 The first item on the agenda is the Executive Director's Report, Mr. Farron. Good afternoon. I have a couple of announcements. I'm very excited to hear from our panels, especially today. This morning, a couple of the folks on the panel, Dr. Marvin and Dr. Pullman, were in the legislature and testified to two committees, House Health Care and Senate Health and Welfare, on the workforce issues surrounding primary care. And it was a really wonderful discussion. So this is just going to be a broader focus with different folks from different sectors of education and other providers. I have an announcement in terms of the schedule for next week. We will be hearing from Vital and Diva an update on their budget. And I think that's it. Oh, I've announced this a couple of times, but today is January 15th for folks in the legislature and folks who work in state government. This is a day that we typically have lots of legislative reports due, so we submitted our annual report actually yesterday. And we have a primary care spend report that is going to be submitted today. And all of those reports are on our website. And that's all I have to report. Thank you, Susan. The next item are the minutes of Wednesday, January 8th. Is there a motion? Second. It's been moved and seconded to include the minutes of Wednesday, January 8th. And on the additions, submissions, or corrections, is there any discussion? Seeing none, all those in favor, signify by saying aye. Aye. Any opposed? No abstention. No one abstention due to relapsed? Okay. We're now going to end the focus of today's meeting. And before I get started with kicking off the panel, I wanted to recognize some legislators who are in the room. Unfortunately, I don't always recognize all of them, and I apologize for that in advance. One of the members I readily see is a former colleague of mine from my days in the legislature. The chair of House Commerce, Mike Markott, who has been laser focused on the issues of workforce for the last couple of years. And hopefully we'll be able to make some huge progress this year. I also see a former member of the Green Mountain Care nominating board, a member of the legislature, an economist, Bob Becker-Oft. So welcome. Mike, if you could help me with whoever I've missed. Sure. I have two other committee members that are here right now. Representative Jim Carroll from Bennington and Representative Zach Rout from the Windsor area. Welcome all. We'd love to have legislators here. You're such an important piece as you try to solve the workforce crisis in the state. I know that it transcends health care that's across all sectors of the economy, but the point that we often try to reinforce from the board's perspective is that in the case of health care, we could be jeopardizing the quality of care, or it gets paid for regardless because hospitals can't turn away patients, and so they're often in the position of paying at least twice as much as they would if they hadn't avoided the schedule for travelers and locums. The focus today is on one narrow focus, which is primary care. And so we're not going to get into any of the other shortages across the health care spectrum, but we did want to put the focus on primary care. And in 2016, Act 113 established the primary care advisory group, and that group was slated to sunset in July of 18. Recognizing the great input and the value of the primary care with the board itself, set it up as a task group that we're entitled to set up under statute under Act 48, and have continued to receive valued input feedback and advice from the group. This year, that group has identified a workforce as its main priority, and as Susan said, several providers testified this morning in both the House and the Senate and talked about the shortage of primary care doctors in Vermont. And one of the reasons people ask, why are you focusing on one segment? And I just want to point out that we could have a panel on each and every segment, but the focus for today is on primary care because if you take a look at what is central to health reform efforts in the state of Vermont, primary care is front and center. And you know if we can get people in front of primary care providers, we're going to have savings over the long run. And if you take a look at other countries in the world, developed countries that are delivering better health outcomes at a much cheaper cost, the main difference is that in those countries, there are two primary care providers for every one specialist. And in the United States, we have it exactly backwards. We have two specialists for each primary care doctor. And despite all our efforts in primary care, legislature and the administration have put additional funds into primary care reimbursement in Medicaid and one care has put a huge focus on primary care in the health care model. At times we feel like we're taking two steps forward, but three backwards. And if you look at recent data, the Physicians Report notes that 25% of Vermont's physicians were mainly in primary care and of that only 12% were from family practice. Also in seven of the 14 Vermont counties, at least 41% of the primary care physicians were over age 60. And as we all get older, we know the demographics, we're not going to need less care, we're going to need more care. And so this is a point of alarming. So this panel has been put together to discuss Vermont's primary care issues and the need for timely solutions. And there are a lot of small pieces that could be done and there are some large pieces that could be done. But what we've asked this panel that's been assembled here today is not just to talk about the problems, but also to discuss some possible solutions. So joining us today in this really high level panel, and Joe, I think that Susan is ecstatic because you're the only male. And Rose among the four. I actually think I need to take a picture of this panel. But on the panel, we're very, very fortunate to have Elizabeth Cody from the director of the Office of Primary Care and AHEC program, the Lyon College of Medicine, UVM. We have Catherine Becker Van Hase, director of health policy and health veterans and business outreach at Senator Bernie Sanders office. I tried to get her to tell me what was said between Bernie and Elizabeth. She wouldn't offer that forward. We welcome Jessup Arnott, the executive director of the Vermont Medical Society. We have Helen Layton, the Vermont director of public policy at By State. We have Dr. Joe Haddock from the Thomas Jitman Health Center, who's also a member of the board at One Care of Vermont. We have Dr. Christa DeZela, interim senior associate dean for medical education at the Lyon College of Medicine at UVM. We have Dr. Kathleen Moreau, department chair of community and family medicine, Geisel School of Medicine, and Dartmouth Hitchcock. So we have the two main suppliers and doctors in our area. We have Dr. Paige Holman, pre-bottom care board of primary care advisory group members, and a member of the Little Rivers Practice. And we have Dr. Katie Marvin, also from the primary care advisory group and from the community health services of the Loyola Valley. So welcome to all our panelists. And what we ask is for each one to take approximately five minutes. There's no egg timer, so don't feel that you either have to take the full five or that we're going to cut you off because we will not, unless you keep going on and on and on. So we are going to start with Liz Cooke. Liz. Hi. Thank you for the opportunity to restate this panel. Let me start first with a very brief overview of AHEC. AHEC is a statewide network of free organizations dedicated to health workforce development. We work with many partners and collaborators. Our aim is helping the monitors, and we contribute to this through health workforce development. By inspiring young people to pursue health careers, supporting health professions, students and trainees, and by administering and consentive programs and serving as a continuing education and resource for the current workforce. I've provided slides about AHEC and data from our programs, including data about educational employment and scholarship incentives. Today's assignment is to present ideas about working towards solving Vermont's workforce challenges and presenting the ideas very quickly. Action area one, language. Language matters. With all due respect, let's consider reframing the narrative and rein in our use of the word crisis. Sometimes there are actual workforce crises, but we tend to use it to describe our state of being. Does not help. Does not allow for a clear, open-minded, creative campaign, analysis, and thoughtful action. Who wants to pursue a career in a field or specialty in crisis? Who wants to live or work in a place in crisis? Instead, can we accept workforce development as a challenge for the long haul and broaden our approaches? Diligence is needed in how we talk about these challenges matters. Action area two, collaborative action network. Vermont needs a highly-functioning multi-sector healthcare workforce development collaborative action network. This will allow us to connect the dots between organizations, activities, and language resources and data for a shared vision and collective impact. The concept has been tried before and all in flat. It's easier said than done. We need to revision, reconstitute, re-engage, recognize and respect that authentic collaboration takes time. It's hard work and it's valuable. We need a strategic plan and a work plan that is actually implemented and monitored. We need a variety of efforts to demonstrate and communicate that Vermont is a great place to live and work. Action area three, get comfortable with the uncomfortable data and behavioral economics. Conventional wisdom is not necessarily true. We cannot ignore inconvenient data. Longitudinal outcomes data are necessary to gauge program effectiveness and impact. Workforce development is complex and there's a tendency to oversimplify. Personal and unconscious biases hinder us. The methods by which education, career pathways, and employment decisions come to fruition are complicated, often are unknowable combinations of factors and values. An example, AHEC endorses the need for educational loan payment and scholarships. It's necessary and baseline for us to be competitive nationally. With that said, these tools tend to receive a disproportionate amount of attention and energy when it comes to implementing workforce solutions. Educational debt is a factor, but it is not necessarily the most important factor for a large segment of the position workforce pipeline. Factors vary in degrees from person to person, but we need to listen to the trainings about what's most important to them and ensure we're responding strategically. Looking at the 2019 national data from the Association of American Medical Colleges, which information in the slide is it provided. There are data from a survey of about 16,000 medical school graduates. One of the questions is, how influential were the following in helping you decide your specialty? Everything about primary care here. Strongest influencer, fit with personality interests and skills. 87% strong influence. Content of the specialty, 83% said that was a strong influencer. Role model influence, 51% said that was a strong influencer. Work-life balance, 43% strong influencer. Income expectations, 15% said that was a strong influencer. Level of educational debt, 7% said that was a strong influencer. 55% said it had no influence at all on their specialty choice. Another question from that state survey, how useful were the following resources in learning about specialty choice and career planning? The top two responses, advising and mentoring, 47% said that was the most important. They're very useful and participating in in-house extracurricular electives so they can explore. 44% said that was very helpful in those decisions. Are Vermont's strategies inclusive of the largest segments of the workforce pipeline? When introduced to these data, I do not fully believe. But as I continue to look at the data and track it over time, it continues to echo these similar statistics. Monitoring these data will be informative as none of the student demographics change over time. I share area four, listen and adjust. UBM and AHEC are useful in these data and other data to inform programming. We implemented the newly evolving Vermont AHEC scholars program starting in the class of 2022 to provide enhanced opportunity to delve deeper into areas such as social determinants of health, practice, transformation, diversity and cultural intelligence, interprofessional engagement, data and systems. Working with the Office of Medical Student Education and the Department of Family Medicine, we're enhancing mentoring and facilitating role model opportunities. Again, based on the feedback that we're receiving. If a practice would like to serve as a clinical preceptor site for medical students, you have to hear Dr. Zale now. If you live outside Chippin County and are interested in providing volunteer housing for up to five weeks while a medical student is enrolled in a clinical rotation and experiencing a different Vermont community and future employer, let me know and I'll connect you with the right people. We strive to understand what these students' professionals value most. It changes over time in baby boomers versus millennials. Well, only 7% of medical student graduates said that educational debt is a strong influence on specialty selection. Our workforce development tools, scholarships and money payment focus on solving that perceived problem. 55% said that educational debt had no influence on specialty selection. What are we going to do to entice that larger pool of 55%? Are our resources and energy misaligned? I don't know, but it seems worthy of further discussion and exploration. Action Area 5, look inward first. It's an anecdotal information. It's beneficial for each organization to look inward about what they do to attract and maintain its workforce. Why would somebody want to work at your organization? What is the culture? How is them around? Do all employees feel supported? You can't focus only on the clinical staff. Do you make the most of your interactions with medical students when you have that opportunity? This is similar to self-help books where the advice is obvious, not new, and sounds ridiculously basic. The problem is that while we know, we're not actually doing it. And the work that AHIC does is position placement, loan repayment, recruitment and retention. We have privy to personal stories and anecdotal information. Granted, we usually hear from folks when things are not going well and less so when things are going well. The drawing on 15 years of working with physicians of the native climate decisions, that storytelling is rarely about a better compensation package or about a better loan repayment deal. When things are not working out, people want out. A sample of the occurring things we hear are from the recruitment and interview process. Personality is not gel, vibe is not right, people see when happier cranking. Facility issues, outdated, poorly decorated, you need a repair, it's messy. These are real things. During the interview process, feedback that we heard that was a turn off. The food that was served during the interview process. The way people were dressed at the interview. Other feedback during the recruitment process. The practices behind the times, they're still using paper records. There was a lack of follow up or delay follow up after the interview process. We also hear failing needs and spouse will be put in that conversation. Retention. During the retention process, these are already working out of place and now they want to change. They're talking with us. They're looking for a different position or trying to get out of, at least from service obligation, what we can as a publication we hear the problems being. Workplace culture, toxic environment, mismanagement, personality and relationship issues. I do not have a voice, I do not feel supported. Clinical safety, clinical quality. I can't practice the way I want. Inadequate time with patients. General burnout, stress, not enough time. Administrative processes related. Death by paper. Complaints about technology and electronic medical records are usually rolled in there. A lack of specialty support and referral resources. I'm not feeling that they do their jobs well. And then family needs come up in that conversation often as well. Enclosing. Recruitment and retention tools such as educational loan repayment are necessary. But at the same time they have limitations. We need a variety of sustainable intervention into starting with KV-12 students. A coordinated federal, state, local, public, private, academic, all hands on deck, skin in the game approach is my professional recommendation. Thank you. Hi, good afternoon. Thank you for having me here today to share a federal perspective on this issue. If it makes you feel better or worse, Vermont is not the only state in the nation experiencing this challenge. There are a number of federal programs that are specifically designed to help address the workforce challenges facing our country today. The demographic challenges that Vermont is facing, we are one of the oldest, greatest states in the country, but our entire country is graying and is experiencing a greater need for healthcare services. A number of programs that I think actually a lot of people don't know about or they know about, but only to be limited degrees. So I'm just going to quickly mention a few. Number one is graduate medical education, which is the vast majority of federal funding to go towards workforce in the healthcare field is for graduate medical education. 