 Hey everyone, welcome to a joint meeting this morning with House Healthcare and Senate Health and Welfare and we have the pleasure of having by state with us today. It is by state primary care association and it is their day in the state house, which we always enjoy seeing everyone and hearing what you're doing. So we're going to start I think with a probably a quick introduction and then bring some of the, I think we have three of the different FQHCs to come forward and we'll just have a good conversation. So introduce yourself and good morning for the record. I'm Georgia Harris, senior vice president policy and strategy for by state primary care association, resident of Montpelier very proudly, despite our very slippery sidewalks. The roads are fine though, if you walk on those, that's what I did this morning. Yes, thank you so much as the chair indicated we are hosting our legislative day today and are excited to bring some of our challenges and opportunities to this joint committee meeting. Also, we're in the card room today. So you're able to stop by, please do. We have a little bit of a game and some jelly beans for those interested. So thank you for that. I'm going to be very brief. I'm just here to open us up and I'm going to invite three of my colleagues from the community health centers of the Chitenden and Southern Grand Isle counties, the Springfield region and Arlington, Vermont. So Jeff McKee, Kayla Davis and Josh, we're going to do the rest of the testimony. And do you want to come up together separately? It's up to you. And I think together might make that. There's three chairs. Great. Come on up. Thanks for coming in so early. See what happens. Good morning. I am Jeff McKee. I'm the CEO of the community health centers. We serve Chitenden County and Southern Grand Isle County. And I'm going to go first and just pass those around if you don't mind. A lot of facts and figures related to the community health centers. I'm not going to go over the whole list of things, but they're there for your reference. One of the things that I really want to make sure that this joint committee here this morning understands is that federally qualified health centers are different than other kinds of primary care generally. And one of the things that makes us different is all of our missions include a commitment to health equity that manifests different how we deliver services. So just to probably preaching to the choir, but to say in the difference between health equity and health equality, health equality, we all do that. We open our services to anybody. Anybody can come. Anybody can come regardless of their ability to pay. We all do that. And many health care organizations do that. That's health equality. We don't close the doors to anybody. Health equity challenges us to go further and to understand the barriers that different segments of our community have in access to health care, which creates health disparities across the communities. And so in each of our missions, it looks different in every community because every community demographic is different. But all of us challenge ourselves to understand who is not getting served. So it's not just about the people who walk in our doors. Every health care organization tries to serve. It's those who don't, who can't, who won't, are afraid to, don't know how, whose other conditions and social determinants of health prevent them from getting to us. So we have a variety of services that we offer to kind of get to that last mile of health care in our communities. And if we don't do it, nobody else does. So that's the thing that's truly unique about federally qualified health centers. There is no one else doing this work, leaning into the work the way that we do. Out of our missions, as I said, and we are so proud to do it every day. This is not a complaint. This is just to you know who we are. We wake up every day living this mission. And in the case of the community health centers, just give a couple of highlights. So we're the state's only home health care for the homeless program as well. So in Chittenden County, that means that we do a lot of work, you know, working with people who are not our patients yet, trying to do the outreach. We literally have people who strap on backpacks and walk into the woods and then in camp in some cities, go to the motels and hotels and try to engage people and offer them care. As I said to Senator Lyons this morning, briefly, we have to now challenge ourselves to also understand our competitive where we need to do things better with respect to substance use disorder treatment. Drug dealers don't make you take a bus to get 30 minutes away to the treatment center. They show up at your door at home. Right. So where we're located, look at us. We have nine locations in Chittenden County. That's a lot for a small footprint, but we understand if we're not in those locations, people make other choices about accessing their health care. But it's too much. So we have that outreach program. Much of that care, even though we have a small grant to do the age program, is uncompensated care. We do it because it's permission to take up funds that we have from other parts of the organization and we subsidize that outreach into the commuter. That's vitally important, right? And we'll process it, but particularly in Chittenden County. We also have an elder care program and our elder care program provides. We do home, we do house care. And we help people age in place throughout the community, people who would otherwise access to eat. So it's a much higher rate. And as you can imagine, when you're providing those kinds of outreach services that require travel, you're working with patients with multiple complexities, social determinants of health complexities, as well as medical capacities. And often with people who have not had their health care needs appropriately addressed for years, these are not 15 minute visits, right? Our model looks different and requires different kinds of funding. My clinicians can't see 15 minute appointments rarely ever. And then you add to that the complexities of the outreach from the work that we do. It requires a different kind of to do that work. And we're grateful that the model we've been offered by the state of or by the federal government actually supports that. If we lean into our mission, we will be OK. And if the if the funding is there from the states and the commercial payers as well to make it all work, you have a problem right now that it's not working, right? The funding is not there adequately to continue that. And in our case, last year, we had a one. We had a well, this current year, we're going to likely have a one point two million dollar deficit starting to put together a budget for next year. I'm looking at a two million dollar budget and a deficit. I don't know how to close that at this moment. I can't cut any more staff. We actually had layoffs last year. That's real. That's likely to happen again. And the programs that get cut are not the ones that have a revenue source attached that serve the people who are the most well off in our community. The programs that have to get cut because the financial math of only works this way are the ones that don't have a revenue source attached to them and are those own mission aligned and are and are serve our most vulnerable members of our community. And so that's that's where we're at. And so, you know, I think the the staff we have, we certainly have over 450 staff or 300 staff. And, you know, they wake up every day doing the work. And there's a commitment that I've made to them. And I always felt like the state of Vermont stood behind me. We'll figure out how to keep the lights on so you can do that when I'm having trouble kind of saying that with confidence in the last couple of years. That's a story with this. I think Kayla's going to go right. Let's go right to Kayla. That'd be great. And I'm going to try to share my screen. Madam chairs, members of the committee, thank you for this opportunity to provide testimony on the role of the health centers and our communities, how our services are responsive to the unique needs in each of our communities. And the residents. My name is Kayla Davis, and I'm honored to be one of the co-executive directors at Baton Co Valley Health Center in Arlington. Much like Jeff pointed out, I want to talk about how QHCs are different. We have rigorous requirements attached to the federal funding that we we have to help support our our programs. But we see the sickest patients. We see the patients with the highest level of need. While also being held to extremely rigorous health care standards. We we cannot manage our payor mix. So many other health care entities can decide which revenue streams, so commercial insurance, Medicare, Medicaid, which visits are the most revenue generating and decide what patients to welcome. We can't do that as if we're open to new patients, we're open to all regardless of ability to pay, Medicaid status and that is part of our mission. While the work is high in cost and labor, it's our mission. This is the work that the Community Health Center movement set out to do all those years ago. BVHC is teeny tiny. We're located in Arlington. We have a little campus with two buildings. We serve just over 4,000 patients. And our pair mixes split about a third between Medicare, Medicaid and the commercially insured. But 48 percent of our patients with known income levels are living at or below 200 percent of federal poverty. Our patients are different. This is why the sliding fee scale program that we offer as FQHC is so important because it ensures that regardless of ability to pay, people can access health care in our building. More than 25 percent of Bennington County residents are enrolled in SNAP. In fiscal year 23, BVHC distributed almost 1,700 bags of fresh food through a partnership with Veggie Van Gogh, 4,600 pounds of food from our food shelves, which are located in each of our waiting rooms. And that's supported through private donations and the Arlington area food shelf. Bennington County's suicide rates, overdose mortality rates and mentally unhealthy days are higher than the state and national averages. This is why we have four therapists on staff, a psychiatric nurse practitioner, why all of our providers prescribe Suboxone for substance use disorder. We're at a critical point in this state and this work is so important. And people need to access it regardless of whether or not they can pay for it. Oral health care. Bennington County has a dearth of dentists, but for those who have Medicaid, it's even harder to access services. I think we are one of three currently, but SVMC's dental practice, I'm not sure if they're closing, will be one of two dental offices accepting Medicaid. We do that work in the office and then we also go out into the community because we know that there's not access to dentists. So if we can educate children, parents, if we can get toothbrushes into the hands of these folks, it's something, right? So we're in the classrooms, we're in daycares, we're in public settings, we're in local businesses. And last fiscal year, we distributed over 3,300 toothbrushes into the community with help of private grants. Chronic conditions in Bennington County are high and this is one of the things that sets FQHs apart. We do population health management and we try to teach life skills. So we provide walking groups, we provide free cooking classes to promote overall mental health and physical wellness, but also to help people develop those life skills that they may not have. And again, it's free, they get to take the food home and they get a skill out of those classes. We have a partnership with Green Mountain Express, it provides free transportation to and from medical appointments, dental appointments, mental health appointments to ensure that transportation is never a barrier to care. We're in rural communities, we are located on the Green Mountain Express bus line, but if folks have mobility issues that don't allow them to utilize the bus line, then we pay for door-to-door service. And we believe that teaching children about health at a young age makes a difference. We supplement the Arlington School District's healthcare curriculum, our providers go in, it's a wonderful opportunity to lead discussions with up-to-date information, it exposes children to different healthcare professions at the same time. And in last fiscal year, we gave 27 health presentations in local schools and daycares. We're also doing, working with Gina at the Public Health or the Public Access Television in Manchester to do mental health and medical shows so that we can get information about ticks and different things out into the community. We're also committed to being part of the solution for the health professional shortage that we're experiencing in the state and it's national, but the state of Vermont is experiencing it hard as well. We host interns from many different fields, but our proudest accomplishment is that five of the 15 dental students that we've hosted have stayed in Vermont. So, critical. In summary, health center model is unique. We strive to be responsive to the needs of our individual communities. We work with community partners to reduce barriers to care and expand programming. And we are constantly working on ways to find equitable access to quality healthcare. Each health center serves a unique population and we have unique costs. Our costs are growing at a much faster rate than our reimbursement. Like our peers, we're projecting a loss for fiscal year 24. In order to continue to do this work, we need to be receiving reimbursement that aligns with federal regulations. We are at a critical point with federal funds that have provided insulation over the last several years expiring. We have to find a way to assure that the safety of the community health centers is there to safeguard the care that one and three Vermonters currently see. Thank you, Kayla, such good work. Josh? Everybody, thanks for being here today. Thanks for listening. I'm Josh Dufresne. I'm the chief executive officer for Springfield Medical Care Systems as our corporate name. That may be familiar to many of you. We were in the headlines quite a bit back in 2019. We are now doing business as North Star Health, which is a federally qualified health center without a hospital. We did spin that off. We have 13 locations that are primary care dental. We're actually in the schools as well. We do have a mobile unit that goes out and meets people that are homebound. We take care of approximately 25,000 patients and we see about 100,000 visits per year. It's getting harder and harder to run by our organization. Last year we did have a loss. Coming out from bankruptcy, you can imagine that we didn't really have any reserves. All of those were pretty much liquidated. So we had to pull ourselves up from our bootstraps. What I'm seeing right now is a loss from last fiscal year. Our fiscal year starts in October. I've already got a $1.1 million loss this year from operations. So what I'm starting to look at is cash on hand, not necessarily operations other than trying to improve it the best of my ability. And that's getting more and more difficult. Not long ago, Senator Sanders called me and asked me to spread the FQHC down into Brattleboro and we've had some good conversation with those individuals in Brattleboro and they want our help. The business plans aren't coming out in the black and that's frustrating. We offer a huge amount of enabling services, whether it's behavioral health, whether it's the dental aspect, the primary care or even vision care. We're one of the only FQHCs in the state that have two optometrists that help people get eyeglasses. If you can't see, it's hard to get a job. If you don't have front teeth, it's basically impossible to get a job. These are the types of things that FQHCs do. We are your safety in the state of Vermont. And I can echo what Kayla and Jeff had said today. We are very proud to do the work that we do. We open our doors to everybody and anybody regardless of anything. There's actually a quite a long list, but anything, we open that door. We want to be sustainable. We want to take care of our patients and one of the ways that I've been trying to revolutionize primary care in the area that we serve is to integrate lifestyle medicine. Some of you may have heard of lifestyle medicine. If you haven't, check out the American College of Lifestyle Medicine, ACLM. And we are taking care of patients by asking them how their stress load is. That's different, right? And this is in primary care. So how's your stress? How's your sleep? If you have a smart watch, you might know what your sleep looks like, right? And you're going to do better. What's your nutrition look like and how does that affect your sleep? How does that affect depression? Those meetings with patients take time. I'm paid primarily by volume. So I have to tell my medical staff about 45 individuals, see more, see quicker, take less time. As a patient, that's the absolute worst case scenario because I'm going to go into an exam room. I'm going to spend 10 minutes with my nurse or my MA, maybe five or so with my clinician. Did I get all the problems out that I needed to know? And that makes it really hard. So what do you do? You reschedule the patient to come back in three weeks. They don't have a car. You have to get a van. We have to get a bus ride. And we get some help with that. We have some free careers that help move people around. We did receive a grant during COVID. Ironically, if COVID happened when it did, we probably wouldn't have gone bankrupt due to the funding that came to the organization. That would have bailed us out at the time so we could have taken care of a lot of things. But to be in bankruptcy and then also have COVID hit, that was a tough mountain to climb. I can tell you, just getting back online and having the operations go the way it did, we got some rain in