 It's a minute after one. Good afternoon, everybody. Welcome to the Green Mountain Care Board. I hope everybody is enjoying what I hope is the start of a spectacular fall foliage season. Looks like it's starting to get beautiful here where I am down in Middlebury, so I hope it's the same for everybody else. It's indeed the season of change here at the board. So today is my last board meeting serving as interim chair. It's been a pleasure to do so, but I'm really looking forward to passing that baton to our new chair, which is Owen Foster. He's an assistant U.S. attorney for those of you who don't know, and he will be starting his term next week. So from now on, chair Foster will be leading these meetings. Another transition today. This is board member Pelham's last board meeting. So his appointment also, it ends on Friday and we'll be joined next Monday by Dr. David Merman, an ER doc at CVMC. But, Tom, I want to really thank you for your service to the state. I know this is your last board meeting, but you have done so much for the state for so many years, not only as a board member, but in your role as tax commissioner, commissioner of finance and management, commissioner of housing and community affairs, commissioner, commissioner, commissioner, lots of commissioner titles, lots of hats that you've worn over the years, and we're really grateful for your willingness to serve Vermonters. You're truly a dedicated public servant, and we've appreciated your time here at the board, and I really hope that you enjoy your retirement and do all the things that you love with your newfound time. So I just really want to thank you on behalf of the whole board. Thank you for that, Jess. You're welcome, and thank you. With that, I think I will turn it over to executive director Susan Barrett for her report. Thank you, Chair Holmes. So in terms of announcements, I just have a few brief ones. The schedule for October. First, I want folks to know that we will not be having a board meeting next Wednesday. It's Yom Kippur, so we are canceling our board meeting. Our October schedule is up on our website. It's posted under board meeting schedule, so please check that out. Another busy month in front of us with a new chair and a new board member. I want to remind folks also that if you know anyone or you purchase your insurance as an individual or family member on your own, you may qualify for additional subsidies that have just been made available in the last couple of months by the federal government. This information is available on our website under premium tax credits. It's actually under what's new on our website, and there are links to Vermont Health Connect and other resources to determine whether you are eligible for these new and improved premium tax credits. So please, please, please check that out and please let those who may be buying their own insurance in this way know about this opportunity. And then last but certainly not least, just teeing off on what Chair Holmes for the last day here, last board meeting said, I just want to thank Tom Pelham for his work at the board and on behalf of the staff to say thank you for all of your contributions to us as staff members at the board. And then also to thank Chair Holmes for stepping up over the last couple of months. And we look forward to next week when we have a new chair and a new board member and exciting transitional times as you say, Jess. And I will turn it back to you, Chair Holmes. Great. Thank you. So I think the next item on our agenda is the minutes of September 12th. Do I have a motion for approval of those minutes? So moved. Thank you, Tom. And a second by, so approval by, a motion by Tom Pelham and a second by Robin Lunge. Any corrections or discussions of the minutes? All right, hearing none. So all those in favor of approval of the minutes of September 12th, please say aye. Aye. Aye. Any opposed? Nope. So we have unanimous approval of the minutes of September 12th. Thank you for that. The next order of business, the next item on the agenda is the discussion of our hospital budget process. So as folks know, we have just completed our approval of the fiscal year 23 budgets. Written orders are going out this week. But I guess in this recurring theme of transitions and change, the board is about to launch a new effort to evaluate its hospital budget process, looking for ways to make it more efficient and streamlined, opportunities to reduce administrative burden, ensuring that the board has the right information to make the best decisions we can for Vermonters and for our hospitals. And looking for some opportunities to update and align the process so it's more consistent with the state's payment and delivery reform efforts. So with that in mind, I'm going to turn it over to Sarah Lindberg to talk a little bit about what's ahead and to facilitate a conversation about what we might learn from the process we just completed. So I'll turn it over to Sarah Lindberg. Thank you, Sarah. Thank you, our folks. Oh, looks like they were not happy with the way I shared. So I'll try a different mechanism. All right. Does that one coming through? Great. All right. So we are here to debrief the hospital budget process from this year. I think it's important to keep in mind that we are not here to discuss any specific decisions or a certain hospital, but we're really here to focus on the process for the hospital budget regulatory review. And I want to let everyone know that this is just the start. We have just begun a scope of work where we're engaging with Mathematica Policy Research to assist us in this redesign or look at our hospital budget process. And while we do that work, it's important at this time to gather feedback while it's so fresh in your mind to help frame the way that we approach that. So this is kind of a very high level framework. But essentially, I'm going to just be writing your ideas here. And there are three columns. The first is our current state. So that's what we just went through. What are some insights and observations? I have some starter questions and observations for you to look at. So what went well? What are the current pain points? And what are we valuing about the process today? And then the second column is kind of near-state process improvements that we have in mind. So some things that I've already but come to my attention is document management, getting our hands or files in a more orderly fashion, making sure that the filings are coming in on a timely basis, providing better summary information, looking at, you know, is regulating from a budget to a budget the most sensible way to look at this process? What are some objective metrics of financial health that we should be considering and then evaluating the administrative burden of this process? So those are just kind of a laundry list of things that have come up in my conversations with various folks that, and again, it's just a start. And then the last one is the future state. And here, I'm really thinking about the goals of this process and, you know, whatever it might look like in the future, how would we know it's working? You know, what would we do if it weren't? What are those goals for this hospital budget regulation? And, you know, what could we as an organization do differently from a policy perspective to accomplish those goals? So that's mostly just some fodder. I'm going to turn off my camera and be typing while you talk. So you will hear a little, but I'll also just chime in when I, you know, I'll chime in. So I don't know if there's anyone who wants to kind of kick us off here, but that's the idea. Thanks, Sarah. Do you want to leave that slide up? I think that would be helpful, perhaps. Is there anybody from the board that wants to just weigh in on any of these questions that Sarah has thrown out at us to think about learnings from our process that we've just gone through? I think one that's a perennial is the alignment with rate review and the hospital budget process. You know, we deal various and in rate review, as we know, the hospital submissions, I mean, these aren't even approved. They're the submissions, you'll play a role that is there, you know, through most of the rate review process. And then we try to kind of like connect them at the end. And it's just, I think, a very kind of crude process where two major forces, a revenue force and a spending force, are not coupled. But one regulatory agency is reviewing both. Go ahead, Sarah. I was just going to say, I initially called that a pain point, but I think that is a process improvement. Does that feel right to you, Board Member Pellum? Well, you're trying to, yes. That's clearly a process