78% of all federal funding for healthcare workforce is in the GME program. Most people think graduate medical education is coming from the Medicare program. That is the vast majority of it. 45 states, including Vermont, do help provide GME funding through the Medicaid program. Here in Vermont, $13 million goes towards GME from Medicaid, which yields a federal match of $17 million. According to a recent report by the Government Accountability Office, which is part of the legislative branch of the federal government, the data provided from the state of Vermont to GAO showed that one FTE resident was funded with Medicaid GME dollars. So $13 million of Medicaid funding from the state of Vermont, $17 million match from the federal government, and one FTE resident funded through that program. The funding goes to support a number of other activities, but that was the data provided from the state of Vermont to GAO. Some Medicaid graduate medical education funding in certain states is limited to primary care. Alabama, Montana, New Mexico, and South Dakota have made that decision within their Medicaid program to limit GME funding to primary care. So that is something that is available to states. Also, as we're saying, I think that with GME funding from Medicare, there is no requirement or limitation to how that funding is used based on the workforce needs of a particular region or as a nation as a whole. Other programs like what is done through the Department of Defense medical education programs, they actually look at their population, they look at their population of providers, they look at the need of their patient population, and they fund graduate education, medical education, based on what the need for certain provider types is. That is not how it's done in the GME program. Another program I want to mention is the National Health Service Corps. The National Health Service Corps is probably not particularly well known in Vermont. We do have a couple of federally qualified health centers with National Health Service Corps members serving at them. The way the National Health Service Corps works is you have a score based on the region of the country you live in. There's a bunch of stuff that goes into that score it has to do with how far you are from another provider. Your provider to patient ratio and the federal government determines your score, which is called a HIPSA or a Health Professional Shortage Area, and based on your score, which is as good as a zero, as bad as a 25 or 26, that qualifies you to leverage funding from the federal government through the National Health Service Corps. The location becomes an approved location and then an applicant can go work at that location. Right now, through FY19, funding for the National Health Service Corps was $319 million. That money has funded a small fraction of health professional shortage areas. So what it means is that there are a number of regions in the country and in Vermont who qualify under this program, but because Congress has provided insufficient funding, those regions aren't able to actually leverage a person to come work with them. So in Vermont right now, we have 16 sites that have a HIPSA score of 16 or higher, meaning we can actually leverage a person. I should note also that of those 16 HIPSA scores, all of them are for mental health. Every single one of those 16 where we qualify as in the greatest needs are in mental health. They're not in physical primary care and they're actually surprisingly not in dental care either, though we have an additional 44 locations that would qualify if Congress provided sufficient funding. So that is one place where from Senator Sanders' perspective, significant federal investment could make a real difference because we know that we have people who want to come work in those sites. I think we often hear a narrative that providers don't want to work in rural areas. Right now, according to the Association for the Clinicians for the Underserved, only 40% of loan repayment applicants have a place that if they are approved to go work. So there's another 60% of providers out there who have signed up and said, I want to be in the National Health Service Corps. I want to go work in a rural or underserved community and we have no place to put them, again because Congress has not provided sufficient funding. There is also a scholarship component to the National Health Service Corps and of those applicants, only 10% are placed. So there are people out there who want to work in these areas and we have the areas identified. So from the federal perspective, my boss believes, and I believe that this is a place for significant federal investment is needed. So with the work of Congress, this is actually something that I think the federal government can really help the state of Vermont to achieve. There is also the Public Health Service Corps, which is different from the National Health Service Corps, but can also help provide providers in certain underserved areas and certain provider types. I will just briefly mention, I think a lot of Senator Sanders' approach to this work is pretty well known. He obviously is the author of Medicare for All legislation in the U.S. Senate over the past number of years, which does define healthcare as a human right to all people. And as such, would allow for more people to access primary care. He also has worked to expand federally qualified health centers, the National Health Service Corps, which I just spoke about, and teaching health centers. All of these are focused on primary care to sort of get upstream at a lot of the critical challenges our specialty providers are seeing today. With support from Congress, we are working to greatly expand those programs, where it wants to double the number of patients you can be seeing at a federally qualified health center. He also supports, and I think this is important to mention in this discussion, is College for All. The Senator's College for All legislation in the Senate is focused on undergraduate education, but we believe that by making undergraduate education free at four-year public institutions, it does allow more people to enter and receive an undergraduate degree and go on without debt to pursue specialized education. We've also worked significantly through the Public Service Loan Forgiveness Program, which is in law. I was talking to Liz earlier. There's a lot of challenges with that program, but it's out there and it can work. And I would just do a little PSA plug for our casework team. The Senator employs five members of our staff in Vermont who's sole job it is to help Vermonters deal with the federal government. We wish they didn't need to do this work, but they do, and we can help people navigate the Public Service Loan Forgiveness Program. So to the legislators, to other people in this room, if you hear from constituents or Vermonters who are having challenges with that program, please send them away. We can do our best to help them. Lastly, before I conclude, and I really wanted to get at sort of the 40,000th federal perspective, but I can't help but just mention a couple words about Vermont and the policies that we have undertaken here in partnership with the federal government on our all-payer model, our ACO. I think as the chair mentioned in the beginning today, Vermont has really made a focused investment in primary care and mental health care in our state. I think this is a tremendous opportunity for Vermont to get on the front end. And I think one of the big challenges with our health care system now is that we are constantly chasing our tails and taking care of people. People wait until they get sick to see care. They wind up in the emergency department before they get care. And once they get care, the bills are higher, the needs are greater, the specialized medicine that is required is significantly greater if those people had from birth been able to see a primary care provider. So I think that if Vermont is really truly willing to make a generational change here, starting with our youngest Vermonters and ensuring that every single one of them can get into a primary care provider's office, be that a doctor, a nurse practitioner, a physician's assistant, and we care for those children from the beginning, we have a real opportunity to actually change not just the health of our people, but also the health care workforce that we need a generation from now. So I would just conclude by thanking the panel again for having me here today and also as a request back to you and back to those here. If you believe that there are federal hindrances to what you want to do or opportunities within changes to federal law or policy, I would welcome hearing those. I know the Senator would so that we can help bring the federal government to work for Vermont. Thank you. Thank you, Kat. Jesse. Thank you very much. Thank you to the board and the legislators who are here joining us this afternoon. I'm Jesse Barnard, the executive director of the Vermont Medical Society. We are the largest physician membership organization in the state and also PA, physician assistant members. We represent physicians of all specialties and practice locations, so not just primary care, though we're pleased to be talking about primary care and focusing on primary care today. I think a lot of the issues that all be focused on apply to all physicians and all clinicians, really. So I'd like to start, and I did submit slides that I'll generally be following along. I mean, at first to echo what Liz said, yes, we absolutely support physician loan repayment and scholarships funding to get physicians here in the state. We support increased AHEC loan repayment funding and also tax incentives for primary care professionals. And I'll also mention support for clinical preceptors. We know largely that is a voluntary position, but once we get students out in the community to learn what it's like to practice medicine, they learn that they may really love rural medicine or primary care. So whatever we can do to help support busy primary care practices who may be really struggling to fit that in on top of all their clinical responsibilities, we think that's really important. But actually, I'm not going to focus on those issues. They are really outlined in the white paper submitted by the Rural Health Care Task Force. We support all of the initiatives in that report. I'm going to focus a little bit on a different angle, which is how we can make Vermont the best state to practice primary care. And it nicely echoes what Liz has heard from some of the recruits who may be wanting to leave a site where they've been placed, so sometimes what's not going well. Because I think we can't, as a state, pay our way or buy our way out of the problem of why we are struggling to find primary care physicians. It has to be a better environment to practice as well. And I'm going to give a little credit. We had a speaker at our annual meeting in November from the American Medical Association, Mike Tuttey, who's their Vice President for Professional Satisfaction and Practice Sustainability. Really interesting blend of the factors that health physicians stay in medicine or have fine joy in the practice of medicine. So I'd encourage anyone to invite him as a speaker. It was fascinating. So I've adapted some of his slides for Vermont. But as we know nationally, a pretty high percentage of physicians report that they intend to reduce their work hours due to what we call burnout issues. Then we also have Vermont data. This is from the physician workforce survey that the Department of Health does that a 15% of primary care physicians report they're planning to retire or reduce their hours in Vermont within 12 months. So what can we do if we can't get new physicians as quickly as we want here in Vermont? If we're working on that through a number of other tools, how can we at least support our physicians staying in primary care or maybe putting off retirement another year or two so they can keep caring for the patients who they love to care for for a little bit longer? We know there are a lot of factors impacting lack of satisfaction in the practice of medicine. And one of the quotes that I really liked that Mike used was that physician burnout is a symptom of system dysfunction. I think one of the things physicians have been hearing is this would kind of become a buzzword in the practice of medicine burnout lately. And it's had a bit of backlash because it implies that it's a lack of skills or resilience in the physician him or herself. You're just burning out. You're not tough enough to make it through this. But I think the medical society perspective and the AMA perspective is that it's not a problem in the physician. It's the system we are creating in which that physician is practicing medicine. So the pace of work, EHR requirements, reimbursement levels, prior authorizations, all the administrative and paperwork burden that take a physician away from caring for a patient. And I'll mention this organization we're working with a little bit later called Luminose. But a quote from Luminose that I heard recently is that if you can spend 20% of your time doing what you love, that's about as much as it takes to really keep you happy in your practice. So if we can think about, can we make 20% of a physician's day really happy? I think that's achievable. It's not actually asking that much. And so that may be more time with our patients and maybe more time I'll talk a little bit later about other things that creates real connection and engagement in that physician's career. Again, I included some statistics. I won't go through all of these, but about the amount of time spent on EHR desk work each day. One of the slides I found particularly your data points kind of compelling is there's a chart of the amount, they did a time study of when physicians are logging into their EHRs to document their clinical catch up with patient records. And then you'll see there's this big kind of peak midday and then kind of a tail off at the end of the day during the work week, but then you'll see on Saturday night another spike. So physicians are logging back in and doing work in what they call date night time when the rest of us maybe reading a book, getting some exercise, watching a movie, they are having to log back in and catch up on people work. And that's not, we know, a sustainable way of practice. So what can we do to improve the practice environment? And another of the slides I stole from the AMA borrowed lays out that there are individual interventions, organizational interventions, and sales system interventions. So we need to work on these issues at all levels. It's not just one locus of change. And I've included the board asked for us to talk organizationally about what we're doing. So some of this is about what BMS is doing, but it's also about how we're trying to encourage physician practices hospitals, medical staffs around the state to look at these issues. So for the individual, we think about it, how can we help physicians find their passion and their peer group? So again, this passion being the 20, can we find something that in 20% of their time they just love what they're doing? And of course that's taking care of patients, but it may also be other ways of engaging, feeling like they have some voice in this health system, some way of making change, some way of improving their environment. So we've partnered with the Daniels Hanley Center for Health Leadership, a main based physician training organization to launch this year. We've just started as we call it our physician executive leadership institute. So we have a course. We have 19 physicians, one PA going through our first year of training in everything from systems change, quality improvement, communications skills. What are the non-patient