 Okay, we are back. This is Senate Health and Welfare, and we are looking at S285 with our Ledge Council, Jennifer Kirby. And then we have some witnesses who are interested in testifying. We're gonna ask that any witness who testifies do it as efficiently as possible so that we can have some time to really look at the bill in some detail. So Jennifer, thank you for being here. Yes, I'm trying to walk us through the changes. As I said earlier, a lot of work went on during our town meeting week to bring the committee a bill that reflects the conversation and the testimony that we have heard and to reflect also input from the folks who have been so engaged in the bill earlier. So we'll go right ahead. Great, so Jennifer Kirby, Legislative Council, this is a new draft of S285. I've shown it, I'm showing it to you in Markup version. So you can see the changes from the previous version are all highlighted. And I tried to do bold for bold highlighted for what's new and not bold for what's struck the most part. And I've provided the source of, for these that came from external parties, the source of the recommended change, just for context. So the first section is still 1.4 million appropriated to the Greenland Care Board in FY23 to engage consultants. And this is on a hospital global payment design topic. So to help the board develop a process for establishing and distributing global payments from all payers to Vermont hospitals that will, and now we have a list. So it's easier to look at things that will help move the hospitals away from a fee-for-service model. That is from the previous version that will provide hospitals with predictable, sustainable funding that is aligned across multiple payers consistent with the principles that were then 18VSA 93.71. Those would be often called the Act 48 principles that are codified in the Greenland Care Board chapter. And those recommendations came from the board and sufficient to enable the hospitals to deliver high-quality affordable healthcare services to patients. And it would be based on the actual and necessary costs of providing services, not solely on historical charges. And that was a recommendation from the healthcare advocate. So that's the first part of what the consultant would be helping the board do as far as developing a process for global hospital payments. Also, the consultant would help the board determine how best to incorporate hospital global payments into the board's hospital budget review, its ACO certification and budget review and other regulatory processes. And then this would strike out some language on data collection and for that, but a benchmarking analysis because that language is included in the budget adjustment bill, budget adjustment act. So it was not necessary, the board pointed out that that was already today. So then we have some new roles for the consultant to help the board with. The next two come from the UVM Health Network. So assess the impact of the board's current regulatory processes, including hospital budget review and certificates of need on the financial sustainability of Vermont hospitals and recommend opportunities to improve possible financial health for the board's regulatory processes. And four is recommend a methodology for determining the allowable rate of growth in Vermont hospital budgets, including using national and regional indicators of growth in healthcare economy and other appropriate benchmarks. And then finally, number five, in collaboration with the director of healthcare reform and agency of human services, identify opportunities to use political payments for providers of community-based services. So not just possible global payments, but also potentially community-based service provider of global payments. So that's the 1.4. And then we would also, if you're a continue to appropriate 600,000 to the board to support the board and the director of healthcare reform in the agency of human services in the design and development of a proposed agreement with CMMI, sorry, from federal agency to include Medicare in the hospital global payments and to the extent practicable community-based provider of global payments of picking up that concept as described in section A. And then additional language suggested by the board that the board would ensure that any services it procures with these funds are supplemental to and not duplicative of analytics and other support available through AHS. And then you would have a report back. This would move the date from September 1st to November 1st, just to try to get a little bit more actually going on beyond just engaging the consultant but actually getting somewhere into the workflow. So by November 1st, the board would provide an update on its use of funds to the Health Reform Oversight Committee. And then in January, they would report on their use of funds and the status of their efforts to get Medicare participation in global payments to hospitals and community-based providers to this committee, Finance Committee, and House healthcare. So that is the 1.4 and the 600,000. So the first two million was section one. Do you want me to stop there for questions? I have one question. I don't know if you can answer this or maybe one of our witnesses can't. But at the bottom of page two, paragraph four, recommend a methodology that paragraph. I think maybe this is a witness question. I'm just curious about how this would work what the goals are and why we would use national and regional educators. So I just wanted to kind of pin this. Go ahead and pin it. And I think that'll be a definite request. Yeah, so Devin, if you're on here, please address that in here. So if Devin's there, she can, Shirley, she hears your question. Yeah, that's great. Thank you. All right. Okay, good point. So section two, the prior version lists three million. This would make it 2.5 billion and you'll see where that additional 500,000 comes in in the later section. So this would appropriate 2.5 billion to the grant and care board in FY23 to engage one or more consultants. And this now is on this delivery systems transformation concept. So to engage consultants with expertise in community engagement, that was a recommendation from the board. So expertise in community engagement with a diverse rural population, that was the recommendation of an advocate and in health system design, recommendation from the board. So I'll stop interrupting that and just tell you now that it says to engage one or more consultants with expertise in community engagement with a diverse rural population and in health system design to assist the board in consultation with the director of healthcare reform and the agency of human services to, and then it goes into a lot more detail on the community engagement process. So again, just to recap the changes here, reduce the amount and you'll see the additional amount that additional 500,000 come up in section three and flushes out a bit more that the consultants would need to have expertise in community engagement with a diverse rural population and to have experience in health system design and this would all be done in consultation with the director of healthcare reform at AHS. And so then the case consultants would help the board and in consultation with the next position to facilitate a patient-focused community inclusive redesign of a non-health care system, this language from the previous bill, a version to reduce inefficiencies, lower costs, improve population health outcomes and increase access to essential services, including both providing the analytics to support delivery system transformation and leading the, I'm changing the word, it's a little bit broad-based community engagement process and provide support and technical assistance to hospitals and communities to facilitate redesign and transformation initiatives. And some of this language is also reflective of some recommendations that the House Health Care Committee had put in their budget memo when they were looking at some of these ideas as well. So in speaking with the board, there was some thought that some of that language would be useful here. So that the first part of that then is facilitating this redesign and providing support to hospitals and communities afterward. And then it specifies that the community engagement process must inform communities about the current state of healthcare providers in their hospital service area and projected trends, engage community members in identifying the unmet healthcare needs in the hospital service area and opportunities to address those needs. These were both, I think, came from Jessica Holmes testimony from the board before this committee. Include healthcare professionals at all levels of the healthcare industry workforce. That was a recommendation from the healthcare advocate, including those providing primary care services and provide opportunities for meaningful participation by individual Vermont residents at all stages of the process with outreach to Vermonters who have direct experience with all aspects of Vermont's healthcare system and Vermonters who are diverse with respect to race, income, age and disability status. And that came from the healthcare advocate testimony. Then this also directs the three mountain care board and so do to use a portion of the funds appropriated in that subsection in collaboration with Blueprint to contract with a current or recently retired primary care provider to assist the board in assessing and strengthening the role of primary care in Vermont's healthcare system and regulatory processes and to inform the board's redesign efforts from a primary care perspective. Then we end out the first report date from September to November 1st. So an update of the use of funds appropriated and that update goes to that health reform oversight committee and also the June 15th report to this committee, the finance committee and household care and just takes