 Good morning. It is January 21st and this is the Senate Health and Welfare Committee meeting. Today we're going to continue looking at the Task Force on Affordable Accessible Healthcare Information, the report that's come to us from our consultant. And we're very pleased that we have a number of folks here to help us go through that report. Joshua, welcome. Joshua Slen of HST, Health Systems Transformation. And you've brought your team. Before we begin, you know, this is a continuation of some of the listening to the report that we did on Wednesday with House Healthcare. And as we go through this report, I think the thing that comes to mind for each of us, or at least it does for me, is how are we going to translate this into legislative action. And so as we're going through a, you know, there might be some things that we feel are important. We and we're, we'd like to reach out to the federal government to help us move forward. Or maybe there's something in our waivers that could be adjusted and we want to know about that, that with it, you know, a federal waiver. But most importantly, how can we put in place some of the very strong and good ideas that have come to us from from the consultant report. So how can we actually move forward with those so Joshua I'm putting a little pressure on you. As we look through the, the report, and hope that we can get start start moving toward legislative action so I think that's what our committee will be interested in as we're listening. So, did you have a thought of continuing through the slide deck at this point. Senator Lyons, I'll take your direction clearly on the committee, you know, sort of where to go with the committee there's a, there's an ocean here I recognize and although we've narrowed it down to four smaller bodies of water. But there's still, you know, there's a lot to talk about in each option. And I hope that the overview the other day was good for for the committee members. We, I think, want to provide a little bit of depth on each of the options not too much but a little bit of depth on each of the options and allow for some conversation and questions before we can be directed and your committee can have a full understanding what those options are. And, but I think that that was our plan for today was to talk a little bit about health equity because we didn't get to that, and then to talk about each of the four options in turn. We did on the 15th at the, at the task force on December 15, but not, you know, not as many hours of that to start with but to do it at a higher level to start with and then to go into the different areas. And I believe to your point about legislation that there's a lot of different things that could be done on the legislative front here, and the coordination with the appropriations committees and finance committees and all of that is, is, is part of the part of the conversation. I'm sure in your mind as you think about which ones to do when and timing and all that so. I also know that there are other bills, which I'm not aware of, right, but you may be or Jen may be. And, and so we're happy to participate in that conversation about, you know, how to get from here to there from a finance perspective from a state, state, other departments and federal perspective. And recognize that there's others you'll need and perhaps we can help to point out some of those if they're not obvious where other points of view and inputs might be helpful to some of those decisions that you need to make. But I think the starting point is the, is, is the giving everyone a baseline on the options. Right, I think that that's that's good. We have two hours. And I'm hoping that within that we'll be able to get some conversation going on this. And I think a note for you all is that the committee members who are here were not members of the task force. So I was but the other others were not so it is important that we begin to understand the options and a little more depth but you know this is a this is a very committee that thinks going forward forward forward looking committee, and they are going to want to understand next steps very clearly so thank you for your comments on that but I think that is for me that's critically important. You know we we don't have the luxury of time. Especially here in the Senate, the house has morning and afternoon for their committee meetings and we are efficient and utilitarian so there you go. So why don't you, why don't you go ahead. Okay, thank you senator for Beth and Tim for your for your information. The Senate has two committees, each that they're assigned to so senators go have a morning committee and an afternoon committee with House members have one so that's that's the Vermont that's what Senator lines was referring to. So, I, what we're going to do is take the same order and, you know, try and try and make this interactive please stop us if we're too high level and push us along if we're too much in too much in the weeds to start with and we can always go deeper but we'll try and stay at a informatively high level, you know in in 10 minute introductions to the to the four areas as opposed to half hour conversation, you know, of us talking heads on it. So with that I'm going to turn it to Beth to talk about the cost growth benchmark and Lorraine's gonna if she's able to share Lorraine can share the slides or else we can if Aaron whoever can do that that would be great. All right, well, while Lorraine gets us to the cost growth benchmark slides I'll start by just giving. Well first let me introduce myself for those of you who don't know me I'm Beth Weldman. I'm from Baylett health and pleased to be working with Joshua and the team on this. And I am going to talk to you about the cost growth benchmark and affordability standards. Cost growth benchmark is, you probably know as a cost team and strategy that really set the limit on how much a state's health care spending can grow each year at the state the provider and the insurer level. And the strategy is important because you know its outcome is really