touch skills that they didn't get in medical school but that might help them lead change within their organization or the state? So we think that a lot for a lot of physicians we work with being able to have the bigger picture of how can I improve my practice, how can I improve my hospital, how can I engage with the legislature, the Green Mountain Care Board feel like I'm having an impact on my practice environment. So we're offering training in that regard. We have been working in this organization, I mentioned Luminose. They've done a lot of work out of the state, actually in Colorado, but they are now partnering with us here in Vermont to present at medical staff around the state on tools for individual clinician wellbeing, how do you find that 20% of your life that gives you the most satisfaction. So if you are a clinician and you work in a hospital and would like a large practice and would like us to come and offer that presentation, we're doing that. We also think it's really important, there's been a general, I think, lessening of relationships between clinicians over time as it's become a movement towards hospitalist services and community-based positions. There's not as much opportunity for interaction and just pure collegiality, pure support, pure relationships. So we're going to be offering again through Luminose some regional gatherings just to learn about ways and models of connecting with your peers over the fall. And then we're also offering sort of an alumni group of this leadership course to keep those connections. This is the leadership course that we're offering. It has positions from all over the state, almost every location, almost every hospital has sort of contributed a participant to that course. So we think these relationships across the state are really important and we'll be wanting to continue that through an alumni group. So that's sort of on the more individuals in the physician level, but what can organizations do, so hospitals and practices, FQHCs? Again, we're having these presentations we're offering with Luminose and those are intended to give not just individual skills, but what can organizations do to improve their practice environment? And I've included some slides that kind of reflect some of that information that they're showing, what are steps to prevent burnout in your practice, doing things like surveys of the staff, what's working well, what isn't, starting wellness committees. Meeting to then look at, well, what's causing dissatisfaction and what as a practice can we do to address those issues? And then sharing practice redesign tools, and this is just as a sample. The American Medical Association has a steps forward program that offers a lot of modules. How can we do things like just looking at our workflow and our practice to minimize as much as possible administrative burden, paperwork burden, things like improving team documentation. Things as simple as looking at your steps through the office during the day. They give this example of, you know, there's one printer down the hall so every time you're printing something, you know, the lab summary, you're going to walk down the hall to go pick that piece of paper up. Well, for $50 these days or $100, you can get another printer in the exam room and that can actually save quite a bit of time. So every time you walk down the hall, it's not just walking down the hall, you're getting interrupted by the nurse in the MA and this person and that person. So how can you streamline the day or primary care clinicians? And then where VMS actually focuses a lot of our work is sort of the health care system. How can we make the system work better for physicians? And I gave some examples of not some items that are actually in the rural health care task force report and things that VMS have been working on for years and we hope to continue to move the needle. There are tough issues but just absolutely critical to wanting to practice primary care in Vermont. So again, building a system that pays for and recognizes primary care. We think the ACO is certainly a step in the right direction in that regard and continuing that work. Streamlining quality measures. How can we do more reporting through claims versus manual data submission? Aligning quality measures. Reducing prior authorization. The ACO as many of you in the room know as a prior authorization pilot. Can we expand that? Can we grow that? And can we hold payers responsible for expanding their Gold Card programs which are if you get a certain number of your prior operations approved each year can you sort of get past and have to continue to do that? We've had some positive conversations. We'd love to see that come to fruition. And then we as an organization partner with the AMA and a number of federal initiatives that may be beyond the scope of what we can address here in Vermont. They're also causing big burdens on physicians. So EHR issues. MAPRA admits kind of paid for quality programs which are very expensive to comply with and difficult to comply with and other federal people work production initiatives. So again, thank you. It's a little bit of a different perspective. But again, I think just improving the practice environment is critical to keeping our workforce here in the state. Thank you, Jess and Helen. So I'm Helen Layden. I'm the health policy director for Vermont, the Bi-Safe Primary Care Association. We represent a range of primary care organizations many of whom are federally qualified health centers and a lot of what I say today are based on the FQHC work. And more specifically the work of my colleague Stephanie Haluca who runs the Reforcing Children's Center for Bi-Safe. She is sorry, she was unable to be here today. I am filling in for her and we'll be carefully following my notes from her. I would just say from my own background, my background has been rural economic development. I have a lot to say about dairy pricing systems. That's my core working landscape type background. I do find it interesting, healthcare providers are the major employers of our rural landscape when you actually look at the numbers. So myself and Bi-Safe would have a lot to say about integrating this into the broader rural economic development conversation. Looking at the range of skill levels and skill sets involved the grow your own talent pipeline that can go into these healthcare providers. That being said, I'm speaking for the recruitment center so I'll be talking about recruitment, not all that other stuff. But it's not for lack of also caring about that. So the Bi-Safe Recruitment Center has been in New Hampshire since 1994 and in Vermont since 2003. We work with primary care practices in medically underserved areas. Not only the FQHDs, we also work with eight small hospitals and handful of independent practices as well. And we are working to recruit primary care providers in a range of different positions into our two states. So we currently have 71 vacancies that we're helping recruit for. And the largest group is family physicians but also pediatrics, physician assistants, psychiatrists, other mental health at a bachelor's or master's degree and dentists and the big changes from month to month. And we feel pretty urgent about this. Everyone has said they weren't going to focus on the problem and neither will I but there are fewer primary care folks entering primary care and more folks interested in retirees. We all know how that math works out. We focus less on convincing people to go into primary care and more on convincing them to come to Vermont and to rural Vermont in particular. So what that looks like is we go to conferences with students who are already interested in primary care or perhaps those who have completed their training and are trying to decide where to locate and we work with them on finding a good match for our communities and for our practices in Vermont. We work with the organizations who are doing the hiring into integrating retention plans from the very beginning and a retention plan is not just your salary negotiation, right? We're looking at the strong fit for the community and often that's a lifestyle question. If you don't like the outdoors or crappy weather, maybe there are areas in Vermont you're not going to be happy in, right? And it's also job structured questions like whether people are working at the top of their license, how to balance time with patients and time with paperwork, something you will hear a lot about probably from every single person. Opportunities for education and skill development and the question of do you feel supported in that skill development? One thing that we are looking at more, for example, is whether telehealth connections can help you feel supported, which we have evidence it does. So it doesn't necessarily mean just in that practice but a modernization of practices to take advantage of all the resources available to them to help those folks feel supported. Just to set up, many of the things that Stephanie would have said about practice transformation, and I'll just skip over all of those and save you time, but I will say that the immediate culture of the organization where someone is working is obviously really important but so is the culture of doing health care in Vermont. So are we doing progressive things around health care, around health care access, things like an all care model in ACO, for example? And does that then work its way into providers to feel like they're part of that innovation, they're probably on the front lines of doing this reform work? And for FQHCs, that's particularly important because when you have that designation, there's just a crushing magnitude of federal bureaucracy that then comes down upon you when you have that designation, which is great because everyone's making sure that they're providing access to care the way they should be, but we really need an avenue towards flexibility and innovation so that people feel invested in the future and in the future of health care. And our broad reform programs like ACO as a way to help people have that investment and feel like their powers are looking bigger and making a real difference. I should say that by state now, I'm going to read Stephanie's numbers. Advice, it has been successful in making these connections. In a 20 year retention study of by state recruit providers, 66% were still working in the region where they originally arrived, 26% of them in the exact same location. Often many of them for more than 15 years, which I personally find hard to imagine in the same place for 15 years, and many of them applying to work there their entire career. And we're having this success in retention partially by giving ourselves a particular problem statement. We're not trying to solve all of the health care work for shortage in primary care. We're recruiting people who are already interested in primary care to communities where we think they are a good match. And then we're helping those provider organizations bring on these new employees in a way that leads to strong retention rates. So we really define for ourselves what it is that we are solving. And we can get pretty creative within that lane. So for example in New Hampshire we are helping expand a fellowship program for psychiatric nurse practitioners that for their first year of employment has a mentorship system and a continuing education and a fellowship for them. We also have worked in New Hampshire around supporting local organizations in how they recruit for substance use disorder treatments to try and get away from the I'm going to steal from the next town over phenomenon that happens being how they work for shortage. So we do get fairly creative. I should say many of the examples are from New Hampshire because New Hampshire pays us to do that. We get grants from the state of New Hampshire so many of them are on the other side of the river. Being able to have this focus and this specialty and set our own problem statement really relies on a broad network of other supports being in place. So although we may not be working ourselves with low maintenance or scholarships we certainly support those. Also the idea of and getting back to the opening statement around the larger world of rural economic development how is Vermont marketing itself as a place to come and work. To this point about calling it a crisis and having one less working primary care that may not be helpful from a marketing perspective and are we building a positive story about the progressive and wonderful things we're doing with access to care in Vermont and how people want to be a part of that. So with that we appreciate participating in conversations like this one like the primary care advisory group like the rural health services task force and we think that those ongoing conversations are really important to moving forward. Thank you. Thank you. John. I don't have any slides. I would say I would prefer everybody here to Dr. Holman's piece in the ground board reformer. She's much more eloquent than I and stated the issues quite well I thought. I think it made it to the Robert Carroll team. I can dig her head. I didn't make it to the mountain village or the Jericho. But I do think it was excellent. I would start by one thing having done this I've been at the top student health care in Wilson since 1978 so this is my 42nd year. And I think you have to stress and those they may not understand that the patients we take care of as outpatients now are far, far sicker than they were not only 40 years ago even 10 years ago or 20 years ago. Monday I was a busy day because the patients coming out of the hospital we now have transition visits we must do it a certain time. And they're all fine patients but out of those 22 patients they've been dead 10 years ago. I think it's important to realize how much sicker and how much more difficult outpatient primary care now is than it was even 10 or 15 years ago. Hospitalists have helped in many ways I certainly belong in your career I was one of the ones that was in having to have a hospitalist but it does make sense and the retrospective is the right thing to do. But the patients coming out of the hospital are so much sicker the patients we keep alive and stay out of the hospital are so much sicker that the job is harder than it used to be. I do reflect more I've done a lot of these committees but I reflect the end of trenches point of view and not the 40,000 foot point of view and I agree it would be nice to have more people in the trenches trying to help to the 40,000 foot but if you're in the trenches you don't have any interest or time to do that stuff it's really hard but I think that would be helpful I would point out as Dr. Holman's article mentions the three big problems they have to face it, it's reimbursement and I was in a big committee with Kevin Kelly who used to be the director of the FJHC and more so I think and the big problem of getting people who are in primary care just to remove the burden of reimbursement is we now compete with hospital ERs and hospitals and we have more hours more responsibilities and many more forms to fill out at 20, 30 or 40% less reimbursement and we don't want to just focus on money as it was mentioned earlier but that's a very real thing the second thing I was mentioning is the non-reimbursed bureaucratic administrative overhead imposed by all the programs are a big issue for people not going into or leaving primary care and for whatever programs come about in the future they shouldn't be tied with more of that I would say we've had innumerable programs our practices, I don't know if it's a large or small practice but one of the larger group practices independent group practices in the state and we feel we're large enough to take advantage of a large program but small enough to be minimal to it, reactively but virtually all the programs that have been proposed or implemented in my 40 years have added to reimbursement in a primary care office a little bit and added to the bureaucratic and administrative overhead a lot and we have to make sure whatever comes down the road doesn't do that because it's one of the things that's wearing people out and the first thing this may be with the denominator as those going into primary care and not the denominator as all students but loan repayment is a big deal in our practice as an independent primary care we don't qualify for the PSLFP or the and even in Chittenden County the loan repayment plan as opposed to the rural parts of the state is a difficult thing to overcome for those going into primary care I would agree I don't want to be burning that somebody else is sending a warrant but I think we are at a asymptotically approaching a crisis it's really difficult to recruit primary care physicians especially PAs and nurse