 So I don't think we have our names in any particular order so we can just go through the list that's here. And so we'll begin with our healthcare advocate, Mike Fisher. Good morning. Good morning. Let me get myself organized. Good to be here. Thank you, Senate Health and Welfare. I'm gonna remember what room I'm in. Good to be here and good to have an opportunity to speak a little bit about it. Join the meeting. About the dynamics in front of us. Significantly, I am going to be speaking to sections one and two of the bill. So, but before I do that, why don't I just first really briefly express support for sections three and four about the blueprint. And also section five, this is really a policy area that's outside of the healthcare advocates policy focus. And though I will mention that it seemed important to make sure that you include staffing and pay issues in that analysis in that workgroup. And I'm confident that you'll hear more about that from future witnesses. But most importantly, I don't believe that it makes sense for the healthcare advocates to be a part of that working group. It's really outside of our policy area. So again, thank you for inviting us to speak about this. We feel passionately about it at the healthcare advocate's office. We strongly support moving forward immediately to plan for global budgets, global hospital budgets. We support the Green Mountain Care Board's funding request and propose next steps to engage communities and prepare for global budgets. The advocate's office as probably everyone here knows has participated in hospital budgets in rate review proceedings from the time the board first took on these duties. Now, let's be honest, we're often frustrated at the advocate's office about the board's decisions in these proceedings. I feel frustrated that the board has not done enough to restrict annual healthcare price increases to a level that Vermonters are able to afford. But I have to recognize that part of our frustration is about the board not having the ability to do enough. We recognize that there are significant limitations on what the board can reasonably do to control costs in our current healthcare system. Quite simply, and I'll probably say this stronger than many others, quite simply, the current attempts to control the cost growth in our healthcare system is not working. Our system rewards high cost, high volume services, and little predictability for hospitals. The all-payer model and one care have not been able to significantly change this dynamic. As healthcare costs continually outpace wage growth every year, we hear from more and more Vermonters who are getting priced out of the ability to get the care they need. Consequently, we believe that Vermont's current approach will never result in a healthcare system that is affordable for Vermonters, or one that provides sufficient financial security for hospitals. $5 million sounds like a great deal of money. We know that and we've heard others say, we've heard voices saying, couldn't that money be used more immediately to provide better, to provide care? But if you look at that $5 million request in the context of hospital budgets, it puts it in a better perspective, we think. In 2019, Vermont hospitals reported $2.59 billion of gross patient care revenue. With these figures in mind, $5 million would support Vermont hospitals for about 16 hours. So we think $5 million is a sound investment to work toward a more sustainable system for Vermonters and for our hospitals. Now, I also have to recognize, and again, it might be an unusual thing here, we also wanna recognize here that $5 million might not be enough. It is the right amount, the board has put this forward as the right amount to start this process, but this is a big job in front of us, a multi-year job. And so I just wanna be honest and direct about that. So we strongly support the proposal. The prospect of a global budget financing system has many potential opportunities and risks, but we must start by committing ourselves to the important work of engaging directly with Vermonters, listening to their concerns and priorities and designing a hospital financing system that is responsive to the needs of Vermont communities. We look forward to engaging in that work and we appreciate the suggestion that our office be tasked directly with engaging in this work. This discussion is not easy for hospitals. We've heard the expression of concern and anxiety from hospital leadership at a time when they are quite frankly, struggling to keep their organizations afloat. But Vermont can't wait for hospitals to recover from the COVID pandemic before we begin the planning process. This will take years to do it right. And so we believe it must be started now. A few suggestions, a little bit more specific. The discussion of affordability in this process, we believe must happen on both an individual level for Vermonters and in a system-wide level. Affordable annual budget growth caps must be established for each payer type, not an average of all payers. So when we assess a global budget, the discussion of how to come up with a global budget, we believe must be done on the actual and necessary costs of providing services, not just based on historical charges. We must consider what role, if any, OCV should have in the global budget process once it's implemented and be direct about that. And most importantly, we must have a robust public engagement process. It certainly must address healthcare workers, the healthcare industry on all levels, but it also must address the community. The process must meaningfully involve Vermonters with direct experience of our systems of care. And it must reach out to diverse Vermont groups with regard to race, age, income, and disability. So, and then in addition, I know this has been talked about by others, the outreach work must be led by someone who has experience engaging with all of these different groups. And this is not easy. I've heard others talk about the importance of having an engagement process that speaks directly and can be heard by the medical community. And I agree that's important, but we must go beyond that. We must reach out to the provider, engage the provider community that are not from the medical systems. And we must also really engage the broader community so that they experience being listened to and so that they have an opportunity. So we have an opportunity for some buy-in here. Couple of additional points I'll just say out loud. I think we've made mistakes in the past when we've launched efforts like this in overselling them. I don't want us to say that if we do this, the world will be better and everyone will be able to afford care. This feels like the right thing to do and there are real opportunities here, but it won't fix all of our problems. We'll continue to struggle even if we do this right. And the other thing that feels different here at this moment is indeed the public engagement process. In the past, when we've launched efforts like this, we've had this concept that if we do this on the back end, we don't need to trouble Vermonters with the details. Life will get better for them. And so I think it's very