 My name is Bruce Hamery, and I'll be moderating this session. We appreciate all of you taking time at the end of a busy day and time away from your families to participate in this. We're going to have a very short presentation before we get to the main purpose of this meeting, which is to learn from you, your experiences and issues with assisting your patients and their families in getting timely and appropriate healthcare in Vermont, and a number of other issues we'll go through. I would note we are recording this session. The purpose of that is to allow us to accurately capture all of your comments, advice, and the issues you raise in addition to the notes we're making. We are also being joined by some members of the staff of the Green Mountain Care Board and the Agency of Human Services. We may have some legislators on the call as well, and if so, I would ask them to please identify themselves and make whatever comments you wish to make. Mark McDonald, Senator from Orange County, here to listen. Thank you, Senator. Others please. Okay. Well, a couple of quick housekeeping points. As always, please stay on mute when you're not speaking. When you wish to speak, if you can find it and sometimes I can't under reactions is an option to raise your hand. If that's a problem, put your video on and wave, we'll call on you. We'll stop periodically to ask if there are individuals on the telephone who would like to comment. So we'll get started. Gretchen, can I have the next slide, please? This is what we're about. The Legislature passed Act 167 last year. It has several different sections. We are working on one, and that section requires the Green Mountain Care Board in collaboration with the Agency of Human Services to conduct a data-informed, patient-focused, community-inclusive engagement process aimed at helping Vermont's hospitals reduce inefficiency, lower costs, I would say, constrain cost growth, improve population health outcomes, reduce health inequities, and increase access to essential services and maintain adequate capacity for emergencies. Green Mountain Care Board has asked Oliver Wyman, my group, to lead this effort to ascertain your interactions and those of the community as well as a number of disadvantaged and other groups suffering from health inequity to determine your interactions with, pardon me, the health system and needs, pardon me, perceived needs to improve equitable health care access as well as outcomes. So what we're about is we've spent several months collecting available data as well as reviewing state reports and prior efforts in the areas of health workforce, mental health needs, housing needs, information technology at a state level, and so forth. We've spoken with a number of state legislators. We've spoken with many of the state agency program directors have a few to go. We've spoken with all but one group of hospital leadership and are now speaking with a number of the board of hospital boards. In the last five weeks, we've conducted over 100 meetings, all virtually, and in the next couple of weeks, we'll conduct roughly another 25. Many of these will be focused on smaller groups of individuals and groups affected by health inequity, by virtue of gender identity, language, ethnicity, rural travel issues, and other related issues. So those are in progress. So we are now conducting the listening sessions among those groups, community meetings, these provider meetings and community meetings are both being held at a hospital service area level. We've also conducted four general statewide community meetings. The provider meetings we define as anyone who gives care in the community. So that includes not only physicians and nurses and advanced practice people, but also emergency medicine technicians, dentists, dental hygienists, physical therapists, psychologists, social workers, nursing home people, home health agency people, and others. So we're trying to reach as broadly as we can. At the end of these sessions, which will be before Thanksgiving, we will collect your observations and the issues you raise, take those into account with the information that's available and formulate a series of options for the hospitals and the Green Mountain Board and ultimately the legislature to consider. We will then subject those to intensive analysis to determine the potential impacts of those on both the hospital and the community it serves and receive the results of those analyses, which will be done by a different group late in the winter. So we'll reconvene, take a look at those, reformulate the options as needed, and then come up in person to speak with the hospital board and leadership at the hospital and then following that to have a general community meeting in this part of Massachusetts, a town meeting of the citizens of that area to again discuss what those recommendations could be and from both those groups to get your feedback, reactions, advice, and then we'll go back, reformulate if necessary those recommendations and then bring them forward in a final report to the Green Mountain Care Board and ultimately to the legislature. So we're hoping to get that process done by the middle of April, if not a little earlier, so that the board and the legislature have time to consider that before the legislature adjourns. So that's the process. We think it will be very open as transparent as we can make it and remember, this is a process and there are a lot of steps to go through. We are not, we are looking 10 years out. So we're, and we're looking not at the hospital in isolation but as part of an organism that includes the medical neighborhood around it, the available community, the current community needs and available services in the community that would potentially reduce the need for hospital services as well as the services that are available when the patient or the person is ready to leave the emergency room or the hospital to go home, go to necessary skilled nursing care or receive mental health inpatient treatment. So we're looking at all the pieces of this as well because clearly the hospital does not act alone and the number of those issues are outside its control. Go to the next slide, please, Gretcher. So this is the team. My name's Bruce Hamry. I'm a physician trained a little over 50 years ago. I have practiced and taught medicine in two academic centers for over 20 years was professor and associate dean at Penn State and then the executive director of the university hospitals and chief operating officer for that campus. Moved to Geisinger was the system chief medical officer. We served a population of about a million and a half, 25,000 square miles of mainly mountains and trees in North Central Pennsylvania where the largest industry was forestry. I had three hospitals, about 1500 physicians and advanced practice people, 70 clinic sites and a budget of about $3 billion. We did a lot of care in very small communities. Some as small as 500 people. One of my colleagues in this is Ms. Elizabeth Sutherland. Elizabeth has worked with me and my partners for 10 years. I've been at Oliver Wyman as a partner and chief medical officer for 10 years. And we are in the business of assisting hospitals, health systems and some small foreign countries to redesign their health systems to achieve the goals outlined in Act 167. Elizabeth has her master's in systems management and engineering from MIT. And she is our person who is leading the effort on health equity. Elizabeth staffed the Pennsylvania governor's commission on health equity last year and has worked in a similar area in California and San Francisco. Sam Winter is our engagement manager, responsible for keeping all the pieces of this large effort together. He has about 10 years of experience in healthcare consulting. Dr. Chudera Chuecky is a neuro pharmacologist with expertise in alcohol and tobacco dependency. And he spent a little over two years with us working with Medicare and Medicaid payers. And Ms. Gretzell Gonzalez, who's staffing this meeting as a consultant and is responsible for a lot of the day-to-day work. So I think a reasonably broad-based team, a lot of experience in doing this sort of thing. And we are excited to be able to work with you in Vermont to advance the cause. Next slide. This is what we're about. We're gonna have a short context setting. We wanna spend the vast majority