practitioners to a lesser extent and even in Chittenden County supposedly people want to do it is a challenge for the law and law I agree Dr. Bromsted has said for 5 or 10 years in meetings that well 5 or 10 years primary care would be in the driver's seat but we have to get to that 5 or 10 years without everybody being gone and I think we have to look at it sooner than that I would say I was going to raise it on the farm so I can't believe this out I don't get my time up here very often so I would say trying to figure out the milk price is a lot in a long ways analogous to trying to figure out what you are going to get paid for by primary care because it is nebulous and impossible we have I don't know if we will ever get a single payer but our office has 80 different insurance companies that we bill through and that increases a lot of overhead and makes it a lot more difficult I do think I don't know if the ACO and I am not sure I am supposed to talk about this up here but I don't want to add up for questions again I am on the AC Board and I am in the trenches and our practice does participate in a presentation like pilot with the ACO which has been beneficial to our office without too much induced overhead data reporting mainly because we were reporting all that data before for everybody and that has been beneficial for our practice now we are one of only four or five practices doing it and I would say that the reason we entered this was that before years ago the worst thing that can happen in primary care is if you don't try something new and notwithstanding all the bigger articles and what you all have to figure out in the trenches from my point of view from our practice's point of view that small portion of the ACO called the CPR how do you like that of all things that we are on CPR comprehensive pain has a comprehensive pain of reform or cardiopulmonary resuscitation I don't know but it has been beneficial I don't know if it will stay I worry that we are going to be in the wrong but I have a concern that CMS will give me a five year trial if you try a thing like this in medicine five years you are going to have to do it longer to see if it really does work and I think there is value just as there is in any drug trials it's a value to try a drug and find out it doesn't work at least know that so if you try a payment reform it doesn't work you won't even try something else if you have questions about that I'm happy to answer that I do think we are at a crossroads in primary care and I think it can't be a solution that takes 10 years because my age and people my age aren't going to be here in Cyprus so good luck thank you for those words I didn't offer any plans did I Krista oh my gosh good afternoon and thank you to the board we represent the learner college of medicine as well as the university of Vermont Medical Center in today's conversation and thank you to all those in attendance as well as our panelists many if not all of them who are very involved in our medical education program and or collaborate with us on many initiatives a little bit of background I have served in the interim role as senior associate dean for medical education for the past year however I've been involved in medical education for about 20 years I'm also a Vermonter who grew up in a very rural community north hero Vermont and then chose to attend medical school in Vermont selected a primary care specialty in pediatrics and then chose to return to Vermont to practice I also did participate in a loan repayment program and that was incredibly helpful to me I think that we're pretty fortunate to have a medical school in the state of Vermont we're a pretty small rural state we were established in 1822 and we are currently the 7th oldest medical school in the country which currently has 152 medical schools and I do think that we attract a lot of our monitors as well as those interested in the outdoors as well as many who are interested in primary care we're a public medical school however we have limited state appropriations and we certainly have increased our enrollment in recent years to try and address not only the Vermont shortage but the national shortage in physicians most recently I'm new to my position we also have a new dean Dean Rick Page who joined us in October of 2018 and we were sitting at enrollment 120 medical students per year and we made a decision to increase we had close conversations with our fire marshal because we are limited in space capacity however we were able to increase an additional four and so now we enroll 124 medical students without any additional state appropriations Dean Page and I made the decision to increase out of those four new enrollments to have two of those be the monitors so we have 124 students enrolled and we have 30 that are Vermonters I would like people to know that previously we enrolled 36 Vermonters however the state wanted to kind of take a new direction and so we have to reduce down to 28 Vermonters again keep in mind we just went back up by 2 to 30 and the state chose to invest in a longitudinal integrated clerkship which we are currently running both at a federally qualified health center in Hudson Headwaters Health Network as well as this year adding one at Central Vermont Medical Center and that type of clinical training really can introduce students to primary care you're paired with a primary care physician and really follow your panel of patient sorry two different medical experiences that they may encounter however that's a pretty resource heavy way of training one of our recent applicants said help them everyone as they were training they were longitudinal integrated clerkship and you're pairing a student with one provider so it's pretty resource heavy a great opportunity but limited number of students that you can put through that type of curriculum you know as a medical school we have lots of data both on students matriculating and on students graduating and we consistently see that about a third of our matriculating students and then still at graduation are interested in practicing primary care I'll make sure to clarify that when we say primary care we do include family medicine internal medicine, pediatrics and in most cases obstetrics and gynecology is included in that and you know we've been pretty consistent in the percentage of graduates who enter primary care residency so over the last four years we've been at 41% of our graduates enter primary care now it's important I think to sometimes pull family medicine out of bed and so because again you're including other specialties so we're pretty consistent at 10-15% of our graduates entering family medicine residencies and I'll add that we can look at data from matriculating students interested in family medicine and then those who end up graduating and entering residency program in family medicine and in our curriculum our students interested in family medicine actually increases as they're going through the curriculum that's a testament to our providers that are working with our students in those clinical experiences I do appreciate that certainly I think competitiveness of the specialty and income expectations and level of education that do influence medical student graduates and the decisions they make and you've heard Liz Coady talk about national data we also have learner college of medicine specific data and we're pretty encouraged that our students actually find other factors that influence more of them than those things and actually they are a level of education debt decreases having that influence their decision decreases as they move through the curriculum and is pretty low less than 20% you know certainly debt is a national issue education debt is a problem and medical school education debt is a significant problem but the learner college of medicine fully supports President Peramella from the university's decision to freeze tuition so we're participating in that as well and my area of expertise is more around education for medical students but we closely collaborate with our colleagues in the graduate medical education program and so some additional information from there is that we do know that 33% of Vermont physicians currently and 41% of the primary care physicians in Vermont either educated or trained at the learner college of medicine for the UVM Medical Center so the medical center has 17 residency programs that includes one dental program and many of those dental residents actually stay and look to practice in Vermont and 25 fellowship programs so there's currently 275 residents and fellows and 80% or residents and 20% fellows and 49% of the resident graduates are in primary care again how we define that in obstetrics however the medical center now exceeds its federal cap for residency training positions and so that's a challenge to consider increasing the number of residency programs so you know I think we need to look at a couple of different areas certainly the learner college of medicine we'd be happy to consider increasing the number of our monitors however we need additional state appropriations and other areas of support for that additional scholarship funding I think would be incredibly important increased ability to train medical students in those primary care areas or longitudinal integrated workshops and increased graduate medical education opportunities so we remain committed to working with our colleagues and partners to identifying creative solutions and I just encourage people to keep in mind I think Helen referred to this too working with individuals who have already made a decision or commitment to primary care is I think important to consider I have worked with medical students for many years and trying to recruit them before they've had any exposure to the different clinical opportunities does from the risk of sort of boxing someone into a career when I work with my students I say it's really really important that you're passionate about what you pursue because that will allow you to be the most successful so I don't want us to create any programs or solutions that might encourage people to do primary care before they really had a chance to appreciate and become passionate about that so thank you thank you Kathleen thank you for the opportunity I'm Kathleen Marl I'm the chair of medicine at across the river at geisel school medicine at darden-hitchcock medical center and I'm going to try hard to say only new things and nothing that repeating a lot of what's already been said so forgive me if I'm jumping around a little bit but I want to start with telling my personal story because it's relevant I grew up I was born and raised in Washington DC New York City I was not a rural kid nor what I've ever been someone identified as someone who's going to spend her entire medical career as a family physician and where they're moving to which is who I am and so I just want to underscore that morality and origins of rural birth are key component to making physicians for rural areas but not the only one and at Dartmouth-Hitchcock and at geisel school medicine a lot of our focus is in identifying early in training physicians with a passion for making a difference for caring about change in the healthcare system and then the care and perpetual feeding of them and I can assure you that that is a very full time ongoing work that requires commitment from a lot of people and faculty because the tertiary care training environment is not conducive to producing primary care physicians who will work in rural and underserved areas I did my training at UVM and I credit UVM enormously with my 30 years of work in only rural practice in Northern New England I spent about 18 years of that in Maine and the last 10 years that have been at Dartmouth and UVM had a culture and an environment that was positive and supportive about family medicine I can't say that as strongly about geisel school medicine or Dartmouth-Hitchcock Medical Center and I can say with some clarity that both environments our tertiary care academic medical centers and they are largely structured funded and designed to train specialists so you're going to hear my emphasis is on how we care and feed medical students who come in idealistic and interested and committed to the kind of work that we're all talking about today that we need more folks doing and then also very importantly the under residency development in both of our two states so let me just start with I was asked to talk about what guys in the Dartmouth do we have all kinds of enrichment programs at the Geisel School of Medicine for early identification of medical students UVM has very similar ones family medicine interest group, rural health scholars migrant health scholars med student for a day we have all kinds of programs that are designed to help us identify who's interested in the beginning and then we try very hard to maintain those medical students interests throughout their exposure to the clinical work that they would be doing largely inside academic medical centers so my I can't say it strongly enough the placement of students in rural communities with one-on-one or two-on-one relationships with rural-based family physicians is really really critical to development the physician sitting next to me probably has had more influence on turning guys old medical students into family doctors than just about anybody else in our on our faculty the power of an individual relationship early train cannot I cannot underscore it enough and then the second big issue that's a real issue so main has four family medicine residencies we're talking about three states that have roughly the same populations made in New Hampshire a lot smaller but proportionally speaking number of family medicine residencies and I'm speaking very firmly about family med residencies because despite UVM and guys will both liking to talk about how many physicians they produce in primary care the cold hard reality is if you want to have physicians who will work in rural and underserved communities really have to train family physicians internal medicine has many primary care tracks but the vast majority of people who go into internal medicine residencies 85 or better percent go into subspecialty medicine so they become cardiologists and pathologists and rheumatologists so if you're focusing your limited resources which I would argue all of us are in training physicians who really will work in rural and underserved communities then you really have to focus your resources on family medicine and that's something I spend a lot of my days at Geiselman and Dartmouth Hitchcock helping the administrations and executives of those institutions understand and help focus on resource allocation to develop further residency training programs so Vermont currently only has one family medicine training program well actually it's not true it's just one one ahead which is great because that's another underserved region and New Hampshire only has one in Concord the Concord family medicine residency program Maine has four so proportionally there are four times the number of residents coming out of being produced in family medicine in Maine as there are in Vermont and New Hampshire the great deal of my work at the moment is developing a new family medicine residency program in Cheshire Medical Center which is in New Hampshire part of the Dartmouth Hitchcock system and we are also working alongside your partners at Southwestern Vermont and helping them with the development very early development both of these residencies are probably a couple of years at least in the future but helping them with their development of a residency training program this is a really critical component of developing physicians who will train in your state and therefore stay in your state the national data is pretty strong that somewhere between 55 and 65% of residents stay where they train in their residency program and there are many exceptions just close with telling you one story about that so at Geisel we produce we're small we have 90 students a year as you know we're an Ivy League school with a very large competitive pool of students from all over the country and all over the world there is no emphasis on primary care training or primary care interest in terms of admissions and yet for the last five years the chair of admissions has been a family doc and obviously he's had a lot of influence I can't say that he's been able to turn admissions around at Dartmouth overnight but he's had some influence we see a lot of those 90 kids come in with genuine interest in primary care and then the course the nature of the culture of the training the way the training proceeds tends to reduce that interest incrementally and with all due respect to the people who told you data about money not mattering