improvement. Yeah, great. Thank you. Go ahead, Robin. Thanks. So I would love for there to be better alignment, but I actually don't think it's the highest priority. Because rate review impacts only 80,000 Vermonters, whereas the hospital budget process impacts many, many, many more Vermonters. And so while I think that alignment is theoretically helpful, and I think for us, it is a pain point, quite frankly, I'm not sure if it's, for me, it's not the highest priority, and I'm not sure if the juice is worth the squeeze. So, you know, that's just my opinion, having spent a bit of time trying to think about how to make those processes be more aligned with Jess in the white papers. So I'll just end on that thought there. I have other ideas, but I want to let other people chime in first. Yeah, I appreciate hearing that, Robin. And I've read the white papers that you and Jess wrote, and they were, I recommend them to anybody who wants to better understand why things are the way they are with the Board, the order in which we do things and the constraints around us is very helpful as a new Board member. I don't know if alignment is my top priority. I didn't try to prioritize the things that I had thought about, but it does seem to me to be a more logical sequence that we do budget review and then rate review, because the rates that we, that are set by the payers or requested by the payers are dependent upon the budgets. So it's, to me, and in this one, the one time that I've been through it, it came up over and over again, not just by Board members, but by multiple stakeholders that having the budgets reviewed and approved before considering the rate requests from payers might be a better sequence for everyone, realizing that there would be some pain involved in changing that flow, there'd be change for some. But that's something that I would like to see happen as well. I don't know if it's my top, but it is something that I think would make this process better. Other other ideas? We can leave that with Sarah for a bit to ponder over. Other other ideas about improving the process or thoughts on what we learned? I'll throw another one out there, which is, I fully admit isn't fully thought out, but it's the connection between the payers and the scale of the hospital. I think in this last process, there is a very large hospital that consumed or that requested a huge proportion of the commercial increase. But there's only a certain amount there. So if one hospital is kind of absorbing that a large amount of the commercial increase that's available, then that means it's not there for the other hospitals. And so kind of balancing out, it's kind of balancing out the payer mix actually in a way that the same problem was in K through 12 education access to property taxes. And I think Vermont over the last couple of decades has moved toward a much more equitable distribution of property tax resources. And I think that is there's a parallel, although subsequently very different, but a parallel issue in terms of access to commercial revenues and how that relates to Medicare and Medicaid. So there is a difference in the types of payers that the different hospitals have. And there are differences in the respective sizes of those hospitals. But I'm just trying to figure out what part of the regulatory process you feel might address that. I mean, that is kind of their reality, right? Is there anything about the process we could do to better highlight or make those decisions I guess help inform those decisions? Well, for me, I mean, I don't have an answer, but I know looking at the state education property tax approach, it was a reiterative process. As you know, it used to be it was every tub on its own bottom. And so Stowe could afford a much larger investment per pupil than say standard, which is at the other end of the kind of wealth spectrum. And so we've gone to a statewide property tax, we've adjusted through income sensitivity, the impact of that on certain people. And the system, it's complicated, but it's fair. But it is an iterative process. It's where we are today is not where we thought we would be when Act 60 passed and when the Brigham case was settled by the state Supreme Court. So it's a process over time. But I think it's a big enough process when you have one hospital consuming 52% of all the revenues that people need to be students, students of the impact of that. So yeah, and I think that Oh, God, please, forever. No, I was going to jump to it different. I was going to throw out another idea, but you go ahead, Sarah. No, that's fine. All I was going to say is I think like one of the things I've found about working in this sector in Vermont is that there's always a million things going on at the same time. But it sounds like a lot of your ideas might be more aligned with some of maybe the Act 167 thinking and how we kind of redesign payment and delivery system. Whereas I think today what I would love to focus on is how we regulate those budgets. And I hear that there might be a piece of four regulation in that, but it feels a little more adjacent to this specific exercise. But I think I'm picking up what you're putting down. So I was going to throw out something that I think went well this year. I felt like including the information from the state economists around inflation and other economic metrics was really interesting and helpful. This year I felt like the process was much more data driven than it has been in prior years. So I'd love to see that continue to evolve. I have a whole bunch of ideas to throw out there at some point, but I'll just echo that from Robin. I think having the state economists was helpful. I think as we think about our guidance for next year, we should let the hospitals know what are the metrics and measure that we plan to use as a benchmark for medical inflation. So having that be in the guidance. And I liked the decision tree and the logic and the data driven analysis very much. So thank you for bringing that up, Robin. I completely agree. And I have a bunch of things that I can share at some point, but I'd love to hear from others first before I give my laundry list of ideas. I'd just like to echo I thought having watched prior years, the hearings and the meetings, I thought the framework that we used this year was beneficial. And I think continuing to refine it and have it have some stability in it would be really helpful. I agree. I think so the other thing I will throw out is I do think that the one area that I think could use a lot of improvement, but it's going to be a lift. I think to get us there is the measurement of the commercial price. And we use charges because that's what's always been used. But as we know, charges don't have a tight relationship to price. There's some relationship for some hospitals for some services. Certainly when their contracts with a payer are based on charges or discount off charges. But I think having a better way to measure that in the future or at the very least a deeper understanding of the commercial relationships that the any given hospital might have with sort of a majority of their payers may also help connect those two things better. I don't know the right way to do it, but just and I don't know that we'd get there quite frankly as quickly as March. But I think starting to think about how to evolve that over time would be super helpful because that is I think the area that's always in my mind the most difficult component in the decision making. Yeah, I think that's a really key point. And we'll be talking to all sorts of partners in this redesign process. But one high on the list are the commercial plans because even NPR is not the most useful number for them to be thinking about. So yeah, thinking about things that kind of translate across those domains is high on the list. Well, I guess I'll throw out some ideas. One of them was around that effective commercial rate getting at that a deeper understanding of that. And I'll just throw out these ideas and anybody can jump on any of them. And they're just ideas to consider, I think to mull over with Mathematica and engage with stakeholders. One of them is this I think we receive a lot of information from hospitals every year. Sometimes I think maybe it's too much. We tend to with every budget cycle, add more information requests that we don't often subtract. And so I'm guilty of this myself. So I'm interested in the process whereby we're going to assess what is actually essential for our decision making and what could be eliminated. How do we streamline and simplify the process so that we have key indicators and benchmarks, a dashboard of sorts for hospitals, which