intended to slow health care cost growth and align that with wage and income growth. There's a number of different measures that you could choose to use but the idea is by aligning it with wage or income growth that makes it more affordable for families for businesses and for the state. And we recognize that while doing this it's important to think about how not to negatively impact access and health inequities so we want to make sure that by making the health care more affordable or not. For example, squeezing providers on their rates so that they don't want to be providers in Vermont right so it's important to think about that. Vermont as you might know has a cost growth benchmark that's part of your all payer waiver at 3.5% growth and not more than 4.3% growth over the five year period between 2018 and 2022 so it's coming to an end because we're in 2022. And it's important to know that it is two things one it's through the waiver and so it is only applicable to those. Those residents that are covered sort of through the waiver and doesn't include all efforts because it only includes those people who are insured whose data isn't your vcures data set so it is excluding a bunch of people. The other thing about it is. I'm sorry to interrupt you there but it would, I think important to clarify. I think we understand the different cost and wage income growth alignments that might take place we did talk a little bit about one of those yesterday. Yeah, but the, the issue around vcures is something that the sometimes folks forget so we're we're not talking about including private insurers who don't volunteer volunteer their information. Yeah, you just mentioned that. So, so the way today you get your information to measure your cost growth is through vcures and that information is limited to those to Medicare Medicaid and those commercially insured that provide it which is not everybody and so what we see in other states that have a cost growth benchmark is actually they don't use their all payer claims database. They have a method where they request all insurers to provide information and so actually hear what you would do is get the information in a different way. It's not voluntary for the insurers to provide it but they're providing aggregated data so they're not giving you all their claims, the things that they don't want in the apcd. And what we've seen in the other states that have done this and there's about 10 states that have or have have are looking at cost growth benchmarks and and all of the states all of the insurers are giving their information. So when you look at those other states. How did it happen that they were able to collect all of the claims database that it require legislation, which, from what I understand sometimes is not possible or was it voluntary. They're not getting all of the claims it's I think it's aggregated information they're sharing on expenditure so it's so it's and you don't get that same level of detail. So the insurers are more willing to give it and regarding legislation versus some other way I will say that the states are also about half and half in how they have put a cost growth benchmark up about half of them have state legislation and half of them have done it through an executive order. Obviously, we're talking to a legislative committee so we, we would recommend that it's legislation it's, it's carries on across administrations that way and I think has more authority to be permanent if, if there is a legislation that requires there be a cost growth benchmark. And we'll have to consult with our legal counsel on this because they're, I believe there was a court case related so I will just I'm pinning that for myself to talk to you mean the court case about the requirement that people report to be insurers. Yes. Yeah, so we're actually we would not recommend that that's what you do here we would recommend that there be a different way to collect the data. And if it is something that you all are interested in. We can share some detailed information about how it's done in other states but in no state are they actually using their all pair claims database to get that information they're using separate a separate data request to the insurance. Okay, thank you for that. Yeah, sure. And I think Senator hooker it looked like you had your hand. I'm just curious. Thank you, thank you I'm just curious to know like what percentage of the whole population are we looking at that we're not including I mean, you know how much of this information. What does it cover, I guess and what doesn't it cover so I'm not asking the question in a way that can be answered. I'm asking what in your current cost growth benchmark what you're including and what wouldn't be included going forward. I mean what would be included that's not today. So, essentially the pieces that are missing today and Joshua correct me if I'm wrong here, but the, the big piece that's missing is the commercially insured today. So those big a risk of plans are not. They don't have any information in your vehicles so they're not as part of the current cost growth benchmark where you're getting your information through vehicles, they're not included. And how big is that chunk, I guess is is the question I'm asking, you know, as far as total population. I don't know that information off the top of my head. Joshua or somebody else might know that. I had it in my head. Month ago and I can't remember so I don't want to give you the wrong number but we'll we can get back to you with that number that's in that's an I we know that number I just don't know it right this second. I think it's probably in the full report. Yeah, and well, keep you keep your question Senator, make sure you everyone is asking these questions is this is the kind of information that we need as we go forward so that we know that we're covering the folks all the folks that we need to cover in our decision making. And I think the important thing that we're suggesting here that actually is a step beyond what happens today, in addition to including