money matters and money matters a lot and it matters more and more and more so I'm going to end by telling you about Rachel and Chris LaRocca Chris LaRocca was our chair of admissions for the last five years a family doc who's just ending 30 years of practice in law in New Hampshire his daughter went to Geisel School of Medicine left the state to go to her residency training out west and I'm going to tell you that the majority of our residents our fourth year medical students go into family medicine go out west for their training and I've gotten over that because there tends to be more positive environments for residency training out west family medicine is seen as the primary care specialty out west in a more robust way so many of our students go but then the wonderful thing about Northern New England is people want to come back and I hand we all have have hand-hold those students through their residencies and then recruit them back and we've been quite successful in doing that Rachel just returned she looked very hard all over New Hampshire at many multiple sites that wanted to recruit her she ended up at which is part of the Scutney Health Center and when I said to her in the end what was important she listed a number of those factors and in the end she said the best loan and payment was at odd period and if you're a kid from a working family your dad is a family doc but remember family docs are paid about of half to a third of what all the other specialties are paid and a mom's a school teacher so she was fully indebted through her training you know the data the average medical student the average medical student comes out with $196,000 of debt if you're a private school student you come out with substantially more than that if you're a state school student you might come out with a little bit less than that but that debt's real and if you look at the starting salary coming out of residency training of $180,000 which is what family docs get offered as compared to $450,000 to $500,000 which is what a great deal of the other specialties get offered I mean do the math it's a big deal and students idealistic want to make a difference really committed to their work have to take that into consideration particularly as the economies of the healthcare system get more complex and the uncertainties so please don't underscore the importance of money in this whole conversation thanks thank you I know where to start because we've covered so many things but we spoke this morning several of us in front of the legislature and what we were trying to do was focus on solutions there are just a couple of statistics that I think are worth seeing about the problem before I talk about solutions right now in Vermont there's a need for 70 primary care providers that is really an unachievable number from a recruiting standpoint we have one of the offices in our federally qualified health center has been recruiting for six years for a primary care position so 70 is a huge number just to reinforce how much worse that number is going to get over the next few years 36% of the primary care workforce is over the age of 60 so if you look at the next five to ten years this does get really does get critical so trying to focus on strategies on real things that we can do that would make a difference I think the selection of students from medical school is critical there's all kinds of data on how to zero in on students who are likely to stay in primary care some of that has to do with their backgrounds being less advantaged sometimes rural background but some of that also has to do with non-traditional students people who have worked in a non-medical field before entering med school there's no reason we can't hand select students for our medical school to meet the needs of our state there's only on the scholarship repayment not being critical intuition low repayment and intuition waiver is not being critical it doesn't square with what I hear in my practice we teach students from both Dartmouth and UBM over and over again I hear students who say I love this experience this is what I want to do but I can't do it and I have met several students when you get your undergraduate and your medical school together 400,000 there's really not a valid choice to go into primary care if you're carrying that kind of debt the training issue the residency issue is a huge one just to reiterate I think Kathy and I had an inclination to talk about family physicians because 92% of family doctors who are trained to stay in primary care and maternal medicine are primary care specialties but you lose about 50% of those to specializing in pediatrics and as Kathy said about 85% of interest in specializing so we do need to train more residents in our state Vermont has the fewest number we're going to talk about this number I can tell already but Vermont has six residency slots per year in family medicine there are some across the lake but in Vermont six slots per year in medicine that's 18 total because it's a three year residency we have somewhere around 300 residents in this state we're not doing enough UVM Medical Center has the power to shift some of those residency positions from specialty care into primary care it will change business as usual it won't be easy to implement but it really needs to happen residents who people who breath in residency tend to stay where they're trained and we can do better on that we can start new ones as Kathy was talking about and also shift the ones at the Medical Center continuing support for over repayment I think is critical early exposure to family medicine I think is critical by and large for the one we teach University of Vermont students that's mostly a volunteer position that we become the community do for the last maybe 10 years or so paying a stipend for teaching and there is a a small stipend for medical education credits for education credits from University of Vermont but valuing the primary care physicians who aren't teaching in their offices in some way I think is very important we talked about decreasing administrative burden I know everyone's heard a lot about that in primary care but I think that is also critical tax credits to help people who are trained elsewhere to move into the state I think are worth thinking about there are a number of states who have that sort of legislation to help offset the cost of your loans if you choose to move to Vermont I understand there's been a program in Vermont to pay people to move to the state let's dust that off and make it specific for a workforce that we desperately need here and then finally I guess I'd like to expand a little on the whole concept of culture change around primary care this is nebulous it's not as actionable with some of the things I just listed but nobody ever told me when I was in training that family medicine was a fantastic career I knew it appealed to me because there was a lot going on and you could use I knew it was going to be intellectually stimulating but nobody told me that I was going to love it more and more as time went on because of the longer I knew patients the more I connected with them and the more important that my role within was we often got the message that family medicine and primary care was where people who can't get into specialty residencies go I taught a medical student recently who was told by her advisor why would you want to go into family medicine when you can specialize then you know everything you need to know about your field if you go into family medicine you're going to not know you're accepting not knowing everything about your field so the messaging and the culture I teach students from both medical schools and I think there is a different way to talk about primary care that lets people know that this is a phenomenally powerful and rewarding and keeps you interested for your whole career that I didn't really appreciate that when I got started so finally I guess I'll just close by saying that healthcare reform is complicated and there's a lot that's not in our control in Vermont I don't think we're going to in Vermont dismantle the medical industrial complex although it would be fun but some of the things that we've talked that we've talked about today really are actionable items if we're really looking for decreasing costs in healthcare there's no particular way to do that without a robust primary care workforce if we want to ensure universal access to primary care there's no road forward for that without a robust primary care workforce and healthcare reform in general I think is not possible without really addressing this problem from as many angles as possible thank you trying to figure out how to follow everybody everything has been said essentially and I think that this morning I started out talking with the committee about some of the things that rural primary care doctors do that other people might not know they do so I think about primary care and one of the reasons that it just adds to what they just said is that you know my patients who live in a small town in Eden or Lowell really don't have the time, money or gas to get to Burlington to get those specialists they really want if possible for us to take care of everything there if possible they'd like us to take care of it on the phone because that's even cheaper but money does matter to our patients we have to go back to kind of why are we doing this we're doing this because our patients need a doctor they need the doctor to be close and they need the doctor to be competent and comprehensive so you know for anyone in the room that wasn't there this morning and I don't think people know that the only doctors and again we're kind of biased but everything from full spectrum gynecologic care contraceptive management IEP placement joint injections SI joints we do all kinds of obviously full spectrum pediatric care I round on the newborns at our nursery where I'm supposed to be right now we have to cop with it because we don't have a pediatrician on staff so there's a couple family doctors and we all take a week at a time we are the pediatricians for the hospital we take care of all the patients at the man or the nursing home we do house calls still and if patients come in on a Saturday they have pain or symptoms of appendicitis or meningitis we get from where they go right away so it's really full spectrum care and it's exciting and so it continues to puzzle me you know when we go back to all these things and we say why is this the lowest paid field why is it that my specialist partners across the road are making five times what I make and I guess I would agree that that does matter to potential med students I also agree that the experience of medical students having us in the office does sheet them and does hopefully guide them and if nothing else when they go into a specialty they understand what we can do and who to talk to and how to refer back to us often times I really like the specialist that I can refer to and have the patients come back especially endocrinologists it's really nice I want to take care of our people so if I was to think of some things outside the box that just might be worth talking about one of the things that Ken is a medical student I'm working with who's sitting right next to his president it's kind of cool and I've talked about it's like board scores for example why are board scores not pass fail there's this hidden curriculum that really influences the culture if you have a high board score you get to go into one specialty if you have a low board score that should be pass fail that does influence culture I don't know if that's a hot topic yes it got us excited over it so there it goes start the conversation you know the scholarship idea I don't want to box anybody and I don't want them to fail in medicine but if somebody wants to do it and they decide that in their second or third year let's figure out a way to help them pay for it so that we can get them on the ground we can design a different system and that's a scholarship because we're asking people to pay a lot of money and 45-55% of whom are female when they graduate they're probably going to plan a family that decreases their FTE it's still the same number of loans as everyone else but they're paying it off slower to make enough money so figuring out how to both narrow the pay gap and provide some financial help to get to the point where we have people on the ground I think some of the other things that just I like the idea of another residency in Vermont and CVH came to mind pretty good size hospital it's part of the UKM network and the other two I may also stir the pot a little bit which would be what about transparency of rates if I do a skin biopsy in my office and DERM does one in their office it has a different cost I think if it was transparent across the board with the quality of insurance it would be different amount for everything patients might understand that going to the primary care cost less and we'd start to use capitalism to our advantage and then finally primary care for all you know patients if going to primary care dot was free again incentivizing wellness exams but also the sprained ankle the sprained wrist doesn't need to go to the ER orthopedics it could really come to the primary so we do just as good a job so you know I think that there are a lot of moving parts and a lot of solutions we have to think about both long and short term ones all do better not to use the word crisis but again we've got so many great people here I'll just close with one thing there was a Darden study a couple years ago that studied medical school medical students perceptions about primary care but there haven't been a lot of actual studies there's a lot of data but there's not necessarily a lot of studies among these lines and that could be done that really needs to be done so let's use evidence based medicine to fix medicine thank you before we start to toss out a couple of questions at the beginning of this afternoon we recognized Chairman Markott some members of this group I've seen a lot of other House members walk in maybe they could just stand and introduce themselves that would be great well I just a number of members of the House Health Care Committee are here shortly but Bill Lippert I'm the chair of the House Health Care Committee Kristi Moran, representative of Springfield Commerce and Economic Development Chairman Markott and I'm the vice chair of the House Health Care Committee Lori Houghton, the House Health Care Committee Reggie Nover David Derrick, also in the Health Care Committee Woody Page also on the Health Care Committee Peter Reed on the Health Care Committee Brian Cina from Burlington Health Care Committee Ann Marie Christensen Health Care Committee Charlie Kimball Woodstock on Commerce Lucy Rodgers-Waterhill Health Care Committee Emily Kornheiser from Rattleboro on Commerce Stephanie Jerome from Brandon Pittsburgh and Central Ann on Commerce Marie Cordes from Lincoln E.J. Merris and House Health Care Committee well thank you all so much and this is very gratifying I think to the people on the panel such an interest from what senators to try to and I will apologize to this because I'm probably the most frequent user of the term crisis because I truly believe that and I'll try to change that tone because I used to get upset whenever somebody was critical of Vermont's economic policies because I didn't think that sent a good message and I'll try to process that. I'm sure I will fail and use the term again because of the dire straits that we're in. I'll start out by throwing a couple of questions and then just to give the board a heads up I usually start with Robbins and I'm mixing them up. I'm going to start with Jess and go this way. Before I start, Catherine you talked about the number of states that focus GME dollars towards primary care what is the process? Who determines how GME dollars gets spent? So I'm going to have to get back to you with some of the details but this is to be clear specific to the Medicaid GME funding so that is determined it's my understanding by the state itself through their Medicaid plans. Medicare functions differently but I can give you the details on how each state has the four states that have made that decision I can give you the information on how to have made that decision to do so. Super. I appreciate that. And then my next question is for Catherine we heard from UVM that 30 per monitors are in the program are 30 per monitors in your program? Yeah, and I should have said something I meant to say was an issue none of us talked about is who do we accept into medical school in the first place and that's a really key issue I threw on had thrown on all your desks a copy of Dr. Scott Shipman's article and anybody who knows health affairs knows this