plans, four non-standard non-high deductible plans and our two reflective plans, one of which is an HDHP in the non-standard portfolio, that is. So what triggered the Green Mountain Care Board review? As Laura mentioned, DFR determined that we do have three non-standard plans with what they're considering significant changes. That would be our Silver One and our Silver One CSR 73 and our Bronze Five. The plan designs for these three plans are almost identical to the previous offering, but due to the amount of increases in deductible and out-of-pocket max, it triggered this review. I'm not going to read through the evaluation criteria, but our plans do fall into item one, where there's a substantial difference in the deductible out-of-pocket max or the RX deductible. We continue to offer plans, we want to continue to offer plans that add value to the Vermont market. The proposed changes to the deductible and out-of-pocket max of the Bronze Five would decrease the premium of this plan by an additional 1% to 2% based on the 2023 plan designs. We're not going to comment at this time on what the market changes are going to do to impact our premiums yet, but the changes to the Silver Plans were mostly due to AVC calculations in that they were falling out of metal level if we didn't make some changes. So, and I will go through that as we as we progress. So, just to give you a little bit of information on our Bronze Five membership, in 2021, when we look at our, what we had as a deductible in 2022, which was 7850, only 6.94% of our members were hitting that deductible, so 93% did not. In 2022, the deductible was still 7850 and 6.95, so we're we're hovering right around that 7% mark on members hitting their deductible in this plan. So, our proposed plan design is to move the deductible from what it is currently today in 2023 of 9100, because we made a significant change last year as well, up to the maximum 9450 for this year. In order for us to continue to offer the most cost-efficient plan possible. In 2023, showing our membership numbers, this plan did hold steady, showing that members were not out there shopping for a cheaper or different plan. We've kind of come to the conclusion at MVP that the members in this plan are not in it because of the deductible or out-of-pocket max. These are most likely members that are, don't use, they're healthy, they don't use their benefits that often, and they want to have health insurance to keep themselves covered, but they're looking for something with a low premium. The impact to the bronze members in this scenario is the is a low premium, which makes the plan attractive to them. Is there any questions so far? So what are we hearing in Vermont? Our sales team is telling us that groups are leaving for level-funded plans because the premiums are increasing at such a rapid rate. We have some comments from some actual bronze members that have mentioned that the premiums are exorbitantly expensive, and if my employer didn't cover 80%, there's no way I could afford a monthly premium. And then we also did a survey, a sample size of 342 to health-benefit administrators, in which 31% of the health-benefit administrators deemed price as the most important factor in choosing a health plan. So that kind of backs up what our theory has been and where we base this theory off of. So our product portfolio for 2024. The first plan would be this Vermont non-standard silver one plan, and the first column will show you what the plan is at today, which are deductible as 2100 and are out of pocket max is 7000. Leaving that as is, the plan did fall out of metal level in the AVC calculator. We currently have 582 members in this plan as of March 2023. We're proposing to move the deductible to 2500 and the out-of-pocket max at 7500 and leaving the other cost shares alone. The only other thing that we were doing was moving the Rx out-of-pocket max up to 1500, which is standard amongst all of our plans today. The next plan with a change would be the silver 173, again for the same reason as it fell out of metal level where it is at 1500 and 6150. So proposing to move this to 1750 and 6500. We have 355 members in this plan today. And again, moving that Rx out-of-pocket max to be consistent with the base plan at 1500. And lastly, our bronze five, which we brought in front of the board last year, where we moved the deductible up to 9100 last year. We maintained our membership in this plan. We have 672 as of March 2023 and we're proposing to move it to the max of 9450 for both matching deductible and out-of-pocket max. Again, not touching any of the cost shares. Okay, so that was the portfolio. I'm going to stop sharing so I can see you. And if you have any questions, I'd be happy to answer them. I also have Chris Pontiff on the line with me. He's our MVP actuarial. So if there's any questions for him, he'd be happy to answer them as well. Great. Thank you very much, Ms. Smith. I'll turn to board questions and comments. Then I'll turn to the healthcare advocate and then the public. Ms. Bellovo, do you by chance, can you publish the potential motion language? Would that be possible? Or I would like folks to see it if we can. Just say, but the motion language is that that's easier for you. I think you're muted. I am. I was. I do have a slide and happy to share that. That is the criteria and I can find the button. That is the suggested motion language. Actually, I'm sorry, Ms. Bellovo, before I turn it to the board, did you have any additional comment or anything you wanted to add? I didn't have anything specific to add, although I will note that DFR. DFR is the one that evaluates whether the nonstandard plans require board review and DFR didn't have any objections to these proposed changes to MVP's rate design. Great. With that, I'll turn to the board members for any questions or comments. I have a quick question, but I'm not sure if others are wanting to go ahead. Go ahead, Jess, if you'd like. Okay. Is it possible to flip back to the MVP slides? I think it would be the second to the last slide. Sure. It was the bronze plan. Just a little bit of clarity. When I looked down the second column and I see 0% all the way down and then I see in the third column, significant changes to me. When you had said there's no changes in cost sharing, that strikes me as large changes in cost sharing. You're absolutely right and that is a typo and I will fix it. They did not change. It is 0% because you can't have anything after the deductible. You'd hit your out-of-pocket max. Yes, you're correct. The base of this plan is that once you hit your deductible, everything is 0%. The two caveats are that PCPs, there are three visits in front of the deductible and tier one drugs are in front of the deductible. I will fix that and I do apologize. Okay. Thank you. And then just my second question is when you were looking at the 2021 and 2022 suggesting that 7% of members hit the deductible when the deductible was 7850. We're in 2023 now and I recognize we're still in that year. But I'm, you know, there was a significant jump this year to 9100. And I'm wondering if you have any preliminary data or analysis that might indicate what percentage of members are likely to hit the 9100 this year. Is that how significantly different is that from the 7% when the deductible was lower in previous years? That's a good question. I don't have that information. Chris is on the line. We, we don't, we did not have it to pull for this meeting. But if they weren't hitting the 7850, the percentage is going to go down significantly to even get to the average deductible that that members are hitting in that bronze in those bronze plans is around $3,500. So even less. Go ahead. Yeah, and I can add a little color. The, it will be lower, certainly, right? Like the deductibles higher the amount of people hitting it are going to be lower. But it's probably not going to be massively lower because the way that the claims are distributed is there's not a lot of people who are utilizing between 75 or 7800 and 9100. It's if you've hit the 7800, you're likely to be above 15,000 type of thing. So it, it will be a reduction in people, but it probably will not be a massive reduction in people. Right. That makes sense. And, and you had suggested that if you had applied this higher deductible, if I understood you correctly to this year's premium, it would have been one to 2% lower, but you're not anticipating what it would be for 2024. Is that what I heard you to say or Christine to say? Yes. Okay. So the hope is that this will be a reduced premiums. Yeah, if we were to base it, if we were to base it on the plan, the plan year 2023, it would fall in the, in the one to 2% less. But because we don't know what the market conditions are going to do to the rates. We still know it's going to be our lowest cost plan. No matter what. Okay. Thank you so much. You're welcome. Thanks for asking. Any other board members of questions or comments? Jess asked all of my questions. So I'm good. I just have a brief comment and I don't, I don't quite know how to. I guess my point, my comment is that I, I know that high deductible plans offer significant benefit to people to be able to afford an insurance plan. And that many people wouldn't be able to afford any plan without the high deductible plans. I just always have concern of which this is not probably the right. Then you to necessarily deal with this concern that it does lead to a significant or probably very small portion of people delaying. Delaying health care. So I think it's a, it's a challenge to think through these plans and our concepts of rational choice in purchasing these plans. So just something I just want to comment whenever I see these high deductible plans, I think about the impact on people delaying care. But I also stand understand that, you know, the lower premiums really allow a lot of people to afford insurance at times for possible catastrophic events. So I think it's a complicated balance with these plans and we do discuss this often and I think it's important to express that. So, but thank you for the presentation. Yes. If I could just comment on that, I just wanted to let you know that we do feel the same way and we do have this discussion internally often. The reason why this plan is actually not a qualified high deductible plan is because we do give three visits at zero cost share before the deductible as well as the tier one drugs hoping for that. That exact thing that you just said that people are not going to skip their care because we are allowing them to have three covered in full visits or no deductible visits as well as no deductible on that tier one drug. Thanks for that. Yeah. Thanks, Christine. And I think, Christopher, for coming in and presenting to us today, the people purchasing the bronze plan you described as, did I hear the most price sensitive? Yes, generally. And you mentioned the average use of the deductible was 3500. Do you happen to know the median? That average would be pulled, would be pulled way down by the zeros, right? Yes. Yep. That's, that's correct. I mean, I can tell you that in, across our entire block, so not just bronze, the nonutilizers are somewhere in the, you know, they bounce around year to year about 10, 15 percent. I mean, you know, there's a high portion of people who are utilizing nothing and bronze, I would expect that number to be significantly higher than say platinum, right? People are buying platinum generally because they need it. And so, yes, you're right. The median would be, you know, that's the, that's healthcare claim cost distribution, right? It's log normally distributed and the median is always significantly below the mean, yes. Yeah. Or the other way around, the median would be higher, right? For claim cost, yes. For, I guess, for amount of deductible used, right? The, that would go that direction. Okay. And the deductible going to 9,450, what are the premiums for that? Christine, do you have the, do you know the current premium of that plan? I do. The current premium for the bronze five for a small group is $580 a month and for individuals, 679. Okay. So, 580 times 12, 7,000, 8,000. So, like $15,000 of exposure before insurance would really kick in other than the three visits. That's correct. Yeah. I think it's, I wanted to ask to make sure that, because I think there's still a lot of people who may not, they don't see that full number because they, you know, the max out of pocket. I think include, would include premium because that's coming out of pocket, but it doesn't. And so those need to be added together. I think it's important to keep that in mind and I know Christine and Christopher, you guys know it, but I think it's important to keep in mind because we really have an affordability crisis. The people who are most price sensitive are facing an exposure of $15,000 a year. They need that in November. It resets in January. So it's, it's, it's a crisis. And I appreciate you coming in and talking with us about it, but it's a tough situation for the folks that need though need to need to make the decision for the bronze five. So, thanks again for coming in. I don't have anything else. Great. Thank you. Miss Belville, did you mind just publishing the, just so people have it in case I want to comment on the motion language. And with that, I'll turn it to the healthcare advocate for any questions or comments they may have. Sure. Just have a question and one comment. So Christine, I'm sorry to do this. We just put up this slide Laura, because he could you go back to your tables. I'm so sorry. It's my fault, Eric. I'm sorry. George, no worries. Okay. So I'm just trying to understand all the numbers that we've thrown out. So the nine four five oh so the