out some of the description of the process because there's so much more was added in to that section. Section three is a new section and it was the idea of put it as a new section and do things differently was a recommendation from the Green Mountain Care Board. So that's why their initials are after the section heading and this is getting at that idea of data collection and analysis that we had looked at in previous drafts. So in connection, this would have in connection with the comprehensive update to the statewide health information technology plan that is due to the Green Mountain Care Board by existing statute on or before November 1st of this year would direct DIVA and AHS to recommend ways to and then get some to the language that was in the previous draft about enhancing the state's data collection and analysis by connecting clinical and claims data for an enterprise master patient index EMPI that collects data while preserving and protecting the confidentiality individually identifiable patient information including health best to optimize coordination and alignment of the EMPI with V-Cures and the Vermont Health Information Exchange and use data on patient care and outcomes to inform the work of the blueprint in collaboration with the blueprint director and the director of health care reform, the state improvement plan adopted by the Agency of Human Services and the interactive price transparency dashboard so that the board has been directed to develop or use beginning this year. And then it would take out this language about detecting potentially avoidable health for utilization and low value care because that has also been included in the budget adjustment act. So as the board pointed out, it was not necessary here. So we're back now to the lead in language so in connection with the comprehensive update to the HIT plan, DIVA and AHS would recommend ways to and now number two is collect and analyze data regarding the social determinants of health in consultation with representatives of the FQHCs as appropriate with an ultimate goal of coordinating that data with the clinical and claims data in the EMPI and that's based on a recommendation from the consultant to the health care task force so that's health systems transformation Joshua's lens group. And recommend ways to integrate the EMPI with unique person identifiers in other state agencies and departments. And this had come from Sarah Lindbergh's testimony before this committee before the break. She talked about the potential to link some of that data across agencies and departments. She worked with me on some of that language. And then this one on the top of page eight is for that other $500,000 from the original $3 million appropriation comes in. The sum of 500,000 is appropriated from the general fund to the agency Human Services and Act 2023 to support the work of AHS and DIVA has had work in that subsection A. You may hear some different proposal on how to get at some of these same ideas when you hear from Ina Bacchus the director of health care reforms I'll just put that out there we didn't have an opportunity to put new language before you today but she may have some suggestions. Wait, I don't know why you want to ask. You wanted to ask this question about this section. Yeah, and actually one on the last section too. No, that's okay, Jack. And maybe these are just queuing it up for, oh, out another bunch of blocks on the screen for the people who are on the screen. One is the, the question, the language about primary care is to pair FB at the bottom of page five. And this question is because actually when Jen and I were doing research on a different bill, this came up that the room out care board has a primary care advisory committee. I was just trying to look at, try to find out the, I can't find it on the website at the moment, but they, and it includes a bunch of primary care physicians and nurses and primary care providers. And I'm wondering, are they not using that? And if not, why? And wouldn't that meet the needs that this is, is proposing and what's going on with that? So. I can respond to that, but I can, I'll talk about it later before that. Well, I'd like to hear from the primary care board as to why did I use that. Well, I'd say we can hear from them, but we'll also, there are others who might have a different perspective from the primary care board on this. So we should, we should, that's a good question. And then my second question is on the bottom of page seven, this integrating the EMPI with the new personal identifiers and other state agencies and departments. I guess I just want to know more about what that means because that sense alone, it sounds like it could be problematic in terms of the way of, for confidentiality, et cetera. And so just wanting to understand what exactly that means because it sounds very walkie-talkie and raises some red flags. Okay, well, then we'll hear from both of them. Yeah. Okay. Okay, we are on page eight and the blueprint for health. So there's no change to what is now section four, adding language to the blueprint statutes to say that the blueprint would include an initiative regarding the use of quality improvement facilitators and other means to support quality improvement activities, including using clinical and claims data to evaluate patient outcomes and promoting best practices regarding patient referrals and care distribution between primary specialty care. But there would be some changes to the section five report. And this would have honor before September 1st, the director of health care reform in AHS recommended health reform oversight committee, the amounts by which health insurers and Vermont Medicaid should increase the amount of the per person per month payments they make toward the shared costs of operating the blueprint community and health teams and quality improvement facilitators with a goal of increasing each plans or payers spending on primary care until primary care comprises at least 12% of the plans or payers overall annual health care spending using the calculations determined by the board and towards the report that came out in 2020 based on the 2019 Act. The agency would also provide an estimate of the state funding that would be needed to support the increase for Medicaid both with and without federal financial participation. So this is taking the place of that attempt to actually direct a dollar figure increase and appropriate funds. This would instead have them come back with recommendation on what those amounts should be and also incorporates this idea of primary care comprising at least 12% of plan spending. So can you for, where did that 12% come from? Is it actually in a report about Vermont or is it just in a report about Rhode Island? It came originally from the Rhode Island. I think the idea of 12% as the figure came from the Rhode Island report and has been heard through in some legislation in Vermont since directing our look at what it would take to get provider to get plans to 12%. So we know where we're at now. We know where we were at a couple of years ago and some of the, I don't know if there are more updated figures that one of your other witnesses can provide. We might hear. We might hear. I think Connecticut was over 12%. Some others were under, right? And it all depends on how you measure it. So the 12% is basically focus. So I don't know why we were putting it in statute. All right. Then we have on page 10. This is the options for extending moderate rate supports and so there are some changes throughout based on both what you've heard from others and in one case, my own change. So this would have Dale, and it still could be a working group comprising representatives of older remonters, home and community service providers, the Office of the Long-Term Care Ombudsman to take out the Office of the Healthcare Advocate who didn't feel that that was necessarily an appropriate place to be one in the agency of human services and other interested stakeholders to consider and the VNAs that Vermont had suggested taking out issues related to and develop recommendations for. So this would just say to consider extending access to a long-term home and community-based services and supports to a broader cohort of remonters who would benefit from, and then I took out, assistance for one or more activities a day living because the actual language talks about potentially just providing case management in which case that didn't exist. So who would benefit from them and their family caregivers including and then we've got a lot of the same languages was in the prior version of types of services such as those addressing activities of daily living, falls prevention, social isolation, medication management and case management that many older remonters need but for which many older remonters may not be financially eligible or that are not covered under many standard health insurance plans. The most promising opportunities to extend supports to additional remonters such as expanding the use of flexible funding options that enable beneficiaries and their families to manage their own services and caregivers within a defined budget and allowing case management to be provided to beneficiaries who do not require other services. How to set clinical and financial eligibility criteria for the extended supports including ways to avoid requiring applicants to spend down their assets to qualify How to fund the extended supports including identifying options with the greatest potential for federal financial participation How to proactively identify remonters across all payers who have the greatest need for extended supports How best to support family caregivers such as for training, respite, and modifications, payments for services and other methods and then finally an addition recommended by the BNAs the feasibility of extending access to long-term home and community-based services and