more populations so that you have your whole state within the cost growth benchmark target. We're also recommending that you pair that with a process to assess emerging technologies and best practices with potential for a return on investment. And, and by doing so, you would help further innovation and ensure that you're really looking at the care initiatives you're putting in place and making sure that there is a return on investment, and tying that into the cost growth benchmark so as you know if you think about your cost might be at 4.5% if you didn't do anything. If you put in place some emerging technologies for example, and look at how they are likely to save you money you can then build that into your cost growth target out a couple of years after there has been time for the initiative to sort of be implemented and have the ability to bring in some savings. So that what you're, what we're, what you're inferring or implicating here is an upfront investment for a measurement, a system of measurement so we can look at that ROI and and quality outcome so there's an upfront investment that needs to be made so that's, and I think we talked about that the other day. Great and the investment is twofold it's both in sort of identifying those emerging technologies, and then measuring what their return on investment might be. Okay. Can you give an example of for, for the sake of the committee's understanding what those emerging technologies might be. I did at the, the meeting that we had with the task force on the 15th have with us a consultant who Joshua can speak more about who had a process for looking at technologies and identifying sort of where there were innovations it could be something that is about sort of doing a higher level of data analytics to understanding where there's sort of gaps in care and or waste in the system and additional you know where there's too much utilization and sort of putting best practices into address those things. It could be some sort of mobile app that you use with folks. It could be a whole range of innovations. It could be just something that's a practice transformation that we've seen in other states to be to be important so for example, one of our recommendations that we'll talk about is expanding the blueprint and that's putting more care management in place to the extent that we see care management having a return on investment. Say it's two to one you put in a million dollars you save $2 million. That's an example of something that you would then build in later to to your cost growth benchmark to assess the fact that you would expect to have slower growth by putting that intervention in place. And in addition, you know it's, I know we always talk about ROI in terms of our financial resources but we're also, we also will have to analyze the quality metrics and that and you mentioned that earlier. Yeah. So, and, and so I would just add to this, just as a reminder for folks from from was it two days ago. And also, as a reminder to all of us that the cost growth benchmarks and affordability index sit up here right they sit at the top to measure overall what's going on and the vendor or the process the vendor and the process that we're talking about include to support that would help us to measure things like the return on investment from the blueprint for health for very specific reasons right there are on payers today those those Arissa employers. You know, the, that don't participate in supporting the community health teams, and a critical reason why they don't is because we can't give them a, here's the return on investment from these teams here's the reason why your folks would benefit and how much you're going to save doing it. And so, from a population health perspective, this, this, having a vendor at this high level to support vetting ideas before they're implemented, right to give us an a standardized way not a health or skeleton way of identifying how those new initiatives or existing initiatives would impact our health care system, both for affordability for households as well as that top line that top line cost growth benchmark, and then allowing for the process to happen as well for those ideas to come in be vetted and, and then to be implemented through the legislative process and appropriated and then for you to have feedback, you know in the next year you actually get a report then that shows on a regular basis, how those things that you approved and paid for on the front end were effective in comparison to each other as part of the as part of the process. The good thing that we have in Vermont is we have systems and people in place. So that doing this now is something that we believe is achievable with the right resources within your existing structures. And so, yes, to your point, Senator Lyons earlier about do we need legislation do we need appropriations yes, yes, we need legislation is on the process, directive at least on the process for doing this that we would expect to see in addition, I'm right that we not we HSD we have Vermont, and, and we need appropriations to support that right and so those are the things that would be necessary to support the cost growth benchmark, and Beth not to sort of steal your right here but in addition to the, in addition to, you know, supporting this with a population health vendor. There would also need need to be some resources human resources at the GMC be if that was where this was located to manage the to manage all of this. You know all those things come to mind as you and Beth are talking so why don't we, why don't we keep going otherwise we're going to be here all day. Thank you, thank you that that's very good. Senator Hardy and listen committee, if you have a question you're going to have to speak up I can see Senator Hardy so she's lucky. Go ahead, Senator. Thank you, Madam Chair. So, I don't see in this proposal anything about quality of care patients and outcomes. It seems to be all about saving money, which I'm all for saving money but ultimately our health care system is supposed to