really focuses our attention on the key metrics that we really need to help us make decisions. So for me, that's an important part of the process that we're about to do. I also think for us to consider looking at hospital performance that's on a risk adjusted per capita basis. I know we've talked about this before, and I've mentioned it before, but I really more and more think that this one size fits all approach doesn't really work as well in a state that has significant migration, demographic changes and varying degrees of patient acuity. So applying the same growth rate to a hospital that has a sick and or growing population as a hospital that has a healthy and a shrinking population doesn't make a lot of sense to me. And I know part of this is we're reimagining the budget process all together, but I want us to keep that in mind of thinking about risk adjusted per capita measures or some sort of metrics by which we can judge that. I think looking at fixed costs, understanding what are the fixed costs at each hospital and trying to deepen on our understanding of cost coverage by payer. I think we did have some interesting analysis by Burns that was done. How do we continue doing that work so we understand what the cost coverage is by payer and how do we understand what the fixed costs of running hospitals are? I'll throw out there. We don't really focus on operating margin. I mean, we do, we look at operating margins, but we don't set targets or we haven't had that conversation around what is an appropriate and reasonable margin for hospitals to try and achieve to make sure that they have the cushion to withstand the financial headwinds and be able to invest in capital and technology. So I think a worthy conversation should be what are the reasonable margins? Maybe they're different for critical access hospitals than they are for the academic medical center. But if we're creating some sort of dashboard and benchmark, what are we looking for in terms of operating margins? And similarly with days cash on hand, I think of them as closely related. What's an appropriate range for days cash on hand? And what is the trigger point when we're really going to start to worry that the days cash on hand are falling too low? And so what would that threshold be? And I think as we think about days cash on hand, it's really going to be important for us to make sure that we're capturing data not only at the hospital, but the parent organization. As we've seen, sometimes that doesn't always align and a hospital can look like it has very low days cash on hand, but its parent organization has plenty. So making sure that we're capturing all of that and understanding all of that. To Robin's point about effective commercial rate, I think we need to understand that relationship between the change in charge and what is the impact on commercial rate payers for each hospital. Another area to consider is border hospitals as they're gaining market share outside of Vermont. How do we treat that revenue? If hospitals are exporting hospital services to out-of-state patients, that's revenue coming into the state that's paid by out-of-state insurers and other government payers. This is medical tourism to some degree and in my mind that's a good thing as long as it doesn't compromise access to care for Vermont or so. Do we think for border hospitals, how do we think about revenue coming in from those out-of-state patients? And then another area to consider. I know we brought this up before and so I think it's just worthy of consideration is two-year budgets, right? Or some multi-year budgets to allow for long-run planning and I think there's pros and cons of that, but I think it's just worth contemplating. And the other thing I'll just say just in terms of this is very, very minute detail, but I think it'd be really helpful and I'm not sure the time would allow it, but to have some of the staff analysis prior to our hearings, I think would be helpful. I think it would allow us to ask deeper, better questions after that analysis, but I also recognize the time period between getting the hospital budget submitted and staff being able to do that review and analysis may not be enough time, but that might be really helpful. So I throw all those ideas out there. As people know me, they know I throw a lot of ideas out. Some stick on the wall, some don't, so I'm happy to just launch into any of that if there's any feedback. I think you raised a lot of excellent points. In one component, I think of kind of this redesign thinking is what things are really about a hospital budget review and what is really about monitoring and how we kind of incorporate all those things. But I think that you highlighted maybe a goal in a future state concept that I'd like to touch on and that is assessing hospital performance. And I'm just curious because I bet there are lots of different answers about what we mean when we're assessing their performance. I agree. And I think that's we're having agreed upon benchmarks. And for me, in performance is always a tricky word. Maybe there's a better word for that. But how are our hospitals doing? What is happening to their operating margin? What is happening to their days cash on hand? Is there a point below which for days cash on hand that we're growing concerned? Same with operating margins and shrinking margins. So to me, I think about having some financial benchmarks that we all agree upon and having some trigger points or thresholds. Ideally, what would be fantastic is to have dashboards for every hospital and having it be green, yellow, and red where the hospitals are operating within performance, performing within benchmarks that we say this is good. This is a sign of a healthy hospital. And these are signs that this hospital may be struggling financially and may be financially vulnerable. So I don't have the answers to what all of those benchmarks might be or all of those metrics might be, but having that dashboard I think would be helpful. If I could just react, I think the way I would kind of trans... I don't disagree with what you said, Jess. The way I would sort of translate that in my mind to a goal is ensuring hospital financial... This won't be perfect. Financial stability, high quality, and access while ensuring that the rate of growth is... We just lost Robin. Hopefully, Robin will come back. Oh, you can't hear me. No, no. Now we can. Sorry. You said... Just repeat what you said because I completely agree with what you were starting to say. Sorry about that. I'm going to turn my camera off because maybe my internet's a little slow. Sort of that balance that we talked about in hospital sustainability around ensuring we had sustainable hospitals, but also ensuring that Vermonters could afford to seek care and that the care that they received was appropriate and in the right place. I think that to me remains the goal, but it should remain the goal for the hospital budget process but would require some statutory change, I think, to move more in that direction. For example, how could we integrate some view on quality and maybe that's monitoring? I don't know. I guess the question I would ask is, should it solely be a financial look or are there other access and quality components that are worth considering as part of that financial look? Sorry, go ahead. No, no, no. Go ahead. You continue your thought. No, that was the end of that thought. The other small picky thing I was going to say is Sarah, it might make sense to move multi-year budgets to future state because it requires a statutory change. To your really good points, Robin, I totally agree that and I think when we first got on the board, quality was not introduced into the hospital budget process at all and we started asking questions about quality and then we had it incorporated in the budget process, but then we actually moved it to a different time of the year and then COVID hit and I think some of that non-financial measures reporting has been sidelined temporarily because of COVID. So I think that's a really important conversation to have is what do we want to be part of our hospital budget process? What needs to be part of the budget process and what could be discussed at a different time of the year or should it be all at one time? So we've brought in some quality metrics. We've also brought in wait times to reflect some of the access concerns that we had. So is there a world in which we gather some of that information in May or June, but it informs some of our questions that we ask in August? Maybe there's a way to gather the information, have it be part of our understanding of what's happening in the hospitals and the hospital