July. That took out two of my clinics. So I had to shut down Ludlow Health Center. I had to shut down Ludlow Dental. Both of those locations were planted up to the first floor and required complete mold removal, new HVAC systems. And in dental, the insurance company doesn't cover your dental equipment that's in the basement, such as suction, vacuums, those type of things. I did not make money on the floor. I thank the state of Vermont for their help and many others that did help us, but we did not make any money on that floor. And that was very difficult for the patients. We did park our mobile unit out in the middle of Ludlow and we were able to help people that needed immediate care. The last thing I want to mention is walk-in care, acute care. We do offer that and it's much different than what I would refer to as urgent care, which is mostly a for-profit organization. For walk-in care, we take care of people that can't get into their primary care right away, which is the thing everywhere it seems. There's not enough primary care folks and that's because they don't maybe make the same as a specialty or a subspecialty. So doctors are going into those type of fields instead to pay off loans and debt. The walk-in side of what we provide is something that will allow people to then establish with primary care. We find a lot of people that that's their primary care walk-in and that's not where you should receive your primary care. It's a necessary evil. We have to be there because it's keeping people out of the emergency room. For lifestyle medicine, we have reversed chronic conditions without pharmacy. That's huge. That's gonna get cut. If I can't be sustainable, I'll have to have lifestyle medicine, which is near and dear to my heart. George, you can tell you, I talk about it all the time. We'll have to go away. These enabling services will have to be reduced. And the way that this structure works, you don't have more money if you're smaller and it's harder to have more money if you're bigger. So it's not necessarily the model. It's the reimbursement. So I really wanna thank you for listening and thank you for all the help that you can provide. Great, thank you all for, and your colleagues for all the work you do for Vermonters, it definitely is vital. We have a couple of minutes if there's questions. Can I talk? Yeah, absolutely. So before we jump into questions, I just wanna say thank you again on behalf of Senate and House Health and Welfare, Health and Welfare and Health. And a couple of comments. Before we finish, it would be great for folks who also are here from FQHCs to introduce themselves. So we could go down the line. That would be great. Why don't we do that first? And then I have one more comment. Any other questions? I'm Dr. John Matthew from Health Center at Plainfield. I'm the CEO and the medical director. Just now, I'm the Chief Operating Officer for Northern Communities Health Care Survey for Montsourpey County. And we're now going to CFO for community health centers of the Rutland region. Thank you all for being here. And we're thinking that your colleagues have spoken for you in many ways. So we appreciate that. Just to say that your comments are extremely well taken and certainly as we're going to be hearing testimony regarding Act 167, which is an evaluation of community needs and linkage of community services with hospital-based care and other care that you are on the ground floor for this. And we appreciate very much that work. We do work collectively and together on ensuring sustainability, in particular for primary care as we work toward health care reform. So thank you for your work. I'll go to questions. Alyssa. And yes, thank you so much for your work. So I was wondering, in our budget last fiscal year, there's a big expansion of the Huff & Spoke two-year grant. You know, the Burlington Community Health Centers, you're the largest spoke. Although I guess I thought you were a hub, but maybe I got my hub. You're a spoke. You're a spoke, you're a spoke. I'm wondering if you are seeing any of this yet or projections of what you may be receiving on this. So we are definitely expanding our services there, in the spoke arena. And so the funding that comes through the blueprint and that funds the spokes will continue to expand that as needed. But really thinking about though is how we'd have to do that service different. The Huff & Spoke model was amazing. We're tired of that. I've been around for a long time now. I was tired of that for when it started and it was a national kind of best practice. But the substance use profile in our communities has changed dramatically. And so patients that want to walk into a clinic and get buprenorphine, and whether buprenorphine in an outpatient setting is really going to meet the need of people who are addicted to fentanyl and other kinds of opiates is a different kind of a question. So we're grateful for the funding. We are going to see that. We are looking to expand the number of clinicians in support for that. But it's, I'm not sure that's getting at the problem. We're experiencing waste and shit in camp. Are you seeing the money yet or? I don't believe we've seen any of the money yet. So I know our team's been talking about the expansion. Okay. But it's also driven by the number of patients we have, right? So I think we're working with the state, the number of, because it's based on the number of Medicaid patients you serve. And so that's, we're trying to figure out how to do that outreach to get more of those patients in the door. And we've been assured that the funding will be there if we can do that. Thank you. Great. So I'm going to alternate between House and Senate. So Ruth. Thank you, Madam. Sorry, I should say Senator Hardy, I'm much more informal in our committee. Senator Hardy. That's fine. Lori. Thank you guys and I apologize for walking in a little bit late. But I have two questions. First, similar to what Rep Black just asked, in Bennington, they're starting a hub actually. And I'm assuming you're a spoke. We're spoke. Okay. And so have you seen any impact yet? I think they just opened or maybe you're about to open the hub. Yeah. So we haven't seen it yet. We're working with, so our, the model, a little bit model in Bennington County is a little bit different. The funds go through the hospital. They're the employer to try to make it so that you have a full-time employee with benefits because we have such small practices throughout the region. And they're talking about placing a full-time community health worker with those funds at Baton Hill. And that will be hugely amazing for our patients. That's great. The piece, Blueprint is an amazing program. And I would suggest never taking that away, please. But it doesn't change revenue stream, right? They're free services. It's amazing to have those wraparound services for our patients, but it doesn't get at the budget problem that we're seeing. So, yes. So yes, we're seeing staff and we're so appreciative for that. Okay. And then I have a question for you. In Springfield, I do quite understand how you spun off from the hospital debacle for lack of a better word. So was it the hospital practices that were associated with the hospital that became an FQHC? Yes, after a very long period of time. And so a lot of the private physician offices, they weren't sustainable so the hospital employed them all. And then the hospital became rural health centers for their primary care group in an FQHC. And the FQHC was positioned up off the hospital. The hospital was subsidiary at the time. Okay, so the hospital's a subsidiary of the FQHC? It was. It was, but it's no longer. Correct. The hospital still is a hospital. The hospital is still functioning. But you're split now. We're good partners, but we are no longer affiliated. I see, okay. Okay. And then I guess my final question for all of you and maybe I missed this because you just said it in the beginning. What, I hear you about the financial struggles and that sucks for lack of a better word. What is your ask of us today specifically besides we need your help, but what do you have a specific ask that you're coming to us with? Yeah. Oh, and that over to Georgia. Okay. Hello, again, Georgia Harris from my state. We submitted a letter to the creation committees earlier this week, requesting 2.8 million dollars in appropriations to short the Medicaid reimbursement so that Medicaid is fully compliant with their future for the hospital services. Okay. Do we have that letter as well? I believe we see the chairs. Okay. It'd be great if we could get that on our website or have it. Can you resend that? Sure. That would be excellent. Thank you. And obviously those are conversations that we'll continue to have. Yeah, I just want to say it's a budget conversation. We will not be talking about it in our committee until we see the budget, but it's there and we did get the letter in appropriations to that. So when you resend it, make sure it goes to two committees. That'd be great. Just one more question. Let's take one more minute. Right, right. Last question. Representative Rebecca from Winooski. Regarding your budget gaps, I'm curious as the state, I know Department of Mental Health and some of the designated agencies have been exploring the CCBHC Certified Community Behavioral Health and Fitness Model. And those have a federal required, well-enhanced Medicaid reimbursement rate. I'm wondering if any of you are involved with that since that model does have a requirement to collaborate with FQHC? Are any of you involved? Is that at all a benefit to some of your challenges? In Chittinham County, we have a really nice relationship between the Community Health Centers and the Howard Center. And it is our hope that when they get to integrating with primary care, certainly they do collaboration with our primary care and our own sites, but we've also talked about down the road trying to envision integrating primary care into the Howard Center. So having those conversations and trying to plan for that. That's about as far as it's possible. And I would echo that for Springfield. We work very closely with HCRS, Healthcare Rehabilitation Services, and they're at the table at the Brownboro Expansion as well and how we can work together. Great. Can we ask you where the sender slides are? Can you send your slides to Claire Neal? Yes. So we can have them. That would be excellent. Thank you. Again, thank you all very much for coming in early this morning. We do have testimony for the next couple of hours. And I know you're only in the card room until noon, but hopefully there'll be some time to have some conversations with us at the table later. And many of our colleagues, hopefully we'll stop by the table. So again, thank you for all your work for Vermonters. It is vitally important. Thank you. Thank you. Thank you. I think we're going to stay live and switch to... Yeah, she's had about a one-six, she said. No one over here, so it's fair. Yeah. I didn't get it. Okay, I'll pass it over at the floor. Sure. Well, it's just like 10,000 people over here. Yeah, okay. Like how... What do you want to put it up? That's my question. All right. Just talking? Yeah. What did you say? Talk, just talk. Huh? Yeah, you're right. Yeah, everything. Everything? Yeah, okay. That's fine. That's fine. Okay. Hi. My man. You're so sharp. It's okay, I'm going to get him as long. No, it's not going to be my man. Okay. Do you want me to start? You can start. Oh, for folks who are sitting back there, there's chairs up here, if you're probably might be able to see the screen better when things get put up. So that's up to you for no compelling reason to move. All right. Thank you, House Healthcare and Senate Health and Welfare for being here. We're going to continue the meeting. Representative Houghton is taking breaks off and on to exercise. So she'll be back. You'll do that? No. The actually physical activity is good for all of us. So, you know, feel free to stand up from time to time. I think that's important. So, Representative Lori Houghton, Chair of House Healthcare. I'm Senator Ginny Lyons, Chair of the Senate Health Care, Health and Welfare. And why don't we have House reps who are on House Healthcare? Just raise your hands so folks can see. And then Senate is here. Senate will raise our hands. We're all, one of the, one is taking exercise. So, that's good. So, we're moving on to Act 167. And we're, last year in the spring, we passed this bill, S285. And we've asked Gen Carby to come in and give us a short reminder of what we passed and what's in the bill. And then we're going to look at the work that's been going on since the springtime that be around Act 167. And I'm not going to talk about it because Gen's going to do that for us and we're going to hear enough about it. But suffice it to say that there is a lot of work going on and it's terrific. And I hope that we'll appreciate what we hear. So, Gen, why don't you start us off and we'll remind us what we are looking at in Act 167. Great, good morning. Jennifer Carby, Office of Legislative Council. So, just a quick reminder of what happened in Act 167 for the pieces you're going to be talking about. And this is Act 167 of 2022. So, for those of you who are new in 2023, you didn't work on this. But in section one, there was a requirement that the Director of Healthcare Reform and the Agency of Human Services in collaboration with the Cream Mountain Care Board develop a proposal for the state's next agreement with the Center for Medicare and Medication Administration to ensure Medicaid participation in multi-payer alternative payment models in Vermont. There were a number of considerations that had to be taken into account in developing the proposal that were spelled out in the legislation and also some specific alternative payment models to be explored. The development process had to have opportunities for meaningful participation by the stakeholders. That was the first part of section one, the second part of section one was directing the Green Mountain Care Board to collaborate with the Agency of Human Services and use that stakeholder process to develop value-based payments, including global payments from all payers to Vermont hospitals or accountable care organizations for both and there were specific factors to be taken into consideration there as well. And there were reports due on each of these last January and March, respectively. Section two dealt with the hospital system of transformation and engagement process and directed the Green Mountain Care Board again in collaboration with the Director of Health Care Reform in the Agency of Human Services to develop and conduct an engagement process for Vermont hospital transformation. There were a number of factors specified and what that was supposed to look like with an update on the community engagement process last January. $900,000 was appropriated in the FY23 budget for the Agency of Human Services work and 4.1 million for the Green Mountain Care Board's work. And then you passed a couple of provisions last year that kind of piggybacked on some of these. So there was a requirement in Act 51, which had been H206 on the responsibilities of the Department of the Run Health Access and other provisions that effectively added a new section to Act 167 even though it wasn't in there when originally passed that directed the Agency of Human Services to engage in transformation planning with up to four hospitals to reduce inefficiencies, lower costs, improve population health outcomes, reduce health inequities and increase access to essential services while maintaining sufficient capacity for emergency management. And so that went to progress report due in February of this year to your committees. And in last year's budget, there was also a requirement that the Green Mountain Care Board submit an update to the Health Reform Oversight Committee by November about various things having to do with hospital performance. And hospital transformation. So that occurred in November of this year at the Health Reform Oversight Committee meeting. And now here we are. Okay, thank you. Good. So we're going to begin with the Green Mountain Care Board and see you behind me. So all three of you want to come up? Okay, why don't we do that? If you need a spot to put your materials and you share. Share. All right, you're good at sharing. So we have, do we have what you're presenting on our webpage or is it something different? Oh, how do you want to go? You should have a copy. We will share our slides and just take a moment. Okay, we can put those up here. So this is the update from under own Fosher's name and will Claire's putting it up? There's not putting it up, she's putting it up. She's putting it up? Yeah. Thank you. Yep. Always IT. I'll let you go. She's doing that too. Okay, introduction. I'm trying to join the Zoom and then I can just run the slides at that. Yep, that's fine, right? You should be able to share now, Claire is saying. Yes, we can see you in, in double. So great. Just what you wanted. All right, so now that it's up, why don't we have you introduce yourselves for the record and we will listen to your presentation information. Great. Well, first, thank you, chairs for inviting us for the committee members to be here to hear us today. My name is Owen Foster. I'm the chair of the Green Mountain Care Board. I started in October of 2022. So I've been there about a year and a few months. I'll introduce themselves. Morning, my name is Marissa Melamed, Associate Director of Health Systems Policy for the Green Mountain Care Board. I've worked with the board for, well, quite a while now since 2016 on most of the different regulatory processes that the board oversees, as well as their special projects. Great, I'm Alina Bearby, the Director of Health Finance Board. I recently returned to the board after taking a few years to work on dissertation and PhD work at Dartmouth in Health Policy and Clinical. Thank you. Great. So I'll give you a little overview of what we'll be