supports and the impacts on existing services. This one have the department they all collaborate with others and AHS as needed to incorporate the working group's recommendations into the agency proposals to and negotiations with CMS for and now we're not aiming for this very next iteration of global commitment with the one actor. So for the iteration of Remind Global Conduct the Health Section 115 demonstration that will take effect following the exploration of the demonstration currently under negotiation. So when was that thing? Later, I'll tell you later. I'll tell you later. I'm not sure what the timing is because it's our problem. And then by January 15th and there may be a more elegant way to say that I'm certainly open to the voices of my foundations. So on our before January 15th, 2023 the department would report to this committee operations, Senator for operations and the House counterparts regarding the working group's findings and recommendations and then instead of requiring them to report on the portions that were incorporated into the new global commitment demonstration and the amount of associated funding needs that would just be an estimate of any funding that would be needed to implement those recommendations. Then we get, we're almost done here to summaries of the Remind Care Board reports. So the board would be right then still to summarize and synthesize the key findings and recommendations from the reports prepared by and for the board including the expenditure analysis and focus studies taken out the word all that was a recommendation from the board because occasionally they have reports that are extremely technical or very short that don't really need to be summarized. They either are not anything that anybody would be using for anything other than their own control purposes or are so short that a summary doesn't make sense. All summary, all reports and summaries prepared by the board would be available to and then this would add and understandable by the public and shall be posted on the board's website. It seems to be an intervention. That was the recommendation from the chair. I mean what was the public? Like every member of the public. Usually you know when a newspaper publishes they try to publish for a third grade reader but we didn't put that in. I think that's it. I think we're a high bar and shall be it down. We're a low bar depending on which area we're at. To be understandable by people who don't have English or foreign language to which it's going to be huge. Well that has to say I would like to, if I want to think about that if I want to help your advocate who has a lot of experience in trying to make sure that I can handle. Yeah, I can handle it. So the act would still take effect on passage and then I put in a potential name change because the bill currently is an act relating to expanding the blueprint for health and access to home and community-based services. So I changed it to an act relating to health care reform initiatives, data collection and access to home and community-based services. Oh, good title. That's so exciting. Yes. All right, Jen, thank you. Yes. So just questions of clarification and then we'll hear witnesses and be able to ask questions. The first, you know, thank you for the hard work that you did last week. We all work hard at this one, so we'll see what happens. I know there are a lot of different interests out there. We've tried in this iteration to put them together and there will still be comments going forward. We know that. Okay, and remember, it's got a really long way to go. So we're gonna, we'll turn to witness and we can sit where, there's a little special. Oh, actually, I don't think the whole set of people can fill up with that. Okay, and feel free to use the table or you can use it wherever you want. Thanks. Okay. All right, so thank you all for being with us and listening through the bill. It is a new draft. So for some of you, we're trying to get it out onto the web pages as early as we could and we following protocol. So it's there now for your scrutiny and we appreciate your interest in the bill. It's an important one to me in particular, but I think to everyone around the table, we know as we go forward with healthcare reform and improvements for access, cost and quality. So having said that, Patrick is here and welcome Patrick, it's good to see you and you are muted, but now you should unmute yourself and we would like to hear your testimony. Can you hear me now? Yes, we can, terrific. And I- Good morning. Okay, I think we have something. Do we have anything from you? No, not yet, okay. No, you don't, but we will send you written testimony after today. I wanna say a couple of things by way of introduction. For those of you who don't know me, I worked for 29 years in state government, mostly with the H.S. I was the commissioner of Dale for seven years. I was the commissioner of mental health after Irene and I was the deputy secretary of the agency for four years. After that, I ran an FQHC up in the Northeast Kingdom and after that, I ran for a short while a housing organization in the Northeast Kingdom. I'm here today as a member of a loose coalition of organizations and people that are very committed to healthcare reform. And I'll just say quickly, here to four, we've been as a group very concerned about the direction of healthcare reform in Vermont and opposed to the ACO based model, but I have to say that this bill has changed our feelings about the all-payer model and healthcare reform in Vermont. I must say that we haven't not had a chance for me to vet every comment I'm about to make with the entire group, but I feel quite comfortable in saying that the members of our group are very excited by the promise of this bill. This bill to us really sets the stage for significant and very patient-based healthcare that we've been waiting for. So without further ado, I will touch on some points. I have not seen the new version of the bill until just now, but I'll say that what I heard didn't give me any cause for concern. It sounds like all those changes have actually improved the bill. And I will have a chance to go through it in more detail, but it just seems to improve it and make it an even better bill. We do have some concerns that I would like to bring to the committee and I know you are probably in a hurry to get your bill passed, but if there's an opportunity to submit language, it sounds like some people did submit a suggested language. We would like to do the same on a couple of the issues if there's time. I could get that language to you within 24 hours, I'm sure. The first thing is global budgets. We think global budgets done properly have real promise on a number of fronts to achieve some important goals. We would all agree they could bring stability and predictability to the hospital budgets, but I think they can also do other things that we shouldn't lose sight of. One is to create flexibility for the hospitals. They could actually think differently about how they provide community services and not be beholden solely to what they can build for. And the other thing is, I think is really important, is I think there can be administrative savings. If we do global budgets correctly, then a lot of the billing and the charges and all that that goes on that's so complicated, including some of the negative sides of it, like up coding, which I'm sure you're all familiar with, can go away. And those savings, we believe, should be reinvested in either expanded services or perhaps in helping people cover their co-pays and deductibles, which you know are very high for a lot of people. We do have one other concern I wanna put on the record. And as they say, we are happy to give you some language if you want it about, there should be some form of standardization of charges and rates and billing processes before global budgets are finalized or otherwise we run the risk of baking in some inappropriate processes that are currently in place. Now, there's language in the bill about benchmarking and maybe that's intended to take care of that issue. And if it is, that's great. But I think there's some need for standardization because as we all know, what gets billed for what is widely different in Vermont hospitals. And I know you had a presentation by the auditor about reference-based pricing. That sort of thing I think needs to be put in place. So that's our major comment about global budgets. I'd also like to take a minute to talk about section three of the bill about, I think it's section three anyway, about the redesign of the delivery system, which I think in the end may be more important than even global budgets because we need as a system to start paying much more attention to prevention, early intervention, to keep people out of the hospital when possible and to prevent more expensive care. The bill uses the language of avoidable and low value care. And we think there's quite a bit of that going on. And if we are able to provide the necessary services in the community or prior to illness or in the early stage of the illness, we think we can avoid a lot of unnecessary care and save a lot of money for the system, which then should be reinvested in other services for people. And I think it's crucial that the Agency of Human Services and the Green Mountain Care Board work closely together, which it sounds like they are to make that a reality because in my experience, all those years at AHS, the connection between health, typical healthcare services and human services is often weak. And we need to strengthen that and realize how connected they are. I will take just a minute to talk about mental health, which I believe is a linchpin to real health reform. If we, I would tell you from my experience that an awful lot of physical health and medical health issues are either caused by or exacerbated by mental health issues. And if we do not only strengthen