service areas, but again, recognizing how do we do this in a way that also streamlines and reduces burden, but that we're getting all the information that we need. And I think it's true that understanding access quality and finances is really important if we really are to seek to understand what's happening in our hospitals and in the hospital service areas. So I think the what we need to collect, when we need to collect it, whether we're monitoring, whether it's informing a hospital budget process, I think those are all really, really good questions to start have us think about. I think the other piece, sorry, go ahead, Tom. No, please finish, Robin. I yeah, I can wait. I was the only other piece I was going to add is as if we continue to see an evolution towards payment methodologies that pay for quality, for example, how should that get incorporated into the review? Yeah, I think those are all good points. And I think it's helpful to I think for myself, it's helpful to remember that societally, we're generally willing to pay a lot of money for things that work, that deliver what we want of them. And so it's not just enough to look at the dollars and cents, it's to look at what you're getting for the amount spent. And so to do that requires looking at quality, requires looking at access. The term that hasn't been used yet today, that's really important, though, to our outcomes. You can have safely, reliably delivered care that doesn't work. We wouldn't want to pay for that. So how do we measure the outcomes that people, that matter to patients? And how does that inform the finances? I tried with my own thinking, I tried to write down like what would my ideal purpose for this budget review process be? And again, this is this more for my thinking, but it feels like based on what people are saying, it feels like it's all right to say it. I'd like a process that aligns, that helps us align the growth in healthcare prices with overall economic growth in the state and promotes affordable access to safe, reliable, sustainable healthcare that demonstrably improves the health of Vermonters. And so that's what it feels like we're trying to strive toward. And the wording is not, I'm not picky about the wording of it, but that tries to capture all the stuff that we're doing rather than only being focused on dollars and cents. And in my laundry list, as Jess had one, I kind of developed one as well. And we've already mentioned having the budget set before the rate review process. And we also already mentioned the other thing, the next thing on my list was to have the staff analysis available before the hearings. I think that would really help. At least for me, it would really help shape my ability to have meaningful questions. And I don't know, Sarah, you mentioned a couple things about is this monitoring or I haven't divvied those thoughts up with my laundry list. But I'd like to know more about the ratio between commercial insurance rate and Medicare rates. I think we can calculate that. There's no administrative burden to that, but I'd like to know that for each of the hospitals. I'd like to develop, and we've got a framework for this, a paper that describes how to do it, an analysis of hospital allocation decision making. Are there the money that's being generated? Is that going to charity care, patient care, administrative expenses, or toward building a surplus? We can analyze. We have the methods available to look at that. And I think that that'd be a good thing to be able to look at. The bad debt to free care ratio, something the healthcare advocate's office mentions every budget meeting. I think that that's a useful thing. There's been a lot lately on the Kaiser Family Foundation about medical debt and listening to it. I think it's a fundamental question. How well are we serving a community if the care provision is putting more and more people into deeper and deeper debt? So being able to monitor that, measure that, and monitor that would be good. There are measures of operating efficiency that we've not discussed. We've had Mr. Tom Reese wrote a letter to us, a public comment with an analysis of operating efficiency. I don't know that his approach was the best approach or one that could be agreed upon, but certainly it provoked me to think more about measures like hours per discharge or a number of employees per bed or the number of discharges per employee. Those types of measures could be helpful in our understanding of how well a hospital is performing given what it's requesting of us as payers. There are quality measures from DFR that we haven't talked about that are in Jess and Robin's white papers that would be good to incorporate in our budget process, I think. Outcome measures that matter to patients is a very long-term project because we don't have any right now, but I'd like to see them, and I think that things like outcome measures like depression, anxiety, screening, substance abuse, suicide risk, detection, and treatment, the proportion of patients who have a positive screen for suicide risk who receive a referral to a provider that can help them would be a measure that I'd be very interested in, and I think a regulatory body should be interested in, in an area where the suicide rate continues to rise and deaths from addiction and medication mismanagement continue to rise. I think those type of the outcome measures too are going to be the key thing that help us better understand equity. For example, if I go into a healthcare delivery system and ask what proportion of your patients with diabetes have an A1C level greater than nine, which means they're very sick, then of those patients with an A1C level greater than nine, what number have not been seen in the last six months? Because within six months is the standard of care for someone who's that sick. If I can answer that question, then I can also say, is that time the same for patients who are black or quite Hispanic, Native American, so that's how you get at the equity sense of things. And all of this kind of ties back, it's my laundry list, right? But it ties back if there's a hospital that's delivering on all these good things, able to demonstrate high outcomes, great access, high quality, great safety, and good equity. We want to pay them, we want them to be paid really well. We certainly don't want that facility going broke. But the organizations that are costing us societally more and more and more, but aren't doing those things. That's where the worry is. So how do we suss that out? Or the phrase that I've grown to like a lot from the hospital budget series and listening to Sarah is, how does that sugar out? So that's my laundry list. And I feel like I've talked too much, but that's my list. Yeah, go ahead. Sorry. No, I was just gonna thank Tom. And I was also just gonna say with regard to some of those measures, I think we've collected some of those in the past in that non-financial reporting. So we should look at what we used to collect and see how we might want to adjust that. Two measures, particularly, which will be really helpful to think about given Mathematica's expertise in this particular area. They've already presented to us before, but these are avoidable ED visits and just measures of low value care as we're starting to move towards payment models that reward high quality, high value, low cost care. It'd be really important to understand where are their opportunities. And so having Mathematica work with us on this will be really helpful given their expertise in those areas. So I'm just gonna add to your commentary there, Tom. Book ahead, Sarah. Yeah, I think we're kind of naturally segwaying into the second slide, which is, you know, what do you wish that we knew that we aren't that's not captured to your knowledge? But I want to make sure before we move on that we've kind of, again, just focused on the process of hospital budget review that we've kind of captured any things from the insights and observations that happened this year, any kind of process improvements for the next year or kind of goals. Again, at this stage, this will by far not be your last bite of the apple, except for Tom Pellum. You can submit a public comment. Yeah, exactly. The only other thing I think I would add just in terms of process or thinking about is, and I think you raised this, Sarah, but the budget to budget versus looking at projected to budget, I think that was helpful this year, given all the uncertainty that we've been experiencing with COVID. And so as we march ahead, how do we think about looking at projected to budget versus just living budget to budget when we know budgets are fiction to begin with? So I would echo that