deductible or the move. Is that for an individual plan. Our individual and our small group plans. Oh, Would the deductible be higher for a couple, twice that for a couple and some larger amount for a family. No, that's the deductible. Yeah, that's the maximum deductible. And out of pocket max. Regardless, I'm sorry. I'm sorry. Yes. Yes. So it's nineteen four fifty for an individual on the plan and 18 nine for the family. Yes. Okay. Okay. So it's actually the total exposure. I'm just trying for a non single person, a family unit, the total exposure to deductibles is higher than what we've been talking about. Um, you know, and I think obviously others have spoken to the affordability crisis and that's, you know, I know us and the board and MVP is all aware of that. So I won't harp on that. I think it's not before the board right now, but I think it's worth thinking about how other states have approached the existence of non silver plan. So I would look at California and this dealing with this issue of past potential consumer confusion and the various policy arguments around that and perhaps that's a legislative. More of a legislative issue, but it is something that I think as a state. We need to we should grapple with when we're thinking about how we want to make offerings to consumers and perhaps in all instances, the most choice is not always the best option. And that's it. Thank you so much. Thank you very much. With that, we'll turn to public comment via the raise your hand function. Walter, good afternoon. How you doing? Hey, how are you? Okay, okay. Sitting here my daily dose of the green weekly dose of the Green Mountain care board. Tom pretty much took the questions that I had raging, burning in my mind. So thanks to Tom for that. Jess and Dave also touched on what I was going to ask. I just wanted to say that we talk about the ductibles and these heavy premiums of 600 and something a month, most for monitors don't even earn that per week. Then you get the taxes taken out of the paychecks. So most of them. You're living paycheck to paycheck and that the purpose of the deduct deductibles is to prevent people from using health care. So they're going to do a good job. I work out on the line in the tourist business and I can tell you stories that the MVP sales forces would never ever hear. I'll zip up now. Thank you. Thank you for your comment. Walter as always. Any other public comment. Okay, great. I'll move to approve the proposed changes to MVP's rate design for the three plans we discussed today, the Vermont non standard silver one. The Vermont non standard one, sorry, silver one CSR 73 and the Vermont non standard bronze five plan. Plans as presented here today under the column labeled 2024 proposed that Christine had on slides 1213 and 14 respectively. A second. Through any board discussion. All those in favor, please say aye. Aye. Aye. Aye. And the motion carries unanimously and the proposed changes are approved. Miss Smith, I think. Yeah, thank you for coming in for your presentation is helpful. Nice to see you today. Thank you for having me again. Of course. Have a great rest of your day. Thank you. You too. Next, we have Zach Cooper who's presenting. I'm not sure if Mr Cooper is here yet is he coming on at 150. Is that right? That's correct. You're faster this season. I believe it's 150. Should we take a break till 150 or is that the best course here? Okay. Let's do that. So we were too efficient today, which is not something that we often have as an issue, but today we're too quick. So we will take a break. We'll go to recess till 150. And then we'll resume with Mr Cooper. Thank you. Good afternoon, Zach. We're all just coming back from a quick recess. We moved through our first topic faster than expected. Something that's unusual for us. Can you guys hear me? Okay. Good. Okay. It looks like we have five board members and Professor Cooper. So I'll call the meeting. I'll take the meeting out of recess. And Mr Cooper, Professor Cooper, thank you very much for being here. I hear you're a Vermont native. So everything you say. We'll have great resonance with all of us. We love, we love Vermonters here. I'm going to turn it to Tom Walsh to introduce Professor Cooper and give an overview. Thank you, Chair Foster. And yes, thanks for joining us, Professor Cooper. Born and raised in Vermont, hailing from Brattleboro. I will say, not born. I will raise for sure, but I will give up the born part. Formative years. Indeed, exactly. Thank you so much for joining us. Just to give folks to some context for today. A couple of weeks ago, we had Jeff Stenslin from MedPak join us. And he talked to us about his research that really kind of fundamentally changed our understanding of what has been thought of as a cost shift. And that was helped us all better understand how price and market concentration really affect costs. So the causation goes the opposite of what we previously expected. And I think some of your work on delving into market concentration has been also very useful. It's helped us, it's confirmed and expanded it on Jeff's work. Your work having all payers and all hospitals involved in your research has really fundamentally changed our understanding of findings from the Dartmouth Atlas, which was Medicare only and not every hospital. And so the findings from the Atlas, thanks to your work, we now understand that those don't generalize to all hospitals and all payers. In fact, there's quite quite different. And so I'm really thrilled that you're here to share with us your research today and the implications from that I'm looking forward to the conversation. Terrific. Well, thanks everybody for having I'm just getting. I haven't used teams on this computer. So I'm just setting it up teams may not be able to record. Okay, that's fine. So let's see if I can share and then we'll get going. So I'm delighted to be with you and, you know, partly because I'm spent a bunch of time and Vermont my parents live in Bennington for for 15 years and also because I think you guys are trying to solve a really really hard problem. And I want this to be much less like me sort of talking to you and much more like us having a conversation about what we do. And I'm going to walk you through. Let's see here. Can I share my screen. All right, I can. Let me do windows. This is like the ultimate professor sin is not being able to to share one slides all I do is share my screen and so if I can't do it, I'm in trouble. Can you guys see the slides that are up there. Yes, we can. Okay, terrific. So what I want to do is, in a sense, give a tour of health spending in the privately insured, and think about what's causing health spending in the privately insured to vary. What's causing it to grow. And that'll lead us to this discussion about the role of providers prices. And so what I want to do is think about why providers prices matter to us why they should, why they vary and why they're growing over time. And I think I'll speak for sort of probably about 30 minutes, and then we can sort of go from there and say, well, what do we do, and what options does that leave on the table for us as policymakers trying to think about how to make a health system run as efficiently and fairly as we can. I am an academic I'm an economist, which means I want you guys to interrupt. I'm actually not comfortable unless you're you're interrupting so please don't hesitate to to suggest that she's nodding. It's like, yep, I know the, I know the economic stuff. But yeah, please just interrupt ask questions. And let's have this feel like a conversation. I wanted to just level set in in two ways. One is just sort of how premiums in Vermont compared premiums and other New England states and also the US, and also just sort of anchoring premiums as a whole. Nationwide last year the average premiums for a family of four, or about $21,000. Most New England states are going to be above average. I think you're roughly in line with where to ensure and main and Connecticut located. The reason I put these dollar values here is I think it's tremendously important to take a step back. And just realize how incredibly high $23,000 are for premiums in the context of buying a new car. And I give this talk every year and and this fact remains true every year for the price we pay for insurance for a family of four, you can buy a pretty nice new car. And different states are toying around with mandates for insurance. And so we're mandating a whole lot of families and states with mandates by new cars worth of health insurance every year and I think if you had an honest conversation with most families, that's not necessarily where they want most of their money. So now I think they're grateful when they get sick and they can afford it. But that's just it. It's just an awesome sum of money and a number we can't forget. The others in spite of paying more than a Toyota Corolla for health insurance for a family each year to go to the far right of this, 44% of folks with insurance coverage. See, there's folks who have coverage who've done the right thing are worried about their ability to pay medical bills. And so it's not just that we have a, I think 15 or so years ago, we really talked about quality access and costs. And the Affordable Care Act did a remarkably good job on the access front, broadly at 50% reduction in the share of the population who doesn't have insurance. The remaining tranter folks, I think split between groups that are really, really hard to reach. And then groups who are in some ways not making a crazy decision not to have health insurance. So often they're folks who are young. And what we sort of transition to is a little bit away from these access problems to cost problems and cost problems that often manifest ironically and access problems. Right, so these are folks who are afraid to literally touch the health care system out of fear of a bill that can be financially devastating. Those folks who touch the health system unexpectedly and then get financially devastated by the experience, all while navigating all of the vicissitudes that go along with being an ill health. And, you know, I think this for me really illustrates this is a survey by the Kaiser Family Foundation and the Peterson Foundation, which is looking at liquid assets for single person households, multi person and all households and comparing that to the max out of pocket limits on the average employer sponsor plan. And what you basically see and these by the way are calling these liquid assets is being very, very generous with this is money market accounts checking accounts savings is non mutual investments. This is your stocks. They actually asked the Federal Reserve. Their guess is the base of the average family has less than $500 in pure liquidity at any given point in time. And we've got family plans that out of pocket maximums of $16,000. And what this means is that a real illness can be financially devastating for an incredibly large share of the population. I think this is fundamentally why we see 44% of the public with insurance. Very, very worried about the costs of healthcare. You know this for me is is incredibly sobering I show this to my students in the very first class of our, our class in health economics and health care policy. This is showing that broadly a quarter of individuals with employer sponsored health insurance are cutting off on buying food, clothing and household items to pay for medical bills. But again, this is the transition for me from this sort of access question to cost question. We've gotten that taken care of we've gotten people coverage. This is the consequence of what happens when you don't get costs under control, right that that you're seeing a quarter forgo food. You're seeing 14% taking on a second job. Why does spending, what drives health spending for the privately insured so this is work from a project I did with john Skinner who's a Dartmouth Jim and doom away who's my colleague at Yale, and some amazing students, looking at the correlation in spending across Medicare, Medicaid and the privately insured and it's actually building on some of the work that the Tom did. So let's step back up until about 2014 almost everything we know about health care spending we know from the analysis of Medicare fee for service data. And Medicare pays providers using regulated payments that are set by the centers for Medicare and Medicaid services. We just oppose that with what happens for the privately insured. So the privately insured are going to pay providers using payments that are set by a bilateral negotiation. So broadly, every year hospitals as you know and insurers are going to sit down they're going to hammer out negotiations over prices. And Medicaid is going to be some rough combination of the two. And what we found in that work was basically Medicare looking at Medicare spending variation doesn't tell you anything about what the world looks like for the privately insured and you can sort of see this comparing panel a on the left and the met of Medicare in the middle, right the correlation between the two is point oh 2%, which basically means they're wholly uncorrelated. And Medicaid is a little more highly correlated, both with Medicare and and private spending but not by much. So what leads spending to vary so for an economist spending is pretty simple read it's the product of prices times quantities. And what do we mean by quantities here. And what we mean is that the mix of services that get offered so different places might offer sort of higher or lower acuity services. It's going to have a second dimension, which is the sort of number of things that get offered, you know, maybe one place only does an x ray before my my. They see me in another place