but expand our mental health services, we will never get a handle on healthcare costs. It's that important. So there, I would take more time to talk about the importance of home health. There's so much more we can do there of hospice. There's so much more we can do there. And I'll touch in a minute on what we call the dual eligible. I want to support the language in the bill about the blueprint. I worked with the blueprint extensively when I was in state government. The blueprint is a great idea. It was a great program. It's been very effective. And I really, I think it's terrific that the bill refocuses our efforts and our attention and money on the blueprint. The only comment there is, I think it's really important whatever the rate is that the blueprint is gonna be able to pay primary care providers be sufficient. Even back in the day, the blueprint asks quite a lot of primary care practices and the payment to the practices really wasn't sufficient to cover what we were asking them to do. I think the situation's only gotten more complicated. So it's really important that that be addressed and the bill does that to some degree. What's missing in the bill, I think is some kind of language about funding, all the services that are necessary in the community. I realize what we're doing here is setting up a process for a community engagement. But if we don't have sufficient funding for mental health and home health and the other services, whatever we put in place is gonna fail. Maybe this is not the bill to put that language in there, but I think there should be and could be some direction around funding for those agencies. And the final comment I'll make is on the last section that has to do with long-term care. I was very excited to see that. And I'll tell you that for a number of years, I have felt that our long-term care services have just not been expanded or improved the way that they should be. I was the commissioner of Dale when we instituted the Choices for Care program and negotiated the waiver with CMS at the time. And that program has done a tremendous amount to keep people out of institutions when they want to be out and save the state a lot of money. But there's much more we can do there, much more. And I think the language in the bill sets that up. To see in the bill talk about flexible funding is just really great because flexible funding is especially important to this population, to make sure they get what they need, when they need it and keep them out of the hospital and out of the nursing home. And that just brings me quickly to the duly eligible. Those are the people that are eligible for Medicare and Medicaid. They're usually poor and disabled and they tend to be the most expensive cohort of our whole population. And there's a lot we can do with the duels to reduce costs and improve care. There was a duly eligible project at one time with the Agency of Human Services and it folded. I think it should be reinstituted. I'll be happy to give you some language about that. Very simple language about reinstituting that because the possibilities are huge. So in summary, I would just like to say that I think I speak for the group of people I've been working with in general by saying that this is a huge step in the right direction. We really appreciate the work the committee has done. And I think we are setting the stage for really positive, cost-effective, value-based healthcare in Vermont with this process. And I want to thank you very much. And again, if there's any room to submit language, I'd love the opportunity to do that. Well, thank you very much, Patrick. I appreciate your positive comments on this. It's been a long time coming for some of us working through HRAC consultants and working through our healthcare access and affordability task force and then also the work of our other consultants and HRAC. So there's a lot of work that's been going on that's been leading to this place. But I think most importantly, as you have acknowledged the linkage between our community services and our social services with our medical community that this is a very important direction for all of us. And I very much appreciate your comments. Your request to submit language would be great. We can't promise anything knowing that the bill has a ways to go, but it would be terrific for you to submit the language that you have. You can send it to me and Erin and copy Jen, please. That would be very helpful. And then we'll look at it, yep, so good. All right, questions, Senator Hardy. Thank you, Madam Chair. And thank you, Patrick. I'm so glad you could be with us today. I have two specific questions, I think, just two about your comments. First, do you have a bill in front of you, the new version to look at by any chance? Well, I'd have to call it up on my screen. I do have it here. That's okay, I can just ask you. So on the top of page two, there was language that was included in this draft that was recommended actually by the healthcare advocate about that the payments be based on actual and necessary costs of providing services, not solely on historical charges. That I think wasn't, I don't want to speak for Mike who's sitting behind me. I don't know if you can see him, but. But I think that was an attempt at least to get at some of the sort of concerns you raised about, not having the payments be based on what was charged in the past, but be based on what is actually the cost of providing the services, sort of like the reference based pricing, but not tying it to a fee for service kind of language. Do you think this is sufficient enough or would you add something to this? And I guess. I, well, to answer your question, I think it's very good language. It's broad enough that it leaves the door open for some interpretation. I think the people I'm working with would like a little more specific language to make it possible to do more in terms of going along a rate setting line. Now, I know we were trying to get away from fee for service. So don't get me wrong there, but I think we would favor more tighter language that would create, say more uniformity across hospital billing. So it's good, but what I would like to send you would be a little more specific. Well, you can certainly include that in your language. I do want to note though, that there are differences between hospitals in terms of what their actual costs are, based on where they are, the region, and type of hospital, et cetera, but I'll look forward to seeing what your language is. And my second question is on page seven. You mentioned the funding for, I know I'm sorry, the avoidable and low cost care. And I just wanted to point out that that language in paragraph C was deleted. And I believe Jen, you said it was somewhere else, is that right? I understand it's in budget adjustment. So that language is in the budget adjustment. So I just wanted you to know that. So if you're looking and you see it deleted, you won't say, why did they take that out? I like that, those scoundrels. So that's, we agree that that's important. It's just already been, it's now law, I think. Well, or it's almost, no, hasn't been signed yet. But the green man. Well, that's excellent. When you hear from Robin, she may be able to tell you. Okay. What is in the budget? Okay, we'll get more information on that later. But I think those are my two specifics, but thank you, Patrick, really appreciate it. Okay, any other questions, committee? Okay, good. Thank you. Thanks again. And we'll, please do send the language along and there's no promises about how much or what can, we'll do what we can do. And some of it may be appropriate to another bill. I think you indicated some of that, but we can't do everything in this bill, but we want us to do something and we want to begin the process. So really appreciate your time. Oh yeah, the long-term care stuff. We have another bill on that. Yes. Okay, thank you. So we have Devin Green here for Vaz. And Devin, why don't you introduce yourself for the record and we look forward to your testimony. Thank you. Good morning, Devin Green from the Vermont Association of Hospitals and Health Systems. Thanks for having me in here today. I want to start off by saying I've talked to the Green Mountain Care Board and the Director of Health Care Reform. I don't think we're too far off on this bill. And there are just a couple of principles I want to lay out that I'll be talking with them later in terms of any tweets to the language. But before I do that, I wanted to go into a little quick background about where we were and where we are. And I have testimony on the website. It just may need to be refreshed for you to see it, but I wanted to start off. Okay, thank you. You're welcome. I just wanted to start off by saying, although Health Care Reform has been paused these past two years, which is putting it mildly, we were at a place where we had successes. We had significant savings for Medicare of $122 million. We were reducing hospital stays and lengths of stay. We were reducing specialist visits. And there were significant decreases in unplanned readmissions. So I don't want us to come from a place on this of we weren't going in the right direction or the system is utterly broken. I do think and continue to believe that Vermont has a very strong healthcare system. And I think that that was proven as we went into COVID. Hospitals and the state really stepped up. A lot of states hospitals were not necessarily vaccinating their community or testing their community. They were just doing it for their patients, hospitals partnered with the state to do that. And COVID really stretched us thin and to the breaking point. I think going into COVID, if you see on the chart in my testimony, you can see our operating margins are getting smaller and smaller and smaller. That's all part of the hospital budget process. But COVID has really stretched us thin. It has resulted in a lot of