important that this proposal starts from a different place. It's being discussed as coming from a different, starting from a different place of bringing people in on the front end and with that public engagement. So Senator Lyons, those are my comments and I'm happy to receive questions or hang out till the end and receive questions with others. Yeah, thank you. It's very refreshing to hear this testimony. It's always difficult to work on something like this. If we can get your testimony and writing, that would be extremely helpful. I already have Senator. Terrific, yeah. Just send it into Erin, we'll look forward to it. And do you mind sticking around? Because I think after we've heard folks, it would be helpful to have a robust discussion and really appreciate your being here very much. Happy to. All right, terrific. And that actually goes for other folks who are testifying today. If you can, after your testimony, we will probably have questions going through some of the testimony, but it would be great if we could get to a place where we can have a short discussion. That would be helpful. So Jill Olson is here. And I know she is, are you here? Jill Olson, she is. It's good to see you. Nice to see you too. Can you hear me okay? Yes, we can. And thank you for being here. And I don't know that I sent Erin the table that you folks sent along on the losses for choices for care. It doesn't directly relate to this bill, but it does relate to moderate needs. So why don't you go ahead with your testimony? Sure, yeah. And I'm not sure what table you mean. I did have my members reach out to some of you and each of you individually to share, but I didn't feel like I could submit that as testimony. No, that's fine. Yeah, it was the losses that were sustained by choices for care over the past two years, up to I think it was over $500,000 significant for the program. That was just for your agency. Yeah, yeah, okay. Yeah, yeah. So what I had my members do just to clarify is because I didn't have, the data I have is from an auditor who works for all of my agencies, but it was not prepared public. Okay, got it. Didn't do all the things he would do to prepare something for public consumption. And so I had each of them reach out to you individually. So that you could understand the losses that your agency and your community is sustaining on the program already. So it's not the- All right, thank you. Yeah, that's helpful. Yeah, just to help you understand. So thanks for having me today. I'm sorry, I started talking without introducing myself. Jill Olson, I'm the executive director of the VNAs of Vermont. I should warn you, I am at home. I have a house with other people in it. I usually go to my office for this or sneak up to the guest room, but my daughter's in the guest room. She's home for a few days. So anything could happen. But I think I've tucked myself away pretty well. So I took a look at the new language that you have on the moderate needs program expansion. And I'm sure it won't surprise you to hear I have some concerns. My primary concern is that as I read the language, it calls for the expansion, regardless of the outcome of the work group's efforts. So it calls for an expansion on January 1 of 2023, although there's no appropriation noted. I think that's really problematic. I think you have to do the study first and really understand the impact of what you're doing before you, and how much it will cost before you do it. That's just a process recommendation that I have. So I would, I have a couple of suggested changes that would I think make the language that you have not feel like a fade-a-compley before the work is done. I can share my screen if you want, or I can just submit it, but it's really a small wording change in the introduction and then getting rid of section B, which is the one that would require it to be implemented January 1, 2023. Yeah. Sure, go ahead and share your screen briefly. That would be helpful. And then you can forward this with your full testimony to Erin and a copy, Jen. Yeah, okay. So I was just sort of pulling this together this morning to give you the wording. I wanted to talk to Dale too. I haven't had a chance to run this by my colleagues at Dale. We talked, I would say, in broad terms but I didn't have a chance to show them my specific concept. So let's- I'll let you know. They also sent some comments in which I think should be, Erin was gonna put up on our webpage from Angela. Yeah, I think Angela and I are on the same page. So first, so I'm in section five, A. And so I think if you change that first sentence, so it says to convene this group to consider extending long-term care, blah, blah, blah and take out issues related to and develop recommendations for, it makes it more of a study than something that will for sure happen. Then I suggest adding this number seven, which is to, because I think this is really critical and this is what we're concerned about. I think you need to look at the feasibility of program expansion and its impact on existing services. So that's what we're worried about. We're struggling to take care of all the people who are on the program now. As a system, home health, AAAs, adult day, we're struggling to take care of the highest needs population as well as the moderate needs population. I just don't think you can expand this program without grappling with those issues. And then I think you have to eliminate B, you can't really see it because of the way I've done this, but you can't see the letter, but you need to eliminate B in my view because that calls for this to be implemented January 1, 2023. So you'd need an appropriation this year and it would mean an immediate expansion. I think if you asked my members today if they would rather put new money toward choices for care rates now or an expansion, they would say current choices for care rates. The last thing is I just wanted to point out, I've just sort of added this onto the end. This is language that is in another bill that's on your wall. This is from H-153. And this is language asking that you make it a requirement that we have a rate schedule with a methodology for regular updates in the Choices for Care program. This is what has been missing. We did 10 years, no increases and we've done the last five with increases that are below the rate of inflation and well below the rate of change up for wages. And that's how we find ourselves where we are. We are now in a place where we simply cannot afford to pay the wages that we would need to pay to hire the workforce. And now those people really aren't out there. And so we're really in quite a pickle to take care of everybody on the program. So you have not taken up that bill yet. I know that you've talked about intending to do so after crossover, but I just wanted to point this out because to us, this is the thing that if you're gonna act on Choices for Care, we need a rate schedule. We need to have regular increases. There needs to be a relationship between the work that we're doing, the subsidies we're putting in on the program. So I'll stop pounding my shoe on the table, but I wanted to share this with you. Okay, why don't we, is that at the end of the