discussing today. First, we're just gonna give a reminder for the Green Mountain Care Board is and what we do and what we don't do. We don't have it ready for. I'll speak a little bit about our process and then some general information about the state of the state in healthcare and how we're doing. And I think that's relevant context for the work that we're doing through 167, why we're doing the work and then we can discuss what we're doing exactly. This is the Green Mountain Care Board was established in 2011. And I wanted to focus on one thing here first, which is quasi-judicial. I'm a lawyer myself, our Executive Director is a lawyer and Robin Lange is a lawyer. So there's two board members who are lawyers but quasi-judicial, what it means is it has a judicial character or some kind of risk to judicial nature such as like a court proceeding. And what we do largely is we review budgets, make decisions on budgets. And we do that by holding hearings and receiving evidence and having witnesses and receiving testimony. And our job is to evaluate that information and then to make factual determinations and conclusions based on the evidence that we receive. So this process is important because it helps us get at what is the best decision, right? We can challenge certain statements that are made to us, right? Everyone has a context that's relevant to what they say but there can be a broader context and that can influence a decision, right? So we're actually trying to think about the entire healthcare system. And I think one thing that the last presentation said was an ounce of prevention is worth a pound of clearer. And that's something that's really top of mind for us. We have a lot of problems in Vermont with our prevention. We have inadequate primary care, we have inadequate mental health, we have inadequate long-term care. Those things help prevent illness. They also save money. So they're right from an equity standpoint and they're right from financial standpoint. So when we're making decisions, some of the information we're receiving in those hearings that we're evaluating, we're thinking about it not just from the perspective of the entity that's before us, but from all entities that are in the healthcare system and more importantly from patients, right? Because there's a lot of competing things. We have a very solemn duty, it's a hard duty. It's not that much fun at times, but what we do is people ask us for a lot of money. Tens of millions, hundreds of millions, billions of dollars. So I think the last hospital budget cycle might have been about three and a half billion dollars or so for requests. Those are gobs for moderate money and the rate requests, but those means how much money is being taken from ratepayers, all of your constituents, our neighbors, our friends, their farmers, their trades professionals, their restaurant workers, their everybody, and when you have a large rate increase, that hits them in the pocket. They have less money to do other things, right? Less money to buy good food, less money to go to the gym, less money to go on vacation, less money to invest in their business. So when we're asked to give a lot of money, it's a really solemn duty. You have to take it very, very, very seriously. And so that's what this process is for. Legislature recognizes, on 11, they set up this board with five independent members, right? And we're different. We have different backgrounds, different professional educational backgrounds. And that to my mind is that we want people who it's not one person, right? Everyone has a different view that we bring when we hear that evidence, different life experiences. And so it's not just one person and it's not behind closed doors in a public hearing. It's very transparent. It's apolitical. We're independent. We do not work in the executive branch. We do not get feedback from the governor. We do not get feedback from legislators, right? And that's a really good thing because we want somebody to be able to look at this information really objectively and make the best decision we can. So that's why this structure is what it is. It's interesting, while we're different and we have different views, this last year, I've been there one year, been through all the cycles. The amount of times that we voted together is overwhelming. Most of our votes are unanimous. Even on the big substantive meeting once. So if you look at the hospital budgets, we have 14 hospital budgets we decide and there's five of us. Herman, member of Herman, he abstained from the UVM once he works at CVMC. I think the votes were 66 to one. 66 votes, all exactly the same, one vote not on 14 hospital budgets. So pretty uniform and consistent. On the hospital budget guidance, it was 10 votes when we had two votes on it because there's an appeal, 10 votes, all uniform. On rate review, 20 votes, zero, opposing. So while we come from very different places, right now in this time in Vermont, we're seeing very consistent and similar things and recognizing that as a group that comes from these problems very differently, but we're voting consistently together. The only one where we don't is the ACO. The ACO, I think we've had two, maybe four substantive votes. One was four to one, one was three to two, another one was four to one, and another one was five to zero. So again, pretty consistent, but on that one we have had some more disagreement as to what the right course of action is, which isn't really that surprising, right? There's a lot of history with the ACO. There's a lot of expectations, some fair, some not. And so we have to use that to help the thing. We want that, but generally in the big meeting ones, this group of five people votes together almost always. So what we're trying to do is make decisions, as I said, that really benefit the entirety of the system. And one of the decisions we made this last year, which I think was kind of under the radar, but I thought really important was on our rate review decisions. And on those decisions, we put in a provision that said when insurance companies decide how much money to award to various people they're negotiating with, they have to consider affordability access and quality in those decisions. Because we want to sustain parts of the system that are affordable. We want to sustain mental health. We must sustain primary care, we must. But what was happening in Vermont was there was very large disparity between what regulated entities were receiving and rate increases versus everyone else. And we didn't dictate give them this, give them this. But what we did say was insurance companies to be cognizant of that. And they need to think about that and their decisions, because if they're not, they're not putting the money where it needs to go. And so that's why we did that. And we'll see how it goes this year and we'll see what the results are. On this slide, the one that I think is most important is accountable. We're a preacher of the legislature. We are accountable to you and to your constituents. I think it's fair for the legislature to ask us, how are you doing on affordability? How is Vermont, and if it's your task and you have all these authorities, tell me what you think. Are you doing well? Are you doing poorly? On access, same thing. We have huge access problems to many different types of care that are really important. We need to be accountable to you and to your constituents as to how we're doing on access. If access is bad, it's not gonna be all our fault, right? We're one part of the system. There's other parts that have other levers. But I think all of us collectively at this point in time need to be accountable for these things that our moderates need. I'll give one anecdote that really resonated with me in my old career. I was a Department of Justice lawyer as a prosecutor. I did healthcare fraud cases. And one of my mentors said, there's people who make cases and people who tell you why. You don't wanna hear from us and people who get paid to do this work why we can. You need to hear why we can and how we're gonna do it. Not we're a small part, not we can't control this. We need to actually come up with a solution. And that's to be accountable. So I expect those questions. I think they're fair questions and I think they should be asked. Another component of accountability is the transparent nature of our work. We have meetings, public meetings, almost every week, we had 53 last year. And at these public meetings, there's notice in anybody who wants to attend. And they've been remote since COVID. So you get people from all over the state who otherwise couldn't come to Montpelier, couldn't afford to drive here, couldn't deal with the hassle of coming here, whatever it might be. And they come in on the Zoom and have a time where anybody can comment to whatever they want. A regulated entity, a patient, anybody, people from out of state, people from out of state do. And it's really insightful, right? Because it's really important to get the whole gamut of information when you're making decisions. You need to hear from the patients. You need to hear from the businesses. You need to hear from the hospitals. You need to hear from the primary care. You just need to. And so this avenue that we have, this requirement that we have gives us that ability. It's a really important mechanism to what we do. We also receive tons of written public comment, tons. So this last year in the hospital budget cycle, we had to start with guidance. We say what the targets are. And in that process, I think we received there's an appeal to have us go to a higher level of money. And there was close to like 200 public comments we received. And they're really valuable, right? So there's a huge chunk from hospital board members, members of the board's full of the hospitals. And they shared their view as to why they should have a higher guidance level. And that was really valuable to understand why that money needed from their perspective. But then there's a huge collection of people who had views as to like all the independence, the mental health and everybody else. So why it should be lower because of the impact, the collateral impact a higher amount would have on them. And they shared that view. And then we had the patients view of if you go higher, what is this gonna cost us and how is that gonna impact us? So that public nature of it is really, really, really valuable. I said this before, but we all try and make sure we get out and meet with the whole spectrum of the health care system. Next week, I'm going to the treatment facility center that we after I'm going to another treatment center. I've been to a number of hospitals, many hospitals, a number of independent primary care clinics. And that just makes sure you're making good decisions. This is just sort of a slide that I've used before about the role of the care board and what we do and don't do. Because sometimes people think we're all of health care, we're not. What we regulate are the insurance rate review, right? So that's really the cross-bueshield and MVP for their small group and individual group. We decide how much money they can charge. They'll ask for, I think last year might have been 17, 18% and then we'll make a decision on all the evidence they've received and that you cause a judicial process and we'll say, you know what? You didn't hit that standard. You didn't prove this much. You didn't prove this much. You're going to have a lower amount. And also beyond just with the evidence we have to think about what this is going to do to Vermonters. Can they afford this? So that's that role. Certificate of need, that's, you know just to ensure that there's appropriate allocation of resources and people aren't buying too much. There could be some recommendations around changing around that to expedite it. That's something where I think the care board can improve. I think we should handle some of these quite a bit quicker. Last year, my first year we adjusted and made automatic the amount of money that would get captured. So now it's actually the max that it can be. So for us to have review, the trigger is the most money under statute that we're allowed to have it at and it's automatically renewing every year based on inflation and other factors to how I can be. So it's at the max that it could be. I think there's arguments that it could be even higher or certain types of care could be not fall within jurisdiction of CON. So, you know, CON laws are written, but then there's changes in what we have in our healthcare environment. And so today, does it make as much sense to prolong and delay how long it takes for a treatment facility to come up or a mental health facility? There's arguments both ways, but I think that's an area worth discussion. Hospital budget, ACO oversight, I think we're all relatively familiar with what those are. Just a couple of things I'm gonna highlight don't regulate, which are FQH systems. Don't regulate independent providers. Don't regulate end of the story surgical centers other than CONs. If they're from a hospital, we do, but not otherwise. DAs, we do not regulate Medicare and Medicaid. We cannot and do not regulate those. I go to a lot of meetings and people tell me that they're medicated. I can't do that. We can't self-insured plans, Medicare Advantage plans. We have no regulatory authorities to connect with those. So affordability really matters because it means that people can have adverse impacts on people's health. People delay care when they can't afford care, right? They don't get primary care. They might not, they'll just avoid or delay care. They'll buy down on insurance. We don't want that. We don't want people buying down on insurance because of the financial decisions they have to make. So we try to keep an eye on how Vermont is doing in regards and respects to affordability. I hear people say, well, it's healthcare is not gonna be affordable. I think those kind of broad brush statements don't really capture the nuance of what we're trying to do. Yeah, it's never gonna be affordable. It's not in this entire country, but does that mean Vermont has to be the worst or near the worst, or can we do better, right? And it's really about doing our best, not saying like, oh, forget that bucket. I think we have to tackle it because that has real impact on Vermont's. So this slide gives you some data. I've said this before and I'll say it again. Healthcare data is to me directional and you need to test it from multiple angles. So in the hospital budget process, we had comparison data that helped us compare how much people are spending on admin costs, how much money they're spending on clinical care, how much it costs to discharge patient. And any hospital system, they're very complex, might have different ways that they account for the money which can change what those numbers really should be. But if you take every change, you now no longer have comparison because everyone you're comparing it to may also have changes, right? So if you change everything for one place and you don't change every one of the other 100 hospitals, there's no comparison left. But it is true that all this data may have some nuance to it. And so I think it's important to not look at any of these things as definitive of anything, really directional and temporally over time. Whereas in over time. This is our qualified health care plan expenses and where Vermont started in 2019 and where we are today. Online is United States, the top line is Vermont. We started higher for a number of reasons. We don't have community rating as an issue and what we provide for people, what we require in our qualified health plans is greater. So you actually get more with a Vermont plan than most plans in the United States, which is a good thing. So we start higher and that's explainable. Then we go up quite a bit faster than the rest of the country. I think we grew out of 58.5% and the rest of the country was under 5% on average. So we're growing quite a bit quicker, more quickly than other parts of the country. Our spending per capita, we're a very healthy state. We're really blessed with an incredibly active population. We're old, that's true, but we're a very healthy set of old people that should really keep expenses down. Healthy people don't cost as much. We're fortunate to have a very healthy population. So around 98, 99, 2000, Vermont was actually in line with spending per capita with the United States. We were equal, right? We were right there on average with the United States. Since then, we've expanded. That could be a good thing. It could be a bad thing. It could be some combination. You might want to spend more money on healthcare. That might be, we don't want to be Mississippi. They don't spend a whole lot. We want to spend more, but we want to make sure we're balancing it. So here you can see just where those lines start to diverge and then how quickly our spending is compared to the rest of the country. I'll spend just a second on this one. This is a total premium for employer-based students. Employer contribution and employee, right? So you have a, you work, you have a job, your employer pays some, you pay some, and then there's a total amount. So the top, top line is Vermont. The bottom line is the United States. The top is the total premium. So our employer-based plans in 2017 were on par with the United States. We were consistent with the average of the country. Since 2017, we've grown faster than the rest of the country on our total premiums for our employers. And our employer contribution has also grown faster. Our employee contribution has remained relatively steady with the rest of the country. So our employers are paying more, our employees are paying less. That could be because of a competition. Our employees here is tight. It could be our employers are more generous and they provide better benefits. We're concerned that this bottom line is gonna start to diverge as we go forward. We've heard anecdotally that a lot of employers are starting to shift some of