be about taking care of people. It's drastically absent from anything in this proposal. I also wonder. I'm actually happy to see that you don't mention the ACO in here at all and that it doesn't seem like we need the ACO at all that we could be doing this with the Green Mountain care board, and get rid of the expensive and ineffective accountable care organization that we have that has not been able to implement this cost growth strategy very effectively. In fact, have not met the current benchmarks that we have so is that what you're proposing that we could do this all through the Green Mountain care board and not even bother with our ineffective ACO. I have a comment about the ACO I'm not close enough to it Senator Hardy to say whether or not I think it's working. But what I will say is that this is, you could, you could do this cost growth strategy with the ACO what this is is additive on top of it. So that there is a cost growth benchmark that covers the whole state and not just the ACO piece of it. And the second thing is this this is an overall as Joshua said umbrella strategy that gets people thinking about cost growth. And as, as we're thinking about the emerging technologies and the best practices that are looking at reducing spending they also, as we've mentioned are looking at the quality outcomes that are part of it, that would be sort of wrapped into it but you're right that the sort of overall standard is how can we keep the cost growth at a limit there are other strategies sort of underneath this. So the focus on the outcomes and the measures. One thing we haven't talked about is the affordability standard so the cost growth benchmark will keep the overall growth rate lower but it doesn't necessarily translate to the individuals and I think that's a little bit what you're talking about. There is also the potential to put affordability standards in place that that measure how much what is the appropriate amount an individual should pay in premiums and that you do some of today. In those cases where there's affordability standards you're just looking at the premiums and not the out of pocket costs and doing those things together a cost growth benchmark plus an affordability standard would give you sort of the ability to look at not just how cost, how cost is growing health care costs are growing across the board and keeping those at a lower level but ensuring that some of that reduction in growth is also supporting the consumer. I would say that you are linking it to the cost for the individual person or as you say consumer but I guess I would like to flip it on its head and say that the first thing we should talk about the overall umbrella of our health care system should be about taking care of people and the quality of care and access to that care that people get and then below that underneath it we can have quality we can have benchmarks and affordability standards to make sure that our system is not too expensive but we need to talk first about the quality of care and there's so much we could do in Vermont to improve that quality of care and we could use some of these emerging technologies to improve care first and foremost and I guess I'm I'm a little disappointed that your approach starts first with this overarching philosophy of saving money rather than taking care of people. So I'm going to I'm going to take a step back to the conversation that we had about vcures and claims data and the use of that in quality metric analysis as well as and and we aren't having a discussion about ACO at this time but ACO does have a system for quality metric analysis to improve clinical care and patient outcomes. So the question is, you know, is that what that group is doing is that affordable. Is it the right metric is it the right clinical improvement or set of data so I think, as we move forward, we're going to hear more about that and the, the issue of quality is so important to us. The committee has talked about that many times, but we're also interested in making whatever we do, whatever is accessible to also making it affordable so let's, you know, these are good questions and we're going to have to struggle with those a little bit so we'll move why don't we, why don't we keep moving along but pin those questions are very important. Okay, maybe the rain we can go to the next slide I don't think we need to go into all of the detail. In terms of how you could determine your cost growth target methodology. So let's set the value for that what the what the actual growth level is, and then assess whether or not you're performing relative to that, that target so I think we can move on to the next slide unless there's other questions about the sort of process that are detailed in the report you have. Likewise, there's there is authority and governance examples and questions for you to consider as you're putting together cost growth standard. And I think here the initiatives to support efforts to reduce cost growth. This I think Senator Hardy talks a little bit to your question around quality because it is essential that we make sure that as we're reducing costs. We're not harming quality in any way and in fact improving it because if you don't improve quality as you go then you're actually likely to end up with a higher cost growth. So the two are inextricably linked. And then finally the implementation strategies which legislations modifying the existing strategy at the Green Mountain care board, requesting the data submission from the plans as, as I suggested, and then sort of having an ongoing review, publishing the performance and being really clear. I think this is a really important piece of the negotiation that would happen between the insurers and the providers and showing sort of where insurers are growing more than your cost growth if they are. It's really important to help sort of keep it in check. And so, so this is a really important piece of the implementation strategy. So there's a lot there's a huge number of implications. And then this me for the current regulatory system