I think we can do better on that front. I don't have anything to add. I think your list is or our collective list is unrealistically long for near term process improvements. So given that we have three folks on the hospital budget team, so I hope that you will think about how to like one thought would be to try and group them into low hanging fruit. So high yield, low work, high work, low yield type of categories so that we can be prioritizing because certainly you and the team don't have the ability to implement everything we've talked about. Yeah, I appreciate that. And I think the more that we can be realistic about the timeline, my informal goal is to have a permanent guidance place within the next three to five years. But yeah, Mathematica is one of their first tasks will be to help us do just that, like kind of bucket and reach out with kind of prioritization. But this seems like a really good start. So yeah, so some things I think I heard mentioned our outcomes feel like we don't collect really anything there. And maybe I heard mention of some quality measures collected by DFR. I guess I would ask too is it would be helpful to think about where we can utilize existing data versus requiring what existing data was already collected that could inform this that would not require a new laundry list of measures that hospitals themselves have to submit. So I think that might help in the prioritization thinking about what's existing out there that we just haven't tapped into. Absolutely. And I think yeah, the administrative burden piece is huge. And you know, there's also just you know, things like the software we're using and opportunities for automation and kind of stuff like that that we're also going to be exploring in the off season here. And so here, this is meant to be a little broader the wish list. So this isn't necessarily stuff that you'd want to know for the hospital budget process. But as we think if there may be our other prongs to what we how we engage with hospitals, particularly on the innovation front, you know, are the things you feel like we're not capturing today that that would be helpful. And you know, no promises here. But just if we're going to brainstorm. I feel like there's a lot of information. And it's really a matter of looking at the existing information that's out there and figuring out what's relevant, what could be helpful to if not directly in the budget process provide kind of that color color so that you really get more of a qualitative understanding of the hospital, right? So like one of the things I did when I first started was go visit every hospital. And you definitely get a lot of qualitative kind of information that helps you understand, at least for me, the nuts and bolts of the numbers better. But I'm not sure that like I think if you looked back to a few years before COVID, I think Michelle had pulled together an entire binder of existing information about hospitals in their service areas that was available for board members to look at and understand more of that stuff. So my sense is there's a lot that's captured. We just may or may not either use it or know how to use it or it may or may not be appropriate to use it. But that's my thought. Yeah, thanks. Thanks, Robin. That's so true, right? We talk about places being data rich but information poor. And so I think it would be, it's good to look at what all's out there, but part of our task would be to create a parsimonious list, a dashboard that links the quality and outcomes that we're concerned with what's with prices and what's being spent. And Sarah, with on that slide, it seems like I can just quickly repeat a couple of the things that I said earlier because I went out of order. Importantly, some people mentioned administrative burden. When I came up with my list, one of the things that I told myself was that anything that goes on the list, we should do. It's no burden on anybody else. So there's not anything on my list that is where we would be asking another organization to do these calculations or this analysis. The ratio of commercial rates to Medicare rates, we can calculate from data that's available. The analysis of allocation decision making, that's probably a bigger lift, but the methodology for it, the paper that came out was in 2021 Wang and Anderson. We've discussed it in prior meetings, but we haven't yet dove into the methods and looked at whether we could do this, that type of work at the facilities in Vermont. I don't see why we couldn't, but I'm new and may not know enough. But that wish list is being able to look at the percentage of revenues spent on charity care, patient care, administrative expenses, and directed toward building a necessary surplus. The bad debt to free care ratio is something that we can calculate. The measures of operating efficiency, those are available. The one place that I know the American Hospital Directory has that information. We just need to isolate the variables for the 14 Vermont hospitals. I'm not familiar with the quality metrics that DFR has used. I just remember reading about those in the white papers. So I think you have those on the list. Yeah, that's, I'm also interested. It didn't, I have written down, I don't know about the break-even analysis from the NASHP cost tool is interesting to me. I know that it's not perfect. I know there are limitations, but my opinion of any measure that we use, every measure we use will have faults. Some of them will still be useful. And so picking the ones that we know, even though they may have faults, that doesn't negate it. And so the break-even analysis is something that I think would be worth looking at further as a group with all the shareholders. Is this a useful thing given its deficiencies? I just think it's important to note on the NASHP tool that they, according to them, they've made it as a tool for payers and they have not, they themselves have said they don't think it's an appropriate tool for regulatory purpose. So I'll just throw that out there. I think it's a great tool too. And I think it would be a great tool for payers to use. My understanding, and this is why it would be great to have more of a group conversation about it, Robin, my understanding was that their primary motivation in starting the project was to help large, self-insured entities, like state employees, try to find, play so they could negotiate better. So payers could negotiate better. Yeah, exactly. Yeah. And so I think that is the reason it was used. And I don't think we would want to use it to base regulation on, but it does help us understand the performance of the delivery system better. I'm not, I'm, I guess, well we should have a longer conversation. I'm not sure it necessarily, I'm not sure performance is necessarily the only component there. It could also tell us, you know, other aspects of what's going on at the hospital. But I don't think it's just performance. Sure. But in any case, we can come back to that. Yes. And that makes sense. Thanks for bringing it up. One thing that, Tom, your comments made me think too was, and Sarah Lindberg, I think you would know better than most. There's a lot of in-house data analysis that we've done that doesn't necessarily always cross across regulatory processes. You know, they tend to be standalone, like the patient migration analysis that was done or the price variation analysis that was done, or even just a trap in general. And that's a work in progress. But how do we bring some of the insights from those other analyses into our hospital budget process? And, you know, there's so much there. There's so much work that's done. I don't know what pieces of it we bring in. But, you know, to the degree that we're, you know, using that work in our regulatory process, I think that we should. So what are the best components of a trap to bring into the hospital budget process or patient migration? I think that's really important to think about where patients are seeking care and how does that inform what we're thinking about with hospital budgets. So I'll throw that out there as like we should look internally, too, to see what data that we have and analyses that we have and which insights we could bring to that budget process. The other thing I was thinking, as I saw your question here, what else should the Green Mountain Care Board know about hospitals that's not currently captured? When I first, you know, years ago when I was on the board, the first few years maybe, there was an increase or an adjustment, an upward adjustment to hospitals for healthcare reform investments. If they could justify needed extra revenue for hospital, for healthcare reform investments. And one