does one before they see me and six weeks after. Which I think is important to talk about that's in some ways under discussed is quality. Right that's sort of an aspect of quality of quantity that we sort of have to think of sort of the type of service that we we offer. And it's that times the prices of those services and so I sort of think about that like what drives spending it's kind of like, what influences what I spend on my groceries it's the mix of things I put in my car. Is it frozen or is it from the fresh aisle. Is it bananas is it blueberries, and then just the sheer sort of amount of stuff I buy for the Medicare population and mostly from Medicaid, it's quantities that drive spending variation. Right and that's sort of unsurprising because the price component is basically regulated on the private side, what we've seen from some of my work is that it's basically 50%. Prices and 50% quantities. Right and that's because you have this extraordinary variation in private prices because they're not regulated it comes down to market determined rates. And when we first did this there were a couple of really surprising facts that came out which I think are important for us to internalize. So the first was how spending on the private insurance varies by about a factor of three across the US. But it turns out that a lot of the places I was sort of thinking we're going to be high spending in advance turned out actually not to be that high spending in places that I thought we're going to be inexpensive turned out to not be inexpensive and so one really good example is Grand Junction Colorado. So Grand Junction Colorado had been sort of touted based on Medicare data as the model for the country. There was a famous New Yorker article by a 12 go on day that named the gallon Texas so everybody sort of knew McAllen is bad but what they often didn't pay attention to in this article he said look the opposite of McAllen is Grand Junction Colorado. And what's really really important is that when you look at the privately insured McAllen is actually below average spending. So Grand Junction is I think the third highest of the 304 306 hospital for all regions in the country. Right and so it just sort of illustrates this picture of a lot of the places that we thought were low spending turned out to be very very high spending. And a lot of places we thought of high spending on Medicare turned out to be not that expensive to probably ensure. Why is that the case. It's basically because if you think about Grand Junction Colorado it's sort of a semi rural area. There's not a whole lot of hospital competition. And they just have really really high prices. And part of what happens is there's sort of a constraint on how much quantities can vary. It's constrained by the just nature of the practice of medicine. But some places are going to differ in how aggressive they are and the quality of services they offer and what they do but it's going to be sort of within a pretty narrow overton window. Whereas what I'll show you is pretty staggering variation in hospital prices that really reflect the sort of bargaining outcomes. And so you get this sort of huge spread and spending half of it quantity half price. But price plays this sort of very dominant role because you get some very very high extremes on the price side. Let's just sort of anchor a little bit on prices. So when I talk about prices from from here on out I'm going to refer to the prices that hospitals negotiate with insurance companies and we can certainly talk about physician prices in the follow up. What I've done here is I've got a graph from our price ain't right paper and it was like 2019 in the quarterly Journal of Economics. And it's going to sort of give you a sense of what the three main prices here look like. We've got hospital charges. Right. These are not competitively determined. They're they're set by the firms hospitals themselves. These are going to be roughly double what private insurers pay. But those are these negotiated prices and that's going to be broadly double what Medicare is going to reimburse. And this is one of the I think many ways the U.S. healthcare system differs from health systems in other countries. We're by and large the only nation that doesn't have some form of regulated provider payments. But now I'm I'm an economist. I think markets work. One of the key themes out of some of my recent work is actually that markets and health care actually don't work too badly. The question that we have to ask and I think this is where I'll end is where can they work. Both in terms of quarters of the health care system and quarters of the country. And I think that's the sort of challenge we need to wrestle with. So I want to zoom in a little bit on how these negotiated prices get set and think about a model that really is the most the work here has been done by Kate Ho who's a wonderful economist at Princeton. Some work by my co author Marty Gainer and a number of others who sort of characterize the setting of possible prices and sort of a five stage model. And it's it's worth sort of just internalizing a little bit what happens. The first is hospitals are going to say look, and these are sort of all kind of happening at once but we sort of think of them in five stages. Hostels going to take a look around, and they're going to say look based on who's in my area, what I expect to have happen, what my costs are I'm going to make a determination about my costs and the quality of the services that I produce. And there's some pretty good work showing for example that in areas with more private payers right and this will get into a little bit of, I suspect what Jeff talked about in areas with more private payers where the expected revenue is higher, they invest in more sort of quality cost intensive services. In other places like Montefiore Medical Center in the Bronx where they're mostly seeing Medicaid patients. They're just making a very very different set of investment decisions so hospitals are going to sort of take a look at the landscape. They're going to decide what their cost structure is going to look like. And the reason I think this is so critically important to remember is costs aren't preordained. They're not sort of not forced into making particular investment decisions I like to pick on Yale right you can pick on your friends right Yale and one of our hospitals as a self playing Steinway piano and Steinway so I shouldn't exaggerate we have a self playing piano and lobby. I think it's a Steinway, whatever it is. It didn't have to be that right that's a decision they've made in sort of looking around at the landscape and saying like that's what our sort of customers want. Right they also have incredibly sophisticated operating theaters and other sort of clinical investments that they've made but those aren't sort of things that you have to do those are those are choices. So second, after the hospitals have made a decision about cost and in return quality, they're going to negotiate with insurers over their reimbursements and their network participation. And basically this is a price volume trade off game, where for hospital care if you don't join a network you're not going to see that many patients and to offer a price concession for the insurance company to send patients away by being in network. The insurer in this is going to think about how important that hospital is to have and I'm going to sort of distill this down to two dimensions that they want to think about. One is, is there an alternative. Right to some aspect of like, what happens if I don't have that person just simply in terms of what care patients can access. The other is in terms of just sort of how prestigious or how high quality those services are. So let's take the former. Again, pick on your, your friends, I could pick on my friends in Vermont but this seems like not the, not the forum I'll make more friends picking on Yale and Haven. We bought up all of our competitors. But there's just not another hospital for me within probably 45 minutes it isn't a Yale and Haven facility. And so if an insurer comes to that negotiation. Their decision is basically like sell insurance if I want to sell insurance I have to negotiate with Yale otherwise there's just literally nowhere for policy holders to get care. And I want to juxtapose that negotiation would say the negotiation that happens. I'm actually going up to Boston tonight so so in Boston, where you know there is a big dominant healthcare system but there are multiple health systems. So there, part of the reason that a high prestige system like Mass General can often command higher rates is because of whether real or perceived quality. It isn't just that you can't sell an insurance product in Boston without partners. It's that you sort of the customer base there maybe doesn't want the plan because they want to go to this high quality place not because in the absence of it, they can't get healthcare. So that's our second stage insurers are then going to take all that information to account they're going to sell an insurance they're going to set their premiums they're going to sell the products. Patients are going to think about what healthcare they're going to need. Right if you're somebody super healthy maybe you don't buy the super generous high actuarial value plan that includes the flagship academics medical center. If you're very sick, maybe that's something that looks good to you. And then the sort of final stage is we buy insurance. I get a health shock, and I then have to think about where to get care to go in and out of the route of network. Where do I go as a function of my cost sharing. And that's going to then sort of loop around and influence my pricing. And so the question the back of our minds. I think as we think about what to do about hospital pricing is, can a market work. And one of the things that I've shown in my work is that hospital prices vary a lot. So this is more or less every hospital in the US ranked lowest the highest but better price for knee replacements. And that's going to be in red. So the height of the bar is the price of the facilities. New replacements, the blue is actually Medicare. That's their regulated reimbursement rate. So I think a couple of things should jump out of you. First, Medicare pays not half, basically pays half as much or less than half as much in certain instances as the privately insured. Second boy do prices vary a lot from sort of $10,000 up to sort of 40 to 50. And third, Medicare rates are really not correlated with private reimbursements. And this is actually a pretty important point. What Medicare is trying to do is as best as they can approximate hospitals costs. So I don't know that they say it officially but basically Medicare wants to sort of say we're going to reimburse hospitals costs plus a couple percent. And so I often sort of say this is like a hundred couple hundred million dollar effort to try to back out hospitals costs. And so sort of costs aren't really that correlated, at least as Medicare construes them with true transaction prices. So prices very nationally, right. This is across the country. If we look in specific hospital referral regions that just put Denver up, I can't actually show Vermont's because I have a minimum self size and then you guys don't have enough hospitals for me to do it, which I'll come back to later, which would tell us a little bit about the scope for the competition. But in Denver, right, the prices of hospitals vary by about a factor of three to four. Right, so lots of prices there. What's amazing is actually that even for things like lower limb MRI scans. So this is a single hospital and it's showing an identical service. The prices here vary a lot within a hospital across insurance companies. This is I think another sort of fact that's leading us to think that bargaining leverage matters. Right. Why do two insurance companies have different prices at the same hospital? In a sense, because one insurer has just got a bigger market share. And so they're able to negotiate more aggressively with the hospital. So one of the sort of central themes in my work has been, OK, well, why is this hospital here on the right high priced? Right. And what explains this variation? And if we basically just decompose out the correlates of hospital prices and think about what explains the largest share of the variance. The largest share is explained by the market structure of the hospitals themselves. So the degree of competition or concentration or accurately those hospitals face. So in the cross section, a monopoly hospital basically has 15% higher prices than a hospital that faces a quadripley market. Now, this isn't the effective mergers. This isn't a sort of causal estimate of what happens when things change. It's just they're saying in the cross section, if you're the only show in town, you get higher prices and and markedly higher prices. And this explains of all the factors, the largest share of the variation. But what's striking is it actually doesn't explain that much of the variation. There's a lot of variation in in hospital prices that exist beyond market structure. And so it's just an example. And I think this is this is based on a paper that I did with Joe Doyle and John Gruber that came out a couple months ago that actually has fundamentally changed the way I think about health spending and hospital pricing in the US. I'm going to go, you know, 15 minutes or so. So market concentration, it's called a Herfindale-Herschman index. That's a measure of concentration. And all it basically measures is like the number of sort of competitors. And you want to sort of think of a Herfindale-Herschman index of 2,500 at sort of four equally sized hospitals. 