that we have but also with the agreements between insurers and providers so we have a lot of questions to ask. There may be some changes to be made. If, you know, should we go through with this one, you know, for example we have no clue what the contract arrangements are so that doesn't give us a picture, or a window into rates for individual providers and reimbursement so here goes right down to the bottom line. Yes. Right and there are also implications for quality because we don't have a clue as to the grievance period allowed for patients or network and out of network issues for patients so there are a whole lot of embedded questions as we go forward with this and there's some other things that I have been thinking about for a long time on this and I, I don't know what, I don't know what the appetite will be for legislation to improve some of this and increase transparency but it's absolutely a discussion will have to have. I brought up the division between DFR and Green Mountain care board and their roles and responsibility related to rates and private insurers so there's a whole bunch built into this. Yeah, and I would say, you know, in other states that that have cost growth benchmarks typically the not always but typically the agency or government organization that's responsible for the cost growth benchmark is not necessarily the one that is setting the rates that they're a separate separate entity and so I think that sort of fits with the structure you have between the two departments and so. So I think there's some good examples for you to look at and that are described in the report. Do you want to go to the next slide. So, here's the legislative options again we would suggest that this happened through the Green Mountain care board, and you could amend their statute to allow them this authority and strengthen some of the language that's currently in there. To give them some more authority around setting a benchmark and as Joshua noted there'd be the need for some additional resources to support them in doing this work. Any questions there. Okay, so that's that would move us on to the next topic so before we do move on are there any other questions about cost growth at this point. Yes, let's go back to the previous slide if we could and let's hold it there for a minute so that folks may have questions or comments. But we do and we do want to move on no question about that but so Green Mountain care board establishing let's suppose that they would establish the cost growth benchmark. Then we also know that currently claims, there's a claims database within the Green Mountain care board. We also know that the Green Mountain care board is responsible for the health resource allocation plan so we're seeing a lot of authority with that one regulatory body. Then the question arises about the quality outcome measurements and where that belongs so is there. Do you have some thought on that. I know that we've been looking at that for a long time but currently it is sort of in the Green Mountain care board, but sort of not so what, what is the thinking on that and what do we see in other states. So again, in other states, you know I am most familiar with Massachusetts where I am, and we have the health policy commission, which is responsible for the cost growth benchmark but it is also responsible for looking sort of overall the quality of care being provided in the state and so I think that they have sort of joint reporting where they have both sort of this cost growth benchmark but then they look to see how the state as a whole is performing against quality measures and they rely on a separate agency in Massachusetts that is actually it's both the rate setting agency as well as the place where the all pair claims database sits but then they also do a number of performance measures based on based on the sort of claims they have and so I would have to go back and check to see, you know, because in, in Massachusetts I don't think in the APCD they have all of the external data either the voluntary data from the insurers. But they do measure sort of quality across the board in Massachusetts and so I would have to just confirm whether or not the, the sort of commercial pay or results are in our part of that, but each of the insurers have their own sort of are reporting on their own results relative to heat as quality measures. And so I think there are things you can look at even if it's not part of the the overall review and reporting. And, Beth, let me just add here that there also our states, like Marilyn that report star ratings on their, you know, and post them on their MCOs. That's done in some instances, you know, for the Medicaid MCOs of which we don't have any right or on the commercial separately right and in Vermont that that type of process could be applied as well. So I think it's important to provide some level of quality direct from a transparency perspective to report quality to consumers. The baseline just so let's just want to set the baseline for this, all of our quality. So I want to put it up, whether it's ncqa or, you know, another regulatory authority, or, or not for profit or whatever it is. All the data comes from the same place. So I want us to understand that that there's requirements for he just stated to be collected there are a ton of sort of warm holes to go down on he just data where it. It can easily conflate different issues, but it's what we have so it's what we use. But when you roll up to those star ratings or point ratings in different states on quality and consumer satisfaction. You're always using caps you're always using the consumer survey on the on the public payer side, and you're always using he to stay on the quality metric side. There are other state based metrics and we could do some of our own. At the very least, I would advise us against starting in that place, which is not, let's not create our own data measures that are one off from the national measures and the he just measures that we're already using, but this You know, before you go. Could you