the financial burden as it's gotten particularly acute to their employees. So this could change, that's something to keep an eye on. You just had also the nature of the plans could decrease, right? So it's not just how much you're paying but what you're getting for it is often a sacrifice. Right. Health care costs show up in a number of different places. They show up in the state budget. They show up in our health plans. At the care board, every state agency is seeing fairly large increases on how much we're paying for healthcare this year. It also shows up in places you don't really see as much in the press, which includes property taxes. So this year, there's a report. I think the number will hopefully go down quite a bit but the average property tax bill is supposed to go up 18%, 18 and a half percent. That will come down I think but that's a really huge increase on people's property tax bills. And a big chunk of that is because of school spending on healthcare. School spending on healthcare is going up 16% this year. It's expected. So people's property tax are going up because of the healthcare costs. Insured rates and uninsured rates. These are another metric we kind of keep an eye on to think about whether or not we're having adverse consequences to increased costs and you want a low uninsured rate, obviously and you want a low under-insured rate. Vermont does very well on uninsured. We have a very low uninsured population but then we have a very high under-insured population. That means they don't have enough insurance to cover and they can't pay for the care that they need. So I think about my brother, my brother's a carpenter and he's up on roofs, probably on a roof today hammering nails. And it's Andrew's work and he's on an individual plan, right? Actually now he has a fiancé and he's not but other carpenters will be on individual plans. I hope he gets married soon because he's been engaged a long time. I hope he's listening to that on the record. He's heard me say it before. In any event, there's a level of equity to how we allocate healthcare costs, right? Because people with high-paying jobs and like the lawyers and doctors and others have less risk to their physical safety. So can I just stop you there? I mean, there is a perception that doctors have the high-paying jobs but that is not categorically accurate nor is it true for lawyers but lawyers probably make more than doctors. We'll have to look at that metric and understand. It's struck a note, sorry. No, fair point. Relative to much of the... That's a fair point. In any event, some of the work... There are people who earn a lot of money. Let me know that. A lot of the people who earn a lot of money are not doing dangerous jobs. That's really my point. Yeah, that's the point. And their insurance plans are generally more favorable than those who have dangerous jobs, right? And so if you have an employer-based plan, you're not paying that much but if you have an individual plan, you pay a lot, right? So a lot of the laborers have a very, very high insurance expense whereas others with less risky jobs don't. And when you're trying to ensure financial stability for the system, what's happened in Vermont is a lot of that pressure has been put on commercial insurance, right? They call it the cost shift and we'll debate that all the time but in any event, lots of the money that we need is coming from commercial. That pocket of that pool of people is shrinking which makes it even more difficult for them to sustain those costs. And as the costs go up, more people exit that market. It's not necessarily the most equitable way to appropriate those costs, right? Because it's not based on income, it's not tax system, it's not progressive. It's kind of by happenstance what your job is really. So anyway, our under-insured rate has been increasing. The under-insured rate over the last several years is going up which is something that we want to be mindful of. I'll go through these quickly so I can turn to these folks. But I want to touch briefly about our Medicaid spending for beneficiary. There's really three sets of money for healthcare, Medicaid, commercial and Medicare. Our Medicaid spending is quite high nationally. We're on the higher end. Our commercial spending is on the higher end nationally. And then our Medicare spending is last. And from my perspective, that's not what we want. We want to pay less with Vermonters dollars, commercial insurance and Medicaid and we want to spend more with the federal dollars. And we have aging population, so we're gonna have more people that are being paid for by this money. And so we actually want this to go up. It's kind of confusing how can you be so high on two measures and dead last on another. So we want this number to be more balanced. And you can see we actually were going up quite a bit and then around 2017, we're at 9,829 per beneficiary in Medicare and then we dropped down, started going down while the others started going up. So that's something we want to be mindful of and the Green Mountain Care Board's decision making. Real quick, this is, so there's a finite amount of dollars at this point and we need to allocate them correctly. And part of the allocation is kind of system-wide. How much are we putting in primary care? How much are we putting in mental health? How much are we putting in hospitals? But then within that, how much money are the hospitals spending on those preventative type services versus other services, right? Nationally, the country has spent 30% of our healthcare dollars on hospital spend. Hospitals are a more expensive place to spend money. They provide some of the most important care and it's going to be the most expensive care. In Vermont, we spend quite a bit more on hospitals than what you see nationally. We spend 47% of our healthcare dollars on hospitals. That might be a good thing. A lot of our hospitals, particularly today, are providing a lot of services that are available in the community, right? You've probably all heard about the boarding issue we have and part of that is because they can't get the patients to an appropriate care setting or the patients are coming in because they can't go to urgent care or primary care. So we're using the ED for that. So some of this could reflect that service that the gap, the care gap that they're filling. And some of them may provide different services than other hospitals nationwide. I'll turn to Elena after this, but we don't use our hospital system a whole lot. We have low utilization compared to national. So this is a national median of admissions per 1,000 residents. See, Vermont is way down on the lower end of the spectrum. So we spend a lot on our hospital system but we access it less. On a per capita basis, right? Yeah. And I think part of this is, so this is a chart national database using Medicare costs report data that looks at hospitals break even points. So that is the amount of funding needed from a commercial payer in order for a hospital to cover their costs. The purple bar charts are for the kind of the national median and the red bar charts are for Vermont hospitals by size, so number of beds. So what you can see here is there's quite a bit of variation but on average, Vermont is much higher in terms of the commercial dollars that it needs in order to cover its expenses. That could be for this kind of rebalancing that Chair Foster mentioned before. So hospital adjusted expenses per inpatient days. So about, again, this is kind of the cost trend. So we weren't kind of below the national average but have the clips, the national average more recently. And so there are a variety of ways to think about kind of what you're getting for your dollars and there's no perfectly measuring this one way is thinking about our mortality rates, more access to care. So while we have lower mortality rates as Chair Foster mentioned, we do have a healthier population in some ways and our access looks quite good in terms of the number of clinicians that we have but we still struggle really with wait times. And this is a little older of a report and we'd love to see this updated but this is kind of a challenge of, we do have low utilization but there's still a lot of remonters that can't necessarily get the care that they need when they need it. And that's part of the system wide challenge that we're facing. And as we've been talking about, hospitals are just one setting of care and they could be doing a lot of different things but they really rely on the broader delivery system to perform their duties and to do that well and to serve the patients. So we have our fairly qualified health centers and other community health centers, ambulatory care centers, extended care and then the acute care setting and all of these things really have to work together to have patient high quality, high functioning system. It's interesting. One area that we know that we have significant access challenges despite having a number of bodies available to us is Vermont primary care. And nationally we are, depending on how you define it, this is the definition that is used to compare across states. This is not the same Vermont definition that we have in statute but when you look at this national comparable definition, we're kind of in the median to lower half in terms of how much spending we have in primary care. But when you look at the Vermont definition that increases to about 10.2% but it's hard to know how that compares to other states. So it's the struggle and just because we have more dollars doesn't mean that they're being used in the right way. So dollars are one way of looking at it but there's definitely a greater need to really understand what high quality primary care means and when it's happening. So admissions is increasing or sorry, admissions are decreasing but the length of states increasing. So this speaks to some of the pressures on hospitals and being able to transition patients out of the hospital into the appropriate care setting. There are a number of pressures that we've heard about through the hospital budget process and elsewhere, skilled nursing facilities, mental health, housing, all of these things are very important and need to be discussed and thought about. So we'll do a quick, I don't wanna take up all the time so I'll do a quick update here and then we can dive into specifically 67. So as you may have heard, 2022 was one of the worst financial years for hospitals. This was after the federal funding dried up and volumes were still kind of coming back. And so it was a real challenge nationally and a lot of clashes. And so but in 2023 at a national level hospitals began to rebound, since our volume came back and their margins were much better. At a system level, I presented a similar slide. Last time at a system level, you did see kind of a rebound but I didn't have all of the hospitals reporting so I didn't show you kind of the level of detail and these are still in flux as they're still reporting their audited financials through the end of the month. But what you can see is that there is quite a bit of negative margins still pervasive across our healthcare system and this is largely the smaller hospitals that are not part of health systems. You know, with the exception of CVMC, the other hospitals that are in the black are those that are part of a larger entity and have kind of more fluidity in their funding to cover some of those costs. Hospital budget requests this year. So we set at 8.4% to here, 8.6% NPR. So the net patient service revenue sets kind of the whole budget that you will be accepting or all the revenues you'll be receiving from patients. And the requests came in at 19.3%. So it's a two year rate. Commercial price was around 9.84% and the operating expense growth assumed in these budgets was around 571% at a system level. We compared some of these commercial rate increases to a variety of inflationary factors to try to understand how reasonable this was relative to what Vermonters can expect to pay. And it was quite a bit higher. You have the Medicare market basket and 3% median household income in Vermont at 3.9% relative to the system-wide hospital rate increases of 10.6%. And this wasn't an exception to the rule. I mean, this is a trend that's been ongoing and it's a real challenge for the board and for hospitals, frankly, to navigate. And this has real implications for the rates. We see this in our QHP rate review process. Cumulatively, this is showing rate increases cumulatively over time. So from 2019 to 2024, we have 60 to 80% growth in rates which is huge and really affects how people can engage with the healthcare system. And the board does its best to control that rate growth but there's really only so much you can do when you're juggling kind of affordability on one side and provider solvency on the other. Nationally, the rates have been increasing and some of the rates around 6.5% are staggering in other states and ours are well beyond that. And it has mentioned real implications for families, what they get for that money and what that means to them in their everyday budget. There's also a sustainability challenge with that. So the statute that we are charged with executing says that we should evaluate for moderate's ability to pay for the care. That's one of the factors we're to consider. How can we afford it? And so if income is here at 3% and rates are 10 or 15, you can do that for a little while to keep it going but over time, you can't. And that I think is part of why we're at 167 of how do we need to transform the system so we have an optimal allocation and using the resources as efficiently as we can because this won't, it just can't work. Eventually that collapses. So that said, we were able to make some reductions to the commercial rate this year as an amount of 7.8% across the system. So 145 million, but this is perhaps not sufficient to make care affordable for monitors but we also recognize the challenges that hospitals are facing in terms of their inflationary pressures. So you correct them? Yeah. So this is a two year guidance period. So we consider the fact that what hospitals got last year in conjunction with what they were asking for this year. So two years, that's what we looked at last year, fiscal 2023, there are very, very, very large rate increases, I think in part because of the board's concern about sustainability and keeping our healthcare system going. And if we were too aggressive with the levels of rates, it would have been very, a little bit of a hassle. This year, so they had a year of planning with large amounts of money. This year there were lower increases than the year before because much of the money was taken up the prior year. That being said, as actually as counting it before we start, I think seven of the 14 hospitals received the budget they requested. The rates and the NPR, 10 of the 14 hospitals received within 2% of the rate increases they asked for. So 10 out of 14. And then four had cuts larger than 2% reductions from what they asked for. And each of those had asked for more than a 10% rate increase and had received large rate increases the year prior. So you can see some of our decision-making around that. The other thing is NPR, that total amount of money that they can bring in from patient services. That's NPR. We went well above guidance, guidance was 8.6. For the most part, I don't think we adjusted NPR other than a small amount of maybe two hospitals. And some of my thinking as one board member on that was that we have access problems. And so if you keep the rate at a more affordable level, but you allow for the services to increase, the hospitals can make the exact same amount of money. More volume to address our access and backlogs and wait times, less money for each service, that's the same amount of money they asked for. So we're trying to drive that access while balancing the affordability. So that's what some of these decisions were. At least for me, I'm predicated on. Yeah, so this just shows that basically the NPR remains largely, our net patient revenue. Net patient revenue. Thank you. Net patient revenue remains largely untouched. We have an acronym list in our committee, but it's not with us. So there might be some folks around the table just bring some with us. And those name tags. Yes. So largely untouched I think for these reasons because of some of the access challenges and wait times, we would like to see better throughput through some of our providers. And so the board has largely left those with the exception of when hospitals come in with utilization assumptions that are wildly different from what we see in actual, sometimes there may be an adjustment to reflect what we realistically expect. You don't wanna overestimate what we think might happen. So I know you spent some time, but I'll just really, really brief history of Act 167 from the board's perspective. This work is not new. These trends are not new. Rural hospitals have been struggling and small hospitals have been struggling for quite some time. There've been 191 closures since 2005 and 138 of those since 2010. And this has only been exacerbated by the pandemic and other kind of challenges to the way that we pay for healthcare. And this has largely affected those smaller hospitals that don't have reliable funding sources. So Vermont hospitals were no exception. We observed these declining margins over time. And as we mentioned, the struggle, this tension between solvency and affordability with as discussion this morning, the Bankruptcy of Springfield Hospital was really, really concerning to the board and to many of you who were around then. And so the board has had been kind of discussing, what is, how much can we do with our current process that really puts this tension right in front of the board, how much are you gonna add to commercial rate and for how much are you gonna add to the hospital, financial challenges. So this really requires a system solution. And this was kind of discussed within the confines of the rural