10,000 is a monopoly. Zero is a sort of hypothetically perfect, perfectly competitive market. The Department of Justice and the Federal Trade Commission say, look, the sort of alarm bells should start sort of chiming when an HHI is above 2,500. The average market in the US is about 4,000 for the hospital sector, which is in itself worrying, but we're going to use that as a cutoff here. And I'm going to show you the variation in prices for places where the HHI of the hospitals is below 4,000, so below average and above 4,000. So first, this just surprised me, right? There's no fancy economics here, but there's a lot of variation on both sides of that. Now you sort of see what I showed you in the graphs, which is like places with higher HHIs do have higher prices. But boy, there's a lot of variation. And so the paper that I did with John and Joe and John Grace, who's also a co-author, was trying to think of this question about whether or not markets can function by thinking about whether or not high price hospitals get higher quality, deliver higher quality care. And it sort of seems like kind of an obvious question, but it's sort of this, I think, first order question about whether or not a market functions. It also turns out econometrically, it's really, really hard to measure because it turns out sicker patients go to higher price hospitals, right? So my dad lived in Bennington. I mean, truthfully, at the end, we did not move him much because he had Alzheimer's. But when he was needing some cardiovascular intervention, I was willing to travel with him and take him somewhere to get intervention. So if you sort of looked at him, he went to a high priced hospital precisely because he was really sick. He was also more likely to not do well because he was really sick. And so we've got to sort of break this relationship to get this econometrically. What we do is we exploit, it turns out that ambulance companies have really strong preferences for where they take their patients. And so you can take the same patient and the same in the two patients in the same zip code. Different ambulances pick them up in an emergency and just have much different preferences and different probabilities about where they end up. And we can sort of use that sort of ambulance assignment to get the causal effect of going to a high priced hospital. What do we see? Okay, well, it turns out that we see very different patterns depending on whether or not a hospital faces competition. So if a hospital doesn't face competition and take into a high priced hospital, you just spend a whole lot more. So going to a concentrated high priced hospital, it's going to raise your spending by about 50%. And what is a high priced hospital? It's basically a hospital in the 80th percentile prices relative to one in the 20th. If you go to a hospital in a competitive market, a high priced hospital that's so again, 80th percentile, it's going to raise your spending a lot again about the same amount. But what's striking is it's going to dramatically lower your mortality. So it's going to lower your risk of dying by about 50%. Right, and that it's going to turn out to be with shock me as somebody who's always critical hospital prices. Pretty surprising. It's actually cost effective. And, you know, I sort of take this as evidence that, okay, hospital competition can work. But you can get prices that are correlated with quality. If, and this if is doing a lot of work. If that market faces competition. Right, so it gets back to this question about whether or not a region supports and can support competition. So, you know, the next question we should be asking about the next question we should be asking about is whether or not. If you want, I'm on a call. So, whether or not possible prices are high because of cost shifting. Right, and so let's just sort of flesh out the theory. There's, I think, two versions of this. One is a sort of cross sectional story. And one is a dynamic story. So, the cross sectional story is like, look, we lose money on public patients, we have high private prices that cross subsidize. I think that's right. But I have no doubt that the margins are better on privately insured patients than they are on publicly insured patients. And so you can sort of cover your costs in some ways using the money gets in privately insured. And what strongly disagrees the idea that this is somehow dynamic. Right, that is if Medicare raise their reimbursement rates, or Medicaid raise their reimbursement rates, that private insurers would actually lower, or the hospitals would lower their prices to the privately insured. And this is what really sort of intersects with Jeff's work. So the sort of first theory about what's happening is, you know, basically, well, let's actually take a second. The hospitals have no choice about their costs. Medicare lowers their reimbursement rates, hospitals sort of respond by raising their private reimbursement rates, it makes them look like they're high priced. The other story, and it's back to that sort of five stage model is hospitals look out and they say, gosh, I have a lot of privately insured patients. Right, I'm the Cleveland Clinic, I'm male, I actually get patients from the Middle East who fly to see me, because I'm so good. And they set a cost structure and response to those patients, which then and in turn makes them actually lose money on publicly insured patients. I think that's probably much, much closer to the reality of what happens. Right, and I think the idea that I sort of think about a Yale is we're a monopoly hospital. And our costs, you know, we I think make pretty high profits. And there's some pause I don't think this happens out loud where we say look like making let's say 20% profits for a nonprofit academic medical center is unseemly. And so we come up with a new cancer center. And we call that a cost. And then the next year, we say, well, wait a second, we are now losing money on Medicaid patients, because we have this cancer center. It was the decision to build in those costs that led them to lose money. Right, and so it's really this question about whether or not cost or endogenous or exogenous. And I think the sort of prevailing view among academic economists and policy experts is very much of this sort of just Stensland variety, which is absolutely you see higher margins on privately insured patients and that can be used to cross subsidize. But that's not a function of something that's like a force major or a fade it completes. It's in a sense because hospitals get a choice about the cost structure that they face. What's the sort of evidence of this. You know, I think there's a series of papers that show this pretty clearly. The first is that regions that have higher Medicare reimbursements actually have higher private prices. Right, so it doesn't it isn't the regions with lower Medicare reimbursements have lower prices. Second, when you see Medicare raise the reimbursement providers, some work by Jeff Clemens and Josh Gottlieb show pretty convincingly and I see some of this in my work private insurers respond by raising their prices. Or excuse me hospitals respond by raising their prices. So when Medicare pays a hospital more the next year the hospital actually charges more for for care to the privately insured. So now we get into this challenge about growth in spending. Growth is more important and more complicated than cross sectional variation it's it's why every country, including those that don't spend as much on us are really worried about health care spending even though they spend less than the US. What we got here is we've got growth in inflation workers wages, health spending and out of pocket costs. And what you basically see is that health spending is going up a whole lot more quickly than inflation or workers wages, workers wages that basically grown with inflation for the last decade or so, after costs have grown much more quickly. What does this mean, even though your pay is going up it feels like you're making less. And the reason it feels like you're making less is because the money that you could have been spending on food and housing and your kids in an increasingly high share is going towards health care. I have worked that's sort of in process that I think suggests pretty consistently with some other work and theory that you actually see that part of the reason workers wages aren't going up as quickly is because of health spending going on. Right that is in the presence of employer sponsored insurance, the money that would have gone to workers in the form of wages is going from the cost of health care. So why is health spending going up. So in the short run. So this is work by the Health Care Cost Institute. I think we see pretty clearly in the hospital side that utilization is basically not changing but prices are growing a lot. Right that is it's hospital prices that are in the short run driving the growth we see in health spending. I talk a lot about hospitals so why why am I focusing on hospitals it's kind of like we asked the bank robber why they rob banks and they say that's what the money is similar story in health care right it's just the largest chunk of health spending. And so, we can talk about these other sectors I tend to focus on hospitals because that's just the biggest chunk of the pie. This is the graph that I think we should all have in the back of our minds that's tremendously important and shows again why we we really want to think about health spending, excuse me hospital prices and why driving health spending growth. So this is work from the Bureau of Labor Statistics it's looking at the price growth by industry and hospital prices have grown faster in the 2000s and prices in any other sector of the US economy. Now we have a glass house situation right college tuition is the second highest bucket so like I am not like blameless on on this but the hospital prices of the highest growing sector. This also tells us why we should care about this for health spending right so hospitals are the biggest chunk. Their prices are going up more than prescription drugs and more than physician services so it started the high base it's going up even more it's what's driving growth and health spending. Why is this happening. Some of this is costs. Take COVID as an example, right the shift to having to look at staffing agencies raise costs for hospitals that's going to raise prices. Part of this is clinical improvements. Right so think about joint replacements that are happening in 2022 or 2023 versus the ones that happened in 2000s now the surgeons are wearing spacesuits and they're more likely than not going to be in a positive pressure room. So that's going to show up on the the cost side that's going to raise prices. The other is market concentration. There's been a pretty profound increase in hospital market concentration in the 2000s so there have been about 50 to 150 mergers among hospitals each year. So if you look at the sort of degree of market concentration in the US it's sort of, it's gone up but it hasn't gone up that dramatically. So I don't think this is the only story. Right now there's really good evidence that I've done others have done that shows that mergers of close substitutes does raise prices. And so I think we got to be very very cautious of this. And then once you have market power. So this is the die is cast. The others is just, you know, I think, in terms of why there are so many mergers. This is a graph paper paper that we're going to put out in a little bit, which shows there were about 1000 hospital mergers between 2002 and 2017. The Federal Trade Commission, which is the agency tasked with enforcement in this sector took 11 enforcement actions. So it's just, you know, they're, they're incredibly underfunded. You know, we do a lot of work showing that a lot of these mergers you could have known would be problematic and the FTC is just just not resource well enough. And those work that I've done that shows that the mergers you could have predicted were bad, are going to raise prices by 1015%. So where does this leave us. And this is where I really wanted, really wanted to kick off a conversation. So, what do we do. We started by saying, call spending is high. It's going up. It's putting enormous pressure on families. Part of the reason that's happening is is provider prices. There's sort of two questions we need to sort of think about, but then influence where we go. But first, and this looks different in Vermont than it does in Boston or New York or New York, which is whether or not regions have the scale that's necessary to support all the services we want to see provided. So there's an excellent paper that came out last week by Josh Gottlieb and co-authors that I think uses a lot of really powerful econometrics to get to a point that I think we all probably reflexively feel, which is scale really matters for quality. And particularly for specialized care. And so they're basically showing that in what is in a sense cities, you get much, much better outcomes for highly specialized services, and then it turns out a large chunk basically a fifth Medicare beneficiaries. And it actually goes up a lot for even more specialized care or actually traveling to cities for the sort of more specialized services we see. I think there are needs to be conversations about as a result of that evidence, what care we want to see locally. And what care we're willing to travel for. In that sort of traveling more bucket and I'll say, Josh's work. A lot of people are willing to travel. One of the things that's incredibly important is the more affluent you are the more able and willing you are travel. And so I think I think there's a lot of scope and