recommended spot or you take your screen share down? Thank you for that. And what we'll do is we'll put this, Angela also sent recommendations on the Medicaid waiver that are slightly different from your recommendation. And Erin, I hope you've put that up or you could put that up so we can refresh and see it, but we still have to go through that. And we'll put this side by side as we go through the bill with Jen and look at the decision points relative to what you're bringing us and then relative to what Angela is bringing us. It's very helpful. Sure. And I'm of course always happy to talk to Angela to see if we can propose something together to you. We just didn't have enough time in this moment. Yeah, but we're glad to, I'm certainly glad to work with her. Yeah, all right. Senator Hardy, go ahead. Thank you. Thanks Jill. When we went over this bill originally, or the other day I was concerned about that date as well, it seemed like a really short timeline. And I was told that the reason that date was in there is because of the global commitment, waiver, renegotiation situation. In your experience, if we were to, sorry, I have chaos happening behind me, I'm a little distracted, but so I feel you. If we were to do this working group and there were recommendations that came out in one way or another, how would that integrate? Maybe you're not the right person to ask, but how would that integrate into the waiver renegotiation? Yeah, so I'm not the right person. That's definitely a technical question. So they are, the renegotiation process is well underway and the items are already on the table for negotiation. I think I don't know that they could actually add something to CMS at this moment anyway. So, but I would defer to my colleagues at AHS about how the sequencing would work. Okay, and I totally hear you about the expansion versus doing better at what you're already doing. And I think that's a really important point. So thank you. Thank you. Okay, any other questions here? And I think as you look at Angela's information, you'll see that she's suggested moving it out to the next negotiation to provide more time. And that's probably a legitimate thing to do. So you may wanna be in touch with her to get to some place. Yeah. Absolutely. That'd be great. Okay. Anything else, committee? I mean, it's just so important for folks to have these services and it's going to get more and more important as our demographic changes. Okay, thank you. Thank you. So we'll come back to that kind of as we're looking at decisions within the bill. So today we have, Ena Bacchus is here, Director of Healthcare Reform. Ena, thanks for being here. Welcome. Thank you. Do we, and oh, I should go back to Jill. Will you please send your testimony in? She didn't hear me. All right. All right, for everyone who's here, if you haven't sent it in, please do. I know we have some of it. But Ena, thank you. Please introduce yourself for the record and we look forward to your testimony. Thank you. For the record, Ena Bacchus, Director of Healthcare Reform and the Agency of Human Services. Thank you for the opportunity to speak with the committee today about S-285. I'm going to provide feedback on sections one through four of the bill. As I previously shared in testimony with this committee, the work that was completed by consultant Donna Kinzer on the topic of global payment is deserving of much praise and consistent with that work. I have also previously said that the administration will include hospital global payments among the value-based payment models that we explore in partnership with the Green Mountain Care Board as we look to evolve Vermont's agreement with the Center for Medicare and Medicaid Innovation. Again, exploring hospital global payments is a logical next step. I do want to point out that Vermont's healthcare reform agenda has previously and over time thought to drive towards the integration of care and services across the healthcare system and continuum. And one important consideration in this aspect is that looking at hospital global payments in isolation will not be inclusive of the community-based provider system. While I note this, I can say that AHS is committed to continuing to pursue payment and delivery system reform in service of an integrated and coordinated system of care. On this theme, as we endeavor to move forward and to evolve Vermont's reform initiatives, we will be best served by coordination and collaboration between providers and state entities and between state entities as well. The bill proposes funding for a contractor to support the design and development of a proposal for a longer-term all-payer agreement. And I would like to note that the Agency of Human Services already has a contractor on board who is supporting this work and coordinating and collaborating between the additional contractors could add more complexity as we seek to work collaboratively between the agency and the Green Mountain Care Board. The Agency of Human Services also values the patient-focused and community-inclusive approach to the redesign of Vermont's healthcare system that's included in this proposed legislation. And as I've previously reflected, the community-inclusive redesign of the healthcare system should include participation across the care continuum and be in service of better integration of services, including those offered by community-based and primary care providers. To this end, specifically, we recognize and appreciate that the Blueprint for Health is a trusted and established program for supporting local system redesign and is a key partner in health reform initiatives. The proposed supports for the Blueprint program in section four of this bill are not only consistent with the feedback that we've heard from the provider community about the strengths of the program, but these investments also build on the Blueprint's existing and proven infrastructure to promote transformation and integration. And we believe that these will be assets as health reform initiatives progress. Is that it? That is it. Okay. Oh. All right. Thank you. And it would be very helpful to have this in writing. Thank you very much. Absolutely. Oh, Senator Hardy. Thanks. We should just have a button to push. Here, Senator Lyon say that to every witness. Ina, thanks for your testimony. I have two questions. I really appreciate the point you made about how this might doesn't, at this point, integrate community-based providers very well and wondered if you had suggestions for language or how to do that better. And then my second question, you mentioned the AHS already has a contractor and I'm wondering who that is. I'm concerned about making sure that this is a really community-driven, community-focused process. And there are some contractors who are better at that than others. And so I don't want to make it personal, but I just want to make sure that we have the right person and people on board to lead this in all of our communities. Thank you. I'll take the second question first. In my read of the proposed legislation, the contractor was for supporting the specific activities in terms of bringing a proposal to CMMI. And I see that as different