please spell out the acronym for he does. What, what is that exactly. What does he just stand for. Yes, health. Well, I think it's not actually a, I think now it's just a term, but it is like I just looked it up if that's helpful. This is Jen Harvey. It's a health care effectiveness data and information set. Yeah, according to and CQA website. None of us will remember that now we got heat us but it's a, it's a, can you explain exactly what it is for us. It is the collection of specific health information, very specific like so what your hemoglobin a one C is for individuals, and it, and it runs across lots of different clinical areas. There's lots and lots and lots of he just measures that then get rolled up into how are you performing on making sure people get their diabetes managed or get their heart condition managed and then roll up to sort of get combined at the rating level when you when Maryland's doing a score with a star rating for a health plan. They're rolling up all of a whole bunch of different he just measures and a whole bunch of different consumer survey information and then giving them a rating, right. And so you can see that's a big process right. Here's the thing and I want to I want to move on because it will we can get into this further as time goes on. But the, it seems to me it links nicely with what we're doing in blueprint, and I'm but that's just say it if you shake your head no then that's fine but I do believe that that is that this there's a link here that can be made in terms of quality of assessment and information. And, and senators I would I would say that diving in separately to the quality issue from a statewide reporting and fitting it into the Vermont ecosystem is something that deserves its own significant amount of attention right. In order to do it well at a statewide if you wanted to go to a sort of a star rating for either providers or health systems or MCOs ACOs that that that's it's all whole own thing. One vision here though is that when you do an ROI investment that includes the, the outcomes right you can't have worse outcomes. There's no reason to do something that's going to produce worse outcomes. And so, when we evaluate as part of the process for evaluating and when we get and really get into this when you talk about the other three initiatives here so when we start talking about the other three initiatives the options. Those options each could be evaluated and, first and foremost, on who they affect and how they affect them right that's how the task force talked about all this stuff is who does it affect. How does it affect them, it doesn't make it more affordable for them do they have more accessibility, because of the initiatives, and in order to do any of these initiatives they have to have outcomes that are beneficial to the individuals. So, okay, this is good. And thank you for reiterating that because that was us that was a, that's a huge part of the task force interest and going forward. If you don't have beneficial outcomes for affordability accessibility and health, at the end of the, at the end of the time, then, don't do it. We want to keep money in people's pockets and we want to keep them as healthy as possible so I think we should move on. Unless there are other questions on this one. Okay. Okay, so from a baseline perspective. I'm going to, again, push me up or down here from how much too much information too much talking on something and not enough on something else. We currently have in Vermont, a waiver right so we have home and community based services in Vermont and we've long, long many decades now been moving people to and are organizing our clinical and care systems at the community level to make sure that people can age in place that disabled adults can be served in their home and settings that they prefer overwhelmingly folks prefer to be served at home, no surprise, right. And it actually costs us on average less. Although some individuals cost more to serve at home on average it costs us less to serve folks at home that need help with their activities of daily living. So we have this program today. The moderate needs group is a technically it's a waiver right so the federal so the Medicaid program can't do things that aren't in their state plan. Without agreement with the federal government without getting without getting a waiver to do those things. That waiver that waivers likely to stay in place it's been in place for a long time and likely to continue to stay in place, both the Trump and Biden administrations are supportive of HCBS and have continued it's continued to grow just not in Vermont but across the country, every country, every state has multiple home and community based services waivers supporting different populations with different sets of services and different geographies and with different delivery methods. So, Vermont has ours, and it's not going away. And we serve right now about 1000 Vermonters at any at any point in time on the moderate needs group in the moderate needs group. These are folks that don't need as much assistance as other folks, but that needs some help with activities of daily living. And that's limited by how much money is in there right now and there is a waiting list for folks to get in that waiting list to get into the weeds just a teeny bit is not held at the state level today it's held at the community level, and they don't they don't update that list in a, in a fixed way so that the state isn't updating it in a fixed way. So, when we say there's 300 to 700 people on it. That's a point in time where the, you know, or we say there's 700 people on it or 500 when you have those numbers. Those are point in time where you've asked Dale, and the Department for aging and independent living has gone and asked the community how many people do you have waiting for these services. And that immediately changes right so so that's that process I just wanted us to have a view into how that process works today, because I think it's important to understand that because you'll get different