ripple effects of things that you wouldn't even imagine happening like gonorrhea and chlamydia, the test shortages, blood shortages, just completely random things that you wouldn't think about. I was on calls with lab directors where they were sending tests to each other. So I think COVID really tested our system. I do wanna say we really stepped up, but we are, which shows our strength, but we are fragile right now. I think it's exacerbated a lot of problems that we've seen in the past in terms of mental health and also people who are waiting for a subacute placement like long-term care facilities or rehab facilities. And that has just been magnified by 100. On top of that, a lot of our workforce is leaving and we have a workforce crisis, both with people leaving and then also just with our people dealing with our afraid society and patients being frustrated and assaults going up and a lot of verbal abuse. So I wanna say we've both been strong in our response but we are feeling fragile because of that response and so I would caution this committee to tread carefully. There's no room for error here. And that is to say that our hospitals want to move forward in healthcare reform, but we also need to be at the table for that discussion. There are processes set up where a consultant comes in and then provides a plan and then the stakeholders give some feedback, but really it's the plan that goes forward and who knows how much feedback gets taken into account. And I think hospitals want to be, and that is not to say that this is what the Green Mountain Care Board has proposed. I think the Green Mountain Care Board is looking to have a very inclusive process, but I just wanna get that in the language here. So I wanna make sure that hospitals are there at every step of the way that this is provider and community led and driven so that any consultants who come in or anyone who's making decisions understands the sort of on the ground work that's happening, the details that are happening. We've heard consultants in the past suggest that hospitals should share services or they should share surgeons. And a lot of our hospitals are doing that already. And we wanna be at the table and say, this is the work that we're already doing. And here are very specific needs because our hospital is very greatly depending on where they're located or what the community is like or what the community needs. So we really think it's important to have that community and provider input from the very beginning before instead of having a process of having a plan come out and people react to it. So I'm trying to figure out, I think we're getting there. I just wanna make sure that we get that down here on paper. The other pieces I applaud the director of healthcare reform being more involved. I want this to be a coordinated and a cohesive process and the director of healthcare reform is the person who does the policy work. And I really would want to make sure that the director of healthcare reform is included in this process. And again, I think the language is getting here too. I also under the idea of our hospital system being fragile right now and no room for error. I don't wanna presuppose that the hospital global budget is the way to go. I think we can easily presuppose that we're moving from fee for service to value-based care. But if the hospital global budget doesn't work because there are certain situations in that community or we can't get the conditions right or something like that, I want to make sure that things are open to other payment models that are value-based. So just wanna make sure that global budgets aren't presupposed because again, I think we need flexibility here going forward just because we don't have any room for error. And I also think Senator Hardy getting to your question one of the things that we're proposing is this methodology for determining a sustainable rate for hospital budgets. I think this is something the green, this is something the Green Mountain Care Board probably already does, but we are just asking that there be a basis for decisions about hospital budgets so we can see the process and have it pointed to. We wanna make sure inflation's increasing. We wanna make sure the Green Mountain Care Board is looking to what things are happening on a national level to inform their process. So that's all that is asking for going forward. I'm sorry, which of my questions were you just trying to say? We need to pitch to the piece where we recommend we have the Green Mountain Care Board recommend a methodology for sustainable rate for hospital budgets and look at benchmarks, national benchmarks and other benchmarks. Paragraph four at the bottom of page two. Yeah. Okay, so can I ask about that? Is that all right, okay. Thanks, Devin. The use of national and regional indicators in growth of healthcare economy and other appropriate benchmarks, what do you have in mind there? What do you mean and how is it directly relevant to Vermont? Yeah, I think there's the rate of inflation just being one and I think that's the biggest one and also just making sure that the Green Mountain Care Board is seeking into account and are accountable to things that are happening nationally and elsewhere that are out of our control. Okay, I guess I hear you, I get it. When I read that paragraph, I didn't know what it meant. And so if I don't know what it means, I'm concerned about moving forward not cause I'm special, but because I read these bills all the time. So I guess I would like to include something there that says such as the blah, blah, blah, you know what there's maybe Nolan can come up with some indicators that would, so that it would keep in people on what you're talking about. So if you have suggestions about what they would be and it could just be a couple examples, like when you mentioned the rate of inflation, I think there's probably a specific regional rate of inflation that's specific to healthcare even. Yeah. And we could just indicate there so it would be clearer. Okay, we can do that. Okay, thanks. I guess the most important thing is agreement. Okay, Devin, why don't you complete your testimony and then I think if you do have suggestions, you can send them in. And again, there are no promises here. We're going to move with some efficiency at we want and this bill is, this is the first stop for this bill. It is a committee bill, so it will go forward. Yeah, just to tie it all together again, where there's no room for error, we have a three million operating margin, which is less than is being funded here. So we just want to make sure providers and communities are at the table as we move forward. We want to involve the director of healthcare reform and we want to provide flexibility to be able to respond if global budgets doesn't look like the way to go and would potentially hurt the system. Well, you know, the issue that you bring up last around global budgeting is an important one, but the bill does land on global budgeting and an assessment of that and then an evaluation of how it could be put in place. There's no guarantee, as you well know, that that would be the case. So there's no guarantee that global budgeting will be able to be implemented or taken forward in total totality. So it's a good comment, but I don't know that we can ask the Green Mountain Care Board to evaluate global budgeting as compared with something else. I think we're a step beyond that. So just a comment. Thank you. Yeah, okay. One more question. Sorry, I know there's one. Devita, totally hear you about the fragility of the system, the workforce challenges, et cetera, et cetera. Is there something that is, is there something you would like to see in the bill that acknowledges that more or is it just sufficient to say it over and over and I'll hear you? Or does the bill do it enough? I think the piece that will be really important is just nailing down the, including providers and communities in the process and making sure providers are at the table and in the decision-making process instead of just the sounding board. Okay. Okay, thanks. Senator Comer, yeah. I guess I've listened to Patrick and listening to Devin. If we go to global budgets, we, somebody up here in this building decides how much money you're going to get and you've given up your control to adjust fees. And so our history of adequately funding the services we fund like mental health is not good. No. And I understand why the hospitals would be very nervous to give up their ability to handle their own income. Or it, yeah. And it's not easy. It's not easy and there's a balance there somewhere. Totally. Yeah. I mean, it could, the devil's in the details with global budgets, right? Like one thing that has come out of the all-payer model is that we have liked the Medicaid payments and the way it's been structured under the all-payer model which is akin to the global budget. And so I do think the idea is worth exploring, but yes, this is why we're uneasy and we want flexibility because there's not a lot of room for error. And so we need to be able to readjust if it feels like it's going to impact quality or access for our communities. Okay, Senator Rooker has quite just a comment. I mean, I just, you know, I can hear you about the fragility of the hospitals and the need to be careful when we try to implement a global budget. But I just want to remember that, you know, as much as we need hospitals, people need to be able to afford these services. So there's that balance. So when you talk, Devin, about making sure that the providers are at the table, I understand that, but we really have to listen to the community as we see it in Vermont. I mean, regionally it's one thing, nationally is another, but as we see it in Vermont, what are people being able to afford to access the healthcare that we have to offer. And certainly I don't want to see any diminishment in the quality of healthcare. And I believe