than the proposed contractor supports for the global payment design and for the community-based process. So I'm reading it perhaps more narrowly, but I'm reading it fairly narrowly as a request for support, contractual support for the negotiations with CMMI in particular. Okay, okay, so that's a different thing then. Okay, and that makes sense that you would have a contractor already doing that work. So that's good for me. I'm thinking more about the community process, community engagement stuff. So, okay, that's helpful. And then the other question about, yeah. Yeah, I'd like to think some more about that other question in terms of the legislation itself, but I wanted to raise it because I do think it's important that as we are looking at this model that we do acknowledge where the limitations are. And I think that Donna Kinzer did talk about some overlays of different models that could promote further integration beyond the hospital. And I think that those are things that should be considered. Yeah, absolutely. Just trying to figure out how we do that is really important. I mean, I think we just heard about the VNAs and how they're a crucial part. And we wanna make sure they're involved in some way. And then also, we just had this whole conversation yesterday about birthing centers. So how do we integrate all of it into a cohesive planning process because they all are connected clearly. So if you have ideas, I'd love to hear them. Yeah, I mean, so I think that that's just, so has been such an ongoing concern for us and having the DAs who are really overseen by AHS integrated with support services and hospitals and clinical services that may be overseen more by Green Mountain Care Board. That's the link we're looking for. So how this happens, maybe it is, there needs to be some language in there that opens up that community discussion. So Senator Hooker. Thank you, Senator. Can I just say that in Rutland, the hospital and the community providers have worked together and maybe we can reach out to them and see how they're working this system. Every time Senator Tarantini and I meet with the groups, they tell us that they're working well. And so there must be a way and maybe we can get some language from the groups down here who are already in that process. Good thought. So certainly through the blueprint process, which I know the hospitals have a blueprint person in place, that may be how we link this and then we'll hear from the Green Mountain Care Board their thoughts with this good suggestion. All right, so any other questions for Ina? All right, so let's move along to the Green Mountain Care Board and we have three folks, Robin Lunge, Jessica Holmes and Sarah Lindberg. And I think you may have coordinated your testimony. So Robin, I'll turn it over to you and then we'll see where we go. That sounds great. Yes, we have Robin Lunge, member of the Green Mountain Care Board. And as you noted, Senator Lyons, I'm here with Jessica Holmes, also a member of the board and our very smart, important data person, Sarah Lindberg, who's gonna speak to some of the data components in S285 amendment. So thank you very much for having us in. As you know, from the testimony that Jessica and others provided to the Joint Committee hearing that the result of our hospital sustainability report was to make a recommendation for three different pots of money to support in total a $5 million ask to move forward with hospital sustainability planning. What I'm gonna do is turn it over to Jess to just do a quick overview of the main points. We'll speak to each of the appropriations and then Sarah's gonna talk about data. Does that sound okay with you, Senator Lyons? Absolutely, go right ahead. All right, I'll turn it over to Jess. Great, well, thank you. Thank you so much for having us back to discuss hospital sustainability. I think as we all know and we've heard about, our hospitals are struggling financially and the headwinds are strong. We've been seeing hospitals with expenses rising faster than revenues, their margins are shrinking, public payers are not keeping pace with inflation and increased reliance on those commercial rates to cover those rising costs is no longer a viable long-term strategy, even if the board approved higher and higher commercial rates for hospitals, there are not enough for monitors to afford those rate increases as Mike Fisher talked about so eloquently earlier. And we're seeing, some areas of the state population declines, technological innovation is moving care out of hospitals to outpatient settings and even into the home. And with a fee for service system, we have reliance on volumes to keep those lights on, but those lights are starting to dim as populations are declining, patients are in some areas of communities, they're bypassing their small local hospitals to seek care at larger centers and new delivery models like hospital at home, telemonitoring and telemedicine are gaining more traction. And we can't ignore the fact that Dartmouth-Hitchcock is building a new bed tower on the southeastern border of the state. This expansion could potentially attract both workforce and patients, which will exacerbate workforce shortages in Vermont and decrease occupancy rates for hospitals that are already struggling to cover their fixed costs. So if we don't change course soon, we're gonna see rising commercial rates leading to more uninsured, underinsured, more bad debt, charity care, free care and potentially could see employers starting to reduce their health benefits. And the hospitals in financial distress may close, they may go bankrupt, they may request emergency relief from the state as Springfield did to the tune of millions of dollars. Others may divest essential services. And as we discussed last week, it will likely be those least profitable services, right? That are gonna be divested or shed first and some of that is already coming our way. So we're not on a sustainable path. And if we don't act, I think that market forces may prevail and we may not like that outcome. So the board is really requesting here as funds to engage experts in intentional payment and hospital payment and delivery system reform so that our healthcare system is prepared for the headwinds that we think are coming our way. So I'm gonna talk to Robin to speak first about the request related to the payment, hospital payment reform efforts. And then I'll come back and talk about the community engagement. And then Sarah will talk about some of the data issues in the bill. Thanks. So I'm gonna specifically address section one of the amendment, which is 1.4 million for payment reform and 600,000 in support of the federal negotiation. So the $1.4 million request is to work on a process to explore fixed perspective payments and evolving our current payment system from where we are today to include more parts of our system in the value-based care framework. As you know, we support Donna Kinzer's recommendation to explore moving towards global payments. To Ina's point, this is I think a component of a next agreement, the Venn diagram between global hospital payments and the next agreement should and must overlap, but it does not necessarily