of this time listening to you and we'll have a couple of thought questions toward the end to just stimulate the conversation. And then we'll provide some additional ways to continue to give us your thoughts, advice, and experience after the meeting. Thank you, Gretzell. So this basically says what you know, both at a national level and a state level, healthcare is in serious trouble. The costs are going up, hospital costs driven by personnel, by costs, by supplies, and by the ever-increasing cost of drugs and biologics. There are shortages of every healthcare professional imaginable, including housekeeping staff and dietary staff because McDonald's pays more. Hospitals have unsustainable margins and families are unable to afford care. In Vermont, certainly this threatens the sustainability of the hospitals. There's a considerably large underinsured population. We'll get to that in a minute. Hospital operating margins have been declining generally for several years and hospital days cash on hand are also going down. We've spoken with two hospitals in the state in the last several weeks who have tripped bond covenants because of one or the other of these issues. And as you know, when you trip a bond covenant, you have a short time to get it fixed or somebody else runs the hospital. Patient access and service wait times are very poor and getting worse. We have data 18 months ago that wait times were many days to months out and certainly more recently have heard stories of six to 12 month plus waits for needed care. Next slide. So the uninsured rate in Vermont people without any insurance is low compared to the nation, 3.1% versus 8.6, but 40% of people under the age of 65 who have insurance do not have enough money to afford the out-of-pocket expenses for co-pays, deductibles, prescription drugs or over-the-counter meds. And so they delay care or don't seek care at all. Next slide. So this shows the math. According to the 2020 census, median family income in Vermont was a little over $67,000. After deducting state and federal tax, the take-home pay is about $43,000. And you see that if the employer and the wage earner can afford a platinum plan from one of the larger insurance companies in Vermont, the total cost of those premiums is close to $40,000 a year. Even with that and with a relatively low deductible, if someone in that family of four becomes ill, the family can expect to spend about $5,000 in out-of-pocket costs. So $5,000 out of a total take-home of $43,000 is an awful lot of money. Next slide. This is wait time in days, 48 days, it's 18 months ago. And you see roughly correlated with the subspecialization at the hospital in terms of weight. But again, the stories even then of six to 12 month waits, certainly this has gotten worse. Next slide. Okay, so we've talked about the house rules. Please use chat if you wanna add additional comments. We've had people send web links to this, happy to get that by chat or later. We're not able to talk about specific issues, it's more for general public of course, but if there are general specific issues regarding a particular patient or need, please contact the office of the state healthcare advocate, phone number and website are there. And we'll at the end of this give you some ways to continue to provide us your advice, recommendations and input. So next slide, and this is the last one. So these are the general sorts of issues we'd like to ask you to address. What issues are you encountering that limit your ability to provide care to more people? What issues can be addressed to make providing healthcare more efficient and affordable? What can be done to ease your life? What problems are your patients and their families having in getting preventive services or medical care? And when your patient needs care from a specialist or from someone else, how do you or can you assist them? How easy is that assistance to get? What are the hurdles that you have to go through to get it? How can we improve health equity in Vermont? We know people live in rural areas, they have trouble with transportation, they may have language difficulties or specific needs because of sexual orientation or other special needs. And we'd really like to hear from you what some of those issues are that your patients are encountering, how you and the other systems involved are able to meet those or not. And certainly last in a perfect world, if you had a blank sheet of paper and unlimited funds, how would things look? Understanding that neither of those things are true and there's not the only folks with the printing press or the feds. So with that, I'll stop, ask for your comments, experience and advice. I'm sure you're not a bashful group. Yeah, Dr. Chase, please. Hi there, good to see you Dr. Harmony and thanks again for your time and all the effort on this critically important, just a beginning question. Is this meeting for providers? Is it for administrators? No, well, I mean, they're welcome, but no, we're aiming at the people that deliver the patient care. Yeah, yeah. So you're quite welcome, glad to see you again. Okay, so is Gifford one of the hospitals that Steve Hall did on the BOD Covenants? No, well, not that I know of. No, that was Springfield several years ago and the other two are working it out. And they tell me they think they'll be successful, fortunately. Yeah, so one thing I wanted to follow up on from last night's meeting, I think we heard huge outpouring from patients about their lack of access and their sadness for the departure of Dr. Barber. And I talked to her for an hour and a half last night and she's been at Gifford for eight years and a great provider, beloved by her patients. And I just think that's a horrible thing for Gifford to let her go, especially since they have an active posting on their website for a nurse practitioner to fulfill her position. And she's 67 years old. And she told me she has paid like $170 something thousand dollars a year. Nurse practitioner is gonna get paid 130 thousand. So you're saving $40,000 for all this irreparable damage to Gifford's reputation, to the morale of the entire medical staff. And most importantly, the patients who feel abandoned. And I just think I told her, she's extremely sad. She's told me she's going to the press. And I think Gifford should think strongly about reversing that decision. It's just my opinion. But I think really it's about the patients. And Chelsea is, I think it's only because of Chelsea and Rochester that Gifford even qualifies as a federal qualified health center. And to lose your own, she's the only MD there. I don't know how it's gonna work. There's a PA there, but PAs have to have a participating physician. So I don't know, that's one concern. I have several, but I just wanted to bring that up just kind of as a follow-up from yesterday's conversation, which we just heard patient after patient kind of heartbroken over that departure. And she is as well. Okay, thank you. Appreciate the follow-up in the comments, sir. Dr. Andrews, you're on mute, sir. Okay, hopefully people can hear me okay. In the car. So thanks for this opportunity. I'm a cardiologist and my background is having come from Dartmouth-Hitscock Medical Center for the last 22 years. And previously did outreach one day a week to Gifford. And then last year, joined the staff full-time and I'm here four days a week. And I am concerned about the state of healthcare and the issues of access. And the things that I think would be helpful to deliver care would be one to provide more support for primary care physicians. So that they can focus on the medical decision-making and try to unburden them of the documentation and EMR interactions, which I'm sure you appreciate are quite burdensome. And I think this extends to kind of throughout the whole medical staff of all hospitals, but it seems like in every patient encounter, there's a few important decisions to be made. That take judgment and expertise, but the visits take a long time because of the cumbersomeness of trying to gather the information you need to make the decision and then to interface with the EMR to order the tests, order the medications, ensure communication. It just seems like folks are not fractured. They're practicing at the limit of their license. And so somehow we go home tired and frustrated and exhausted, but aren't seeing 30 patients