we have a good healthcare system as far as quality goes. That's something that I think we really have to balance between the hospitals, the patients and those of us paying the tax. Any other questions? Just to respond to that. I think if you could send your testimony, that's helpful. We've gotten into a conversational mode and we really don't have time to do this right now, but we will return to the bill and you are all welcome to be zoomed in to get into the conversation as we look at additional recommendations from folks. So we will be doing that, I think. Mara. We'll be back. Make your last comment, Devin, please. A lot of turning. And the director of healthcare reform in the Green Mountain Gare Board can speak more to this. I do want to manage expectations around affordability. I think global budgets are good. It moves things in the right direction. It provides people the right care in the right place and value-based care in general, not just global budgets. I don't know if it's going to save money for people tomorrow. It's the sort of long-term strategy to get people healthier, to save money for the whole system. If you look at the Pennsylvania model, which is a global budget model, they're being asked to save 35 million over seven years. We saved 122 million in two years. I'm not sure if this is going to get to the immediate savings piece, but I do think value-based care is the right direction for Vermont to be going in. Okay, thank you. Thank you for that. That's a good reminder. And what I'm going to suggest is that we move on to Ina Bacchus, director of healthcare reform services. And then we'll go to Rebecca Copens and Mary Kate Mollin. But Ina, thank you for being here. Let me ask you a question. I have a question to ask of Robin Munch. Are you intending to testify or are you here to respond to questions? I am here to respond to questions. I have a few comments about the new version, but I can be pretty short and sweet. Okay, so we'll get to one. Good, thank you. That's what I mean by efficient. That's great. All right, so Ina, thanks for being here. Thank you. For the record, Ina Bacchus, director of healthcare reform and the agency of human services. We appreciate the work of the committee in this updated version of S-285, which is moving to acknowledge the importance of including community-based providers in healthcare system redesign. Over the last two years, the state of Vermont and AHS have been partnering with providers across the healthcare system to respond and adapt to the unprecedented global health pandemic, as you know. We are very proud of the ways that we've come together across the system to ensure that care is available for those who are sick, including those with COVID-19, establishing a statewide network of testing centers, providing large-scale vaccination opportunities and much, much more. And Vermont has one of the lowest rates of death due to COVID-19 in the country, and we owe this to this spirit of collaboration across the system. We can see clearly some of the ways now that COVID-19 has changed the healthcare landscape in Vermont and the country. Two key examples of these changes are, we recognize clearly that one of the non-COVID risks of the pandemic has been delays in preventive care and treatment. And we see now that people are arriving in the healthcare system with more acute need for care because of these delays in preventive care. Workforce shortages also have stemmed from the pandemic and are particularly acute in health and human services systems. And there is no substitute here for the human beings who are essential as caregivers in our system. As we turn to recovery and revitalization after these two years of COVID-19, we are implementing a workforce development strategic plan and we're investing in short, mid, and longer-term strategies to address significant workforce challenges in the health and human services system. Similarly, our approach to healthcare reform necessarily must be informed by the impact of COVID-19 on the system of care. So I want to take this opportunity to expand on the concerns we previously articulated about how the bill has written is providing some significant resources and support for hospital global payments when it's also essential that any system redesign and subsequent proposal for an all-payer model include accountability for total cost of care and not only the care and services delivered by hospitals, particularly in this environment where we know how important preventive and upstream services are, as well as those services delivered by hospitals. We've been clear that the predictable and prospective payment models that Medicaid put in place prior to the pandemic have created some stability during the pandemic. When visits to health and human services providers sharply declined in the early days of the pandemic, the fee for service revenue that was generated by these visits fell away for those providers who were participating in these predictable prospective payment models, that steady Medicaid revenue provided some stability during this challenging time. So we are fully in support of exploring hospital global payments because this model, depending on its design can provide for the predictability and stability in the system and also provides incentives to redesign care and again to support upstream strategies that impact health and wellbeing and move toward value-based care. But I want to be very clear that hospital global payments in isolation can have unintended consequences. Hospital global payments alone can result in inappropriate shifting of hospital-based services to outpatient settings that are not covered by the global budget. For example, discharging patients to another care setting before it is clinically appropriate so that more dollars are available within the global budget and are not a cost to the system. Furthermore, in Vermont where patients travel frequently between hospital service areas to access care, a system of global hospital payments in isolation would require a complicated and frequent recalibration of these budgets. So for these reasons, I really urge the committee to consider that support not only be provided for the hospital global payment design but also for the design of a total cost of care accountability structure that includes healthcare expenditures beyond hospital-only services. As we explore a next potential agreement with Medicare to participate in an all-pair approach in Vermont, we need to ensure that we're using our resources to explore not just hospital global payments but also the potential for broader global budgets inclusive of community-based providers. And again, that our plan includes a strategy for total cost of care accountability and that this plan incentivizes the healthcare continuum to work collaboratively across service types to deliver high quality care in the least cost most appropriate settings. Vermont's all-pair model agreement today includes accountability for the total cost of care in services both hospital and non-hospital services. And as we consider a global hospital payment model, we need to consider, again, a total cost of care accountability overlay that would work with a potential new payment model for hospitals. Maryland is another state, and you're very familiar, that has implemented hospital global payments and it too has a total cost of care accountability model that works in companion with the hospital global payments. This total cost of care overlay in Maryland creates the incentives for care to be delivered in the most appropriate settings and to ensure that care is not withheld if hospital global payment were operating in isolation. As the director of healthcare reform, I and the agency of human services must approach healthcare reform through the lens of the full care continuum both upstream and downstream, not just from the perspective of hospitals. If resources are provided to inform Vermont's future healthcare reform direction, these resources should steer towards a comprehensive plan for reform inclusive of this total cost of care approach rather than an approach that is siloed to hospitals alone. As you know, in my position, I'm also required to coordinate healthcare reform initiatives across state government and with the Green Mountain Care Board. And when it comes to exploring these frameworks for a potential next agreement with the federal government, the responsibility to coordinate between the Green Mountain Care Board and others to ensure a plan rests with the director of healthcare reform. I think further the Green Mountain Care Board would agree that their purview doesn't extend across the full continuum of health and human services care. And yet these providers do need to work together across settings, particularly as we seek to redesign care in a way that is successful, in a way that does provide for more flexibility and more support both upstream and downstream of hospitals. Certainly the director of healthcare reform is ideally situated to support coordination in this regard. And in particular, the blueprint for health, patient-centered medical home program is an essential component of our healthcare system today. Is certainly essential as we consider a system that is moving more so towards value-based payment that will rely on the integration of a strong primary care system with mental health and substance use disorder services, for example. And in the role the director of healthcare reform along with the blueprint for health certainly want and urge the committee to incorporate considerations around our existing primary care infrastructure and its importance as we consider healthcare system redesign. And finally, as indicated when Jen was presenting on the changes to the bill, I am also the chair of the Health Information Exchange Steering Committee, the HIE Steering Committee. And I would like to propose an alternative approach for the committee