need to be the only component and to the points that Ina raised, we do need to look at how the system works today and how that would fit within the larger system. To be frank, we've been staying in our lane and focused on our work around hospital sustainability and we certainly will continue to work with AHS to collaborate on how that larger reform effort looks. So I don't actually think we are in disagreement there. One piece that I wanted to mention just so that you are aware is that healthcare did include support for the funding in their memo to the House Appropriations Committee, which is not yet delved into it. So at some point, we will need to true up the language. Of course, you need to do your work first, but I did want to just mention that their language is a little more focused on process and include some current statutory language about steps that we would need to take before implementation. Yours is a little more directed toward Donna's recommendation. So I do think there is, at this point anyway, slightly different approaches. Really for us, what we're looking for is to begin the process and to start working towards how we evolve to the end goal of ensuring that we have more value-based payment in our system. So I think those are the highlights for the 1.4. On the $600,000, we certainly look forward to working with AHS and their contractor in support of the all-pair model negotiations. However, I do think that the contract needs are more diverse than their current contractor, who is terrific by the way. Last time in the first negotiation, both parties, AHS and the board brought dollars to the table in support of the model negotiation. Some of those dollars supported actuarial work and modeling around total cost of care targets, which are the type of thing the federal agreement usually contains. I do think more resources could be valuable. I do agree there needs to be coordination. We certainly need to be working hand and glove together in terms of the modeling and it's not our intent to have dueling contractors. But in addition, the board is an independent body and we need to be able to ensure that when we come to the table on a particular agreement concept that we have the support we need as a board to do our own independent analysis of components along the way. So I do hope that you will maintain support for that funding in the bill. With that, I'll turn it back to Jess. Great, so it's critical that this payment reform effort be done in parallel with a patient-centered community and provider-inclusive redesign of our healthcare system or delivery system. You want the payment system to support an efficient system that's designed to improve a monitor's health at the lowest cost and the highest quality. So the 3 million of the 5 million dollar request is to support the design and planning for a series of data-informed discussions specific to each community with a focus on how best to meet the needs of the patients in each community. So we think about sort of three parts to these community conversations that would likely occur at both the hospital service area and then at the larger regional level. The first part is really an attempt to start to begin to inform communities about the current state. So looking at the local hospital, what is the financial health of the local hospital? What's happening with margins? What are relative prices look like? What are relative costs to look like? What is quality? What are the occupancy rates? How have these trended over time? What is the health status of the patients in the community? Where are the biggest unmet needs? Where are the biggest opportunities for health improvement in that community? Where are the residents of that community seeking care? Is it in the home hospital or is it elsewhere and for which services? Is there a rural bypass happening and if so, why? And what does access to essential services look like in each community in terms of primary care, in terms of mental health and substance abuse, in terms of dental care? Are we seeing evidence of avoidable hospitalizations in each community that could be prevented through more timely access to primary care or stronger investment in the social determinants of health? So the first part will be a current state and understanding of that current state and a listening session. Where do community members think their needs are not being met in their own community? So part of it is sharing information that we have and the other part of it is listening and hearing what communities feel like their needs must are. And then it's an understanding about what are the trends on the horizon? How well is the local healthcare delivery system prepared for those trends? What headwind should each community be prepared for? So is the local population shrinking or growing? Is it aging faster or slower than the rest of the state? Is this hospital gonna be impacted by, for example, the Dartmouth-Hitchcock bed expansion? How will that impact their occupancy rates? How will that impact local workforce shortages? And then thinking about is that hospital prepared for the shift to value-based payment? Regardless of what Vermont does, the feds are moving in that direction. So when hospitals are gonna be held accountable for cost and quality, are they ready? Where does each hospital system currently stand in their readiness? And then the next part comes around innovation. What is possible? So this is where we would all benefit from the knowledge of health systems experts who have successfully facilitated system redesign and transformation. So how might some of those unmet needs be better addressed? How do we shift resources towards more primary care and early prevention? How might we reduce cost and increased quality? Could regionalization of care leverage some economies of scale to lower cost and increased quality? Would centers of excellence benefit this community? And how might a fundamental change away from fee-for-service better ensure community access to essential services? So the money is gonna support careful design of that process to ensure that all stakeholders are included. We need to identify the best approach to facilitate really meaningful community conversations and we don't take this step lightly. We would benefit from expertise in this area to ensure that the process is inclusive and informative and that we're listening and that we have the right people at the table to be hearing what we need to hear and having those meaningful conversations. So part of that process is gonna require packaging complex data for each community so that it's understood by community members, the data that we do have and the data that we do know about each community and then preparing for and facilitating the many conversations that are gonna have to happen with community leaders and stakeholders, hospital leaders, trustees, providers all along the care continuum both inside and outside the hospital walls, community leaders, employers, and healthcare advocate, patients, all folks must be included in these conversations and they have to occur at both a local level and a regional level. And we're hoping that legislators can help us