or 40 patients a day, seeing far fewer, but it's exhausting process. So I think my other comment, I guess, is that it's hard not to feel defensive being in a small rural hospital and wondering about plans to limit the existence of small hospitals. And I think my perspective is that they do play an important role in small rural communities, particularly at the primary and the secondary care level. I think for tertiary care, I understand that the rationale of consolidating that to centers where volumes are high enough to maintain expertise. But as you know, from what sounds like you've had experience in rural areas, many people don't wanna travel a long way and are unwilling to travel a long way to get care. So I also wanna make a plea to appreciate I think the important role that small rural hospitals play in providing access for people who are intimidated and bewildered by academic medical centers. Right, no. So those are my two suggestions, my two comments, I guess. No, thank you very much. Let me ask a question because you're a specialist who's practicing at a small hospital. And certainly, I mean, I trained in Houston with the baking and cooling many, many years ago. And the practice of cardiology has advanced a great deal. And you need, for example, echocardiography and some of those things, even for non-tertiary care purposes. And so are you able to access those where you are? I've heard from some other specialists, not cardiologists in other hospitals that they have to send people for pulmonary function tests or something and it slows down their process of care and decision-making. Yeah, I think we do a good job of kind of delivering the subspecialty care that can be provided in a small hospital. So for example, last year we have a brand new state-of-the-art GE nuclear camera with attenuation correction. So I think our myocardial profusion spec studies are on par with the tertiary centers. We have a brand new Phillips epic echo machine. We have a TE probe. And I think I have a fantastic sonographer. So I think our routine nuclear medicine routine echo, including TE, are on par with really any tertiary medical center, but we know our limits. And if someone needs a cardiac MRI, they need a PET, cardiac PET, they need a right-hard cath or a coronary angiography, then those services we don't try to provide. But I think the bread and butter stuff we deliver, we have a kind of very creative solution for pulmonary function tests where pulmonary function tests are done here and they're read by a pulmonologist who doesn't wish to see patients, but wants to stay involved in reading pulmonary function tests. So the patient can get the test done here and interpreted here. And if they need to see a pulmonologist or then they're referred out for that. So I think there are creative ways to deliver at least high-quality secondary care in a small rural hospital. Right, and very needed. Thank you. Yeah, sure. I greatly appreciate your comments, sir. I'm glad you're able to do that. Oh, you're welcome. Dr. Wade. Thanks for hearing me out a second time, Dr. Harmony. I am Michelle Wade, nurse practitioner, and I am a hospitalistic Gifford. So I do the inpatient side in that particular role. And some of the challenges that Dr. Andres talked about, it's fabulous that we have on-site echo, we have great ability to stress, and then we do work well with our area facilities, but our challenges are different in being a small critical access hospital. When we have really sick patients, we can't get a bed anywhere. If we need to transfer this patient because they need ICU-level care, which we can't supposedly provide because we're a critical access hospital, we can't get them to UVM, we can't get them to Dartmouth, we can't get them to Central Vermont, even Rutland. A couple of weeks ago, I sent somebody to Boston. Sending people outside our service area is a hardship. It's a hardship for the family, for the patient, and for the providers. I mean, there was a point in time once where I spent over three hours making phone calls, trying to find a destination, while I still had a full census to take care of as well. So that's just one of the things, but I think we have a really special place in our community where we take care of a lot of our patients, hometown, local, we know them. Their primary care providers call us when they come in and say, hey, I saw Mr. So-and-Sos in the hospital, here's the backstory so that we don't have to guess or probe. And having that tight-knit community around our patients is really, really important. And it makes it so that we can also reach out to these primary care providers and say, hey, I admitted Mr. Smith, tell me what you know, because you can only see so much in an EHR as Dr. Andrews alluded to. And thankfully, we have just onboarded a new EHR at our facility, so we're now into one instead of four. We were in four different EHRs between our nursing home, our emergency department, our primary care, and our inpatient world. So thankfully, we're all in one, but we still have to search out stuff from Dartmouth, from UVM, et cetera, where some specialty care is received. I also wanna say that I think it's great that we can refer patients out from wearing my primary care hat and my inpatient hat. We can refer patients out, but part of the long wait for patients I find sometimes is because they're not getting sent back to the right place. If I'm a primary care provider and I refer this patient out for help with a specific issue for a patient, most of the time, if you give me some guidance, I can continue to take care of that patient and decrease the wait time for that specialist so they can see another acute patient and they can just guide me as needed. I think that's an issue. I wanna spend just a minute talking about working to the highest extent. We have some phenomenal nurses in the state of Vermont. Many of them have their hands bound because of rules at either facilities or at the state level where they can't do things that they're trained to do. There's no reason that providers should be doing prior authorizations. Frankly, a nurse doesn't even need to do it. It can be an MA. There's no reason that a provider who has said yes, refill this patient's prescription, their labs are good, that the nurse can't make that happen, but right now the regs do not allow that to happen. So these are some of the things that we need to do to unburden the providers so that they can do direct patient care. And I know there's other people, but one other thing I really wanna bring up and I'll circle back if there's more time at the end is tuition support for preceptors and for nurses. Workforce we know is a huge issue. Part of the reason workforce is an issue is because there's not enough faculty. There's not enough faculty. I left faculty, I was full-time faculty for seven years. I make twice as much doing direct care. We have to fix that. Right, thank you. No, I understand. I guess I really take your point about the prior off and the med refills. And it would be, and I've heard with the, I guess as I understand it, it was an issue with the Board of Pharmacy or Nursing and the implementation of the electronic health record that now requires the conversation and documentation and all of that. And so is that correct or am I wrong? My understanding it has to do with the Board of Pharmacy. Board of Pharmacy, okay, thank you. That's where we can aim. Thank you and we'd look forward if you don't get a chance to circle back. My email's gonna be at the bottom of this. Please add some more detail and some more of these because this is exactly the sort of thing we're looking for to increase the ability of nurse practitioners and PAs and doctors and others to see people not paperwork. So thank you. But Dr. Andrews, Dr. Andrews, Bruce, you're on mute, sir. Okay, let's go to Dr. Johnston then, please. Yeah, so I'm one of the midwives at Gifford. And a couple of the things that I've noticed, I worked in Utah for about 20 years before I came here. And just a really different regulatory environment, a really different just way of approaching innovation on small levels, right? I was intensely involved in a lot of legislative efforts around like freestanding birthing center licensing and just because of population concentrations there, we had very concentrated population centers. And then we