I'll get into this for a need for people traveling longer distances. But I think we've got to be very, very conscious that that's not the experience of that and and the ability to do that differs. And so it's got to be something that we really support. So that's the sort of force. First question. The second is whether or not regions can support competition. I may believer in markets. I think I'm a believer of markets in the hospital sector I think competition has the power to offer a lot of virtues, comma where competition can exist. I think what different parts of the country have to do is take a look at the market as we see it today and say, can it support market determined prices. And I think there are just a lot of parts of the country. It's a minority of the population but a large chunk of the physical footprint of the US where competition just isn't geographically feasible. That's not where hospitals don't face meaningful competition. That's not because they're doing anything wrong. That's because there just aren't that many people per square mile to support more than one hospital. And just like you can't have a monopoly bread company selling bread, you can't have a monopoly hospital setting prices for its services. So, you know, then where do we, where do we go. In a sense, there's two directions. One is a sort of market based strategy that would have, in a sense, three components. One would be more antitrust enforcement. One would be potentially rolling back consummated deals. And, you know, sort of so called some people for the unscrambling eggs. And then making sure you block deals that are going to lessen competition going forward. I think there's a big chunk of the US where we should be pursuing this. I think there's very real questions and I, I'm happy to offer your offering my opinion to solicit it but I think there are real questions about whether this is the approach for Vermont. At the other extreme. And I think this isn't sort of inconsistent with economics is saying, look, like, there are some parts of the country where competition isn't feasible. So what should we do. So, you know, one, I think you can think about regulating prices. Here's the challenge I have with regulating prices. When we started I said spending is a function of prices and quantities. And it turns out if you fix prices. Evidence from Maryland suggests that providers can respond by just shifting their quantities. And spending in Maryland where prices were regulated grew just as fast as spending in every other place where prices weren't regulated. Such that Maryland moved and instantly like you're going to, there are a bunch of folks who will talk about regulating providers prices will say, look, if you lowered their prices by 40%. Like you'd save this much money. And they sort of ignore. You know, what economists refer to as the general equilibrium effects but basically ignore everything else changing as a result. So I'd be very cautious of anybody who comes in and gives you a number and says look like, if we just regulate providers prices at 40% of what we are now we're going to save, you know, X billion dollars. It just isn't. I don't think how how that's going to work out and sort of ignores the, the really important subtleties of the issues. What Maryland has done, which I think is interesting. I don't think it's been well studied. Frankly, it's something I'm starting to do now and we need to get a better sense of is basically setting budgets for hospitals. And saying look here is your budget. We're going to set this collectively as a group for all the different payers together. And we're going to just all come together and try to have trajectories now. The hard part here are the politics of it. I hope because there are winners and losers and one of the things markets can do, which is something that nobody wants to do is decide which firms grow and which firms don't grow. And it's worth sort of thinking about it in the context of an industry where we don't much care about openings and closures, which is the restaurant industry. If you open a restaurant that isn't very good in New Haven, and the sort of medium term it's not going to stay open. If you open a really good restaurant, it's either going to get hard to get a table or it's going to grow. Maybe it's going to open two sites. Same thing actually happens in the hospital sector in the long run. I think the hard part is hospital closures are complicated for a number of reasons. The first is we all myself included have emotional attachments to the hospitals in our area. The number of times I've been to Bennington Valley Regional Medical Center with my dad when he was in bad shape is too high to count. So I have a particular set of emotions attached to it. For a lot of us where our kids were born and the parents passed away. It's hard because in the short run what in the long run places that are expensive and inefficient aren't good for the economy. In the short run they offer a lot of jobs. And we got to sort of think about that. And it's not as simple as sort of saying presto place closes. Nobody loses out. But they're just they're winners and losers. The upside of a market is it doesn't know people's names and it can't lobby it just sort of does its thing. Once you move towards these non market mechanisms. You're having to sort of choose winners and losers and that's that's very very challenging. The last is sort of thinking about how you integrate payers and providers. Yeah I think particularly where there isn't competition. Those two being a little more sort of unified starts to make a little more sense. I'm going to finish just by talking about patient travel. It's really clear that patients do better when they go longer distances for specialized care. It's also true that patients locally do better when their neighbors travel longer distances for care. And that's because it has the ability to also increase the competition that facilities face. So just use the example of Yale and Haven. I'm going to drive to Boston tonight when I get on the highway on my way to it. They're actually going to be signs nearby the hospital for special surgery in New York that are located in Connecticut. What they're trying to do is basically get people from Connecticut to travel to New York. And what that does is it exposes Yale and Haven to competition that they otherwise wouldn't be facing. And there's a very very strong literature. I actually think the most pernicious consequence of lack of concentration of competition or a law low too much concentration or lack of competition is actually on the clinical quality side. But there's very very good evidence out there that hospitals that face more competition at better outcomes. And so I think part of what you can get once patients start going longer distances is the incumbent either saying look I'm going to specialize in what I can only do. Or I'm facing competition and this will let me improve. So with that I'll turn it back and I'm happy to chat about any and everything. Nobody interrupted me. I don't know if that's good or bad. But yeah, we'll take it for what it is. I've been to quite a few talks by economists. We're not that raucous. We're a little bit more polite and subdued. But it'd be fun sometime to do that way. Thanks so much for coming in and going through things. You know, I think it's it's valuable for me to learn from your work and to recognize that coming from Dartmouth and I've been teaching people to use the Atlas since 2010. And in the early years of teaching people to use that it was really things have changed a lot because I would be trying to encourage them to see the usefulness of it in their own practice. But more recently since your work and a lot of it coming out as far back as 2015. I've had to teach. I've had to talk about not over generalizing. That the findings and it's possible to possible to be a very low Medicare spending hospital. And a very high commercially priced hospital. And we don't understand that if you look at just the Atlas. I also appreciate just hearing the amount of evidence that you can that you're able to bring to help us understand that markets and leverage matter. And you you introduced us to the H H I I'm not going to try to say the agents, but I do know from my own reading that scale goes to 10,000. We have 14 hospitals in Vermont. 10 of them have a score of 10,000 of the other four. One is below 4,000. You're cut off. Right. And the FTC, we'd like them to start getting more aware of hospitals when they go over 2500. So our lowest is like 3900 and it's just one. I liked the part when you when you talk about setting budgets and some of the non market ways of of regulating this. And the politics of it. It's tricky, right, because a board, a regulatory board in Maryland, for example, could set a hospital budget growth of 5%. But a monopolistic hospital could come in and say. We need 10. And what enforcement mechanisms does the board then have to say, no, you get 5. And what can happen, we see it across the country. If the if a regulatory body sets it at 5, the monopolistic hospital comes in at 10, they often get 9. So the regulatory pressure that could improve quality and contain costs really doesn't manifest from just setting the budget unless there's some type of enforcement. At least that's my reading of the literature and of from your work. So I just I want to thank you a lot for coming in. I'm going to turn it back over to chair Foster to run the Q&A and the rest of the board to have comments and questions. And just thank you again. You're very kind to join us this afternoon. Thank you, Professor Cooper. I think I really wanted to jump in and interrupt at moments, but I was so engaged that I couldn't do it because I was learning so much. I didn't want to interrupt because everything you said was took me a minute to make sure I understood it. So it was really, I think, reflective of what a great presentation it was and how informative it was. Your students are lucky to have you, and we are too. So thank you. Are you, what's your timing? I have you down till three o'clock. Do you have a hard stop at three or what's your? Yeah, I can go a little over. I'd say like 310. I've got to probably hit the road 315. Great. Okay. So I'll open up to board members for their own questions and comments, and then we'll take comments and questions from the healthcare advocate. So board members, please, please go ahead. And just while people are thinking of them out, you know, just a quick sort of response to Tommy, you know, I think what you're absolutely right about is, in a sense, you need some disciplining function on healthcare costs. Right. You can either be competition or it can be a sort of regulatory intervention. What you can't do is just sort of have nothing, right? That's the, that's the really big challenge. Yeah, so it's sort of, it's just two sides of the point and you got to pick either one, one or the other to get there. Tom, did you have additional questions or comments? Okay. We can go to member homes and then Dave and then a member lunch. Zach, thank you so much for coming. Excellent, excellent presentation. I was going to say the same thing that Owen did, which is your students are obviously very lucky to have you as a navigator on this very complicated world that you've become very, you know, expert in. I, and I also just want to say I'm familiar with not all of your work, but some of your work and always very thorough thoughtful econometric analysis, clever instruments. And I just really appreciate, you know, how you're improving all of our understanding and to the, to the degree that you can improve our work here at the Green Mountain Care Board. All the better. And I'm just, I'm wondering, we have a pretty small data team, I mean, pretty strong but small data team. And I'm wondering how can our data team take some of the learnings from your work, you know, and trying to assess the drivers of price and spending variation here in Vermont. And recognizing the limits that we have in small sample size and the, you know, the volatility that comes with that, but thinking about our own hospital, you know, regulatory process. How do we measure efficiency better. And trying to, you know, get at that balance that you were talking about between, you know, small hospitals trying to deliver a wide range of services in their communities at low volume that may compromise both cost and quality. But they're also the economic engines in their community. Right. We know that issue. But, you know, how do we start to think about efficiency about scale and about measuring it in a way that improves our hospital budget process. And how do we use some of your analysis, you know, that you've done on price variation on spending variation with the data limitations that we may have with small sample size. Yeah. So, you know, all really good questions. It's great to see you. So, first day, I think I'm a fan of descriptive statistics. You know, I think before you can sort of get into the more high powered work, starting by just saying, look, here's what our prices are. And, you know, there are a variety of ways to get price indices that are pretty darn reliable now that that will give you a sort of good sense of what prices look like for things where quality really doesn't vary. And so it's sort of start with, you know, building price indices, I'd have prices for maybe a basket of procedures, a couple of sort of really non differentiated things so non differentiated are things where quality doesn't really vary so like MRI scans. And then maybe some baby deliveries and then, you know, some others. So I would just, I'd have those, I'd plot them over time, I'd benchmark them to Medicare. I think Massachusetts