identify key stakeholders and actively participate in these conversations in their communities. And we need to bring an expert who can help us assess what is possible? How might access to essential services be enhanced? How might we reduce that cost growth so that healthcare is more affordable? And how can we better allocate the scarce resources that we have so that we're allocating those resources towards services that have the highest value and the greatest impact on the monitor's health? So that's what we're hoping that the $3 million of the $5 million ask will allow us to do. Careful data compilation, facilitation planning and those community conversations that will be long and hard and will take some time and thought. Thank you. And actually for both of you, I think it would be helpful to have your comments in writing if you have those, can send them along to Erin. The issue of process is always an important one and how to communicate with everyone who needs to be in the room and in the conversation. So I think we can consider a framework for that but it's only when you sit down together and with others, including AHS and community partners that the full process can be developed. So I think we can put something in on process but everything that you have said is key to making decisions about how to build that. So we'll be happy to look at your testimony and I doubt very much whether we're gonna go all the way down to the bottom of the pit to find everything that's needed in that process but it's certainly important and we understand its importance. I have one question. I have a lot of questions but let me just ask one right now and that is with regard to how the Green Mountain Care Board plans to work with in particular the Agency of Human Services and I'll save my other folks for later but to realize a robust process both of working with AHS and then also with community partners. Sure, so I'll go ahead and jump in. So we are currently working with AHS on the next federal agreement and as you know, the board as a public body has some limitations in terms of how many members of the board engage outside of a notice public meeting. So the chair, Kevin Mullen and I are the two board members who are working directly with staff and the AHS folks on agreement development. As you also know, the board as a whole only makes decisions in the public. So the process that was used with the last agreement was when there was an initial concept once that concept was developed that came before the board as a whole in a public meeting for a vote and again, post-negotiation. So just that's a bit about board process. I think what we envision with the dollars in S285 is that we would have a stakeholder process for the payment design because that is necessarily a very wonky detailed kind of exercise. And then as Justice spoke, a larger community process and we support having involvement from AHS and others to ensure that that is a robust conversation. I think what we would likely do on the second piece, the community piece is of course we'd need to put any, to get contract support, we would need to put things out for bid through an RFP process. And then we would work to figure out what the right design is. So I think from ours, because we are so much always working in the public sphere, I think for us engaging with others and including having a robust process is important and really the only way we can operate because anything that needs a board vote needs to go through a public meeting. All right, thank you. And then so in thinking about the wonky part, there are a lot of people in our state who are very interested in the financial piece. And so you're not, I guess my question is, you're thinking about going beyond the specific organizations that are affected by payment reform and looking outside to those who have been engaged and trying to offer support, help, questions. We are actually required to do that as part of existing statute. So in 93, 18 VSA 9375, there is an existing process and statute for how to work towards payment reform methodologies by the board. And that does include a public process. It has to be done by rule, which of course has its own process. There's the board process. And then prior to implementation, there's a report back to the legislative committee. So the existing statute has a robust method for ensuring that there is engagement. Just one last thing on this and then we'll ask others, but is there anything in that requirement that is going to inhibit the work that we're talking about? Hi, I'll take another look with that in mind. I wouldn't say inhibit. It could lengthen, of course, because the rule making process- That's really what I mean. Yeah, yeah. Let me go back to the statute and kind of map that out in terms of time and think that through a little more deeply. I had sort of just taken it as a given that we would follow that process because it's been in statute, but I do think it does have multiple layers of public engagement, which would be somewhat add time into the whole process. But let me get back to you on that, Senator Lyons. Okay, adding time isn't always a bad thing, but then if it looks like it is, it's a question. Yeah. Any other questions right now for Jessica? Go ahead. Senator Hardy, go ahead. Thanks. First of all, I wanted to make sure that is Sarah gonna get a chance since she's- Yeah, she's next. Okay. Well, thank you, Robin and Jessica. I'm wondering if in order to accomplish some of the things that you talked about, particularly Jessica's lengthy list, which I love, by the way- We all love it. If we need to change the language because I don't see that in S85 as it's currently drafted. Like it would not lend itself to a process as robust as either of you talked about, I don't think. So particularly if we're gonna need to reconcile our language with the house language, I wanna make sure our language is robust enough to begin with. So when it inevitably gets whittled down, it gets whittled down to something that's good enough. So it would be great if you could look at the language and see what we should add in order to ensure the process sees that you're talking about. And in particular, another area, Robin, you mentioned your own sort of in response to Ina's concern about your own funding and person to do the waiver renegotiation process. I guess it would be helpful to have language in there that ensures that there's collaboration and communication even though that may already be happening just to double down on that. Absolutely happy to suggest something and I'll run it by Ina first. Okay, great. But going back to Senator Hardy's first point, I was trying to get to that point. So it is, I think it will be important for us to have some process language. We aren't gonna be able to do it all. That's gonna end up being your job. But I think her suggestion of sending us some language that would support process is really important. Happy to do that. Okay. Terrific. So it's okay, sorry. Yeah, go ahead. I was gonna say, if it's okay, I think if there aren't any other questions, we can move to Sarah's. Good. Oh, Sarah, you are not being heard. The Zoom problem. Any better? That's