had extraordinarily remote centers, right? And so it was a little bit different, but one of the things I was super surprised at here was like the lack of ability of the small hospitals to pick something that could be a real moneymaker for them. And the more research and investigation that I did, and I've worked with some of the midwife groups here a little bit to work on like the freestanding birthing center, licensing here. And understanding the certificate of need is a huge, like there are more required certificates of need in Vermont than pretty much anywhere else in the United States. And what we see a lot of nationwide with the places you have more detailed requirements for certificate of need and require those for many smaller things that we end up with a lot of stifling, a lot of that free market innovation that does make things more nimble. Having, and then you look at like, I think it was 1979 when they first kind of rolled out the whole concept. Like there's a lot of great thinking behind it to make sure that we aren't duplicating services and that things aren't just hugely, hugely massively profit driven and driving out competition and things like that. But I don't think it ever was meant to really regulate the really, really small things because that small, nimble, innovative community based innovation is really, really important. I mean, in Utah it was accustomed to the way a lot of the level two hospitals managed is because they had eight, there was one place you got your hips done and they were good at it, right? They were extremely good at it. And it was a cash cow for what was able to keep the rest of that community running with a hospital. And as well as the other thing, and this is one thing that baffles me too is why so many of our hospitals, we have one tertiary care. And then as far as like nursery care for babies, we're all just level one hospitals without a lot of that support. And having especially worked in freestanding birthing centers is like, there's not a whole lot that a level one hospital has that a freestanding birthing center doesn't have with a lot lower operating costs, right? And one of the things that Michelle Wade was saying was the difficulty sometimes in getting a room for our patients who really do need tertiary care. I've been in the same position as her having somebody who, and it happens even under the most low risk circumstances, right? That people can get critical. And I have seen my people pull it out of the woodwork to take phenomenal care of somebody but then be unable to find a bed. And the same thing, you know, when we've had babies that have had to ship to have to ship a baby six hours away or three hours away, this is just devastating to these families. And when actually all I needed was a NICU nurse or somebody with that level two nursery skill who was able to even come to my hospital for three days, you know, for a little bit. We don't have to always staff there. But also, because a lot of our nurses also work at Dartmouth, you know, that hospital has lots and lots and lots of low risk births who would be really well served in their communities but we have cultures of like bigger is better. And I would be safe for going somewhere else but they're really not. We can provide extremely excellent outcomes in care as well as personalized care. You're not a number here, we know you and you know us and that's one of the beauties of like really good rapport. And so that's another thing is like, you know, some of that just culture of like making robust local health centers to do really, really well what they do. And I don't know if in the individual, I don't know like just how each hospital is its own entity kind of thing. If there would be a way for when we do need a little step up care that needs a little bit deeper skill set, you know, if there would be a way to have a little traveling teams, you know, particularly right in the middle of COVID, you know, and Nick use were shut all over the place because they didn't have, you know, it was a lot of some of the staffing issues and stuff. It was like, it's extremely, extremely challenging. Okay, so how's the understand what you're saying? How are you staffed for midwives? I mean, everybody else seems to be having problems with getting enough nurses and everybody. Will you have enough midwives and OB support to do what you wanna do? So my midwife support is really good. We have struggled a lot the last two years with obstetricians. We had a really lovely stable staff of three OBs for a long time and there was various reasons why they left. The other thing that we've found is like, we've had a lot of people who would have loved to come work here, but, you know, getting work for usually their physician partners is challenging in an area. Yeah. Has housing been at all an issue for you to recruit? To some degree, but that's the issues have always come before. Okay. Cause we've been hearing a lot, you know, with trying to get providers and they can't find housing, but okay. Yeah, I mean, it might be for some folks and I've heard of it for some other folks, but not anything that I've personally run into. We've always been able to, you know, find actually pretty darn good housing fairly quickly. Okay, good. That's good to hear. Ms. Dr. Salwe? Let's see. Whoops. Hi there. I'm just trying to get my video. Hi, so I'm not sure if you guys can see me, but I'm a nurse practitioner who works in primary care at Gifford. I've been there for seven years and I have some fantastic things to say about Gifford. You know, one quick example is I consider Bruce Andrews to be a friend and a peer and I love having our specialists on hand for us. They're extremely accessible and I think that's a really unique quality of our small hospital that makes our staff a stronger team. I think, you know, this issue of accessibility is my biggest challenge. I have what I consider a very, very big panel, way too big for four days of working and my schedule is constantly full and I can't fit in my patients to come back and see me. And so then I'm still getting new patients and it's really a disservice to my current patients and it makes, you know, the care worse for everybody. And then, you know, a patient of mine the other day asked me if I would take on her two elderly patients who just moved to the area. She was told Dartmouth, you know, has no openings and, you know, my staff told me that we have an over year waiting list to get in. And so sometimes, you know, we do things on the side and try to squeeze them in and it's really not fair to me and it's not fair to all my patients. And I think part of it, you know, when you think about our full schedules is that I agree if we could have people working to their highest level of their licenses we could be way more efficient and we could see more patients. But what I'm told is that there's this workforce shortage and we just can't, we don't have those people. And so we have who we have and we just kind of have to deal with it. And that means that I'm doing, you know, data entry in the middle of my patient visit trying to find mammograms and then, you know, figuring out, you know, what they're due for and just a lot of like more menial work that is not to my highest level of clinical training or even, you know, the people underneath who could be working to a different level too. And what we hear from an administration is we're really sorry we understand you're burning out and this is just the state of healthcare right now. There is no solution coming and, you know, just try your best. And so that's really leading to more clinicians burning out and the, you know, the nurses and the MAs are unhappy and then the patients are unhappy too. You know, and I just think we're in a unique spot. I love the Gifford patients. I have many multi-generational families. I feel really dedicated to them. And as someone who has three young children it's really hard to think of this as a sustainable career. And I think about that all the time. And then patients beg me like, please stick around. We've been through 10 doctors, you know, in the last 10 years. So I don't have any easier solutions to that but I think, you know, thinking about burnout, this workforce shortage, working to those highest levels of the licenses, you know, and another thing that I think, you know, maybe Gifford could