health services task force. You passed Act 159, asked the board for recommendations. We provided recommendations and then those recommendations served as a basis for some of the language in Act 167. So just as a quick reminder, the board suggested the design implementation of hospital global budgets to provide more flexible and sufficient equitable funding to hospitals and a health systems optimization expert to facilitate community engagement so we could think about what we should deliver where based on the needs of the population, how we could do that more efficiently, improve quality and access and then providing the resources necessary to make those changes. And that was really, we're very thankful for that Act 167 work and the funding that you appropriated for this purpose because we think it's one of the most important things that the state has done in these years. Well, you won that. Yeah. So I just, we kind of organize it and you have these two sections but we organize it in these four buckets. So and specified leader and follower I think as well in the statute. So the subsequent all payer model agreement led by AHS and the director of healthcare reform. GMCV was to lead and collaborate with AHS on developing value-based payment models. We were going to evolve our regulatory process some of that work that started just prior to Act 167 and then the community engagement work which has been a real eye-opening experience for us at the board. So now we'll dive into the meat of what you asked us here today and I'll turn it over to the next element. And thank you for the opportunity. I feel like that was all an exceptional and comprehensive setup for the exciting work that we're doing on the community engagement piece which is where the legislature gave us the opportunity to go into communities and talk with our friends neighbors, colleagues in each community in Vermont to gather feedback on the current state of the health system not just through all these numbers but through the actual lived experience of people in our communities as well as start to look for solutions. So in my current role at the Green Mountain Care Board I've served as the project director for the community engagement work. I'm gonna walk you through a couple of slides on the progress of that project which completed its first phase at the end of November. So it's a good place to give you a status update. So first I wanna introduce you to the Oliver Wyman principles that we hired to help us complete this work. Many of you may have already met them through the planning and community meetings that have happened so far that started in the summer of the fall. So this work at Oliver Wyman is led by Dr. Bruce Hamery who is a clinician leader and facilitator with over 50 years of experience in healthcare practice and systems. He has three years of experience in Vermont as well. You may be familiar and was cited earlier the health services wait times report from 2022. He led that work as well as the COVID data modeling with the Department of Financial Regulations. He is located in Central Massachusetts so not terribly far away and is planning trips up here to Vermont with hospitals, community members and lead our second phase of meetings which will be in person. So if you haven't had a chance to meet him yet through some of the virtual meetings you will have another opportunity plus he'll be here in person. As well this work is led by Elizabeth Sutter Lynn, the second principal. She brings an expertise and was brought into the project with Oliver Wyman because of her expertise in state health equity through her most recent work identifying health equity zones in the state of Pennsylvania where she is located. And she will also, they also have a team that supports their work at Oliver Wyman. So I'm really excited to be working with them and hope you all get a chance to speak with them correctly. So this project contract started in August and it ran through several months of engagement plan development. So these are hopefully the phases. The first phase that ran from August through October was specifically to plan how the engagement was going to be done. So there was a round of being with stakeholders all across the state. Many of who may be in this room who helped us actually plan out how the engagement and was going to happen and give feedback to the Oliver Wyman team. They were targeted to community members at large providers, members of diverse populations and they submitted, they presented a couple of iterations of the plan that Oliver Wyman team did and we worked with our partners at AHS to approve that plan so that they could then begin implementing it in October, which was the first public phase of the plan which ran from October through November and that consisted of meetings out in the communities done virtually which were focused on specifically community members at large and providers. That ran about six weeks. Those meetings, I'm gonna go through some of the numbers and the stats of how many people we spoke to during that time. It was a bit of a condensed timeline but I think it generated a tremendous amount of publicity with the help from all the legislators, all the stakeholders we worked with who helped get the word out so that people came. So I think that that six week time primary made it that there was a lot of attention during that period of time. And those meetings wrapped up at the end of November. The current stage we're in now through March is the data synthesis and analysis where the Oliver Wyman team will use the data collected from the listening sessions so that the qualitative data as well as relevant analysis of health systems claims and hospital discharge data to inform preliminary options and recommendations for hospital systems. So we're in that phase right now. They're working through a data analysis work plan and we'll begin scheduling meetings. They'll start the scheduling process in the next month or so and begin those meetings later in the spring. This is a timeline that's been pushed out a bit since we addressed the health reform oversight committee at the end of November. So for people that heard that, I think at the time we said, this is ambitious. We discovered through the data analytics work plan process the availability of data that the work would be able to be done better if we could push the timeline out a little bit and there didn't seem to be a recent launch or anything. So the community meetings are gonna start more, we're looking at now, May, which hopefully for legislators will allow you to participate a little bit more easily. So that might be helpful. So let me ask you the quick question on the March date. If we were to ask to have some preliminary report or report of the data analysis in March. So it won't be ready in March because they are still working through the data analysis. What I am gonna, what we do have now is some preliminary sort of findings from those community meetings. And Dr. Henry is actually coming to the Green House Fair Board meeting on January 17th. Next week and he's gonna talk about that. So that's what we have available now. What about March? I mean, just thinking about two committees getting together and listening to some preliminary report. On what the data is showing? Yes, we can talk to the Oliver Army team and see what they might have available in that period of time. Thank you, of course. Yeah, and ask them about it on Wednesday as well. So I think that probably covers, yeah, so the round two meetings, again, we have spring 2024 here, we're looking at having those actually start and happening communities in May. You can go to the next slide. This one. Okay, so we are really pleased with the numbers of people and the organizations that were engaged. And I think this is really a testament to how involved stakeholders were in legislators in helping us get the word out to get people to come to these meetings. Also, they were, we made the decision to have them done Zoom for this round so that it would increase the accessibility for people to be able to join. We also listened to feedback about the best times. Most of the meetings were held in the late afternoon or evening specifically for providers so that it wouldn't disrupt people's work day. But also we found for many community members those later afternoon or evening times were just better in general and possible to find times that are good for everyone, but most of the meetings were held from 4 to 6 p.m. or from 6.30 to 8.30. But then we also held several meetings at different times at 9.30 and 11.30 so people have the opportunity to join those. And it generated a lot of participation. I wanna highlight a couple of things on this slide. We had over 1,800 participants across all stakeholder types and meetings. So across the community and provider meetings. The initial phase of the engagement planning, we held 16 meetings with 91 participants. So that was just for planning the process and making the plan. And then we moved into the community and provider these meetings which you'll see which I can walk through the numbers here below. But on average, there were approximately 52 participants per community meeting, including the statewide meetings. So that I've been through a number of stakeholder processes in my time with the state of Vermont and this seemed like exceptionally good participation. And over a hundred organizations were contacted for their input and to get the word out that these meetings were happening. The all of our team sort of broke these numbers down for us into these different groups. It's not necessarily clear who kind of fits in where but I can kind of walk you through and let you know what each of these categories are. The team met with hospital leadership and boards directly. So those were 28 meetings with 235 participants. There were meetings with diverse populations. This is the work that was led by Elizabeth Sutherland. So she was doing sort of a concurrent process specifically to outreach to groups that are more difficult to reach back to the equity and inequality conversation from earlier. Also I'd make a point there that our board meetings are very open, transparent, people come, people comment but that's not the same as going out and trying to reach people where they're at. People come who have a specific interest in making comments. There is a specific focus on this project to go and try to meet communities where they're at. So that is, so these meetings specifically the diverse populations, it was with organizations. It was with the state's office of healthcare equity and then there was several meetings that were organized specifically to reach a disabled population as well as with the organization serving mental illness and that generated so 13 total meetings and 96 participants. Our state partners with 12 meetings and 18 participants those were specific meetings with different agencies and departments that would have a particular point of view on these issues and questions. Includes obviously the agency of human services who we've worked in close collaboration with Department of Health, Department of Mental Health the EMS office and State Office of World Health. The community leaders groups, that was another bucket that included Vermont NEA, the VA, Vermont Federation of Nurses and Health Professionals and Vermont Business Roundtable. So then we get to the community meetings and the provider meetings. These were held in all 14 HSAs around the state but we covered the entire state. There was both a community focused meeting and a provider focused meeting organized specifically to get clinicians and that is all types of clinicians. So there were 18 community meetings. So that's the 14 HSAs plus four statewide meetings. There were 931 participants in those meetings. The provider meetings directed specifically to people who work providing healthcare service directly. There was 14 meetings with 460 participants as well as specific provider interviews and other sessions. There's 15 of those with 108 participants. We had the, at each of the meetings, we also have participation from Green Mountain Care Board members so they could hear the input. We had coverage at each meeting from board members as well as staff working on the project. The Office of the Healthcare Advocate participated in probably every meeting as well as worked with us significantly through the engagement planning process and provided input. And I'm out but we do have extensive list of all of those organizations and others who participated and they all grew on with you that these counts for us. Dr. Hamery and Elizabeth Sutherland facilitated each and every one of these meetings with help from their staff. So they were extremely busy during this six week period going to our three meetings a day which was possible through the virtual platform. What are the next slides? I just want to comment, that's really outstanding work connecting with all those people and organizations. Yeah, thank you. We're really proud of it. The team worked really hard. It's really wonderful to be able to speak with and feel like we brought so much of the healthcare system together to provide their feedback. So like I said, this is really, I really only have a basic high level key themes from the round one. Dr. Hamery is gonna come and present directly. I think it'd be better to hear it from him directly to the board. So we would invite participation in that meeting. But at a high level, community members and providers reported both challenges and bright spots within these key themes. So I know there's a lot of difficult statistics that we've gone over today, a lot of things that looked sort of bleak but people also brought bright spots, particularly stories around exceptional care that they've received at Vermont hospitals and from Vermont providers. But there are a lot of challenges as we know. So those themes are organized into the category we have here and this is sort of the way that Dr. Hamery's team will kind of start looking at solutions but it's around hospital and provider operations, coordination between organizations, transportation and infrastructure was a huge area, workforce, financials, patient centered care, healthcare services. None of this is a surprise. This is all gonna be familiar. It's issues that you are and we are already working on. I think the important thing here is that this process really brought the community together to talk about these issues in that and that is the focus of what we're trying to do. So again, this qualitative and quantitative data will inform around two conversations which will be bringing actual options and recommendations to the communities directly and that's the later spring work. So then next, I think my final slide is the next steps for the community engagement work. So as Dr. Hamery and his team are working through the data, he is going to bring back to the communities options for their local areas. And again, the important thing here is that he's bringing these options back to the hospital boards, back to the communities. It's not a, you have to do this, you must do this or if a rebound care worker is gonna tell you to do this. It's here are some things that you can do. I think of it as sort of this Act 167 work has provided technical assistance for these communities to start looking at things that they can do to improve sustainability. So he's gonna bring those options directly to the communities. In the spring, talk with the hospital boards, talk with communities about them, gather their feedback and then turn that into a report back to the Green Mountain Care Board on what he has found. And then we can go from there in terms of solutioning. It could be thought of as things that the legislature can do, things that the board can do within their authority, also things that could just be implemented within communities without any type of action. That is the exciting work that would have had of us. It's a, I'm really excited to be working on this project and have this opportunity to talk to you about it today. And that includes my remarks. Great. Thank you. Good work. One thing I would say about the recommendations and the types of options, they're gonna be pretty diverse. I think there'll be discussion about identifying care gaps and what we need to add systems. There'll be opportunities about even, there will be some things that the legislature could be involved in helping for solutions such as licensure issues or regulatory issues, whatever they may be that are beyond just money, right? There are so many other things, efficiencies, EMS, all the transport, all these things work together. So that there would be a pretty wide spectrum of things that we can address to start tackling some of the challenges we do have. And thank you for recognizing how great it works. Yeah, it's been great. So just another question regarding the timeline, having the options available during the summer, it would be helpful, maybe this is just a message, helpful at all possible when we have folks in March that we get kind of an inkling of what some of the options may be and understanding the, and I understand the analytic process, so it's not always simple. Great, so we'll move on to the next section, just developing value-based payment model, including hospital global budgets. My last Zoom connect, you guys can still see it. Go ahead, Senator Weeks has a quick question. While you're doing your IT, can you just give us an example of what the range of options might be or just a couple of examples of what options would be? Yeah, well, let's see, I have sort of broad categories, but so far I know the team has been looking at, there can be areas around service addition recommendations, service transfer recommendations, service avoidance recommendations, intra-HSA collaboration, I know there's some of that going on now, there could be more areas for that. Those are kind of some of the high-level categories that he's given us. I don't have more specific recommendations that I