is the December issue of this year the entire issue is devoted to rural health. Dr. Shipman is a pediatrician who's on the faculty but primarily works for the AAMC and he did this big national study on the declining morality of applicants to medical school it's really astonishing that we are now currently in this country only admitting 5% of our total medical school matriculous that's, you know, we admit about 16,000 medical students a year 5% are from rural areas and it's been a steady state decline for the last 15 years that's kind of stunning and we could spend a long time you know on and this article is really worth a quick to try and get it some understanding of that but more specifically you know Dartmouth is a, Geisel is a private medical school they have never felt that they had any compulsion as UVM happily does to make sure they admit students from its state having said that they have always had a policy of taking Maine, Vermont and New Hampshire students and keeping them in the last year of applicants and took 90 students so the odds are obviously not great but they have always taken the three in urban and rural states and put that group in a pool itself and there are always they don't have any quotas despite us working to try to get some but they have always every year there's a couple of kids from Maine and a couple of kids from Vermont so it's not a clear nothing like the quarter of your medical students who come from Vermont but certainly there is some attention at least to that issue of where you come from and what does that mean about where you might want to be practice long term. So just to continue on that same questions theme been a lifelong Vermont resident and for years the majority of the doctors and the community that I live actually grew up in that community and came back and yet for the last few decades we haven't seen any doctors who grew up in the community coming back is that a national trend? I think that if you look at this data I would have to say yes it is that given this finding morality of who is applying to and getting into medical school and we might really say that we have a responsibility to hold our medical schools nationally to task for this substantial change but there are innumerable factors including finances and debt and all these other issues that we've been discussing but the fundamental question I would have to say yes it is. Thank you. A couple of questions I don't want to take up too much time but I do want to ask a couple of you touched on it in your presentations but as we know Vermont is undergoing pretty significant payment through the all-hair model and as I think about it we've touched on this redirecting some money from hospitals to primary care there is efforts being made to pay for care management and some of that time that primary care providers are spending on the phone managing care there's resources now that are we've heard from primary care providers Dr. Haddock we've heard from you because of your participation in the model and application model you're able to hire a nurse that specializes in psychiatric care in your practice if I remember correctly from how earlier support the behavioral health and I'm just wondering and to some degree hire us or lessened through this model I'm wondering how can we leverage some of the innovative things that are happening in Vermont to attract more providers to the state you know I hear from providers that they want to get off the feet for sort of this treadmill that they don't want to be chasing volume all the time they want to be caring for their patients they want a payment structure that allows them to do so the old pair model is moving this day how do we reach out to providers in other states to say I want to get off the feet for this model I see what Vermont is doing please let me help how do we do that until we do that and that already needs done except for the recruiting efforts that are already being made I mean yes this is the short answer we are focusing on that part of the answer is that sometimes something seems super duper innovative and then you do it and you forget that enthusiasm and how innovative it was that you went there so now when we talk about the minutiae of the budget line by line for one care I do think we begin to lose track of how exciting it is that we have this model so part of it is simply having the talk in Vermont about the bigger goals while we are also dealing with the day-to-day of how do we implement this so that's partially simply a communications thing I know there is a long long list of how do we structure it this way and that way we can continue refining it and we will continue refining it forever but there is an element of an I am the prize conversation to have in Vermont about how exciting it is that we have this opportunity for federally qualified health centers there are some things that are more specific that matter more to us so we have a high percentage of our money is tied up in what the federal government allows us to do with it so the nexus of fire authorization waivers and telehealth option waivers there is just a whole bunch of stuff that structurally because we participate in this we now don't have to deal with it we can set up our practices differently because we can say oh yeah we have all these options they have to sit down with the CEOs of the organizations and say this is the new world that has now been opened up to you how do we restructure the practice to match this new payment world so there is certainly also one on one there but I think a lot of it is simply how do we have the conversation around this throughout Vermont and then we are very good at bragging so we can just take that ball in front of it we are good at bragging but as part of the local conversation there is a great question and I want to address a couple of thoughts that brought up for me part of it is that I think it is really challenging to complete that messaging while we are still in transition because I think right now for practices it is actually harder or at least as hard because some of your world is maybe capitated and simplified but who heard Joe say he still has 80 payers he is dealing with a lot of the day to day maybe changing for some patients but not all and until that we continue that transition let's stick with this and really see how it plays out it may not be easier yet but I think we should keep talking about the promise that capitated payments could bring especially in primary care so a little sensitive mention is publicly a piece I keep thinking about and keep talking to physicians about how they can translate it into how physicians are paid themselves because as clinicians are still paid in some systems on a largely what they call RVU by their work basis it may not again make their day to day life feel different the practice or the institution can be paying differently but if they are not changing their physician contracts to reflect that you are paid for keeping a panel of your patients well that you are paid based on how many visits you get in that day again their life may not feel different but as we are having these conversations let's keep pushing it so that it does translate into on the ground day to day difference I think it has a lot of promise to do so a couple of things I think the details are important and as was said here we are still 6-7% fee for service the hospital at the end has the same problem all the New York people are fee for service so it is really difficult to do a continuous a detail that I would say has been a real difficulty a real difficult problem for the capitated seeker algorithm is the feds screwed up pretty bad and in the first year for the first 6 months they paid us fee for service and capitation and then they charged us interest to hand back or recoup it in some other way so it has been a very difficult system to watch closely I am a numbers person I am not a business person but I am a numbers person and it is hard to get the numbers right I think that hurt us the first 2 years and hopefully they won't do that this year the other thing I would say is the capitated system at least in primary care is not for everybody it depends on your practice you may have a practice demographic where patients are seen 6 or 7 times a year instead of 3 or 4 so the capitation system as it now exists may not fit well for that problem or a style of practice so I think we are in a test time to see if it works or not for some and I think we are limited to know how well it works Medicare is proof of that but also it will take a while to see how to adjust it so it fits for more practices and work like ours is not evil this thing but that is the thing I see the problem I appreciate that and I think we are very cognizant of the need to achieve scale before we can actually make any assessment of whether this is we are really seeing a delivery system reform that we want to be able to see I remain on this one more at least immediately I can tell you that the blueprint for health resources that we use every minute of every day now are I don't think I can go without it and I think if we looked at the outcomes from that we have an in-house nutritionist behavioral health social work and a mat clinician in the building and so I can move to people that do a great job doing what they do and I know that Vermont at least if you were to look at using those mat clinicians as spokes you could look at from an advertising standpoint the data in terms of the reduction of death surrogates disorder using the primary care doc so I mean just but I don't think anybody is doing that advertising to talk about it and it is such an unusual system that the rest of the country is going to do what we need to do more advertising perhaps my second question is really this is my last question but I'm applying all the efforts to potentially grow our own by increasing residency potentially or helping to create costs through loan repayment those seem very long term or potentially medium run to long term solutions that you have to explore in the short run I heard from Dr. Holman 70 primary care physicians are needed right so this seems to be a short term concern and so I'm thinking one of the creative ways that we can think about attracting already trained providers my first question addresses a little bit of that but I'm wondering two ways that just occurred to me and occurred to me recently one is opportunity to attract foreign providers and whether that's been explored enough I know we've just recently renegotiated trade agreements with our neighboring bordering countries in Mexico you know are there special visa status that allows us to practically import workforce to you know sort of address the workforce shortage not prices shortage and you know what efforts are under way to think more globally about recruiting that was the first one and then the second version of that is sadly I think most of us who have been studying the rural health landscape in this country know that there are many communities out there that are recently decided in more and more to close their community hospitals last year alone there are 29 hospitals that were bankrupt and I think another 18 that closed there are there's a workforce associated with that those hospitals and those are individuals who are trained who also have chosen rural health care as their site and I'm just wondering not to take advantage of another community's unfortunate you know circumstances but at the same time these are displaced workers who are now looking for jobs and they've already chosen you know to work in a rural setting and I'm just wondering are we thinking differently about how to approach some of those communities or the piece of work in this community and buy them to come to Vermont and maybe pay them $7,000 as somebody said to come work in Vermont I don't think a lot of those with primary care provides they may not be I don't know you know that there's certainly nurses in those areas and maybe there's practitioners in those areas hospitalists I don't know I'm just wondering well it's some of it you know some of it does get back to have the state and guests in promoting itself broadly for workforce because all those people are going to they won't all have partners going with them but many of them will have partners going with them so you really can't divorce it from the overall statewide conversation around you know some of the advice they would love to do and I apologize to the agency of commerce and community development because I've not told them this yet but you know we would love to work with the state marketing organization to have any message can we share resources can we be a fully integrated part of the messaging around Vermont and Vermont is a great place to come to work so I think they're indirectly targeting those other earlier there's lots of ways that you can address it through that combination of outreach and I forget the first half of the question so someone else can answer that oh yeah well Mike I was going to say talk to Lou Bermanis but I was going to say talk to John Olson from the Department of Health I know he participated in the rural health task force and he was talking about this was actually something I learned maybe wrong I think it's the J1 visa there was a category of healthcare visas that healthcare workers that Vermont is apparently not taking advantage of the full number that we have so I think he has more information about why that may be I know something that the task force also talked about it was sort of a resource center or sharing of resources so that hospitals and other healthcare providers that are trying to hire such you know in particular positions or other healthcare providers can help navigating that process and it gets fairly complicated to get that through the pipeline and so what tools and assistance can be available that help that be a smoother path forward another thing mentioned on the task force is around looking at licensing requirements I think both for physicians and nurses other healthcare providers you know what possible without lowering obviously our you know standards to protect public could there be to simplify translating a degree from some other country to a degree or training in the US thank you so could I add a bit to that sure in our area we did some work on trying to get international grads and it proved pretty challenging most of them were willing to take a job when they could try to learn a more urban area but as soon as they found you know that they were completely out of their their universe for all of Vermont compared to where you know the places they were from which were by and large much more urban and it was just a stepping stone so it didn't work out too well with us but I think the idea of outreach to doctors where a hospital is closed is a fantastic one I had not thought about that but coaching them from elsewhere is not a bad idea we and the tax credit idea for low payment would be part of that but also and this might be something where maybe the Commerce Committee I'm not sure who's for you it is but outreach to people that are mountain physicians who are mountain bikers who are skiers who have a second home in Vermont you know people who are previously trained at UVM and really have that connection to Vermont already might be right candidates for that Thank you Lori First I think very much was really very informative and I think we really framed the challenges that we have really well and the solutions seem to be a lot tougher to come by particularly looking at the number of openings that there are it seems that the colleges when we talk about they're trying to almost funded to train specialists you know and so how do we how do we aid an advocate's favor recruit people who want to go into the family practices and then kind of shift the paradigm on the supply and demand where we're getting the funding at the colleges to be meddling schools to be pushing more towards family medicine and towards those residencies I don't know what the solutions are but you brought up a lot of issues and we don't have a lot of time to change that shift and I think when you talk about whether loan repayment or not money matters and you know I think part of it might be the expectations of people going into medical school do they think they're going to have a loan repayment you know so maybe it wasn't a top priority because they didn't really go in thinking they would get a repay and two you know we know we have far more specialists coming out than people in the family medicine so they may go in knowing I'm going to have a lot of debt but I'll be able to pay it off and I think there's you know it definitely matters and some of the choices that are made just a couple questions Catherine you brought up it