work on is we don't get paid more based on experience for the nurse practitioners. And that doesn't make any sense to me. I think I'm such a stronger provider seven years in, you know, and I want to be valued for that. Let me just ask a question because, you know, I've been involved in some of this for a while. And there's not really a reason that a medical professional in a sense, even an MA, although MA certainly can do the data entry and searching for the information you want. But, you know, an educated college graduate or a smart high school person could probably do a lot of that. They couldn't, you know, write the diagnosis and that sort of thing. But if you need mammograms found and that kind of thing, I mean, it would seem to me that there would be other options. I mean, everybody's hoping for, you know, artificial intelligence, but, you know, there may be simpler ways to deal with that. Yeah, I'd love to hear what they are, or maybe you could work with our administration on that. I mean, I think you might know we just switched to a new electronic medical record system and unfortunately, almost none of the data came forward and we're having our poor nurses stay till 8 p.m. at night manually typing it in and then they're really miserable in the day. So, you know, we're told that there weren't other people to hire. So I'm not sure about that, but that's a challenge. Yeah, Ben was through that a number of years ago with a different system. So I'm sorry to hear that. Other comments, experiences, please? Dr. Chase again. Yeah, I'll just piggyback in second what Rachel said about sometimes having a lack of staff for some of the menial tasks. And part of the problem, I mean, the Gifford is such a small hospital that I honestly don't know if there's an extra chair or an extra desk to have a high school student or someone help it with those things. It really is a small space. And then just another kind of separate issue in terms of efficiency and cost which is one of your solicited inputs is turnover of staff. You know, we had a surgical division meeting today and one of the issues I wanted to bring up, I got to talk about a little bit is I counted the number of OR scrubs and circulators that I've worked with in the last seven years and it's three operating rooms. And that number is 66. 66. So one that is extremely inefficient when they don't know your procedures, they don't know where stuff is. You know, Gifford, you know, the cost of, if you average the top outpatient procedures done at Gifford and you compare it to the closest other critical access hospital, Copley, we charge our average cost is 80% more. Then Copley, we charge, and if you look at per minute of operating in time, we charge $165 per minute where Copley charges 106. And so if you have this turnover of staff and they didn't prep the case or they don't know where stuff is, that adds up. And it also affects patient care. And, you know, the Vermont program of quality and healthcare came out with this report that shows the number of serious reportable events has skyrocketed. And the first thing they attribute that to is variation in staff because of staffing shortages and turnover. And so I brought this question, I brought this issue up in the medical staff meeting and I gave a good, reasonable solution to it where I also contracted a hospital in North Conway, New Hampshire and it's a critical access hospital, same amount of ORs and they have this night float system where they have a team of scrubs and nurses that just work at night. And those nurses, they call them the call dogs, they love it and the rest of the OR staff loves it because they're not post-call all the time. And so, you know, that's, and I know I'm not optimistic it's gonna get much traction. I'm not optimistic anything is gonna change like it hasn't changed in seven years. And I think that is also touching on Rachel's point where when you're an employed physician or really a physician, either contract unless you have your own practice in your own hospital but you can't make the changes that you wanna make to make your practice better, to make it more efficient and to save costs because there's these administrative roadblocks. So, yeah. Sorry, where do the North Conway folk, hospital find those folk, do you know? Well, that's the thing so like I said, in seven years in Gifford there's been 66 different OR scrubs or nurses the ones in North Conway at the it's also critical access hospital, they retain their staff and I don't know how they do it but I think it's partially this smart system of having unburdening the OR staff from taking call because I'm an orthopedic surgeon. When I take call, I only take call for orthopedic things but the OR staff, they take call for ortho surgery, urology, everything. So when they're on call, they're working and then that leads one that leads to them being tired the next day and it just decreases morale and then quit and then leave and that's again, I think it's a big cost issue which goes to efficiency and it also goes to patient safety and quality, yeah. So it's really good. Good points, thank you, sir. Ms. Wade. I'll actually defer to Dr. Holman since she hasn't been up yet and then you can circle back to me. Okay, Dr. Holman. Yes, hi. Unfortunately, my computer wasn't allowing me to raise my hand so I'm using my wife's, Dr. Holman's computer to do that and we're both here, so as you can see. I'm Alex Sokoloski, general surgeon at Givert and Don Holman is my wife is also general surgeon at Givert, so we work together. So I just have a couple of, I guess a comment and then a question for you, kind of a broad question. The comment I have has to do just to set up that the state of Vermont has with post-hospital care which is a little bit puzzling to me, I don't understand it. It has to do with home health care. We've had a few patients that require home health immediately after hospitalization and we've had difficulty obtaining appropriate timely home health. And I've been told, and I don't know how true this is but I've been told by our social service folks at our hospital that we only have two home health agencies that are licensed, supposed to work in our area and no other home health agencies allowed to cross the borders of that area because of the insurance reasons, some sort of contract reasons, et cetera. So if the two agencies that we have are supposed to take care of our patients are not able to provide care in a timely fashion, we are stuck. So our patients don't get care. So very recently I discharged two patients back to back with colostomy bags that needed to care and they couldn't get a phone call from a home health agency for a week. So they were at home for a week without supplies, without any kind of help. So one of them actually came into the emergency room every single day for a week with a leaking colostomy bag because we could not get a home health nurse to come see the patient. So this is concerning and admittedly I come from the state of Missouri, the state of Illinois, the state of South Carolina, state of Virginia, state of New York, which everywhere I practiced in private practice for quite a few years never had this kind of experience. My sister used to own a home health agency and when she heard this, she just basically did not believe me. She says, you're lying, that's not possible. You call another agency. Can't do that in the state of Vermont for whatever reason. So that's one comment. The question I have is a little bit more broad. Again, coming from a different experience, coming to the state of Vermont and kind of learning about this mysterious entity called the Green Mountain Care Board that absolutely makes no sense to me, but for multiple different reasons. What I don't understand is it seems like we are working against ourselves here with the regulation versus delivery of care. And I did have a conversation with a colleague this morning who explained to me a little bit of how this works. And I understand that one part of this regulation is to limit price gouging by the hospitals, which I 100% agree with. So you don't want the hospitals to start raising prices and patients not being able to afford it and insurance companies start raising their coverage rates for the patients because the hospitals are raising prices. That's understandable. What I don't understand and I hope