don't even have them myself, so. Before you continue, we also had one question a while ago, Mari Cordes is online. Mari, did you still have a question? I do, thank you very much. This is about the community engagement and the list of folks that were involved in this outreach, including provider meetings, state partners, were pharmacies, pharmacists, whether hospital-based, community-based, independent pharmacies involved in these conversations and I'd like to have further conversation about making sure that pharmacies and pharmacists are involved as really critical partners in community health and potentially an ad or an addition to meeting gaps in communities where they might need healthcare provider access and there's no clinic. Pharmacies may be able to build some of that gap. That's a great point and a great question. I believe that the association was, but I would probably double-check that for you. It's not on the list that I have in front of me, but it's not on the list that I have in front of me, but the list I have in front of me is not exhaustive of their full contact list. Thank you. Is that, I wasn't sure if we were asking questions now or not, so I didn't raise my hand. I think what we'll do is if there's a question of clarification on the Act 167 community engagement, we'll entertain those and then try to move on because we have a hard stop at 1030 and we wanna take a short break prior to that time. Okay. You have a question? I just would love to see the full list of the organizations that you participated with. I had made a number of suggestions early on and I just wanted to know if they were followed up on. And I also, I participated in several of the community engagement things and some of them were awesome, really great conversation and some of them were not. And some of them were frankly, for they were a little bit hijacked by what I will call hospital plants of people who went and sort of tried to steer the conversation into their direction. So I mean, I'm assuming that Oliver Wyman is professional enough and experienced enough to sort of recognize that and deal with that kind of, you know, shift in the conversation but I just wanted to know if that's been part of the conversation of sort of how do you deal with that? And there were a number of people who I suggested send written comments to and I know that you've got a lot of those and that's gonna be part of the analysis too. So I'm gonna suggest that that's a great question but that's a question we can get an answer to may probably through the appendices when the report comes out but maybe beforehand you could share with Senator Hardy and others. Do you want me to respond to that now or hold? Yeah, let's hold. That's a different question. We'd have to go through the whole list. Is there a quick answer? Second part I could respond to. Yes, that one you can do. So I recognize that they were open meetings so anyone could go and there's certainly a challenge sort of in making sure that we can sort of pull in the full community and not just people that are already engaged. So I'll take the opportunity to say that there was there's a whole other set of meetings sort of happening that were being facilitated by Elizabeth Sutherland where she did more targeted interviews directly with communities. Specifically a very successful one with the disabilities community where they organized their own meeting for that community specifically and made it easier and more accessible for people to come. So it's one way that we address that. And you're right, we don't have the written comments the numbers of written comments but we received an incredible number which I can get the exact number of either people sent in follow up written comments things that they said at the meetings or just people that couldn't go to meetings sent in comments and those are also would be part of the analysis as well. Well, but it is a concern that there's some redundancy and people are traveling around the state to make the same comment in other parts of this geographically and one of the goals was to have a geographic understanding of community needs. But so it is a real issue and you've addressed it somewhat but it's something we probably want to hear about going forward. Thank you. Back to, I will try to speed through the rest in the next minutes. So I won't read through your language but you directed us to design the global payment. I just want to kind of recognize that in order to design an all payer global payment for hospitals requires Medicare's protection. And the opportunity right now to engage with Medicare is through the head model which you'll hear from our colleagues at HHS on more detail, but that was really a starting point for the Medicare portion. So the GMCB staff have been working with HHS and director of healthcare reform to lead the global budget technical advisory group to solicit input from a variety of stakeholders in anticipation of the release of Medicare's payment model and methodology. So we still don't have those details. So we have some insights about what it could look like but there's still that this black hole of understanding. So members included representatives from hospitals, payers, unions, advocates and others based on their technical expertise is really kind of like how would it work exercise. And the charge is to make recommendations for conceptual and technical specifications for a Vermont specific alternative to the Medicare standard methodology. So we anticipate federal limits and guardrails to any methodology. So we certainly have one view of what we think they might be willing to accommodate and have been trying to kind of work through that. So there've been meetings approximately every three weeks for two hours since January and all of our materials are posted publicly on our website so you can kind of follow the slides and the areas. So they covered a variety of topics. So including defining services to include in hospital global budgets, populations, commercial payer participation, provider participation. So should it be mandatory or voluntary or how would we engage either of those groups? Calculating baseline budgets, that what you would start with in terms of your overall revenue that you would take in and then how would it grow? What kind of adjustments might there be to the budget? And then thinking through how that would work with regulatory processes a second step and then transforming a transformation administration evaluation. So all the other things. So what would a hospital need to do to be successful under such a model? How would we administer it and then evaluate whether it's working? So where we are kind of headed next. So the global budget is kind of our global budget tag and those technical recommendations are kind of being wrapped up. We expect Medicare to release their specifications in February. And then there will be some hospital specific modeling about what the Vermont model would do for them. And then a comparison between the Vermont specific model and the Medicare specifications. We are also beginning now because this was largely lent by thankfully board member lunge with her expertise and AHS and some of our staff but to start engaging board members who haven't been kind of involved in this process to help them understand kind of what we've learned and then public engagement. So there'll be a variety of public presentations on the work that has been happening. In terms of evolving our regulatory process. So as part of this legislation, we asked us to recommend a methodology for determining the allowable growth in Vermont hospital budgets. Decide how to or determine how to best incorporate value-based payments or global payments into the board's regulatory process and consider the appropriate role of global payments for Vermont hospital. So does this make sense and how? So resolving these three, we haven't figured this all yet out yet because there are a number of moving pieces to consider. It requires understanding what can be negotiated with Medicare but we are already kind of thinking about evolving our regulatory process with or without, I should say, an anticipation of or as an alternative to. But a brief history of hospital budget regulation. So we've actually had hospital budget regulation since the 80s. It's looked quite different. So it turned into the Vermont healthcare authority and we had Bishka and then the Green Mountain Care Board more recently, but this is not a new process. Why regulate hospitals? As we mentioned before, hospital expenditures make up nearly half of our spending and is growing kind of exponentially compared to other states. Vermont's healthcare system is also highly concentrated. So we have a non-competitive monopoly market. Some Vermonters don't really have an option to go beyond their community hospital. Some have more capability to kind of pick and choose where they can go and can leave the state, but this is really a matter of equity and making sure that all Vermonters have access to best quality care or have access to care at all. So as I mentioned, the board was already kind of thinking about we kind of adopt this continuous improvement framework every year we're learning. And so before the passage of Act 167, we started thinking about establishing objective metrics for hospital financial health, improving the evaluation of delivery system and hospital performance. As we mentioned, hospitals are just one piece. A lot of what we observe through their budget process is other parts of the healthcare system. So parsing that out is often quite challenging, but there are ways that we can do that and get data and measures to help us understand what's happening. Alignment of our regulatory processes, particularly hospital budgets and rate review, this is where that tension kind of exists, how much we end up paying for insurance and rate growth versus hospital, growing hospital budgets. And then we would like to increase the consistency and predictability of our regulatory process. I think COVID was a particularly challenging year and kind of recognized space to the delivery system to do what it needed to do as quickly as it needed to do it. And now we're trying to kind of pick up the pieces and figure out where we are going next. So we're always looking to minimize administrative burden. That doesn't mean we don't want data or wanna know what's going on, but we wanna make sure that we're asking for what we need and that we understand the whole system over time. And so that is a challenge. But as technology improves, it's much easier to kind of, when I think of administrative burden, now it's not the amount of data, it's how often you change what you ask for. So I think if we can kind of move towards standardizing and then kind of, there's ways to automate the actual reporting, we shouldn't be reporting less. We should provide more transparency, just more predictable. So this was our first year with this new regulatory process with benchmarks. The whole process was really focused around benchmarks, comparing hospitals to like hospitals, academic medical centers to other academic medical centers, small regional hospitals, community hospitals, 100 Galaxus hospitals, others, right? And so you can see, are they starting really expensive? Are they asking for huge increases? Is there a reason for it? And so that judicial process I talked to you, I spoke about earlier, that's what we're doing. They have to make a case, we evaluate it, we look at how expensive they are to start, how much are they asking for it? Does this make sense in context of what we're seeing? So the benchmarking really, really helps do that. So this year, we put it in the guidance in March, which we voted on March, that said here are the various benchmarks we're gonna be looking at. Then this was Sarah Lindbergh, our former director. We owe her a huge nod and appreciation for her really advancing. We're really fortunate to have Elena step in, take over totally seamlessly. But in terms of like the resources allocation I spoke about that earlier, it's for us too, how much burden are we putting on a small hospital like Gifford, right? The hospital's small, their asks are not as big as UVM, UVM's a much larger, more complex system. I think you saw in this regulatory process, we spent a lot more time looking at a larger ask, larger financial asks, than we did smaller financial asks. So the seven hospitals that were approved as submitted, those are pretty quick and painless and easy. Two hit guidance and we're quickly approved. The other five were pretty easy too. UVM's ask was much, much larger and it's more complex system. So it took more time and we spent it. So CON, you wanna make sure we're putting the right amount of time of ours and burden on the regulated, as soon as possible. So I'm very aware of our time. So if you can get to a good place, it'd be great. You're there. So I won't reiterate, we set this, for the first year I think capped commercial rating places so that I won't get into the technicalities of it but we find our level of detail, lots of work to continue to make that connection with affordability but there was a significant improvement in using data. And not all data is gonna have a one for one adjust. We're not gonna use data that, there's no formula. So there's a lot of data, none of it's perfect but it can help us understand directionally what's happening. This year, we're in the throes of it right now. We're kind of starting our first draft of guidance and we're gonna expect to set more benchmarks, financial health, net patient revenues and one that we've relied on but really focusing on commercial prices, operating efficiency and financial health and balancing these targets. With an eye to how important our community engagement process has been, is this an iterative process with hospitals so that there is an ongoing discussion? Yes, so actually in our rule, February 15th we have to start, what are the targets that we'll be thinking about? And so we are aging in those conversations and then while the Act 167 community engagement recommendations will just have been coming out, we wouldn't expect the budgets to look substantially different because hospitals won't have had time to digest that but we would love to hear from them on kind of what they've learned and what they think is coming and what they'll be thinking about. So I'll just turn it back to our last slide. I wanna thank our team and Julia Bowles for putting together this material for the committee for having us. All right. We have noise back here, so it's just got really hard to hear. So I think you were just saying thank you but if there's more, we need you to speak up. These guys and Julia, thank you. Oh, thank you. This has been a terrific overview and background historical context for us and those of us around the table understand the work that's been going on over many years but we also understand our role and your role and we'll continue to work together with this. Thank you very much. Thank you. So at this point, we're going to go offline for five minutes and take a little break. How about Tan? All right, we're back. This is a joint meeting with House Health Care and Senate Health and Welfare. We're continuing our look at what's happening as a result of Act 167. We're now going to join, have Wendy Traffton join us and Wendy, why don't you introduce yourself for the record and then we have your PowerPoint here and we'll get it up on the screen as well. So thank you for being here. Thank you, good morning. My name is Wendy Traffton. I'm the Deputy Director of Health Care Reform from Vermont Agency Human Services and thank you so much for inviting me here today. Should I share my slides now? That'd be great. I want to make it a little bigger if you can. I might be out of my wheelhouse. I'm going to try. Presentation. Yeah, on the far right. Lower right corner. With a little podium looking thing. I'd have to move some things around. I used to have an expert. Okay. Oh, good. That's great. Awesome. Thank you. My testimony today is an update on the Office of Health Care Reforms work related to the 1967 of 2022, section one, which is the development of a proposal for a subsequent all-payer model agreement. So for the record. She did. Did you introduce yourself for her? I did, but thanks again. We were one time. I don't know. I don't focus on it, but it's very exciting. This is not good. I'm nervous of something able to share the screen. The charges listed here. And that includes, we are previous, but I'll just repeat the development of a subsequent agreement at the Center for Medicare and Medicaid Innovation, which secures Medicare sustained participation in multi-payer alternative models for moms. Ensuring the process for developing that proposal includes opportunities for meaningful participation and I'm sorry, for meaningful participation from the full continuum of healthcare and social service providers, payers, participants in the healthcare system and other stakeholders, providing a simple and straightforward process to enable interested stakeholders to put easily and providing an update by March 15, 2013, which has already been submitted last year. I'd like to provide a brief background on the current Vermont all-payer model. The Vermont all-payer accountable care organization model agreement, which is signed by the governor, secretary of the agency of human services and Green Mountain Care Board Chair is an arrangement with the federal government that allows Medicare to join Medicaid and commercial payers to pay for healthcare differently. Within the model, the state has accountability for cost, population health and quality. The model creates a mechanism to shift from paying fee for service for each individual service to predictable prospective payments that are linked to quality. The goal of changing payment is to reduce healthcare cost growth, maintain or improve quality and improve the health of our monitors. The current model that we're in today relies on an accountable care