numbers on who's on the waiting list for the current program. The concept here is to say, again, just at a high level. Once you hit 65 you're going to 70% of us are going to need assistance with activity as a daily living at some point in our lives. Once you turn 65 the chances are, you know, if there's three of us sitting there that two of us are going to need assistance with activities that daily living and our insurer is not going to cover that. So our commercial insurance is not going to cover your home health aid to come into your house and help you take a bath or, or other things. And they will cover your, your, you know, your acute visit to the hospital because you fell right, but they but they're not covering those those activities of daily living in the house by and large in your commercial policies. So Medicaid today is the insurer that people end up going to to get their long term care needs served, right, those activities of daily living serve, and people end up spending down to Medicaid, right so the reason we have the need group is because it helps people avoid spending down you don't have to spend down your assets, sell your family camp or get rid of your second car, or whatever else in order to access the moderate needs group, because we don't have an asset test in the moderate needs group. So, the idea here, writ large is to say, Medicaid has become from a de facto perspective, the long term services and supports area the area that supports individuals regardless of income unless you're a millionaire. If you're needing lots of care met you're going to end up selling your stuff and becoming eligible for Medicaid. So, how do we do two things here, how do we help people not have to get rid of their lifetimes worth of stuff, right at certain levels right and so not folks that have tons and tons of stuff and can pay for cash for this, but folks that are just above Medicaid today. They end up having to spend right down into it and sell their last thing in order to do it. That the moderate needs group has been focused on that which is helping those activities of daily living for that for for for folks are just over. This proposal is to say, you know, we should do two things here we should expand what we can do to support family caregivers. More individuals can be served because right now there's workforce issues and lots of those types of things. And to we should expand the number of individuals that we provide this access to, and we should do that, because it will reduce the number of individuals on an annual basis that have to seek higher level more expensive care placements. And so providing a small amount of service will reduce over time, the number of people that have to spend down to Medicaid, and the number of individuals who end up, you know, in the hospital, or in a nursing facility at much higher cost. So those things are measurable right we can, we can do and we can do a how much how much does this help someone, how valuable is it to you as an individual to not have to go to a nursing home to not have to go into a hospital. Right. Sandra. Yes, and while you're going into this we understand that we're getting it very well. Yes, the question is, at what point is there something that we can do to connect with the federal government to increase access to moderate needs coverage. Yep. Can we go to the next slide. So, just pointing out here that there's other states that have done this and connected with that have done similar things to what we're proposing, it would be slightly different in Vermont than every states a little different about how our programs designed today and what we would do at what what the benefit level would be I want to point out that we can target what that benefit level would be so you can control how much you're going to spend, how much you're going to provide to people. And I think that when, when you have the department for aging and independent living in to talk about this that they'll talk about using a flexible benefit so a cash benefit that people could use to train caregivers or to do different things. In addition and directly to your question, Senator Lyons. We believe and have a very high level of competence that the federal government will participate in this program. The same way they do in our current program by paying their portion of it to the extent that we can demonstrate that there are savings to the federal government overall and there are savings here to, to Medicare and to Medicaid for individuals who don't spend down to Medicaid, and for individuals who are on Medicare who do not end up needing nursing facility level of support for some period of time. So there will be a waiver so to directly to your question. There will be a waiver amendment, and we believe that that is an easy yes from the federal government and needs to be teed up and supported with a one time appropriation to do the necessary analysis and make the case for that for that 1332 waiver what which waiver is that in Vermont it's underneath the 1115 so it used to be in the 1915 area but today it's all under the 1115. Okay. So it's a matter. I mean, it seems like there are several things that need to happen here legislatively some of them at the state level but then asking to have this negotiated waiver. So it's going to be an appropriation some additional authorizing legislation and right. Okay. Madam chair, go ahead. Yes, oh, go ahead center. Thank you. Well this one I actually like because this one is actually about providing better care for patients. So thank you. This one should have been first. But, you know, we have a bill I think it's h 153 that is about trying to figure out how much more resources we need to provide to home and community health care providers in order for them to keep doing just what they're currently doing. Because the system is as you know so incredibly stressed and there are workforce issues, etc, etc. So my question is how do we support what we're already doing and expand what we should be doing to more people in this group. Yeah, that's a