to consider in terms of harnessing claims, clinical and social determinants of health data. This approach would support the Steering Committee's ongoing work to promote a one health record for each person. The Steering Committee has made progress on this path in recent years. The Steering Committee is working along this path, has a strategic plan to support this path and has embarked on and tested the integration of Medicaid claims data with clinical data already in the HIE. And because we have established tools within the HIE to provide for this integrated and longitudinal record, we think that the creation of an enterprise master person index may be duplicative with tools and strategies that already exist for better integrating and linking data. And so we would recommend that the health care, the Health Information Exchange Steering Committee continuous work to create one health record for each person that integrates data types to include healthcare claims and clinical mental health and substance use disorder services data and social determinants of health data. And specifically in furtherance of these goals that the Health Information Exchange Steering Committee include a data strategy in its 2023 Health Information Exchange Strategic Plan update which would emphasize merging claims data in the Vermont Health Care Uniform Reporting and Evaluation System, V-Cures, with the clinical data in the HIE. And with that, I will close my testimony and thank the committee for your continued interest from hearing from me and the opportunity to provide this additional testimony relative to this bill. Oh, yeah, thank you so much. And we don't have your comments yet, but if you could send those along. And I know that you sent recommended some suggestions for language. So if you could also get that to us at the break. Okay, we have 10 minutes left. So if it's a question of clarification, we'll do it, so yeah. Okay, I just, I know it. I think you're sending this anyway, Ina, but what you just covered with the technology stuff was hard to follow for those of us who are not in the lead. So I'm assuming you sent that to Jens. Take a look at it, or no, Jens, you will. Okay, great. Thank you. Yeah, we'll get that. Yeah, it is, I did talk with Ina about the HIE executive groups and it does make some sense. Yeah, it sounds reasonable, but it also sounds technical and difficult to follow. So yeah. Okay, so let's move on to Mary Kate Pullman and then Rebecca Copans. And we may go over a little bit, but we can't really go over because we're going to lose our ledge council and she's critical to our working on the bill. So Mary Kate, welcome. Hello, thank you for having me. For the record, Mary Kate Pullman, I'm the director of Vermont Public Policy for Biscay Primary Care Association and I will be presenting our members' views on 285. Going forward, I just, I first want to thank the committee for addressing these issues. These are some really tough, thorny issues to work through, so props to the committee for working on it. I'll start, I know we've heard from a number of our witnesses today. We're coming out of a once-in-a-century pandemic and our providers are exhausted. I just want to make sure everyone's clear on that part. I think they are, but I think you are, but... And I will also call out... I'm exhausted. Sorry, we're all exhausted. And I also want to call out that we're still trying to wrap our minds around the full impact of such significant disruption. What's the impact of the delayed care on health and health services utilization? Are we going to see an uptick in the need and if we do it with care? What loads of care will need to continue or want to be continued and which will revert to a pre-pandemic model? So that's the context we're working in and should be part of the considerations as we go through this. I just want to echo Ben's comments. Providers really need to be part of the decision-making process around this work. This is a pretty significant shift to our system. Some might even go so far as seismic shift. And so we really need to understand what is feasible to put into operation. And why are primary care FQHCs interested in this? Well, a global budget for a hospital requires a strong system, both for the upstream care so that we can reduce potentially avoidable needs and the downstream care so that we have a place to move patients out of the hospital once they are ready to be discharged. And right now we don't have those pieces in place and that could actually hurt our hospitals if we can't move patients where they need to go. I want to applaud the director of healthcare's call for looking at the total cost of care outside of a hospital. But in this, I'm speaking to the specific global budgets for community providers language. I would call out that that language really needs to be focused more on specific payment models need to be appropriate to the type of provider. And I want to call it, for example, FQHCs. We have very clear federal requirements for alternative payment models and that needs to be part of the conversation FQHC budgets also depend on federal programs and being in the 330B or 340B prescription drug program and then the 330 grants that they receive. We also have our operations are heavily regulated by a federal organization person. So like how all those pieces fit into thinking in a systemic way around global budgets really needs to be part of the conversation. On this issue, we are in the process of reaching out to the Maryland Primary Care Association. This is to understand really how the FQHCs are participating in Maryland's total cost of care model. And I think that would be really helpful as we move forward. I would echo Devin's comments on the increased role of the director of healthcare reform especially with the need to focus on the next federal agreement, Medicare's role and the framework through which payment models will be implemented really needs to be understood before we wrap our arms around the significant shift in how we develop and strengthen our healthcare system. We heard questions earlier on the primary care advisory group for Green Mountain Care Board. And I just wanna touch briefly on that because I'd say the idea of having a program primary care presence with the Green Mountain Care Board is it gives that person much more access to data and information that the PCAG does not have access to. And the PCAG they are an amazing, they provide amazingly rich conversation and advice and perspective on primary care. But I think having someone who is more regularly immersed in the conversations has access to the data and information is valuable. Going on to the section on the data and social determinants data, federally qualified health centers are mentioned there. And I wanna echo Ina's comment about the work that's already happening in the HIE steering committee with the data strategy and data governance and the role of the state's data chief data officer. Some Senator Hardy mentioned kind of concerns around bringing all of that data together. And I completely agree that is something that we need to be very careful with public trust in how we are using data is essential. However, I would also call that we weigh what is the risk of not bringing that data together? What are we missing by not understanding different elements of a person's care and services that they're getting? And that can be detrimental to the individual. And there are a lot of states that are working on this. And so I think following their lead, learning from their lessons, those are important pieces. And the HIE steering committee has got this, they're working on it. So that's kind of my comments on the global budget portions of the bill. I just wanna turn to the sections on the blueprint for health. We support increased funding to community health teams and quality improvement facilitators. The community health teams are critical to our members' patients. They really build on the FQHD's model of integrated whole person care and the ability for someone to go into their primary care, flag a mental health concern and then being able to walk down the hall and talk to a community health mental health provider is really important or nutrition or social services, whatever's needed. It's really important for bridging those connections. The quality improvement facilitators, these were previously known as practice facilitators and they originally had a role in the blueprint on preparing practices for the transition and preparation for becoming patient centered medical home recognition. And then they continued to go work with on ongoing quality improvement initiatives. As we start looking, increasingly looking to shifting to value-based care, practices are gonna need this additional facilitative support to make those clinical transformations so that they can align their model of care and really optimize how the payment is coming in when it's coming in differently. But in having that facilitated support is really helpful to our members. I hear our medical directors saying, hey, I understand the financial side, but how does that impact how I get care to my patients? And I think having that external voice is really and supporting our practices do that is really important. And I would say that the clinical, the quality improvement facilitators, they're pair agnostic. And I think that's one of the enduring strengths of the blueprint program is that these individuals can come in and help a practice, make this clinical transformation and implement a new care model for all of their patients, and not having to segment it out by pair population. So that would be a voice for why the clinical facilitators or the quality improvement facilitators have such a large, important role. And that's what I had. I tried to cover it a little bit given the new draft of the bill, but I am happy to answer any questions. Thank you. This is helpful. And if