sounded like almost 30 million dollars of money that was coming in from the Medicaid reimbursement and it was equating to like one FTE and so just trying to grasp that concept of you know if there really is a whole bunch of money coming in how does that get more towards whether it's primary care or family medicine where is that being used maybe I was just interpreting all the money that would seem to be coming into Vermont and how it's being utilized and how can we shift that to where the needs are so while I hate to punt because that is Medicaid funding obviously there's a federal match to that the determinations may be made by the state and so I would certainly encourage you to find that information I was honestly surprised when I read that in the GAO report and also curious as to how specifically those decisions are made but they are state level decisions one thing that came up the other thing that kind of came up that was culture and job satisfaction and getting people into family medicine and I don't know how you shift that but on the corporate world there's always a lot of different things going on to change the corporate culture to studies that are done and changes and it doesn't seem that on medical practice side there's that much change that goes in to do that and certainly with millennials coming up and different expectations there's a lot of work force that's going to become a bigger issue I don't know how you shift that either but job satisfaction is becoming a key thing for people to go into so doing the shift that is too so I just wanted to clarify because I didn't think it would come back I never said money did not matter but it matters less than we sometimes think it matters there are lots of things that matter that aren't getting attention that's kind of where I'm going with that but I knew my remarks might rankle some or be taken out of context but of course many matters but along these lines data tell us that of all of the countries that have the student graduates in 2019 about the 16,000 67% of them without any educational debt they may have encouraged that from medical school but they came into medical school without undergraduate debt that's a really interesting statistic because it tells us something about who is going into medical school tells us something about who's being admitted to medical school if we look at first generation college balanced students who have gotten an undergraduate degree that percentage in medical schools across the country is very small in Vermont we have a lot of first generation college balanced students making relief from college all the way to medical school is huge and we're not seeing big numbers there that's important that should tell us something about our strategies that's why I think we really need to back up this is the long term, the long range not the short range but the long range we need to look at what's happening in K-12 and what's being supported through their early education into college and then getting them into health profession training program so those are the things I think are important that are not getting the attention due I agree I don't think the long range program is necessarily what's going to drive people into this field of where I'm at money matters specialists versus in family medicine so that's obviously a big pearl and you guys have brought up a couple things why is there such a differential there but I think that just putting them on the payment program is it necessarily going to attract more without the different points if I may I want to piggyback off of something that Liz said that I think is really important and also stealing something that Katie said which is that who are we attracting to the field of medicine and to family medicine in particular there's really good health care research out there that shows that a lot of the clinical research we do is focused on the average white male practice decisions are also made that way and so when we have providers that look more like the patients they're serving we actually also get better patient care so I think that as we think about this discussion sort of that long range decision about who we're attracting to medicine it matters not just for the volume of care that can be provided but also for the quality of care that patients will receive Tom like Marina I want to thank you all for coming and discussing this and hopefully we'll have all of these discussions some of the staff will turn into syrup and we'll be able to solve these problems over time one of the issues I want to follow up on too I want to follow up on the 7th initial question about this $30 million when I first came on the board I spent some time and looking through the EM budget I saw that this $30 million isn't appropriated in the state and I'm sure it's appropriated by the legislature in order to make the match legitimate and the money I think goes to the Warner medical school so I was just wondering if Kristen knew anything about how this money was used there because looking through the appropriations information in the state budget I couldn't find out what it was used for but I'm sure I'm certain it's not $30 million for one FTV so there's more to this story and I'm just wondering if you have to know I would have to follow up on that for you and I don't have that information today but certainly happy to look into it but it is an issue for the legislature can I say because in New Hampshire there is no Medicaid money that comes through GME and so we have we have dug into this in great detail and I sit on the primary care workforce commission of the state of New Hampshire and so we've done into this issue quite a bit and the only I might shed here is I urge you to look hard at New Mexico because they're a national model for a state that took their state appropriated Medicaid money and put it all into they started five new family medicine residencies and rural parts of New Mexico precisely to address the issue it's quite remarkable when you look at the map of where they put them in these very remote parts of New Mexico in order to address specifically the shortage so that and I know in the past that state Medicaid money went to Dartmouth at one time this is long before my tenure there and it ultimately the state voted to stop appropriating it matching the Medicaid monies because they were ticked off rightly so I think fairly that Dartmouth was not doing anything with it to help support a development of a primary care workforce now it's more complicated than that and I don't want to oversimplify it but I do think this is you all picked up on it and I do think it's really worthy of pursuing how where is that money coming to and how is it being utilized and can it be shifted to help support something like new family medicine residency development which costs a couple million dollars I'll tell you being in deep in the midst of working to start one in New Hampshire they don't just make themselves overnight when you look at what Benedict has proposed the numbers are pretty staggering we begin to wonder if there isn't another way to try to get those doctors here that might be less expensive because it is so expensive to start that residency program My next question has to do with one here in the ACO I this is kind of like my broad thought that Vermont has more than 30 years of work struggling with healthcare reform going back to Ralph Wright Howard Heaton and Shull Rivers and the legislature in the early 90s for a single payer system and that kind of recycling again more recently and then you have the three market types and this work will solve our problems and I somehow feel that one here is in the middle of that the replacement it's the connective tissue that people are looking for to kind of connect the system that are making more efficient and help people get healthier but it's not the full panoply of government oversight and intervention I'm sensing from listening to all of you who spoke to about the ACO in one here that you're generally in favor of this experiment I mean it is a test it is an experiment that the federal government has made available to us I can follow the numbers of the ACO from a budget perspective and money is walking for the ACO out of the way from it it is growing in each of them and I'm not sure what that money is unfortunately so I'm just asking if my sense is correct that you folks generally feel who are on the front lines of health care in Vermont that one care in the ACO is a good place for us to go I think so I don't think anybody knows for sure I'm on the board I will say that the ACO budget for me is a nightmare and I'm sure you all look at more closely than I do I will say my involvement is that my goal is to have primary care and I admit that it's very provincial and small but it's my feeling that if we preserve primary care some method of health care reform may succeed so my goal looking at the ACO what does it do to preserve primary care now that may be too narrow but from my point of view and being in the middle of it I think it's worth a try I don't know if it will work but I think and I think five years is too short to find out and I'm sold, I don't have to be around when you find out anything but I think it's worth a try I would say there's a lot of paranoia and thoughts about Machiavellian goals and things like that my experience with them and I don't belong to UVM or anything else I applaud them here but my experience is the people running it firmly believe that this is the way to go and they're trying hard to do so whether they're right or not I don't know but the goals are correct and their intent is correct whether it works or not so I think it's worth a try from my point of view does anyone on the panel have a contrarian point of view? I don't want to be qualified as contrarian before and then pick up the mic this isn't really contrarian but we're outside the ACO so that it's from a distance it's very hard for me to imagine the money flowing through this entity that is so closely wedded to the tertiary care center and really having faith that primary care is going to be their goal and that they're going to be able to make the substantive changes that will need to be made at the tertiary care level in order for primary care to flourish I haven't negotiated with them I have never looked at a contract I don't know what any of it is about but just from the thousand foot view in the trenches in a town of 350 people in primary care it's hard for me to imagine a system where the money flows through the tertiary care center so I should say my dad is the vice chair of her board and we at the family dinner table play out the communications challenges and exactly what Dr. Hoeman has just described so I am paid to explain these things my father looks at me blankly so and that's part of the problem to what Dr. Haddock was saying is well I come from as I said an agricultural policy background and we talked about generational change and investing in things when you look at food and health you're changing things by generation to be asked to see turnarounds on a quarterly basis or one year basis is just anathema I can't even get my mind around that so giving providers on the ground and FQHCs the tools to build that bridge from generational change to what am I going to do tomorrow is a really challenging thing that we all need to work together to navigate and I've complained and asked about how the communications have worked but it's not just on one character it's on anyone entity to do it it's on all of us to have those really constructive and structured conversations to navigate this path forward and my final question is for Elizabeth I'm looking at your slide 17 which is your 2020 loan repayment program applications and I'm just wondering looking at the numbers here do you have any kind of senses who holds those loans and should we do who holds those loans and what the interest rates but is it usually there or are these interest rates from people that hold the loan that are being put by those who hold the loan so we do have that data I don't know it off the top of my head but many of these loans are federally subsidized loans and they are held by the direct student lender program at different servicing organizations all across the country we do verify educational debt so we have that information in our office we verify the amounts and we verify that their educational loan programs are not private loans or that sort of thing so we have a lot of data on this but there are some loans or some interest rates that are higher than others for sure there's some variability especially if they are private educational loans again I don't know those numbers off the top of my head if you can just get a summary of that I'd be interested in that certainly okay, Robin thank you all for spending the afternoon with us to talk about private care workforce as I think you all or most of you know I chaired the rural health services past summer and fall so I've been thinking a lot about the workforce issues across our entire health care system lately and I think I don't really have a question I wanted to just kind of pull out some themes that I felt like I heard from a number of you including the need for short medium and long term strategies we have some alarming statistics certainly in the primary care area with 70 vacancies in the nursing area it's 5,000 vacancies in 2020 so across our entire health care spectrum the vacancies are alarming quite frankly not to get into the crisis mode but you know we and we're not going to necessarily be able to solve that tomorrow so we need to be moving forward and planning in a thoughtful way Liz I was glad you mentioned strategic plan because there is a workforce strategic plan in 2013 that is in need of being updated that's an area that we have pushed on AHS about in the past and I think it might be time to do that again one of the recommendations in the rural health services task force was for the department of labor to prioritize health care workforce because they do have some prioritization among sectors and given sort of the magnitude of the problem I think the task force would love to see health care rise as a higher priority in the department of labor strategies and so I think I think that I'm really hopeful that we will see movement of the legislature this session across a number of different sectors on the workforce issues and areas and there is a lot of consensus among our community in general in terms of strategies for moving forward so I think that consensus will be helpful in terms of providing the legislature with areas that are meeting more actionable in a shorter period of time that's a few things I wanted to bring out thank you Robin so at this point we'll open it up to the public yes Deb could you bring me a piece of room I guess I have not for you I swear but you recognize you next Deb Richter I'm a family physician and a happy family physician actually in rural Vermont Cambridge people from elsewhere don't know where that is but we have again in independent practice we're not part of the ACO and I think one of the reasons oddly enough that we're very happy there is we have paper charts you know it's I spend two and a half hours a day charting calling patients back and I finish and I don't ever do things on the weekend unless I'm on call or I have to go in every you know every eight weeks on a Saturday so I think you know that we need to look at some of the factors that I feel that's really when I first went into medicine that was sort of the conditions of practice and I think one of the other things though I'm unhappy about is the fact that my patients do not have equal protection in terms of their coverage some of them have up to $12,000 deductibles which of course changes the way I'm able to care for them and we did a survey a few years ago where we looked at what would happen if we had a single payer in Vermont and we did a national survey and 200 doctors said they'd move here 60 of them were primary care if we had a single payer so let's do it on a smaller scale and make universal primary care including mental health and substance abuse services free for all Vermonters it's a small price tag for a huge benefit as we all have been saying this is the most important sector in care and it's as Katie Marvin was saying it's important that every patient be covered so I think we could attract if we said all of your patients are covered same coverage we could do risk-adjusted capitated payments reduce the amount of administrative burden and all that other stuff which would increase our productivity we could probably see more patients if we didn't have as much paperwork I can't help you guys who have electronic records I'm sorry and again I'm not against electronic records except we