great. Thank you. Okay, fantastic. Forgive me, I'm also at home with small children and the internet here is amazing in a facetious way. So, five any blips, please let me know. So my name is Sarah Lindberg, thanks for having me today. I am not a native speaker when it comes to policy. So please feel free to interrupt me if there are any translation issues. I had three kind of major buckets of responses I wanted to share. One is that some of Donna Kinzer's work, I believe has already been taken up in the BAA and that specifically has to do with the benchmarking work and the low value care work. As I understand that's now passed out of conference committee and appears like it will likely be funded. So in the Green Mountain Care Board's recommendation that was not intended to be included with this appropriation. So I just wanna make sure that everyone's clear about that and we do have an RFP ready to release as soon as we get confirmation that that will be funded for us. The second has to do with the language related to the blueprint for health and our coordination with them as it relates to the price transparency work required in statute. I believe that our fundamental V-Cure statute requires collaboration with multiple stakeholders including the blueprint for health and this tool in particular is something that's publicly available. And I just wasn't sure what the intent here is that needs to be added so that we can be responsive to it but to me I didn't see a lot of kind of add for our current duties or efforts today. And the third is probably one of the more complicated areas I wanted to address and that has to do with the enterprise patient index which first of all, 100% for that's a really great thing to have in Vermont. It's essential. Many other states already have these resources. However, there's a couple technical issues that are not gonna necessarily make sense for that to be specifically at the Green Mountain Care Board. One of which is that as current statute has it we are not allowed to collect identified information which would make index not very useful. So we do have that technical correction in another bill that is somewhere, sorry I don't know that part but that would be essential before we would be able to use such a tool. We would certainly want to use it and I would say that the opportunities for integrating data is much broader than clinical information. So there's vital statistics, immunization registries, potentially other survey level information that might be helpful to one day bring together. So it might be helpful to think about some of that integration language a little bit more flexibly. And finally, while the Green Mountain Care Board would love to use index, having it be the host might disadvantage particularly the provider community because the claims data we see is for Vermont residents wherever they get their care but there are plenty of people who are not Vermont residents who are seeing Vermont providers. And so having that resource placed someplace that's closer to the provider community and also probably closer to some of the other rich data sources we have in the state particularly at the Agency of Human Services might be more beneficial to us as a state but it's a really important resource and one that I certainly think is worthy of pursuing but it kind of didn't fit in my mind to where it shows up in this bill. And so those are my major comments. I'm happy to address any questions or translate anything. No, thank you. That's very clear. The issue, let me ask a question or make us comment that yesterday we did, I don't remember when it was, it could have been yesterday the week has compressed. We did look at adding social determinants of health into that data collection and I think that's what you were referring to that type of information and perhaps other. Yeah, and there's a kind of effort, not kind of there's an important initiative over at Vital right now brokered by Diva for this collaborative services effort. So we would want to be really mindful of not duplicating any effort with that initiative. However, the more state agencies that kind of average a common index but not necessarily have their data travel with it would be really powerful. So you think about really interesting things like say the Agency of Education data where I used to live or even pack, some areas that are very difficult to ever really truly bring together. And so what I'm hearing you say is that you are not the appropriate, Green Man Care Board isn't the appropriate host for this and is your thinking that it would be a place like the Department of Health where they do a lot of data collection including medical collection or you said AHS generally. So I'm wondering what specific department you were thinking about. Yeah, so I'm not expert of all the master person indices that are currently afoot. I know that a lot of agencies have had to stand up their own, but the Virato solution that Vital's using today I understand is one of the more promising areas. I do know from my work with Donna Kinzer that in Maryland the health information exchange does serve this purpose there. So I think there is precedent for that sort of organization to provide these services. Yes, and she did indicate that. So overall I think the importance of having this kind of data is to allow for the Green Man Care Board to understand the outcomes, quality health outcomes. And then so it goes hand in hand with the work that you're doing in understanding community work as well as blueprint, as well as hospital and other organizations. So somehow this all has to fold together. So again, it will be important for us to work with our Ledge Council and have you connected in both with Ledge Council and with Ina Bacchus with AHS so we can get it right. We don't wanna get it wrong, but we do wanna ensure that this de-identified data is available to put together to determine how any change is working and how our clinical efforts might be improved. So yeah, for me this is a really critical part of what we're doing. So that is absolutely critical. I mean, otherwise, we can look at cost until the cows come home, but if we don't understand quality outcomes and access, there's no benefit to the patient. So, okay, I'm sorry, I won't go on with that. Okay, but it would be helpful to have you folks linked in with Jen and we'll try to get to a good place on that. Okay. That sounds good. We're happy to work with Jen and Ina to see if we can come up with something. Yeah, and understanding that our support, the work that we had, that HROC had from Donna Kinzer was key in our understanding how we would like to move forward as a committee. So it's important for us to continue along her path as well as the path that you've set before us. I have one other question and I know Senator Hardy wants to dive in here. It's important. So as you were talking about the BAA and I think there were $500,000 available for that work and that is a limited amount of work that was based on what Donna Kinzer brought to us in HROC. But it's again, the question I have is is that money coming out of the initial appropriation that we have in our bill or is that in addition to? So