of the things I think that was obviously to incent more investments in population health and healthcare reform. So something to think about, you know, we don't do that anymore, should we? And, but I would, the other piece that I was going to say is I learned a ton about what hospitals were doing that was innovative in those ways when we were, you know, giving additional dollars towards healthcare reform investments. So just something to think about if we want to find out more about the innovative things that hospitals are doing, we might be able to do it through some sort of adjustment there, upward adjustment, if you justify. Along those lines, the other thing that I think it would, that we used to do that would be good to start again at some point in the future is the traveling board meetings where we went to individual hospital communities and learned more in-depth about the hospital, its place in the community, how that all fits together. Those were really valuable, I thought, to learning really about what was happening on the ground. Again, those were outside of the budget process, but I thought they were super helpful. Yeah, I appreciate that. Yeah, and like I said, this was meant to be pretty, yeah, the sky was the limit. But it sounds like the theme here is that not so much that we probably need to be capturing more is that we need to better organize the stuff that is out there and kind of distill it and synthesize it in an actionable way. So Roger will attempt to co. And it'll be a process. Like I said, we'll keep bringing this back to you. We do have a few slides just memorializing the decisions from this year. We're not going to spend time on them today. However, I will be updating these so that we are using two significant digits for everything because some of the decisions were that way. So make sure that matches the orders that we'll be going out on Friday. So that was all I had. Thank you. Oh, here, I can turn this back on. Thank you very much for, like I said, just the beginning. We're fortunate to have our partners listening in as well to get the gears going here. But yeah, it's super exciting. It's not going to be any simple answers. But I think that I think we can see, I think we'll start to see some improvement within the next cycle. And that's exciting too. So thank you for your time. I imagine we probably want to take a public comment before I find off here. I will. Thank you for that. And thank you for spearheading this effort, Sarah. I really, really appreciate it. I think progress is on the horizon. So at this point, I will open it up for public comment. Does anybody from the public who would like to comment on the conversation? Mr. Del Treco, I see your hand raised. Jessica Holmes, Chair Holmes, we call my dad Mr. Del Treco. So a couple of comments. First, Board Member Pelham, you've had an incredible service to the state of Vermont. It's noted and it's recognized amongst my members. Thank you for your service and thank you for your service on the Green Mountain Care Board. I hope you never, never think about hospitals and hospital budgets again and you enjoy your retirement. Jessica Holmes, Chair Holmes, thank you for your commitment and dedication and serving as interim. I know how hard it is to be interim. It's not easy and I share some bumps and bruises and I thank you for your dedication over the past month or so. Sarah Lindbergh, keep up the great work. Really appreciate it. Now I just want to comment on the discussion here. I don't know where to begin because the conversation was deep. It was simple yet deep and complex. Maybe a multi-dimensional chess board. We talked about, I appreciate the comments of Board Member Walsh, Chair Holmes and others, if I missed you, about the administrative burden and challenges. I ask, simplify, simplify, simplify. Show great restraint because the conversation did not show restraint. It showed more. I understand the purpose of this conversation but what can we do? What are we going to measure? What do you need to make your decisions? We, this conversation went from a regulatory space to a policy space and back and forth. Those are very challenging for hospitals and members to understand where this, how they will be measured. So that's I think point one. The metrics are important. They are not static and they are fluid. So if we're looking for static metrics, it particularly financial metrics, why are you good here and not here, that's not going to exist. I know you probably know that. I think they should be standard metrics and I think they should be industry standards and none of the places of what should be an operating margin or days cash on hand should be a regulatory choice. It should be, what do the bondholders expect? What are your debt folks that hold your debt expect and be standardized? And there's lots of information around that. We talked about medical inflation and Chair Walsh, you said something that was terribly scary to me. You said we should track at state GDP. That's a race to the bottom. State GDP is 2 percent. Medical inflation is much greater than that. I understand and I appreciate your thoughts there because I do agree with the affordability message that you're sending. But we need to be very careful about that. Yeah, go right ahead. Thanks, Mike. And that's not what I said. And what I said was that a process that aligns prices with overall economic growth. I didn't comment on inflation. And so just to be clear, because I know it's, I agree with you that that would not be a good approach. Fair enough. Fair enough. So if I got that wrong, I stand corrected. But if we do that, it would be a challenge. Did I say simplify, simplify, simplify? Yes. So how does this plan, as a question, how does this plan propose itself to be nimble as we move to new regulatory space? Just a question. I'm sure there's not an answer. The conversation talked about quality and access on more than one occasion. I think that's appropriate. I think this process has got out of balance. I think there's this expectation of having certain things and value without the understanding on how what resources are necessary to do those things. We've done some incredible things in the state of Vermont, and it comes at a cost. So I agree with some of those thoughts. We need to rebalance to whether it's the quadruple aim or the triple aim. However we want to capture that, that'd be great. Thank you, Sarah. So it was also mentioned about planning. We need to be able to plan for more than one year. Really important. Our organizations are fluid. They're alive, and to be static in one year is very difficult. So any ratios and any quality measures, I just think they need to be industry standard. I remember early on in our sustainability conversation, and this is a restraint discussion. We had 10 financial metrics, and I'm making up these numbers, but it's illustrative. It's not perfect numbers. It was seven or eight to 10, and it grew to 25. I think we need back to that restraint. What do we need to do so we're not measuring things to just have them on the page and not be able to analyze and think? So I think that's everything. I appreciate all your work and the hard work you do. This is not easy. And then, and again, Tom Pelham, rocket in retirement. Thank you, Mike. Thank you. I see Eric Schulteis from the HCA. Your hand is up. Great. Thank you so much. I echo what everyone is saying about board member Pelham, and just want to add on a personal note something that I said to Kevin is, and I think sometimes for God, and I've said this to Mark H, too, is people who devote their career to public service, it's really inspiring to the next generation. And I think at least personally, I look up to people who have devoted their career to something, whether it's public service or public interest, and it helps me keep going. I just want to say to Sarah, I think the number of ideas is overwhelming, but I think it's indicative of this body's desire to be more effective. And it's also indicative of everyone's faith, if that you will make sense of the many ideas and prioritize them effectively. So tough to ask. I do want to say that cost continues to be the black box in healthcare reform. Whether you look at NASHP or RAND or some other measure, I think it can be instructive. We do have someone locally who has used NASHP and talked extensively with Maryland about it to negotiate a self-funded plan, and that would be Mark H. So if they throw that out there is that might be someone who's worth talking about to learn about the on the ground reality. I want to echo what Robin lunch said about qualitative data and urge folks to there's also a rigorous way to