you could shed your testimony, that would be terrific. Because you have many comments that would support some of the language changes others have made and perhaps some language changes that you might include. Okay. Yeah, that's great. I think we're gonna keep moving along unless it's a question of clarification or any additional. I just make one quick comment. So Mary Kate, the language on the bottom of page seven is that it's not that I have concerns about the broader thing. This language is so wonky that it doesn't make sense. So I think Ina was gonna send in other language in this whole area. So maybe Ina, if you're listening, if you can make it less wonky. It's data. I get it, I get it. But we have to understand what we're saying here. And it's really just from the perspective of somebody who's not in the weeds as much as you all are, and we are sometimes, it really, it doesn't make sense the way it's written. Yep, that makes a good cause. I just wanted to call out a couple of things about that. Yeah, yeah. We good? Sure. All right. I think it reads great. But you're a woman, too. Okay, no. We have to adhere to the rule at the end of the bill where it says, make things understandable. Yeah, we have to practice what we need. So, Mary Kate, thank you. And we'll, we would look forward to your written information. Rebecca, thank you for being patient with us and we're glad that you're here. So we welcome your testimony. Thank you. Thank you for having me. Rebecca Copans with Blue Cross Blue Shield. And my testimony is focused on the flip side of this bill. The blueprint for health, supportive care coordination and other programs within our healthcare system. While it was a novel approach 14 years ago, these programs have failed to integrate value-based payments and other reform efforts. And it continues to lack detailed reporting to ensure transparency and the ability to accurately measure quality outcomes. We appreciate the language in the newest draft and fully support a study that would take a deep dive into recommendations for evaluation, reporting and targeted efforts at an individual level. Since its inception, our members have invested over $67 million into the blueprint. This is a massive amount of funding for a program that cannot provide patient-level reporting data. The blueprint has devolved into a narrowly funded program. Originally, a number of self-funded, self-funded employers voluntarily participated, but there's been a continued exodus due to the lack of quality reporting and clarity of outcome, which has left only six self-funded Blue Cross customers contributing. The future of the all-pair model is tenuous at best and now reform planning is turning toward global hospital budgets, which if done in a thoughtful way, has great potential for stability for both the monitors and the hospital system. It must be done with a keen eye on community engagement and we must ensure that those who are footing the bill, the small and large employers and regular verminters have a prominent seat at the table. There are people like Pocosello who have spent a year engaging with Vermont communities and they're a career engaging with Vermont communities and they're really good at bringing people together to have difficult conversations and engaging folks who may not attend or feel comfortable speaking out at a board-style meeting. And there are other people who are really excellent at health systems like Johnnick and Durr or Josh Shlens. And I would encourage that the committee really delineate between those two expertise by stipulating that a one-size-fits-all consultant doesn't work for this project. With this and all of the policy proposals that you're considering, please remember the Vermonters who are paying the bill. If you haven't ever attended a public hearing during the Greenmont Care Boards Rate Review process, I can tell you that the stories are consistent in your message. Vermonters are angry and they are all asking why their premiums are going up year over year. Collectively, every policy change we make must balance both choice and cost for Vermonters. We need to take into consideration the full spectrum of income, health status and their access to care statewide. Thank you. Thank you very much. And we do have your comments and writing and we greatly appreciate that. So thank you for your comments. And I see that Robin Lunge of Greenmont Care Board has turned her self on. So before we get to you, Robin, questions for Rebecca? I'm sorry. Rebecca, I totally appreciate your comment about the consultant issue and I've been trying to figure out how do we embed that in the bill? Because I think you're right. If we get the wrong consultant, it will never work. But how do we, do we have suggested language to say how do we get a mix of Donna Kinzer and Paul Costello, like merge them together and that kind of thing? Do that would be helpful? I think you need to say, instead of just one or more, it should delineate the two. I mean, because speaking of, I'm a communications person and so often people put in one communications role, they do like graphic design and communication. Those are two different people and two different roles and it's wishful things going to have one person be expert at both. And I think it's the same for that. I mean, there are people that are really good at health systems and there are people that are really good at community involvement. And those are generally, I've not met the person that's the same. I'm gonna suggest Robin Lunge way in because it looks like she's interested in responding to that question. It might be helpful. So Robin, welcome. Sure, and certainly we, our intent For the record, you are? Sorry, for the record, Robin Lunge, member of Green Mountain Care Board. I couldn't agree with Rebecca's comment more. I think we were intending that by using the term one or more consultants that it would be a team of people with different skill sets and happy to kind of take another look and see if we can make that clearer because those are two different skill sets and that's why a team approach would be necessary to get the right expertise. Will you be setting us a suggestion for approving that language? Sure, given the time, what I was gonna suggest Senator Lines, if this is amenable, if the committee is amenable to this is that after today, this afternoon's Green Mountain Care Board meeting, I am available to meet with people and work through language suggestions and try and get back to the committee and Jen later tonight with, to work through some of the issues. Devin and I briefly met this morning, we're gonna meet this afternoon. I reached out to Mike Fisher, he is available, but certainly anyone who wants to work with me on sections one and two, so the hospital sustainability sections, I'm happy to do that and try and work through some of that process outside of your room if that would be helpful. Well, that would be terrific. This is the hallway conversation that is very useful. And so what I'm gonna suggest is that you work with those folks, people are setting stuff into Jen and to me and to the committee. And I'm gonna suggest that we keep the committee out of that discussion that you're having with others and get your comments and recommendations to us. And then we'll see where we go from there. Tomorrow morning, we will have an opportunity to look at everything and make, do some markup on the bill based on what we're seeing in here. It's, you know, this is where we're actually getting the sausage made, so it's great. I appreciate that. So Senator Hardy, go ahead. There's one quick question on page five, Robin. Yes. I wrote in the margins, I would be great to actually use the words listen and hear because engage and inform sound, especially inform, it just sounds like you're gonna be talking at people and saying this is what the healthcare system is. And I would really like to hear from people what they think the healthcare system is and how it's working for them. So listen in here, what's working, what's not working, what's needed and what's missing and so, and maybe find another word for inform because that sounds very top-downy. But I look forward to hearing what you, I look forward to hearing what you guys come up with. Great, thank you. So I guess let's defend the word inform because sometimes when you have these public gatherings, they need to hear information before they start, but it is, I agree with you. The listing is really critical concept. All right, any other comments, Robin that you'd like to make about the bill at this point? I think most of them I can work through with the folks that suggested them. The one thing I would suggest is in relationship to the work of the HIE Steering Committee, there is a section which would add a change to V-Cures to allow that data to be combined with clinical. Right now, there's a statutory prohibition that gets in the way of that. That change is in S164. So we would ask that perhaps you add that V-Cures change so that we can proceed with that work. I'm happy to talk more about that tomorrow because I know that's a bill that we didn't have time to take up. So what I'm going to suggest that you include that language and as you send along recommendations to Jen, to me and to others, so that's good. That sounds terrific. And then lastly, I just wanted to mention that when we were here before town meeting week, we did provide two summaries as examples to the committee of how we were approaching those. We'd be happy to get some feedback, particularly in terms of whether or not you think they're understandable by the public, that would be very helpful to make sure we're on the right track. All right, thank you. Okay, terrific. Thank you everyone for helping informing us today. We have been listening. So we're going to take a four minute break. Oh, thank you. Our committee needs a little break and then we're going to come back to 195 and 194.