organization to develop a voluntary network of providers that agree to be accountable for care, cost and quality for their attributed patients. The original performance period for the model was 2018 to 2022, so it's expected to have five performance years. Currently in a two-year extension period is set to end this year. The extension period was suggested by the federal government to serve as a bridge to a future federal state model that at the time of those discussions was still under development. At that time, it was expected that the federal government would implement the new model in 2025. So there are many benefits associated with continuing to include Medicare and Vermont healthcare reform. Vermont is and has been a low cost state for Medicare by continuing to participate in these programs with Medicare. It supports the development of baseline financial calculations that recognize the state's past reforms that have saved money for Medicare. We've had positive evaluations showing that there's been savings generated from programs like the Blueprint for Health and SASH. Continued participation allows Vermont to influence Medicare reimbursement for providers. It maintains over $9 million in annual funding for Medicare's portion of the Blueprint for Health and SASH. And it allows for certain waivers of Medicare regulations. These waivers allow the state to deliver care differently. And it also allows the state to propose new waivers during the terms of the demonstration. And it also allows for alignment in priorities, payment models, quality measures and reporting which sends a stronger system to the healthcare system partners. The Agency of Human Services and Green Mountain Care Board met regularly with CMMI, the Center for Medicare and Medicaid Innovation involved the new model was in development. During this time, we received significant feedback from providers and other partners regarding elements of a model that would be important to the state in order to advance healthcare reform in a subsequent agreement. So our current partnership with the Center for Medicare and Medicaid Innovation allowed AHS and GMCV to educate and inform the federal team developing that model. We continuously reinforced a lot of the things we were hearing and it helped learned over time. Those are supporting rural provider stability and sustainability, recognizing concerns we're all hearing about workforce and inflation, increasing the predictability of payments. So although currently Medicare offers advanced payments under the model, it requires reconciliation of those payments back for service ensuring the right amount of revenue. The state has been effective in keeping Medicare costs low and new model methodologies, particularly ones that are multi-state methodologies must recognize that's the Vermont has had. Need to support investments in preventive and community care. Make sure that payment models and quality measures are aligned across payers as much as possible and allow Vermont to move forward on important healthcare reform efforts. We've really been clear that transitioning to a new model should not require the state to move backwards because there's been many successes we've achieved with the federal government and many of the demonstrations we've been a part of. So I think I mentioned this slightly but the federal government has decided not to continue single-state agreements and is seeking to offer models that multiple states can apply to under consistent terms. They've indicated that states like Vermont, Maryland and Pennsylvania that currently have single-state agreements and apply to the new states advancing all-payer health equity approaches and development or as we typically call it, the AHEAD model. A notice of funding opportunity was released on November 16th of last year which this provides further details on the model. There are still further details still to come but this lays out a lot of the approaches and strategies within the model. So there are multiple cohorts that vary by the length of the implementation period and implementation start dates. Proposals for the first two cohorts of states are due on March 18th. The earliest implementation date of the Medicare payment provisions of the model would be on January 1, 2026 and you have the states who want to start January 1, 2026 must apply for cohort one and be selected. So this meet timing means that the current model will need to be further extended or Vermont would be reverting back to fee-for-service payments for Medicare and lose some of those other benefits we mentioned earlier, I mentioned earlier in the presentation. The state and federal government are currently negotiating what a 2025 demonstration year might look like with the goal of providing a smooth transition to a new multi-payer model in 2026. So as mentioned before, Act 167 directs the health care, the director of health care reform to consider multiple elements in a new agreement. The ahead model does include many of those elements. So they include total cost of care targets, global payment models, strategies and investments to strengthen access to primary care, mental health and substance use disorder treatment services and strategies and investments to address inequities, social determinants of health. While we've raised the need to focus on health care for health care reform efforts across the care continuum, including sub-acute services and long-term service support, the model does not include explicit strategies for achieving this. So that is something we've continuously raised with the federal government and we need to be doing some really creative state-specific thinking on how to achieve this. But CMMI has stated that the ahead model aims to support hospitals and transforming care delivery and shifting utilization to primary care and community-based care settings where appropriate through the incentives and flexibilities of the hospital global budget. So they see those supports coming out of that hospital global budget flexibility that would be provided under this model. So the next few slides focus on opportunities for partner participation to date. So AHS and the Department of Financial Regulation convened the health care reform work group in 2022. It had, it was pursuing four goals and mentioned again, it started in 2022. So at that time, the goal was addressing issues impacting provider stability in the short-term, many of which were caused by the COVID-19 public health emergency and associated workforce issues. Addressing challenges created by the current regulatory environment on provider stability, informing the design of future financial and care delivery models and anticipation of the state of Vermont entering a subsequent agreement with the federal government, which would allow for multi-pay reform and informing activities that support long-term hospital sustainability. So consistent with item above. So the work group includes participants representing hospital and provider groups and health care payers. It has several groups and technical advisory groups that are focused on specific topics or issues. Since the summer of 22, AHS has extensively engaged the health care reform work group and initially focused on that short-term stability I'd mentioned and resulted in a list of action items related to workforce, regulation, systems flow and revenue. And the fall of 2022, work began to establish a framework to inform discussions for the next multi-payer model. In February, 2023, several technical advisory groups were formed to support technical discussions on design of a global budget model, which we just heard discussed by the GMCB and Medicare waivers that would support care delivery transformations under the model. Pair and primary care work groups were also added. And then additionally in 2023, while there were a number of discussions at existing AHS and GMCB forums, mechanisms for public input on our websites, regular updates at GMCB public board meetings by the director of health care reform and numerous additional meetings with provider groups. Cover this in further detail on the next few slides. So AHS, I'm sorry. Do that one rather quickly. The AHS leveraged existing forums to promote engagement with a wide range of stakeholders. So this included multiple engagements with the Department of Disabilities, Aging and Independent Living Advisory Board and Mental Health Integration Council convened by the Department of Health and Department of Mental Health. It also included engagement with the Green Mountain Care Board's primary care advisory group meetings, which are now weekly with the Health Care Association Coalition, which includes membership from the American Academy of Pediatrics, Vermont, by State Primary Care Association, Health First, Vermont Association of Adult Aid Services, Vermont Association of Hospitals and Health Systems, Vermont Care Partners, Vermont Dental Society, Vermont Health Care Association, Vermont Medical Society and the Viennese of Vermont. It also includes presentations to various organizations. So some of the examples listed here are the Cathedral Swear Board, Vermont Information Technology Leaders Board, Viva Clinical Utilization Review Board, Northeastern Vermont Regional Hospital Annual Meeting, Vermont Medical Society Board, Health First Leadership, and the co-chairs of the Health Equity Advisory Commission. So that's our continued update from our March 16th, 2023 report. Can you do something for us? And that would be, let's just hypothesize that the AHEAD, we were accepted in the first round for the AHEAD participation. And then that became our program and implemented. What would that look like for our hospitals, our providers, our community-based services? Can you just talk about it on a very sort of the boots on the ground? I can give you a sort of a high-level overview of the AHEAD model. That would be good. Okay, great. And if invited, we'd be happy to come back and give a further. We can do that. I'm just understanding that Act 167 has significant influence and what's happened, I think Vermont is having an influence on what's happening at the federal level. And some of the reasons why the federal is moving from individual states to multi-states, seeing the benefit of what Vermont and that Maryland is doing with their hospitals and Pennsylvania with their global budgeting. But we are having an influence, which is nice to know. So it would be helpful to hear about AHEAD, AHEAD when it's happening. I'm not happy. So the way the federal government sort of defines AHEAD is their goal is to collaborate with states to curb health care, cost growth, improve population health, and advance health equity by reducing disparities and health outcomes. So participating, so so far they've noted that this model would be available top to eight states. As first, we mentioned that the application deadline is March 18th for the first cohorts. They've indicated they would select up to five states, not first selection period, preserving another three for the cohort three. Just going to that timeline since we're here and we have a timeline, a March timeline for negotiation or putting the NOFO responding to the request for funding piece. And here we are as a legislature and we might have some suggestions that we would like to make. How can we be involved before the March 18th deadline? We're currently working through all of the various components and questions that need to be responded to. So we can sort of, I'm happy to take back thinking through the best strategy to do that and which areas you might want to influence the language on. I will note a lot of it is very high level and really CMMI looking for states to communicate their readiness to be able to participate in this model. So a lot of the details are going to be worked out from between the being selected and starting that implementation period. So that implementation period would start on July one if you were selected and goes through, so July one, 2024 to the likely execution of a state agreement on July one, 2025. But that said, we do have to be very thoughtful thinking about how this will work within Vermont. We've talked previously about trying to figure out with the Medicare methodology versus the state specific methodology for hospital global budgets be better for the state. So we're trying to work through a number of those elements now. So it's also my understanding that there's less attention being paid to longterm care in the model and disabilities. So can we influence that in any way? Or is that some decision that's been made? Well, we have been, so we have pushed forward looking for the model on the national level to really be including and thoughtful about how we're engaging in those important areas across the air continuum. So as we've heard, there impacts the quality of lives of individuals as well as all other parts of the healthcare system. But the model itself is really the way it indicates those are included are really within those hospital global budgets, which and within, and I'll just note that with the strong health equity focus, people with disabilities, for example, are a population of concern in our work to address health disparities. So as we develop our statewide health equity plan and the hospital they're developing our health equity plans, I would expect there to be on these populations. I just would obviously be interested in your partnership on some of those strategies because there is a significant funding coming for those purposes from the federal government. It is something we are going to continue and we'll continue to be exploring where it could be strategic in this area. Second, all right, one second. Are you good? No, I'm gonna go back and ask my first question again. So, but do you want me to? No, that helps, same thing. Head model? Okay. And my question's probably that question. In three years, going on for, this is my fourth year dealing with health care. I hate that. I'm still trying to get my head around all these models, okay. What does, what would a head replace in our system? Oh, does it? Or is it an add-on? That's good. Exactly what problems does it get at? And that's similar. So I'll try to answer that in the end. That's our question. That's a great question. There we go. So today, the Vermont All-Payer Accountable Care Organization model agreement is the way that we're able to change the way Medicare participates as a payer here in Vermont. So it allows Medicare to pay differently in an alignment with Medicaid and partial insurance. Without that, Medicare would continue to pay for fees for service, offer Medicare Advantage plans, but we wouldn't really be able to have that multi-payer alignment. So that is what the federal government's saying. That's sort of ending. What we did is we had that, because we had the relationship, we had a good opportunity to really push what is working really well within our current system. What do we want to see you recognize in a future model since they weren't sort of willing to accept a subsequent request from us, which was sort of what Act 167 asked for is a sub-model, a subsequent agreement model. So what we did is we really pushed on, these are the things we need to see continuing. These are Vermont's successes. This is what it would need to move forward on healthcare reform. So their response was participate in this multi-state model ahead. It has many of those elements that have been successful in Vermont. There's some things that we wish to see in there that aren't there, mentioned a focus across the care continuum. I think they were really trying to say, if we're sunsetting these special agreements we have with Vermont, Maryland and Pennsylvania, how can we make sure there's some flexibilities for those states that continue to be doing, what has worked well for them or continue to advance reforms in those areas. So to that, the participating states that are selected to participate under a head, they'll be accountable for state-specific Medicare and all payer cost growth targets. So that's similar to what we have today, but also primary care investment targets. So that is something new, accountable for population health and health equity outcomes. So we have a population health and quality measures under our current program, but this is a new focus on health equity, which I think is very exciting for the state and consistent with a lot of efforts that have already been happening, but a real focus to be doing that in our healthcare reform efforts. We have three questions in the queue. Okay, I'm sorry, am I too long? Representative China, who's up on the screen, Representative Rebeco and Senator Hardy. Thank you. I'm still struggling with understanding like what exactly a head is gonna do. It sounds like it's going to replace the one care with something that goes across state lines. So I guess I'm so confused because does this mean we just spent millions and millions of dollars on administration of one care and it's just gonna go away? And then I guess I'm wondering how much is it gonna cost to join this partnership and like what the benefits are and the risks are and I'll stop there. I'm still really struggling with understanding it. And I'm also really sick. I'm very confused today by everything. This is not helping. Join the club. I think so we didn't do a comprehensive head model of overviews and I'd be happy to, I feel like there's gonna be a lot of questions on that. If that's something we could... Yeah, but I think his question is really important to answer in terms of sound, it's not joining other states. No. That's key. That's key. So I'll answer that and also just go over the model components and finish that first question. So by multi-state, it just means they're putting out an opportunity for more than one state to be a part of this model. So no other state could come in and say, I wanna be in the Vermont All-Pay-R-Account or the Parable Agreement, right? It doesn't, if we were in ahead, it doesn't mean we were working with Maryland or another