has done a remarkable job with their, I'm blank on what their group is called, but can sort of offer both comparators but also some inspiration about what looks good when I was on the analogous audit queue and Connecticut, we looked a lot at what Massachusetts was doing. So I think that's the first thing that I would do. I think the Medicare costs reports aren't perfect, but they give some window into costs and I think I would, you know, I would sort of just have those visualized to hand. I think the really hard thing to measure is quality, because patient selection is just such a big issue. Now I think I don't know how what quite the density is in Vermont, but there are some, you know, Peter Hall was a economist who's a brown who's sort of taken this this ambulance work and and used to come up with quality scores if you sort of wanted to get fancy that's probably the direction I'd go, you know, I'd want to sort of think a little bit about which areas you can, you can do that for but I think that's how you can start getting at it. So I think just that's the first step. And once you're sort of comfortable with being able to measure some sense of price, some broad sense of quality, then I think you can start getting into these conversations about productivity. And I was just thinking about where patients go. So I think what would be really, really interesting and incredibly useful for the state. And I was very, very surprised by it. When I looked at the work that Jeff Clemens or excuse me, Josh Gottlieb did on on travel was just how often people are traveling. And so I actually think it'd be worth taking a peek at data from the state and say where are patients actually going for high acuity services. I'm really willing to travel who is willing to do the traveling and where in the economic distribution are they coming from. And I think given that in some ways travel is going to be inevitable in Vermont. I'd probably sort of spend a bunch of time looking at that because I think it's both an area of opportunity and an area where there's potentially a lot of inequity that's happening. And I think a lot would sort of I think allow you to say, look, how can we, how can we say, you know, we'll make this easier for some groups, and, you know, we'll be able to facilitate it. I think, again, you didn't ask the question and it's, but I'll say it, not every hospital in your 14 can do everything. And, you know, I think it's probably easier for me to say that in some ways. And I think given that that's the case. At the end of the day, what got me to health economics was, in a sense, a desire to make people's lives at their most vulnerable better. And what that means in part is getting the best care we can get people. And in some cases that'll be locally, both because people have a play, you know, my father was dying in Bennington. We weren't taking him to Boston, we weren't going to take him to New York. It was a trade off between potentially the high acuity services that might be on offer and just the convenience of dying in your home. But for others, you might be much more willing to do that. And might be at a stage where that's much more appropriate. Can we facilitate that and make that easier? And I think getting to that is going to be, you know, partly incumbent on Vermont. Navigating the complex set of issues on the healthcare policy landscape in a very different way than you would if if we were having this discussion in New York. And it's saying, look, we're sort of all in this one together. Right, we're not going to compete our way out of this. And what we got to think about is in a state that's much less densely populated. How do we get the best for our residents, many of whom just are not going to be able to hop on 91 and the mass pike and get to Boston. Hugely helpful. And, you know, some of what we're trying to do, there's an Act 167 that was passed that's actually allowing us and has given us some funding to be able to look at some of these questions and address some of these issues and in a data informed way. And so, you know, your analysis helps us with some of that data, but we have to bring it local. So, you know, some of what we need to do is get that data on a local level so we can have those conversations with communities about how do we ensure that community members no matter what your economic background your financial status is that you're getting access to the best care possible. Lowest cost highest quality so that's, you know, your equity concerns I really appreciate that I recognize same as you that who gets to travel to the highest quality lowest cost care. So, I don't want to take up too much time but let me just ask one more question. Can you speak to some of your work on the out of network billing by hospital physicians. I think that's really interesting from your work and just to hear a brief description of some of your main findings. Sure, so I'm going to loop just one quick second back to, to somebody I want to raise and then I'll certainly talk about out of network billing. So, two things so that the first is what I think is really challenging and hard to sort of wrap our heads around is it turns out there's actually not terrible is pretty good evidence that when hospitals close in certain instances mortality actually goes down. And that's because the hospitals that are closing aren't sort of randomly closing it's, it's the hospitals that that we're struggling to provide good quality services. And so when they shut patient health actually gets better. The second is, you know, I'm, you talk to my students a lot I as I discovered they stay the same age I keep getting older and they sort of now are reminding me of that. I feel your pain. And when I first started doing this, I think I was more bullish about saying this is right and this is wrong and I cannot explain things and here's what we do and I've gotten much more of a point about her to the point where I'm sort of, I think you just going to echo what you said which is that these are conversations. And they have to be conversations that people have really thoughtfully with big swatches of the public. Say they're not simple there are trade offs. There are most policy issues, don't have clear yeses and clear nose and clear sort of, you know, they're not this and more comfortable sort of become verbiage they're not all Pareto efficient that is like they're going to make some people worse and some people better. And we got to be able to just have that frank conversation. So surprise on a network billing. So this is just this again very idiosyncratic feature the US healthcare system where hospitals and physicians independently negotiate network participation agreements with insurance companies. And so it's possible to go to an in network hospital, let's say in an emergency where you don't get to choose your doctor and get treated by an out of network physician. There's some work in the New England Journal of Medicine and then in the journal political economy that shows this is happening 22% of the time for emergency room patients, which is just striking. And we're we sort of back to the envelope that when that happened the average bill patients were getting worth about 700 bucks. And again if we go back to this sort of average liquidity. One of the things I say to my Yale undergrads and to my master students or to policy communities is, but for most of the people who come to the seminars where I speak $700 bill is incredibly upsetting. But it's not going to be the difference between eating or not. But for a large chunk. It is the difference between eating or not or major household expenses. And so the business happening 22% of the time is is frankly shameful. We did find that most of that was concentrated in a minority of hospitals, where this was not an accident. We're bringing in a large for profit staffing companies who made a sort of deal with the hospital that in exchange for waving the subsidies that you traditionally have to pay staffing companies to be there. They'd allow them to be out of network. So, you know that that's really the sort of source of the problem. You know there has been a lot of amazing action on this at a federal level President Trump really got behind the no surprises act as did a large number of Republicans and Democrats in the Senate. There was a big law in 2021 it had two prongs one was that it protects basically patients from getting an out of network bill so they're only going to pay in network cost sharing they see an out of network provider physician in an emergency. And then it sets up an arbitration process to settle disputes. A lot of a lot of the companies that were engaged in out of network billing were not. They delighted with this change. And so they've been suing the administration pretty concerned both administrations pretty consistently over it. I believe March 8 a judge in the district court in Texas actually stayed the arbitration component of the law. And so right now patients are protected but there's no mechanism for settling the disputes on that will actually affect patients. In Vermont but it will affect physicians and insurers in Vermont and I think it sort of speaks to the need to address this. Both at a federal level that we need to figure out what to do in response to the lawsuit I think it also speaks to why states can still have a role in helping to eliminate the financial pain doesn't cost. Thank you so much appreciate it. Yeah. Hey Zach. David Marmon. So I went into emergency medicine for pretty much the exact same reasons you went into health economics is pretty fun to consider but trying to help people at the most vulnerable times. Have better outcomes live better lives and get the best care we can so it's it's a fun. It's a it's a fun relation there so I'm nice to hear. I really appreciate your presentation and I guess I have some thoughts but I guess I just wanted to say I really appreciate your discussion regarding the complexity of trying to figure out what sources what resources to be locally and what can be what can people travel for and and also the real socioeconomic socioeconomic impact and really you know who has the financial means and time means to travel for for health care. My experience in the emergency department which is you know different than general health care that's different patient population that that we see but would that that would be profoundly impactful for a lot of people that I see to have to travel for specialized care. I think one of these I'm just sort of thinking out loud and sorry if I don't come up with a question to later but I think one of the interesting things is that you know we we don't have a lot of places in Vermont that do a lot of things we have one place that does cardiac catheterization one place that does in patient dialysis very few places that do intensive care. We do have places where you can get an appendectomy get a knee replacement or hip replacement more more broadly you know in patient care for you know for for general medical illness but not requiring super high level of care so this but it does come up often you know in the sustainability work about what you know what should be where and and what makes sense and and all these things you're talking about the economic impact of a hospital on a community as a large employer the access of care issues and I thought I think it was you that mentioned this early on that you know when when cost goes up access goes down because it costs too much and all these things really I think resonate with a lot of the the challenges that we have on the board of trying to figure out how to best regulate our hospitals here in Vermont to to improve access improve quality you know and try to keep our costs in control and actually I think Tom's comment there thinking about the impact of market power on the regulator is something I guess you know we think a lot about it and insurance negotiations but I think it also does have an impact on the regulator because because you know we really want these institutions to thrive. So wow I don't know if I have a specific question for you know this challenges of transportation you know it's really hard to me to wrap my head around how you could really help move patients to around when right now we struggle with transportation as it is but anyways yeah yeah I mean so actually I mean I think these are incredibly important points you know start by by saying you know PhDs or Latin for a doctor who can't really help you so like trust me there you're getting a lot more phone calls at two in the morning than I'm getting nobody nobody used to wake me up for much and and so I think having providers involved is incredibly important and I you know I think the question of travel is one where we need to be willing to sort of be pretty creative. You know so certainly like emergency room care. The broad sort of distinction I draws between things where something literally is going to like somebody's hands or whatever is physically enter my body versus things that don't and you know I think primary care certainly seeing certain specialists you know I think that can be be local non emergent things that start to get get interventional. I think starts to be in that bucket of we probably want to start thinking about it. Now I think some of this is our time horizon and I say that for two reasons. The first is I actually think we're going to start in the not too too distant future seeing really big changes in surgeries such that the surgeon isn't necessarily going to have to be in the same place as the patient. And I think that I actually don't think that's that far away. And that's going to fundamentally change the sort of calculus on a lot of that. And again if I were to say I were