maybe you can explain to me, if you're aware or if you had the knowledge of this is how is limiting a hospital's budget going to help us provide more and better care to our patient population and hire more qualified healthcare professionals in enough quantity to be able to provide that care to all the communities that we serve. So if we're limited in our budget so we can only bring in so much revenue and we can only spend so much money which is mandated by the legislature then how are we supposed to increase? For example, I come in, I'm used to doing 600 colonoscopies a year myself. My life used to doing the same amount, right? So I'm used to doing 10 gallbladder operations a week. That's where I've always done. So for that, I need to have more patients come in and see me. Well, if my hospital is not allowed to raise any more revenue than they were already raising and which gives me five colonoscopies in one gallbladder a week, then where is my solution, right? So and by the same token, if for example, and it's not to say that we don't have the patient population for it, we do. We have patients who are waiting for over a year to get their colonoscopy at other places but how can we bring them in if we're not allowed to get that revenue from the insurance company because it's gonna put us over budget? So that's one question. The second question about this is, everybody's up in arms about the physicians being let go and the nurse practitioners and the physician assistant being hired. And I understand their point, but the second point that I'm, the other side of the coin is if we're limited as to how much care we can provide and we're limited as to how many people who can hire to provide that care, how are we supposed to hire more physicians and more nurse practitioners and more VA's if our budgets are limited that who we can pay how much, right? So can you maybe put shine a little bit of light on that? I mean, how is this, how does this square? I don't understand the logistics and the economics of this. Yeah, and to be blunt, neither do I. Okay, so, no, I understand what you're saying, sir. And I, it's one of those issues that we're gonna have to address, okay? I mean, I agree with you. I think, you know, the issue of how you allow a hospital to set its budget and how much control you give it. I mean, I've run a couple and one would like some latitude in that so that you can adjust salaries and pay people and build the business. And I think that's one of the efforts of this activity because clearly, I mean, I, you know, I'm an ID guy, not a surgeon, not a GI guy. But when I look at the rate of screening colonoscopies by overpopulation against what's recommended, it's low, right? And that's an important cancer screening thing. So to me, that's one of those things that we've gotta fix. And there are a bunch of other sort of clinically relevant things too. But no, I take your point, I agree with you. I think that, you know, there have been not only constraints on hospital budgets, put there by the Green Mountain Board, but also at other levels. And some of those have different regulatory levers, for example, that I suspect will need to be addressed. But I take your point absolutely. I'm glad you and your wife are there and we'll try to make it possible for you to do what you do and help people. I mean, that's all I can say. This process is early. It will require legislative action. It will require, as you've heard, some of the other folk talk about some changes and some of the professional licensure and regulations. I would add for you, I've practiced in Missouri and Virginia too and it's in Tennessee and it's a considerably different environment. So, but, you know, the goal is to get your kind of services more readily available in the communities that are not Burlington. Right. So thank you for your comments and questions. I wish I could answer them more fully. Thank you. Let's go to Matthew Boutallier, please, before we go back to Dr. Chase. Hi, thanks for taking my time. I've listened to our community members and my colleagues tonight, but what has frustrated me over this is actually as Dr. Chase using both of these forums to air his grievances, you know, in my opinion, I don't think he's operated here in over 18 months. To then pinpoint management seems to be pretty unfair when he's, has not been involved in the system for over 18 months and just disappointing to see that he's using this as his forum. That's really all I have to say. All right, I appreciate your pointing that out, sir. Thank you. We'll go back to Dr. Chase briefly and then to Mr. Anderson, Ms. Wade. Okay, I just want to apologize, Matt. I didn't mean to... Let's not get into a back and forth here, okay? Let's deal with the issues I'm trying to deal with. I'm trying to, and I'm trying to go off this solicited questions that you asked, but in terms of there's, I guess I'll, so I have some insight, I think, or my opinion on Alex's question about the budget. Happy to discuss that, if my opinion on that, if you want or not. And then there's a question in the chat about, you know, really my intention here is to improve the cost of things. And in terms of practicing at Gifford, I've been there for seven years. I have full privileges at Gifford. I've offered any time to take call at Gifford for my community and my patients. Currently we have no call. And I will take call at any time for my patients at Gifford. It's not my decision not to take call at Gifford. I just want to make that pretty clear, okay? But in terms of, so why there has to be some kind of budgetary cap in Vermont is because Vermonters pay for it. So the cost of health insurance premiums is going up 15% a year. And that's because of the hospital budgets. So if hospital budgets are unlimited, then healthcare is unaffordable because the premiums are just too much. I mean, we presented that. So that's why there has to be some cap. I do agree though, in terms of, I think there should be hospitals should, hospitals who provide low cost care should be able to have extra revenue. If they're per unit of care, if it's really, if it's a good value, the hospitals that are providing value care, they, I don't think their revenue should be limited. But that's my take on what I know about the Green Mountain Care Board or this hospital thing. I just want to address a question in the chat. And again, my intention here is to improve cost, improve efficiency. And that's why I suggested this night float call system. And I think everyone can agree that retention is a real issue. And so in the chat, someone asked, is North Conway Maine Medical? And yeah, it's part of Maine Medical. And then they also asked, do they do state interviews at Maine Medical? And they do, or at North Conway. And so they do a Gallup Employee Engagement Survey there. And I think that's really valuable. And I was at Gifford for Stelion for over five years. There was never an employee engagement survey done. And from all the physicians I know who have left there, there's been no exit interviews. So I just, I think, I don't think you can, I don't think I'm airing my grievances by saying retention is a real issue. Thank you very much. Mr. Boutea, and I apologize for the pronunciation. So Matthew, okay, let's go to Mr. Anders, please. Dr. Anders. Hi, thanks. I want to address your invitation to, to consider a clean sheet of paper. And a fresh, kind of fresh look. And I want to try to be a little more, a little more concrete about, about a kind of vision for improved healthcare in Vermont. So sort of my idea, vision of the ideal is that a schedule is set up such that there's always capacity each day for urgent visits. People who have an urgent need. We have to, we can't oversubscribe clinicians so that there's no capacity for urgent visits. One of the basic obligations of clinicians is to provide healthcare for the acutely ill. So you have to protect that. And then I think that the appointment should be structured such that a medical assistant can go into the room, kind of collect a basic present illness from the patient. What are your main concerns? What, what do you need from this visit and collect as much information as possible? And if that's a urinalysis, if that's a, I mean it's getting a peak flow meter, if that means checking blood sugars and getting that stuff collected before the clinician