state, it just means we were all in their consistent terms. We'll have smaller state agreements with those other states, but our agreement is between the state and the federal government. We would have, we liked other states that are selected. Our model would include components like hospital global budgets and enhanced primary care payments, as well as we would be implementing the strategies laid forward to improve care management, mental health and substance use disorder integration and have a focus on health-related social needs. So there's flexibilities on how states do that. And we have a lot of work behind us that actually have a good step forward into doing this. So I'm thinking about the blueprint for health really puts us forward in being ready to do a lot of the advanced primary care work they're seeking and care integration. So we're a lot ahead of other states in that area. There's some other states that have done more in the hospital global budget space. So that will be newer for Vermont, but all of the up to eight states selected will have those similar components. We'll learn from each other, but we're not compelled to work together in any other way. Easy. I think this is very exciting. And I'm so glad that we're beginning the conversation where we can all learn more about the head. I've heard a couple of things. One is that what we've already done in Vermont has greatly informed this model and been a kind of significant component of building it. And also that we've had a visit from the director of CMMI recently. So I think that's very promising. I might go on auto limb to say that's very promising for our application. It also suggests that we might have some ability to be more innovative and step ahead of ahead in areas around the state of Vermont. Where a head really isn't gonna get Vermont ahead. Like if I understand right, correct me if I'm wrong. Components of a head in substance use and mental health are actually funded by the areas where providers are making cost savings and are those reinvested into mental health and substance use. So if they're not making great savings, we're not gonna have great investments in mental health. And substance use, is that how it works? Well, there are enhanced primary care payments and we've been really pushing the fact that we need to continue Medicare's participation in Blueprint and SASH. So thinking about ways in which we continue to work on through Blueprint expansion efforts and using those, working with the advanced primary care requirements under the model. I think that has some additional promise to meet what you're discussing. But also, yes, there aren't a lot of new dollars that they're saying here's a new funding stream for these other areas across the care continuum, except real flexibilities and those new flexibilities under hospital global budgets, as well as the advanced primary care payments, which are an additional added PMPM payment for the related to this program. I understand that better. Thank you. Well, well, this is our first shot, right? Yeah. Senator Harry, go ahead. Thank you, guys. I think it would be really helpful to have a deep dive into what the AHEAD model is, because I didn't actually understand your answer to Representative Rebecca and so that's concerning. And so, will this model include an ACO? And if so, how will the ACO work in this model? So the model does not require an ACO. It's not an ACO model. I think thinking about functions that an organization like an ACO can perform is something that we're continuing to be able to think through in that infrastructure that is currently available and supportive of our health care reform efforts and how to make sure that some of those activities are continued. So that is an area that is a difference from our current model to the one today. And CMMI has indicated an ACO wouldn't coexist in the same way that our system does today. But that doesn't mean that the functions performed, some of the functions performed could not continue. So there's a possibility that we could take the couple good things that our ACO and get rid of most of that ACO. It's balanced and more than good in my opinion. But is that a possibility? Yeah, I think opportunities for sort of that centralized infrastructure and support are ways that CMMI would allow those to continue under the model, but they would not allow a risk-bearing ACO to be a component. Okay, that's good. So we have her back shake one more deep dive. I'm sorry, I didn't hear what you said. Could we do a more deep dive to be a head model? Senator, yes. One of the issues that we covered in our health reform oversight committee was a deep dive. And then I did provide my committee with the slides that you brought into that meeting. And this was an opportunity really to look at S167. And then we will come back to whatever we need to do going forward to offer some suggestions on the AHEAD model. And that will happen. We'll have to do that sometime before March, but this is not, I did ask for a little bit of information on ahead today. I think we both did. So, but we'll have to get that possibly another day. But this is a very good conversation because I think it helps get some of the fundamental questions out that folks have. We did ask a number of questions during the ATROC meeting. One of the- That was November 30th. Yeah. And we will send out the link in the document. You can look at that. That'll get a start when we would like to do that. Was it November 30th or November 5th? No, it was the end of the month. Oh, we had to end it at the end of the month. 29th or 30th, one of those dates. I think what I would love, and we don't have to do it here, but a more clear understanding of from you all is what you do need from the legislature before March. My understanding is any updates, changes, things we want to maybe get in to the model is now only happening once we're accepted. So I'd love some clarity on that if you can answer it now. And just in general, what do you need from us from March? How can we make sure that the intent of the legislature is included in the application? And the application, so right now as I had mentioned before, we're really working through what are ways to be responsive to the questions played out and which will be scored and be the way that the federal government decides which states to select. So we are working through those. I can't off the top of my head think of the specific areas where we might ask for persistence, but definitely once we, if we are selected and need to move through that the negotiation process of what would the Vermont state agreement look like, I think that is an even more opportune time to be thinking about and having those conversations with CMMI. Because right now, as I mentioned before, we were meeting with that very regularly to inform the model, but as soon as this notice of funding opportunity was released, they're no longer allowed to talk with us. So we can't really influence the elements of it now until we're selected and can start those conversations again on the agreement during the pre-implementation period. So I think for those, I've heard some concerns from people that the legislature is not involved in this process. And so help me, correct me if what I'm about to say is incorrect, but when we passed Act 167, we put our intent and legislation of what we wanted from the next all pair model that intent helped direct the conversations you all were having with Green Bank care board collaboration with the federal government. We've now gotten to a point where they have outlined the ideas and some of the basis behind the model. So now we apply for it and then our intent will continue to evolve and we will continue to provide our intent through the negotiation process. So although we don't specifically talk to the federal government, we provide you our intent during these phases for healthcare reform in Vermont and that collaboration then happens at the agency level with the federal government. That's exactly right. It's particularly where we have this slide where we went over the elements within Act 167 which were important to examine during a subsequent agreement. So that directed sort of our attention to those areas and our discussions with CMMI and those further opportunities are forthcoming to in which we would be engaging with you. Thank you. All right, so legislature passes its statutes and you do all the good work and then negotiate with the federal government to make it happen other places but to take us a next step. I'll say forward. Yeah, so this is great. Other questions that folks have, understanding that this is just like the thousand foot, 10,000 foot level on the AHEAD model and certainly both committees will have a chance to look at it further, go ahead. Art? Yes, I'm looking at your first slide, you're the opposite of healthcare reform. How do you interface with the Green Mountain Care Board trying to make it reform? What, how does that work? Yes, so we are within the agency of human services and I think there was a really great slide that the Green Mountain Care Board shared during their presentation with the various elements of Act 167 and where GMCB took the lead and AHS collaborated versus where AHS took the lead and GMCB collaborated but we work very closely in our discussions with CMMI and within some of those technical assistance groups we had mentioned particularly on the hospital, global budgets, Chair, sorry, Green Mountain Care Board Member Lunge and to the Director of Healthcare Reform co-chaired to those meetings and staff really far from participating being very helpful on all of the other work, on many of the other work groups. So been trying to at least make sure we're all hearing, learning and explaining to the federal government the position of the state of Vermont. Thank you. Other questions? Okay, so in terms of the work that you're doing on 167 and next steps, you've done a huge amount already and AHS is working synchronously with Green Mountain Care Board. Can you talk a little bit about sort of the intersection not just with the AHEAD model but also with the 167 work that's going on? Through the Secretary's office probably more but you're also a part of that. Is there a specific section you're referencing? No, just generally how you guys are working together with Green Mountain Care Board, yeah. I mean, I don't know how to fully answer that other than we're very collaborative and in approaching all of the work we're doing. So particularly one of the highest areas of activity at least for me, I don't want to speak for everyone across the agency or our office but is working on the development of the proposal to just do March 18th. So we're all have varied responsibilities in developing sort of the content related to that. So there's just sort of seamless communication and in that work and then where there's a number of other activities happening, I think we're all trying to be as helpful as well as leaning all of the information that's being learned from other activities. So for example, the Great Stakeholder work that's happening, that's going to be an important part of informing things like our health equity strategies. So I don't know if that fully answers your question. That's good. Just a flavor for what things are happening. Were you involved when the CMLI folks came and visited along with the Green Mountain Care Board? And so the one story that I think is very informative about our rural environment is the CMLI folks came in and their experiences have all been in larger urban areas. And I think one of the really smart things that happened was that, I don't know whether it was you or the Green Mountain Care Board put everyone in a car and took them to the Northeast Kingdom to understand the rural nature of Vermont and our healthcare system as being geographically remote. So, yeah. We did have great discussions with for two days, one with providers who are kind enough to sort of come to a single location despite us trying to really get that statewide feel. And then yes, we did quite a caravan to the Northeast Kingdom. And I think that was very helpful to see what this looked like at a single hospital that looked like hospitals that served for mongers across the state. And so I think that was very impactful for them and the team they brought. And they were very excited about stopping for creamies too. All right. All right. That's good. Well done. Any other questions? Any, this is very quick. Do you have a model has a website? And I'm wondering if you think that's a good resource or is it not necessarily a good resource for us? The federal website, I think does have a lot of good material. It's great to hear their perspective too on what they're seeking to achieve. We are monitoring it regularly because they're doing these frequently asked questions documents as well as they're having opportunities for office hours for states to call in. So, I visit that website quite a bit. And some of the infographics are good pictorially. They don't give you that full detail, but between the notice of funding opportunity and some of the materials on there, there's I think it's a helpful way to really ground yourself in the model. Any other questions? Okay. Thank you. Thank you very much. I understand the 167 was one question. I had a slightly different one. We appreciate your expertise and coming in and sharing with us very much. Thank you. Thank you for having me. Oh, thank you. Unless there are other questions for Wendy or is there any, just before we end, I mean, look around the room. Is there anyone looking at Green Mountain Care Board or Blueprint or others, Diva hospitals, any comment you'd like to make or questions or? Oh, I'll just ask something, Senator. Why don't you come up here so we can hear you. Thank you. I took the comfy chair back. I'm going to put it in my terms if I can. Introduce yourself for the record. I'm John Saroy and I'm the Executive Director for Blueprint for Health. I've spoken to many of you before. It's not all of you. I'm going to put it in my simple terms because I don't dive deeply into the website like my colleagues in the corridor do of healthcare reform. I looked at it. There's like, I think one image and a slide that I saw and I said they're copying the Blueprint expansion that the legislature just funded. And the reason why I said that was because they're emphasizing enhanced primary care, which we've talked about, that it's more than diagnose, treat, and out the door. It's screening for other things that might be affecting a person's health that you don't necessarily get about in an interview. And it's embedding a person to help address those needs. For example, a community health worker, which you all, the legislature funded for Blueprint and were already implementing. So that was my just very quick reaction. They're very, in my view, the hospital budget. Global budget. They're taking that from Maryland and they're taking a lot of the screening for mental health substance use disorder from Rhode Island and from Vermont. Now, I don't know what's going on in every single state, but if I could ask them and listen in on those rooms where they all come up with, that's what it looks like on the surface. But I'm not giving you a heavily technical explanation We like heavily on technical. It was just, it was just, it was my immediate reaction of like, are they listening to our conversations? Are they visiting our website? Did they watch testimony? It was a bit odd, but flattering, I guess. And it looks like that because, you know, we were instructed under Act 167 and we did have that opportunity to really go forward and push the really successful initiatives in the state. So they were listening. And I'm not prepared to give you all the dollar figures, but Medicare underpays in the community health teams. They underpay into a patient-centered medical home. They just do. They literally underpay. And we have evidence that people with Medicare take advantage, as they should, of community health team resources that we're not getting our fair dollar amount from the federal government. I mean, it's just, it just looks. That's actually a big question. You know, one of the concerns that I've had from the beginning is we're doing all of this and we're, it's not an add-on, but it's, it is an expansion in care and continuity of care. And the federal government has always underpaid the state of Vermont and they do underpay Medicare. So what resources will we get? What incentive payments will we get? I know, I know it's small, but we will get some incentive payments if we are selected for a head. Was it $2 million? So there's sort of two funding streams. Make me think about, there's the $17 PMPN per member per month payment for advanced primary care. So that goes to the eligible population. And then there's also, which you were referring to the cooperative agreement funding. So state who are selected can get $12 million to be spent. That's better than two. It's unmodeled implementation over the first six performance period. So about up to $2 million per year, although one of those is a six month chunk. So the first 18 months is $4 million. Thank you. This was helpful. Yes, thank you very much. It depends on where you are, relative to the elephant in the room, what you see and you were seeing primary care for us and that helps us. And blueprint extends, as you all know, into addiction and to women's health for sure. So it's, we are definitely more than that, but when I looked at their model, I just looked like they were listening and on our conversations. Yeah, exactly. Are we proud? No, but the blueprint, yeah, and we all know the blueprint has received significant attention across the country, ever since we started it. And it's just so important to us all. Thank you. Thanks for your work. Thank you for your work. Any other questions? Any other comments? What happens when you ask for comments? We're good. So we'll call it a day. Are we going to have one? I'm good. Thank you all. We can go up there.