present at UVM right that that would be an area where I'd be thinking a lot about sort of research priorities because I think there's just sort of a lot of scope for that changing the nature patient shop. I talked about the time horizon again to also reflect your point about the economic opportunities and the economic costs of a high cost healthcare system. And it's why boards like yours are tremendously important and it's important that the appointments of the members are not on the same appointment cycles as elected officials. And it's because sometimes certain people need to think in the short run and certain people need to think in the long run. You know I I remember David Lee. You know my dad had Alzheimer's and so I would come up every weekend to Bennington and I'd come up Elm Street and take a road to Maine and I'd drive past Bennington Regional Valley Medical Center and it was the nicest piece of property in the town the most well maintained it was the sort of anchor property in many ways for for Bennington. And if it were not there Bennington would look different. And that's certainly true in the short run. And it's equally true in the long run that a health system that is high spending and inefficient slows economic growth. And I think too often the economists focus on the long term without acknowledging the sort of short term pain to get there. But it doesn't mean that that's not in the long run sort of better for communities. And I think part of the sort of challenge we all face because we're all in this one together is just sort of how you manage that transition and understand that different people will do better and worse during that and that it's OK for people to say this isn't nice for me because they're not wrong. But to sort of just understand that what might not look fantastic for a year or two isn't bad in the sort of 10 year time horizon. I'll speak about Connecticut because I'm just a little more willing to be very very blunt. My state is getting choked to death by two hospital systems with two hospital systems in the state. We have some of the highest as I showed you premiums in the country that makes it very very hard to have companies come in and be able to afford to hire workers and our work our firms are leaving our state getting slowly bled to death by our health care costs. You can make up that what you will for Vermont. That's not good in the long run. Now it is equally true that if Yale and Haven took a 10 percent haircut there would be a spike in unemployment next year. But I think we owe it to ourselves in Connecticut as a state to say the long run interests of having economic vibrancy are such that we have to be willing to have serious conversations about how to mitigate the short term losses that would take us to that place where we're going to do better in the future. Great. I'm just mindful of the time and Professor Cooper I'm going to give the health care advocate a chance to comment or question and then you can be dismissed after the health care advocate if you need to get going and then I'll do public comment after because I know you're I won't be respectful of your time so please go ahead. Yeah. So having done the drive from New Haven to Boston a few times I want you to get on the road Professor Cooper. So I could just talk before public comment that would be great. But thank you so much for your presentation. It was wonderful. Cool. I let me I'm going to literally I think I should be fine. So I'm happy to take a couple more questions and then hit the road. Eric go ahead and you can ask any questions you have and then Professor Professor Professor Cooper hit the road. Thank you. So I was just you know that the idea of Professor Cooper about looking at willingness to travel. You know and I think it it's really interesting. I think from my end and the board has some appropriated funds for this is being like there are multiple causal factors about why a person travels or not. So like for instance like you could look at the work of Maple Kwan and some other kind of quantitative or mixed methods geographers about how time and costs influences travel decisions. So for instance my brother lives in Brookline. I have a free place to park and to sleep that radically changes my willingness to travel for care versus someone else. And so I think as we're looking to be data driven it's not just say an analysis of B cures and what the patterns were seen but trying to get behind that. And we might it might be interviews some form of a structured or semi structured interview to understand why people do certain things and then you abstract or retroduce out of those interviews the causal forces at play. And I think you know in a lot of ways and with an end of 14 we're always left in this situation in Vermont where statistical models whether I mean for the love of God even linear regression fixed effects let alone a more complicated model fails right because it's so small. And I've wasted countless hours trying to figure out a way to do it. I would love and you know the board staff me and Sarah have talked ad nauseam about our frustration. But I think the approach towards descriptive statistics and then qualitative methods is probably the best we're ever going to do to understand the relevant questions in Vermont. And that approach is data driven. People's experiences are data data driven is talking about the method and how you're analyzing it. That's what makes something valid. And just before you go Professor Cooper you did your talk about out of network care was actually one of the factors that influenced me in thinking about how we provide free care in the state. And that resulted eventually in Act 119 which did that unfortunately the out of network provider piece of that having to offer free care assistance fell out for various reasons but your work was at least for me was one of the major early ideas that kind of got me thinking about the need to address that issue. So thank you. And then thanks for putting the work on it. I mean a couple of just quick reflections and then I'll head out. You know it does with the points that were just made. And I think Jessica made earlier in terms of what we would do. I look as a sort of scientist. I'd be curious about doing some experiments. You know where you'd sort of think about how you'd offer the chance in some ways randomly to different people to get care. And then see what effect that have. You know and and that'll really sort of give you the answer. You actually don't need that many people to do it. In terms of you know traveling and it being hard and listening to people I think you're absolutely right. And I think too often economists are pretty darn arrogant and don't talk to people and don't listen and then we'll sit in a room and say you know why doesn't anybody do what we say. And it just turns out that the world's a whole lot more complex than the models we we predict and write about. But the flip side to that is I think what we do know incredibly well and I think we can state with confidence is that rising health care costs are breaking in the backs of a lot of folks nationwide and a lot of folks in Vermont. And it sort of gets back in many ways to where Tom started which is like there's just a choice you can have markets you can have ration. I think the challenge of Vermont is if you don't have either. I don't think you have competition. There's nothing that's going to constrain spending growth and the residual claimant of that harm. It is not spread equally across the population the residual residual claimants are often the most vulnerable. Those folks often have the least access to a board like this and least access to elected officials. And you know I think one of the things that's important for you guys to think about it can change my views of this. The industry in the U.S. and since more unlobbing than any other industry is healthcare industry. Right and so I think there just there needs to be a voice for the folks who are really sort of feeling this burden day in and day out. So I'm grateful to get the chance to be here if I can help in any way. And please don't hesitate to reach out and it's sort of extraordinary the work that y'all are doing. So thanks for letting me chat a little bit and hearing about the issues that you're navigating. Thank you so much. Zach for doing this for us. This is extremely enlightening. This is really really informative. So I'm sorry Dave Merman has his hand up. Go ahead Dave. I just want to say two quick things. One is regarding the out of network emergency positions being an emergency physician in Vermont and I know of no hospital or practice or group of emergency providers in Vermont that has that practice where they have out of network providers. I'm aware of these throughout the country. It's sort of a it's a scar on my field where there is provider groups that intentionally select patients when they come to the department. They certain providers select certain patients that are out of networks. They have different providers that are in network to different patients. I know none of that existing in Vermont. If the health care advocate heard of any of that we would like to know and other regulatory bodies would I just want to make that clear to the public as well. The other just one little tidbit I wanted to say about travel is that my understanding is that the from from some data is that the number one reason to refuse admission to the hospital is for care of pets at home. And I will tell you that is my experience that the number one reason by someone who is very ill will not stay in the hospital in Vermont. It pets includes farm animals. But it's the care the care of animals. And so when we think about travel you know people traveling to Boston for care from you know Derby you know I mean there's just who's going to take care of the pets. It seems silly in some ways but they're so important to people and it's so important to their existence and who they are and how they live their lives that I think I just think that we have to have humility that there's a lot of reasons why people don't travel that we can't model. And I'm not saying that you're advocating for that at all and I really appreciate your nuanced view on this but I think just in that conversation of traveling for care that it gets there's more than socio economic factors that that will lead people to to making decisions that an economist may not call it rational but but I think are totally that are that are really impactful so just want to know. No first of all I actually think you have pretty low incidence and surprise feeling in Vermont. It turns out you Texas that's the place you really want to mind your P's and Q's if you go on vacation but about the travel. You know I think in one of the things I was just sort of thinking about as we talked is first of all it turns out usually high price high quality care if you travel is both better and cheaper. So often the sort of savings is there. And so I think a lot of companies are starting to do this and you know I think one of the ways you can sort of think about this and with the companies that I talk about is you actually offer pretty substantial cash payments to folks to travel. So you're going to save $5,000 in the price of the surgery you transport the patient you give them $1,000 subsidy. And part of the reason you give them that cash is because they're going to hold know a whole lot better than you about what they need to take care of and whether it's, you know the the alpaca or the cows or the dog Rosie for me. How to do that. And so I think it's just figuring that out. Professor Cooper. Thank you to have a safe drive and we appreciate this. See you later. Thank you. All right, thanks. And with that I'll open it up to public comment. Mr. Ham Davis, how are you please go ahead. Thank you. I several questions for Mr. Dr. Cooper but I can turn them into brief comments. Striking striking presentation. Here's what is the way it appeared to me. Well, I don't think it affects Vermont at all. And the reason is that in the reason as that the hospitals of any kind don't have any power whatsoever to negotiate on their own with the private sector with the private payer. The reason is that the Green Mountain care board decisions include not only what you can spend it as a as a net patient revenue. It depends exactly can depends completely on what you're allowed by the Green Mountain care board to charge to to in the commercial so it just doesn't doesn't mean anything here. You can say you can a hospital or anyone can say that they they need X amount of dollars. OK. And the only place they can get it since they can't get it from Medicare and Medicaid. They have to get it from a cash for that to get it from the private sector. But you cannot ask you cannot not ask the private sector in Vermont for a nickel over what you're allowed by the Green Mountain care board. And that is going to be not only has that been important in the past. That's going to be absolutely critical in the future. Number two I think the I think the just a comment I think the I was struck by the Dr. Cooper's reference to go on this article which I've read 20 times and make all my friends read that about the about his judgment about Grand Junction Colorado. Well that may be in there. But the main comparison that he made in that article was not with Grand Grand Junction Colorado was with was with the Mayo Clinic. And in 1984 I spent I spent a total of three years working with Jack Winberg who started who who invented the whole small area of variations data. He was the father of the Green Mountain of the Dartmouth Health Atlas. And I can tell you in the in the 19 late 1970s and 1980s it wasn't just Medicare and then in