walks you in the room. If it's a periodic health exam, then it should be the medical, it should be someone like a medical assistant who has Scott, who reviews a chart and learns this person needs a mammogram, a colonoscopy and a tetanus shot and a flu shot. And I have that already and ask the nurse practitioner or PA or physician, hey, this is what's needed. Would you like me to get this done for you? The clinician can walk into the room, talk to the patient without typing on a computer, agree on a diagnosis and a plan and then instruct the medical assistant, please enter these orders, order these tests, I'll sign them off. And then walks into the next room where a medical assistant is presenting the question and data for them. The other part of this utopian vision is if the primary physician has a question that they're uncertain about, ideally they would have immediate access by Zoom or by telephone to a specialist. And it seems to me there's a lot of referrals that are made and that people wait months for to answer a fairly specific question that if we had immediate access to a consultant, we could get an answer in two minutes. So in this utopian world, you'd be able to pick up a phone and get help and that would include mental health and social work. But I think we need to support primary care physicians so they can get specific answers quickly and that they can interact with patients more and with computers less. So I just wanna make that a little more granular than my previous statements. So thanks. No, thank you. And I can, if I can remember his contact information, I know a man in Sacramento, California who does exactly that. Took him six months to train his MA and get her comfortable and him be comfortable but that's exactly what he does. She collects the information, she reviews the lab, she presents the patient, she actually goes into the exam room with them, she has a portable terminal and while he's talking to the patient and making observations, she enters it. When the interview is done, he adds the diagnoses, couple of comments, signs accept and when he walks out of the room, it's all done. So take your point, made notes and great thoughts. Thank you, Will. I don't know that we can get to that operational level but certainly with the appropriate folk and training and support, that's possible to get there. Thank you very much. That's a great exposition, Dr. Andrews. Yeah, thank you. Ms. Wade. Bruce is a tough act to follow but I wanna go back a little bit to some of the social determinants of health and issues in that area. As you know, Gifford's fairly rural and so I know it was brought up during the community forum about transportation so I won't rehash that one but in the questions you posed out to us, one of the things is what is your facility doing to help with this? And I mean, some of the things that we do that I think need to be noted are we do veggie van go and that line wraps around the block. We have to have people controlling traffic out on route 12 the day that we have them there. And we feed a large number of people in the community through that program. During COVID, we did all kinds of meals to go and things like that. We have a community health team that works in our communities to try to get people into their appointments, to try to help them understand things, to try to help them get set up with insurances when they don't have insurance. So I do think we embrace that fairly well. However, there's not enough community health team members to serve the population. As you pointed out in your slides, there's a very underinsured population in Vermont and that underinsured population is the one that they're often helping because they've got huge co-pays or they're unable to afford meds which is why they landed the ED or in my inpatient unit. Another thing that was on your list here that I wanted to talk about is, who are the stakeholders in the community that share these same priorities? I gotta tell you, Gifford's got a really neat community. I don't live in that town. I drive an hour and a half to go to work at Gifford because I like it there and they've got a great community. You might remember I was on your Rutland forum because that's where I live. And so I think that they do a great job embracing the stakeholders in town, the entire town comes together, all of the people that have businesses in town and they support both the patients in town as well as Gifford. And just, I don't wanna start a dialogue but I do want you to know we did hire a phenomenal orthopedic Gifford and we do have orthopedic coverage. Good. Okay, thank you. Thank you very much. Yeah, it's interesting. I spoke to the Vermont UVM people today and they've, you know, done a fair, they've, at least in the children's hospital really kept track of the social determinants of health and they said, you know, sort of what they'd come up with was the most, the best predictor of a lot of those needs was Medicaid enrollment, which, you know, makes sense, but. Completely agree. Yeah. Dr. Andrews again, or did you not lower your hand? Okay, Dr. Andrews. Okay, Dr. Johnson. That was just. You're zinging, but can't hear you. Me again, lower hand. Okay, no, I'm sorry, you can't hear you. I'm gonna go to Dr. Johnson. Johnson. Yeah, so I wanted to just, okay. I just wanted to just kind of follow up a little bit on what Michelle said about the social determinants of health and also kind of what Katia Evans has said in the chat. We recently, oh, it's maybe been a year and a half, we have a community health team member in our office now, part-time, she's there 20 hours a week, and I cannot tell you the phenomenal difference her presence has made in our office, simply arranging all of the things and being able to do short-term mental health work and counseling. She is one of those arms of my people who, I really can't say, hey, Justine, here's the situations, can you take care of this? And she does. I think that has made, it's enabled us to take care of a lot of people that we used to transfer out simply because we didn't have that social support network now, and now these people are able to be cared for right in their communities. They're not, these folks with the highest needs and the most difficulty interacting with large systems and stuff, we're able to take care of them and they live a block away. And that's phenomenal, right? It's a lot easier, I mean, a lot of them are, they're able to walk to their care appointment, and now I have the things to take care of them with, right? And so I think, I'm with Kasia, I think that has been phenomenal, and I think particularly, the more we come to understand that those social determinants are really determinants, it's not just a word, extremely, especially for new families and the more we can help, I mean, I'm a huge fan of primary care, I think it needs to be really strong, but also launching families well, particularly where for some people with their birth experience, this is our first time really interfacing on a sustained level with the healthcare system. And then if we get that to be a positive experience and we get them hooked into those resources and we get them launched well, and with good mentor resources and stuff, their families are much better off than if they struggle and if they're lost to a lot of follow-up and stuff. And so, thankfully getting out of COVID, going back to creating our moms groups and our local resources that create community and support. So I think that's an incredibly important part of the process. Absolutely, thank you for pointing that out and the value of the community health team. How effective, I guess, is the coordination between the different state agencies. You got a CHIP program, you got a mental health program, you got these different ones. And it would seem to me that's where your social support staff would be particularly important is helping get all those folk on the same. It is because I think the coordination is actually really poor. We joke on a regular basis that she has a master's degree in 20 years of experience and she still struggles with it. Okay, by the way, well, that's what I wanna know. Cause I, you know, as I said, we're talking to the various state agencies. And as I may have mentioned the mental, I know the mental health, the lady who's in charge of the mental health group, she's looking