Senator Lines, I can take that one. I think it was intended to be in addition to because while we would certainly use or potentially be able to use the results of the benchmarking analysis in the development and the community process, it is a separate stream of work. Okay, but as far as low value care goes and we must in our bill integrate that in with the work that's going forward because it's integral. If we integrate. Absolutely. Yeah, okay, I used that word twice and that sentence doesn't make sense. Everything is so important. And I would say that as a matter of course, we always make sure that we have substantial methodology and code so that we're able to extend analysis over time and that they're not just the one shot deal. We got it. Thank you. Okay, Senator Hardy, you had your hand up. Thank you, Madam Chair. My questions were just as you were going through to trying to figure out where in the bill you were referring to, but I think I've figured it out. And yeah, I think it sounds like you're going to work with Jen to make sure that we get this right. But I did want to come back to one comment you made about the blueprint. And if you could just clarify, are you saying that the language that's in this bill is unnecessary because it's already happening or what specifically about the blueprint? Yeah, it's already happening. In fact, we work extremely closely with the blueprint. Their analytical services related to their all payer work right now is actually in a contract of ours related to the all payer claims database. So we work extremely closely on efforts like that and have a pretty long history of trying to collaborate and make sure we're all rowing in the same direction. I think that we have much different perspectives and I always value kind of bringing that really boots on the ground kind of vantage with more of our macro level kind of system view. It's something I value and I can't wait to meet the new director. I haven't had a chance to do that yet. Okay, so that sounds good. I'm glad that that's happening. So that basically you're saying that the language in here is unnecessary or is it helpful to have it just to if there are different people in the future to make sure it happens kind of thing? Yeah, so the way I read the way that the VTURES was established is that we must share all this types of data for these types of purposes with multiple agencies including, I can't remember I should double check if the blueprint is specifically mentioned, but because they weren't at AHS obviously when that was, I'm trying to remember if they were officially there, but that might be a place to add it, just I don't know, let me get back to you about the specific place where I think the language might cover it and you can make sure that it feels comfortable for your intent. Yeah, we think that 9410, which establishes VTURES probably covers it. So that I think it's in, hold on, let me just pull up the, I have the bill on one of my tabs here. Thank goodness, I couldn't even get the bill number right. It's section two, A to B that we think is already covered in the VTURES statute, but we can verify that and make and talk that through with Jen and see if perhaps it makes sense to make any amendments to 9410. Okay, great, thanks. Yeah. Yeah, good question. All right, anything, any other questions, committee? Okay, there's a lot here and we wanna get, we do wanna get it right. We do wanna be inclusive and certainly the community outreach for us as elected officials is really so important. So any other comments, questions, committee? Wow. I just wanna say thank you and please stay available to us as we go forward. And that includes Ina and Jill as well. So we'll reach out and our ledge council will reach out so that we can have some changes made and a new draft before us when we get back after town meeting. I do wanna take this up in earnest. We will have a couple other folks that committee members have asked to have testify and we'll do that. But our goal really is to move as quickly as we can and get this down to the appropriations committee and knowing that we have a long way to go here. And I will be talking with my house counterpart because this, our bill was supposedly the lead bill but now everybody, everybody right now is very excited about doing this work now that folks are coming together. So it makes sense that appropriations are stepped out and that house healthcare is stepped out and we're just gonna have to pull it all together. And nobody will be happy in the end but we'll get our work done. So thank you all, I appreciate your time. So we're gonna committee, we're gonna take like, gotta check my agenda here. Thank you. Hang on please, it just disappeared. We're gonna take us a little bit of a break and then we'll come back. Jen, before we take a break, are you there? Hi. Have you been listening? You have been listening, I know. And there are a number of issues and folks to reach out to, what questions do you have at this point and how can we help with that process? Jennifer Carby, Legislative Council. I'm not sure I necessarily know what question I mean, you've asked people to provide written testimony but I guess I'm not clear from the committee which changes people have suggested that you are interested in pursuing what other changes the committee is interested in making to the bill. Okay, I think what we've heard is some improved language or more language on process and that we can for the Green Mountain Care Board community process. That one, I think is probably easier done than others perhaps. Then there's another question about where the EMPI, the patient index lives and with a responsibility for that, how that data can be collected and be identified and does that go through where in AHS might it go through and we have a decision to make here about how we wanna deal with that. So we're just looking to see the best place for that. And I don't know whether that's an ENA question or Green Mountain Care Board question or both. The suggestion was through HIE Diva, Vital, but that's Medicaid. And so we wanna get as much other data as we can. Okay. And then- Okay, and then as far as the moderate needs group, are you, is the committee interested in the proposals from Dale and BNAs? BNAs? Yeah, the Dale proposal keeps it on the front burner or maybe the back burner going forward. And that has been posted on our webpage. We haven't talked about it, but it would be helpful to see what changes that would make in the bill. I think it just, it moves it forward to another, the next time the negotiation takes place. Okay, and then there were a number of recommendations from the healthcare advocate. Again, are those recommendations the committee supports? Yeah, no, I think we should look at them. I think it would be helpful to see some highlighted or comparison of what's in the bill and what these changes bring to us. Does that work? And I'm, I think reach out as needed. We're happy to talk. Be good. Okay. Committee, is there anything else that you remember or have in mind from the testimony? Okay, that'll be good. My suggestion is that we take a 10 minute break and then come back and we'll look at some other.