collect and analyze qualitative data. It does not mean just talking to people or going to a public event. And I think it can be combined with quantitative data to really present a more effective picture that kind of mixed method approach is something that I took in a previous life. And we collect some qualitative data and I'm somewhat critical of ways that I have done it in the past. So I would be happy to work with the board on that issue and whether it's a survey or open-ended interview protocol. I'm happy to help with that. I continue to think as we look to collecting available public data sources that the issue of data variance looms large in the healthcare sector and we can collect all sorts of public data but it often conflicts and we don't really know why. And I think answering that question about why they differ and where they align is critical to effectively using available data. And just lastly I think and I think this speaks to Mr. Del Treco's notion of simplification to some extent is you know we really have to think and what board member Wall said we have to think about moving from data and using it to generate information and using that information to generate knowledge and you know just collecting a trove of data does not help a regulator and does not help in policy circumstances. We have to figure out why we're collecting it and what it says because you will never get buy-in to collect the data effectively unless the person or the entity understands why you're collecting it and why it's useful. And I think that's a fact of reality that is often overlooked in this data centric world. Thank you. Thanks Eric. Walter. Jessica, sorry I missed the advisory meeting. I was the only one at my work that day and I couldn't break away. But we're glad you're here today. One guy left sick and then we got hit with leaf papers filling up the coffers for Vermont. I generally agree with Robin and Tom most of what they said about it's time more or less to think about the humanity of the hospital budget process versus just the economics and I'll just summarize it there. And then I just want to ask a question that's neither critical or praiseworthy but it's just a generic question. Take the UVM budget for example is something like 19, 20 percent and the board gave them 14 percent rate increase. How did the board come up with that figure? That's all I'm just really curious about how the board came up with that. Sure. The guess or was it? No, so there was a deliberation where we walked through that and the idea was to get some flexibility based on differences in governmental payer changes and then potentially if required to reduce the commercial impact, look at the mental health funding. But that should be outlined in the presentation that was the last day of deliberations. The exact date escapes me but if it's helpful Walter I can send you the presentation and look at that if you have any questions offline. Yeah that'd be cool. And it's probably just worth noting Walter that we can't speak to past deliberations. The orders will be issued Friday and certainly you can get the reporting of the meeting as well but legally we you know we can't really comment on what we already discussed. Just a curiosity. Thank you Walter. Shule. Your hand raised. Okay. Yes I did. Good afternoon everyone. I'm Shule Gerovic. I'm the project director at Bathematica. Very excited to start this work with the team. Thank you for selecting us and I'm glad this meeting is recorded. I think I need to listen to it many many times. Great notes Sarah but there are quite a bit of great ideas and thoughtfulness in the process. A couple of reflections and like what we are planning to do. I think at the end healthcare is not stagnant right so what we are seeing is a changing environment with COVID a lot of things actually even accelerated at some level and also created this concepts of you know balancing accountability resources needed for healthcare and the cost to consumers so all those things are very complicated and they became even more complicated with COVID. I'm glad to hear Eric mentioned qualitative. Our work plan actually includes interviewing with stakeholders on a very structured way and collect that information so we'll be reaching out to many of you to kind of think about that protocol and who to talk to but we will be certainly talking with hospitals and other interested parties to kind of set out our work plan in addition to kind of thinking through what we need to do based on our experience. Data came up and I worked in Maryland before. I worked with NASHP Rand tool and then my team actually quite experienced with Medicare cost reports so we'll be bringing a lot of data to you but what I heard is we have a lot of data but we really need to figure out a consolidated way of making decisions based on it so that's something that I'm going to take it to my team really strongly on that as well and finally I wanted to say the timing right. I think we envision this to be a long process and really think about what we could do in the next cycle what are the quick improvements that we could do and then think long term how you can change the process to align better with the what is happening in the ground and really thinking through the burdens and I agree we do want to kind of think about what we are adding and what we are subtracting from what is already collected and with the technology tools I'm also hoping that we may introduce some modernization in the way we collect the data from hospitals. Initially it may increase some of the pain but hopefully we can figure out the balance so in the long term it should help hospitals and the board to collect some of that data more efficiently in addition to what we collect. Again very excited to be part of this team. Vermont is always the trailblazer and we are going to be working together and we'll see what will come up with it the next two years. Thank you. Thanks Julie we're so excited to have you working with us on this and your expertise will be invaluable so we really really appreciate it. I see on your radar wall your hand is raised. Hi and thanks get my hand down first. I don't normally comment in these sessions but since I'm not sure what kind of public comment you'll be seeking beyond this I thought it was important to speak up and I first want to echo what Mike Del Treco said and thank you Chair Holmes for taking on this interim role. It's thankless I know except for these meager things that you get from us but we really appreciate it. I want to thank Tom Pelham. I think Tom and I first worked together in like 1992 so I'm acutely aware of just how long he's been in public service and I really appreciate it. And Sarah I want to thank you too. I think you've brought some improvements already to the process and really appreciate that. What we're looking for from the UVM Health Network is more predictability in the hospital budget process and more standardization. So the use of outside benchmarks sounds great to us. Obviously they need to be legitimate benchmarks but our concern about the process in the last few years has been the unpredictability and the extent to which it really undermines our ability to plan on a multi-year basis which you need to be able to do particularly under the kind of strain that we've been been under in the last couple of years. So moving towards something that's more predictable more standardized and more tied to legitimate benchmarks say that with their quotes legitimate benchmarks is something that we a goal that we share. It's important to use benchmarks that put Vermont in a national context while continuing to have high expectations. So I think one of the challenges for you all and all of us is going to be how do we expect Vermont to outperform the nation and why. What's a good reason for expecting that Vermont can do better on cost and quality on access on whatever measure and where is that okay to assume and where are we as we are now kind of victim of national health care economics. Second I think it's important to use benchmarks that are appropriate to peer groups. So this may be obvious but one of the things you'll have to consider is who you know all Vermont hospitals are not the same and you'll need to stratify some in order to compare apples to apples academic medical centers academic medical centers critical access hospitals to critical access hospitals etc. And again we saw in this last year how the availability of funding to critical access hospitals for example presented a very different picture in their finances than for other hospitals. And lastly I would just note that the UVM medical center is both a community hospital and an