for a thousand people, right? She's a thousand mental health professionals short. So, and I'm sure that occurs in some of the other agencies and what I had heard in a different hospital area a few weeks back was that, you know, they've seen enough turnover that some of the newer folks who have been hired in some of the different agencies are not yet familiar with all the, with the job and all the roles and what the rules may be. So have you got? I think, I think that's probably true. You know, it took a little while for her to kind of run up. But I think, you know, now that she knows kind of the right people to call the right behind the scenes kind of stuff to do. You know, I think she does, I mean, I've seen this with the gal who used to do some of what she does to call them up sometimes and be like, no, this is the way it's done. I'm telling you, this is the way it's done. And I'm gonna be here till you get it done telling you how it's done, you know, and getting our babies covered on Medicaid, you know, and making sure that sort of stuff happens because a lot of times they don't know. Okay, thank you very much. Appreciate the comment and the information. Thank you. Other comments? Yes, dental care. And I guess question, that's a question for you because one of the other things for the group, one of the other things is that certainly there are some services which the individual small hospitals may not be able to support by themselves. And so one of the things we're trying to think about are things like mobile dental clinics or mobile mammography units or whatever that could be in a sense, regionalized, the services shared between several of the smaller hospitals. Would something like that concept fit in your area? Ms. Johnson again in this way. Yeah, I mean, I'll agree with that. I mean, that's one of my things I think as far as like that level two kind of nursery care, instead of having staff make an extent expensive bed in a level three or level four nursery, be able to have just that mid-level kind of support by really one person would do it with telehealth as well as having that presence and having seen that process. Honestly, I think a lot of our providers would very easily get more up to speed. One of the other things that I would love to see is more coordination, say with taking our nurses and giving them a rotation for one week a year or whatever in a NICU setting, right? So they can kind of hone some of those skills that very rarely come up that we need but when we do they're really excellent to have. Yeah, great idea. Thank you very much. Yeah, that's our way. I'm not sure you know, but we do actually have a mobile dental unit that we use through the hub. I did not know that. That's great. Yeah, and it's helpful. However, they only do cleanings and they do do all ages, so our kids go there too. But unfortunately a lot of our patient population needs much more than dental cleanings and then we don't really have anywhere to send them or at least not an affordable place to send them. And I just wanted to piggyback that we also have a mental health team embedded in our primary care, which is phenomenal. We have two social workers, a number of other therapists and then unfortunately our psychiatric nurse practitioner who's been there for a number of years is leaving. So that's been extremely helpful but we really need more psychiatric support in our community and I'm sure everyone's telling you that. And so that's a lot of our patients go to Clara Martin which is right in our community but they only have one psychiatrist and there's a six month waiting list there too. So I'm not sure how you could approach that but we would love the help. Thank you. Or the question, do the mental health people in your clinic do more than screening? Do they carry a group of patients that they treat? Yeah, they carry a group of patients. They also respond in the moment if you have someone with suicidal ideation. They also help and work with our blueprint community health team to help with those social services. So it's kind of a combination there and then some do men management. And the practice you're in is what sort of, are you in a private practice, FQHC? Oh, no, no, I work at Gifford. I'm in the primary care family medicine department. I see, okay, fine, thanks. I just wanted to understand, thank you very much. Sounds like a great team. Yeah. Ms. Wade. So yeah, Rachel, we are in FQHC for primary care to answer your question. But the one thing that I see that could be really helpful as a floating service would be dialysis. That's something where we get really hung up and patients need to be dialed three times a week usually. And if I have a patient in the hospital for heart failure, I can manage the patient until they gotta be dialed and now I have to transfer that patient. So that might be something that is useful that can float between multiple facilities around the state too, because again, patients don't need it every day. You know, if they're that sick, they don't belong at one of our hospitals, but if they just need their regular dialysis, then it would be beneficial to them. Right, no, the great, great point. Thank you. I've heard that before, so it's important. Thank you. Other comments. We have half an hour left. We are in danger of letting you go, finish your supper. Any other comments, ask if there are any public comments or Senator McDonald wants to make any final comments. Well, I've been a patient at Gifford on several occasions and I know they work hard and they're part of the central part of the community. I've seen most of the folks tonight that have been making suggestions at work there seem to be looking for how to improve things in the future. And this has been an education for me. I'll have to ponder it and see, and I'll be better prepared when we discuss, when the healthcare committee in the Senate makes its recommendations and asks for our input. Thank you very much. Thank you, sir. Thank you. Well, let's, yes, we'll give Dr. Chase three minutes for a final comment and then we're gonna draw this to a close. Yeah, I just didn't want there to be any confusion that I absolutely love Gifford. I think it's a great hospital, great people, my colleagues, but most of the patients and really my interest is in line with Gifford's mission, which is improving and creating access to affordable quality healthcare. And I just wanted to make that clear if it wasn't. So everything is, if it's criticism, it's constructive. And I think there's just some great comments tonight and it was great to hear my colleagues and thanks for listening. Right, thank you. Could we go to the last slide, please? Okay, so this is the way to continue to give us your advice, experience and suggestions and input. And I greatly appreciate everybody's comments tonight and the help you've given and the suggestions made. We'll try to take them under consideration and see how we can make a number of them happen. There are two ways to do this. The public way is to go to the Green Mountain Care Board website, which is up at top, gmcboard.vermont.gov backslashact-167-community-meetings. And if you actually just go to the Green Mountain Board website then you get to choose the community meeting part. And there you can leave a written comment either with your name attached or not. They'll be posted. We do monitor those, we do collect those for this project and we will add those to the comments you've given and we'll add those to the comments you've made and others and take those into consideration. The other way is that my business email is at the bottom of this. It's bruce.hammeryatoliverweiman.com. If you send me a note because there's something you didn't wanna say in public or you have a thought tomorrow morning in the shower or next weekend whenever, I can certainly acknowledge it. As you know, we're going through all these meetings and all this other stuff. So I probably won't be able to engage in a discussion with you by email, but this is another way for you to get directly your comments in consideration. So we'll close this out. Thank you again very much. I know you're all finished a very busy day and you've taken some time from your families. We appreciate all of that. Hope you'll have a good Veterans Day and a happy Thanksgiving. And again, thank you very much for your help and attention tonight.