all know the real reason that we're having problems is the really more about maximizing reimbursement not about documenting what we're doing for our colleagues and for ourselves and our future visits the other reason I'm a happy doctor is because of the patients that I saw 20 years ago I tell them do you know what you weighed when you were two months old? they're now 20 I have it right here on this paper record and so the fact that I they've known me I mean now I'm dealing sadly enough some of them have now addiction problems I dealt with them I cared them when they were babies that continuity is what Faye was talking about is one of the reasons we love what we do is the relationship that we have with our patients I guess you did Faye I'm sorry that is another reason I'm a happy doctor and I think that's something that we need to again we can emphasize I again I would say H129 would give us universal primary care which I think would be a great recruiting tool to get people to want to practice in the state of Vermont simplify it and all our patients would be covered as far as a federal national thing we asked Senator Sanders to maybe introduce something we did a back of the napkin and what it would cost to fully fund medical education this was years ago four billion dollars sounds like a lot so let's do half of the students and say we're going to fully fund your medical education but you have to go into primary care and stay in primary care fully funded for two billion dollars that's chump change that's a rounding error in national terms that's nothing I mean we could maybe take some of Trump's wall that was what 2.7 billion and fully fund medical education half of the students thank you Jeff yes sir good afternoon I wanted to tell you about a bill that I introduced last session and it's H374 and that would cover five critical areas for shortages that we have in the state physicians, assistants, nurses teachers and the way the bill would work essentially is what I call two for one for every year of medical school or nursing school that the state would cover we would get a two year commitment so theoretically for nurses and teachers we get 12 years and the belief is that after those 12 years we've worked I'm confident that those folks are going to settle down become property taxpayers payroll taxpayers by homes and become Vermonters which is what the governor has talked about in his inaugural address we need people we need property taxpayers that's what we're desperate to be sure of I spoke with the president of UVM last week to talk about perhaps partnering with UVM with respect to the cost particularly of doctors and nurses through scholarships with the intention that those doctors, nurses, teachers police officers, physicians assistants would have to commit to living in Vermont and they would go where they would need it not where they want it so we should be in the center but I wanted I think that's it actually in addition to that this would be a very intense program so during the course of the long repayment whomever was eligible for this program would have to make their student money so at the end of the first two year commitments they would be reimbursed so it wouldn't just be open in the floodgate finally what I'd like to convey to you for your assistance is that if we include the state college and open private colleges to participate in this sort of program so that it's spread out I think if we were to do that it would become a recruitment tool for the private college and state college and university to be able to tell those students in those five critical areas that we're not going to have these students over and I think it would foster a sense of competition that would bring the best into those programs and they would have the confidence knowing that at the end of their education there's no doubt that's it thank you yes I'm not going to ask you to go into things and since I think most of the topics are supposed to be around recruiting and retention one of the things that I didn't hear discussed was the percentage of physicians regardless that will be employees and so then as an employer how are you reducing the barriers or increasing the capacity to hire the other has to do with the pressure of the day on the EMR I think the literature will work but also the reimbursement capture of the total work effort in we're partnered with CMS later that they get to really value the work effort and then to the value based system around peer coordination patient center will hold that if those work values were re-evaluated that would help bridge that gap of reimbursement where you have a primary care physician that used to could see 22 or 25 patients I feel like they had a good day they now struggle to see 14 and that unfortunately is translating to either loss on the fee for service side or yet that we haven't hit upon the correct ratio even within the ACO environment to pay for primary care the second with respect to attracting primary care or any position to the state hospitals are disincentive of us to make provider types to be an employer I mean for N and C I don't want to check about half a million dollars a month for the primary care and positions that we employ and I could add two and a half more primary care positions in my community where we had a different need if it didn't go to the provider tax so I think that when you're looking at attraction to the state you have to look at also the barriers for either a private practice to get in their roles and take on the risks of a new provider coming into the area and also the hospitals who through the collective triple aim really need to drive primary care than the curve on the use of specialists so curious as we have someone, a senator represented here around that valuation is there discussion with CMS around the work value in primary care to help drive or reduce the discrepancy between what primary care position can make versus a specialist Thanks Not at all So I would say that that is worth the discussion with CMS and in the senator's office we would be happy to help connect you with CMS for that conversation we do not have influence over the decisions they make on work values and how they determine that but I do think what you raised is an important discussion around particularly within the frame of the ACO we certainly know that a significant amount of funding comes from CMS through the ACO and back out to providers and so looking at how that valuation is determined is an important piece of making that investment in primary care because if what is happening is using claims that are just a quarter or a year old that are all based in a deeper service environment and those are the data with which we are making determinations around the next set of payments are we really transitioning to a value based care system or are we doing deeper service under a different name so we would be happy to help you connect to CMS and have that conversation to the extent that we can serve as your fellow partner John I was just the first part of your question would be the hire for the hospital you are trying to defend it and it's a real difficult time in this generation young physicians see being employed by some out there as security in older physicians because they will see security as having somebody else not tell you what to do and that's a real generational gap but well shown in many studies that as soon as a physician works in a hospital the cost of care goes up and that's shown numerous times so I went at a terrible time trying to recruit versus the hospital over the next few and some difficulty recruiting with FQACs because of better loan and payment plans so I don't know how you do that but it is a difficult situation other members of the public like my college chair Dr. Moro brought something up that was really interesting for me the biases of educators moving students into certain areas and it's something that we have been looking at over the last few years on high school level with guidance counselors always trying to push kids into college when technical education is probably better for them or just as well for them where their student debt is generally zero and so I found that interesting that even those biases within the medical education field operate as well and it's just how we we should let the students make the decisions of where they want to be and not try to influence them to a certain path so I found that really interesting that I think throughout the education we have will find you know you bring to mind this funny thing that happened to me this week which was I was asked to do some women's health teaching for the physician's assistance Franklin Pierce University one in the private I love teaching that stuff and they said we'll pay 100 bucks an hour and I said G-grade you know I don't and the same day I got a bill for my plumber and the labor rate for my plumber was 100 bucks an hour and I thought hallelujah because really when you think about skills and all that it takes to get there plumbers are pretty important just a funny little anecdote there but I think you know this comes down to culture we all care deeply about what we do and we're human beings and we can't help but be influenced by good faith and the three of us will all say exactly the same things about the wonders of the work of family medicine continuity and relationship over time and commitment to communities and being in communities and how meaningful that is and you know we could go on and on and on about that but you know the cardiologists feel that way about their work surgeons feel that way about their work and so people are naturally passionate about what they've devoted their life to and so humanly we see all these right remarkably bright young people come to us and of course we're all interested in helping influence them and fighting the right niche and none of us would disagree with the notion that you know primary care journalism is not for everybody it is not the right work for all people it would be awful if everybody was forced into primary care that doesn't make any sense but helping make sure ensure that we accept into training in the first place the kinds of people who are going to evenly distribute themselves across all our needs is really part of our responsibility I think all of our responsibility and I want to say another thing about the interdependency of our specialties here you know I applaud us for spending this much time focused on primary care but I have conversations on a regular basis with my colleagues in surgery in OB-DYN and in psychiatry about the demise of generalism across those specialties and these are the impending crises beyond primary care has got to be our first line of attack because we're broad spectrumally trained and can do the majority of care but boy let's not forget we've got real crises coming in general surgery you have to travel long distances now to get your appendix out and that can be a tough thing to develop at night OB-GYN has become a some specialty specialty everybody's some specialized there's decreasing number of generalists and OB-GYN and of course I don't have to tell you anything about the problem of psychiatry so we're I always want to remember that we're all in this together this issue is a broad issue really across the medical spectrum primary care is looming the hardest in front of us and I do believe is the one we have to focus on for solving first and foremost but not far behind are some of these other specialty ones I want to thank you for making me look introspectively at myself because I had a bummer at my house when I got the bill the response was in California I'm Grace Solomon I'm a third year at Grisle actually and I just had my family medicine rotation with Dr. Hellman at the little workers clinic and had a wonderful time I always knew I would want to do primary care but family medicine just wasn't quite on my radar I have a lot of exposure to it as you mentioned especially in pre-clinical years we just don't get a lot of education on what it means to go into primary care the culture is kind of set around us thinking you're dealing with a lot of chronic conditions you're just treating diabetes and hypertension which doesn't sound as alluring as someone saying oh we have a stroke victim here and we have to manage that quickly and other more quote-unquote fast-paced specialties so I think for our pre-clinical culture our lecturers are usually specialists and cardiologists kind of teach us about cardiovascular system and things like that so having family med docs or people in primary care in general would be awesome because they're really admiring the knowledge and confidence and experience of all the doctors who come in to teach us those things and they should be compensated for that time to represent it as much as the other more specialists so Grace you're coming with me to my next dean's meeting other public other yes I'm Rob Penny I'm a family physician and I'm on the primary care advisory group as well I would just like to make a plea for keeping the term crisis in the discussion it may not be a good bargaining tool but maybe it's a good motivational tool for those that have to make decisions you've heard a lot of good suggestions here in the last few weeks I was cleaning out a closet mostly retired so I've done to do that now and came across a lot of newspaper clippings and things that I had and others had written around 2008-2009 when there was some interest in nationally and locally about health care reform they're all very applicable today I could spread them around you think they'll have written today the same problems with air particularly with primary care the under reimbursement the bureaucratic burden the hassles and medical debt they've gotten worse 10 years earlier they were there I've been around for a while I'm one of those over 60 people sorry but things need to be done this year, next year significant things or will some of you be doing the same stories but again worse so it's a crisis and you've heard a lot of the deficiencies we have in the primary care particularly failing medicine work for so I'm going to make a plea looking back on the history and fearfully on the future that things need to be done this year, next year and then follow through because everything that's been mentioned has really more to do so keep crisis in there in the discussion I'm sure I probably will I do want to tell you Rob that a year ago in my morning commute to Montpelier a DJ was talking about finding a pamphlet from 1931 and it was about the biggest issues of that time and in that we started reading some of the chapters in that pamphlet sustainability of education sustainability of health care these are issues that don't go away that we will continue to deal with as a society and we make incremental change and that's the best that we can really hope for other members of the public if not seeing none I read Walter I'm sorry I think we could do a bigger change if we wanted to trouble as we don't want to and for the primary care docs here I know as a patient I've been through five of them probably eight or nine years from the practice I've been visiting because they all leave they get so sick of that everything you've mentioned here they get so sick and they just you know hot whatever wherever they go they go I've been through with one for three years now and he's been talking about it so I'm going to have to find probably have to find another one somewhere and this is in a rural semi-rural practice so that's another thing you know and again you go to an office and you love you to get five minutes maybe ten minutes with that primary care doc because it crunches on numbers it's not on specifically care it's on numbers numbers counts receivable filling that kind of thing we have to really change the culture as one British person said last night that health care hearing we have to stop thinking about it as an insurance program but as a human right you're right in that there's no other public comment is there any new business to come before the court is there any old business to come before the court seeing none I really wish to thank the panel especially want to do a big shout out to the doctors who spent their day here I know it's going to be a long day because there's a primary care advisory meeting starting at five but it shows the passion that you've had for your field and as Dr. Holmes always reminds us of opportunity costs or lost costs you certainly had some today by being here and on behalf of everyone in Vermont I wish to thank you for making the choice to try to make a difference so thank you with that is our motion to adjourn moved in second to adjourn all those in favor signify by saying aye aye thank you everyone have a great rest of the day