academic medical center. So that provides for a particular challenge but we stand ready to work with you on anything you want to do to improve the process and particularly in these areas of of making it more predictable more standardized and tied to benchmarks that are legit without giving up on our high expectations for being being better and and constantly improving. Thank you that was helpful. So Sarah I think you probably have way more than you can possibly manage in terms of suggestions and thoughts and and we appreciate you just taking them always again or ideas that we've all thrown out there and you know I think working with Mathematica and trying to prioritize what's doable and feasible in the near future and what's probably a more longer run thing to tackle would be helpful and I'm wondering if you have a plan to update the board on this process sometime you know what is I'm just thinking it'd be really helpful to have maybe a an update at some point maybe January or something I know we're going to be doing hospital budget guidance in March but is there an interim kind of check-in that we might be able to hear what how you've maybe even prioritize this list or something like that might be helpful. I'd prefer to just surprise you guys next to. No of course we'll be briefing you on this work and engaging with you both one-on-one and in public format here so yeah you'll be very tapped into this work and our kickoff meeting will be attended by board members Walsh and you know if possible lunch but we will have board representation in that as well so yeah it really important that we all stay as aligned as possible. All right well thank you. If you don't mind just jumping in for one minute I'd say Sarah the other thing to put on the list is things that you know I personally took this as somewhat of a brainstorming challenge like and so in the spirit of brainstorming there may be ideas that are are bad ideas and so you should feel empowered to come back and say yeah we don't you know thanks that interesting thought but no so. I'll be my best overcome my shyness and tell you what I really think. That's great because I think you know what a lot of people may not remember is this is our only way of brainstorming and talking with each other and so certainly watching four people brainstorm a topic in public has got to be somewhat painful for people to watch and as well as quite frankly for us to do but that's the structure we have so. Yeah yeah to good good point and yeah yeah so thank you for everyone for participating today and more soon. Great thank you Sarah. So again I guess the next item we have and the spirit and consistent with this general theme of transitions our next item is actually delegation of authority so I'm going to turn it over to Mike Barber our general counsel just to to kick that off to that up a little bit. Thanks Jess. Yeah so the background here is that the board and the agency of human services are currently negotiating with the Center for Medicare and Medicaid Innovation CMMI regarding a potential extension of the all-payer accountable care organization model agreement which is set to expire at the end of this year and we are also collaborating with the agency of human services on the development of a proposal for a subsequent model agreement and a host of other work that's required by Act 167 including hospital sustainability and regulatory redesign and interim chair homes and board member lunch are currently leading that work for the board with a lot of staff support and that's pursuant to a delegation of authority that the board adopted on June 22nd 2022 and we thought that with a new chair coming on board it might make sense to have him step into that work and replace Jessica who's who really stepped in when Kevin left earlier this year and so that's kind of what's on the table so there was a an order written order delegating authority I can pull that up if if folks want to take a look at that again but essentially it's it's a delegation of two authorities so negotiating with respect to any amendments or modifications to the all-payer model agreement in any subsequent agreement and then number two delegation of authority to pursue activities required by Act 167 related to hospital sustainability and a subsequent all-payer model agreement including community engagement payment model development and regulatory redesign and there is a caveat in there that the delegation of authority to negotiate with respect to the all-payer model agreement in any subsequent agreement does not extend to the ratification or execution of agreement of an agreement that would be a board vote when it came time to that so any questions or well I have a question because I think at the time when we were when we were talking about this in June I think there had been a previous delegation for around the hospital sustainability which is kind of in a different place so I wonder if really what we should be thinking about is the all-payer model delegation and then maybe revisit the second part I mean I'm I'm personally happy to continue to be the delegate for both if that's what makes sense but with new board members and with sort of that work becoming more granular it actually might make sense to divvy that up more you know across more people I'm just throwing it out there we could keep either keep it the same for now and then revisit after everyone started or I'm not sure what makes sense that's interesting it's interesting I was I was ready to make a motion to just undo what we did in June keep it at that but it sounds like you might have more so it would right I think I think for the hospital sustainability I think the problem with just undoing it quite frankly is that we are still in active negotiations with the feds around the extension and the all-payer model so that component if we undo it then we have no one at the negotiating table right so we need a new we need a new delegation I think for that well I think the idea was we were going to delegate replace me with Owen Foster so then there would be it's not really undoing its replacement yeah that's kind of what I had been thinking as well as to just have Owen step in for Jess with you Robin on this work stream well maybe we just keep it the way it is in terms of like just do the replacement for now and then revisit the hospital sustainability stuff later that makes sense so just replace replace me with Owen and then once the new board members are on we might have a conversation about you know who can step in and get involved with you know act 167 work I think that makes sense would it be helpful if I made a motion to replace Jess with Owen that would be helpful that would be one move I move that the delegation of authority adopted by the board in June was it 22nd 2022 be changed to replace board member homes with the new chair Owen Foster great thank you Tom is there a second to that second great so motion made by Tom well seconded by Tom Pelham wonderful any discussion of that motion typically open it up for a public comment I guess I will do that is there any public comment on this uh motion to change the negotiating authority to the new chair no I'm not seeing any so hearing none all those in favor of the motion to delegate all pair model negotiating authority and activities required by act 167 to our new chair Owen Foster in place of me Jessica Holmes please say aye all right aye any opposed not hearing any opposition poor Owen doesn't get a vote in this he's just kind of find out on his very first day so it's unanimous approval of that motion to delegate the authority to our new chair Owen Foster so great thank you very much I appreciate that is there any old business to come before the board being none is there any new business to come before the board none of that either so is there a motion to adjourn Tom Pelham's final board meeting here here I move to adjourn if Tom Pelham moves anybody gonna second that we could do we did last time and nobody seconds it but that would be cruel then Tommy I'll cover my eyes I'm gonna take a second from Robin I think you said something in there second I think Tom wash already second oh Tom washed it okay then Tom washed it too it's double seconded all right all those in favor of adjourning Tom Pelham's final board meeting please say aye aye all right any opposed no there's no opposition Tom thank you very very much again we so appreciate you and we will miss you at our future board meetings but hope you'll send us pictures from the golf course on Wednesday morning so we could just feel you know jealous well for my small stay I'm sure we'll cross past with each of you sometime or another yeah