the original in the original formulation it was all the care and all the payers and those and the and the differences per capita were very very very great. And it's different now because of because it's the the the Dartmouth Health Atlas goes all over the place and and the covers tried to hold the country. Winberg himself worked both in the UK and in Norway. And I looked at this in a long television documentary in 1984 and these differences with the with the original formulation of the of this small area of variations technique covered all the care not just not simply all the payers not just simply the government payers. Anyway, so I just think that the the real question here is the real question is in Vermont. I think they hold all the all the conclusions about about about the high prices that can be forced by hospitals that have total market power which they do almost everywhere. And so and so if if you folks have a future chance to ask to talk to Dr. Cooper privately or whatever. Well one of the things I would want to ask him is, is he familiar with any system in the United States where the whether the whether any hospital dominant or otherwise has has is completely completely blocked from using their market power to get more money. Thank you. Thank you for your public comment. I see member Walsh has his head raised so please go ahead member Walsh. Yeah. Thank you. It's common when we have public comments to listen and appreciate them and I very much appreciate public comments. But I feel compelled to respond to the most recent. I taught with Dr. Winberg for a number of years I think he'd be very disappointed in me if I didn't speak. So, Dr. Winberg's variation research started in Vermont in 1973 by 1980. It was entirely Medicare based in regards to price regulation. The Green Mountain care board has approved hospital budgets. Since its inception, we've approved 99.9% of what has been asked for. We set growth rates. Hospitals ask for higher than the rate. And we approve nearly what they ask. It's impossible to say from data that healthcare in Vermont has been heavily regulated. They've gotten what they've asked for Dartmouth's data about quality and prices. Applies to Medicare. Does not apply to commercial Vermont's hospitals. Their growth and prices have not been heavily regulated. The data is all there. Mr. Carpenter, Walter, please go ahead. Thanks Owen. Again. Tom Walsh said what I had on my mind. Close to it. I do want to say that. To add a little bit to what Tom said, I think the care board should have more powers than. What it has now, I think. To me, who almost died from market based healthcare. 16 years ago. There is all of this is an argument for single payer. Some form of it. Not necessarily like the British National Health Service or the Canadian model. There are various models of single payer. What Tom said about the hospitals and I think he's right. And to go on further with the networking problem, I was real interested in his presentation about that because I suffered through that network problem for months. In fact, the networking problem was one of the difficulties I had and why I went from being yellow. To the same color of charcoal or ash in a fire pit and why a nurse was so shocked that I was still alive. Because of this constant ridiculous out of network problem that patients don't understand and have to fight all the time. I wish he was still on. I would have questioned him about that, but. I'll be quiet. Thank you. And we're quite a bit behind schedule and I have a hard I have an appointment this evening I need to prepare for and do so. Mr Davis, I see your hand is raised again, but please, please go ahead, but we'll need to move on here in a minute. Well, I just wanted. Okay, I'm going to sell her literally with 200 pounds of Vermont healthcare data with all the payers. Okay. That's all I have. I want to see him. Great. Thank you for your comment. Can you take just a 2 minute breaks of folks and get some water and then we'll turn to Mr. Barber. Thank you. You see that. All right, Mr. Chair. Yes, it looks great. Thank you. Okay, I will try and get through this pretty quickly given the time. I'm here to speak with you about something much, much less interesting than the previous presentation. I'm here to talk with you about certificate of need monetary jurisdictional thresholds. So, the CO and monetary jurisdictional threshold is basically a dollar value where if a project goes over that that dollar value, it requires a certificate of need. So for example, the statute says that a healthcare facility that isn't a hospital has to get a certificate of need to purchase a piece of diagnostic or therapeutic equipment. If the cost of the equipment is greater than a million dollars. Not all categories have these dollar amounts associated with them. For example, construction of an ambulatory surgery center requires a CO and regardless of the amount of money involved. But there are there are a number of them with these with these dollar values and under this under the statute before we can adjust. Those dollar amounts provided that the adjustment. Does not exceed an amount calculated using using the cumulative consumer price index rate of inflation. So just over a year ago on March 30, 2022, the board voted to increase each of the CO and monetary jurisdictional thresholds by 12.8%, which we calculated to be the maximum allowable increase at the time. We implemented those adjustments through an administrative bulletin. The statute used to require that adjustments be made by rule. And I think that's probably part of the reason why they were not made. But the legislature repealed that requirement in 2018 so we can do this without without a rule. So last year was the first time that the board exercised its authority to increase these thresholds. And we had to make a few decisions about about how to do this. First, we had to decide when do you start calculating inflation from. And we decided that we would start from July of 2018, which is when the legislature last reviewed these thresholds and made adjustments. And then second, we had to decide what rate of inflation to use and we ended up using the broadest measure of inflation, the consumer price index for all urban consumers for all items seasonally adjusted. There were a couple reasons behind this, which I don't think I need to get into, but using CPI for all items resulted in the greatest possible adjustment. Growth in CPI for medical care, which was the other measure we were looking at was 10.2% over the same time period. So I just wanted you to see what what are these thresholds. So this slide and the next slide shows the CON categories with these monetary thresholds. As well as, you know, what what it was in the statute and what it is now. So the the crossed out dollars are what the statute says the underlying dollars are what's in the CON boat and that I mentioned with the revision. So, as you can see here, there are thresholds that apply to hospitals and thresholds that apply to health care facilities other than hospitals and the major categories are first construction, development, purchase, renovation, or other establishment of a health care facility or a capital expenditure buyer on behalf of either a hospital or other health care facility. Second, the purchase or lease of diagnostic or therapeutic equipment and then third, the offering of a new health care service or technology, in which case it's the annual operating expenses that that are relevant. And then if the project is expected to be really costly, you need to secure what's called a conceptual certificate of need in order to spend money on planning activities like architectural or design services. And then finally, we don't see this much, but there isn't kind of exclusion. You're allowed to spend a certain amount of money in preparation for obtaining a conceptual CON. And so that's the final row on this slide. So it's been a year. I wanted to bring this to you and see if you want to make revisions again. So this slide is showing you on the left. On the left hand column, the CON category, the base column is the dollar amounts that are in the statute. The current column is what the thresholds currently are. CPIU all items column is showing what those base amounts could be revised to now. So the growth in CPIU all items between July, 2018 and February 2023 is just over 20%. And then I wanted to show you on the right hand column, what the growth in CPIU medical care has been. So just a little bit over 13%. I also thought it would be helpful to see how Vermont stacks up to other states in terms of its monetary thresholds. There's not unfortunately kind of up to date survey for the states with CON programs that has this information in it. There was at one point, but it's pretty dated now. But I did take a look at our neighboring states to see where they are. And as you can imagine, other states categories don't match exactly with Vermont. So it's a little difficult to compare them like this, but I tried as best I could. And so that's what the next three slides are. So this is main main updates. It's thresholds or at least most of its thresholds it by CPI medical care. It does not update this new healthcare facility category. This is showing on Rhode Island. This is showing Rhode Island's thresholds. It updates as best I can tell its categories by CPI all items. And then Massachusetts has a kind of complicated setup. I hope I captured it right, but I'm certain that they update their thresholds or at least the dollar values here by an index that's not CPI. It's Marshall and Swift index. And then I also put together some slides just to give you a sense of what are the CON projects that we've reviewed since 2018. What were the dollar values? How did they come under our jurisdiction so you could get a sense of how they relate to the thresholds as they currently stand and potential revisions. So that's the remainder of the slides. I don't think I need to go over it in detail given given the time, but I guess I would say that I didn't see a ton of concern that by increasing the thresholds we would be excluding a bunch of stuff. There were a couple of things that I noted in red where in red text that, you know, so for example, this is looking at the hospital capital expenditure thresholds $3.37 million currently could be revised as high as $3.6 million. In 2023, we reviewed EVMMC's project to relocate its terminology and ophthalmology practices because of the dollar value that required a conceptual certificate of need. If it was increased, if the conceptual CON threshold was increased to $36 million, that wouldn't have triggered that need. So I tried to note things like that, things that were on the line with red text. And one thing that they became clear in doing that was that some of these capital, some of these equipment replacements trip both the equipment threshold and the capital expenditure threshold. So if we increase the capital expenditure threshold, it, you know, potentially might exclude some of these from that category, but you know, I think they would still be reviewed. They would still trip the equipment threshold, if that makes sense. So, sorry I sped through that, but we haven't answered questions. Really, we didn't notice a vote for today, so I wasn't looking for a vote, but I can come back at a later time and get your vote if that's what you want to do. I just really just wanted to, like I said, it's been a year, bring this back to your attention and see if there's any interest in revising these again. Thank you very much, Mr. Barber and I really appreciated the context you gave us with looking at what the other states have for their thresholds. I appreciate that. This is really great. This is made it really simple to assess. I have no questions. I'll turn it and I'll be ready to vote, you know, next week or at some point soon, but I'll turn it to my colleagues to go ahead with any questions or comments they have. That's one quick question is, is it possible to have this automatically adjusted as opposed to having to vote each year to adjust up these thresholds based upon CPIU? Yes, it will be possible. It may be something to consider, but I support those. I support it also. I support automating it if it's possible. I also think it ties in really nicely with the presentation we had from Professor Cooper because decreasing barriers to entry can be helpful for competition. Right. So the certificate of need process originally was meant to protect patients and control costs, but the evidence from across the country is that the process of going through certificate of need has gotten very expensive. Well, the outcome hasn't improved quality very much or reduced costs. So rethinking how we think about certificate of need seems smart. Rethinking some certificate of need also seems smart because it's the only state tool that allows some control over. It's an important tool for states to constrain dominant healthcare systems. As Dr. Cooper talked about, we need some ways of constraint. So I think it just flows really nicely and it's an important topic. So thank you for talking with us. If there's any other board comments or questions, I will turn it to the healthcare advocate for any of their comments. If any. No comment. Great. Thank you. And I'll open up to public comment. Right. Mr. Robert. Thank you very much for this. And I'm sure we'll take this up pretty soon. So thank you. Okay. Thank you. So that's all we have on the agenda. Is there any old business to come before the board? New business. And is there a motion to adjourn? Second. All those in favor, please say aye. Aye. Aye. Aye. Aye. Motion carries and the meeting is adjourned. Thank you everyone and have a nice evening.