great question and the task force explicitly discussed it so we have I can speak to it because the task force spoke about it at length. I'm sure you're aware of the workforce issues and of the workforce that work that's going on on the workforce. We at the task force level had a number of discussions about that and there was a decision made to let the workforce issues be dealt with, you know, in another place and so I don't. I'll tell you that there are workforce issues that the department for aging and independent living will say that we can't fill all of our care hours today. And I'll tell you that nationally we're only filling 70% of the care hours for everybody on the CBS waivers nationally, and that all has to do with workforce, either wages or or availability of willing souls to do it. That's the combination of those things. So, we believe that expanding the family caregiver supports and aggressively working with our families in Vermont to to support them so that the so that our family so that your family can provide these services with supports that they don't have today can allow for an expansion here that otherwise wouldn't be viable in the short term given the workforce issues. Okay, so just let me make sure I'm clear about this so I have a constituent who I've spoken with a lot recently who is caring for her mother who has Alzheimer's. And she is so she's caring for her mom she herself as a mom trying to balance working her own job and taking care of her own kids, and she basically gets no money to help support her in her all the hours she puts toward caring for her mother. So, with this proposal provide fun. And so she's not even included in this workforce right she's just a daughter doing the right thing. So would she be able to access actual money to help pay her to take care of her mother is that what you're proposing. So, we've so I'm again not going to punt but I'm going to qualify before I give you my direct answer. And that is that we tried very hard not to design the programs for the administration here right um, however, now I'm going to answer the question which is, yes, yes, the individual that's exactly the type of individual at a high level here without getting into the eligibility details. Yeah, that that would receive payment just to for the hours that they're providing over some portion of the hours that they're providing depending on funding and eligibility and all of those issues. Yes. Okay. Great. Thank you. And then, I think we, we need to continue to reiterate the importance of the data collection and clinical data collection that are included in the benchmark the growth that benchmark I understand that Senator Hardy you're very concerned about it's not being mentioned but it is integral, very integral to that initial cap on expenditures and so we'll have to talk further about that so we can appreciate what's in the first one because I think it for me these all linked together in some way so we'll have to sort all this out. Can we go to the next slide. I think we've talked through these items these are the high level items I've been been hitting on so the next slide please. So, just, just wanted to target for you very briefly sort of what we're talking about from a dollars perspective. And the current moderate needs group. That's the folks on your waiver today. This is, this is their spending right so there's an out of pocket of about 200 and on these services so on the, the things that that we're talking about here not on everything that they spend money in the health care system on. There's about 1600 that's paid, you know, buying insurance so we are talking about a small piece but it becomes significant. This is a monthly number so it becomes significant when you add it up and you think about income levels for different folks and the fact that there's lost wages involved. Next slide please. I want to start here very briefly that there, there are folks that are below 65 right, but predominantly we are talking about folks that currently on the moderate needs group are over 65. So we look at the potential beneficiaries so we mined the, the database here in Vermont we looked at all of the individuals who might be eligible based on their clinical diagnosis and their care patterns in the past. There are individuals in the 45 to 64 year age group that are not, you know, eligible today and not being seen by the system today that are almost certainly eligible at a higher percentage than are represented in our moderate needs group today and so that shouldn't be surprising to any of us because the folks to the right from an age perspective. There's a higher percentage of the population that has a need and so that's who we're capturing today naturally. And it'll take a little outreach to capture some of the other folks who need but are not on a disabled waiver today because they don't meet that level of care, but they do need some assistance. So the local cohort that 45 to 64 cohort is also likely to be a place where we have significant savings to demonstrate to Medicaid and Medicare on the waiver front when we're asking for federal funding. So that's that's exactly, exactly what would happen here is is you would, we would hire Dale would probably hire a vendor right for a couple hundred thousand dollars to do an analysis that would, that would could be put into a waiver application and delivered to the federal government that says, here's the people we're going to serve. We did the analysis of Vermont they would take our analysis and go further than we've gone in order to make the waiver submission the way they need to. And would say, and here's the folks we believe we will find. And here's our plan for measuring that to show you the federal government that we actually are saving you money so you'll help pay for all of this. That's the, how that will work. Who does that analysis. The analysis would be done by, it could be done in house but it almost certainly, and again not to speak for the department almost certainly they'll hire someone to do it. And there's lots of firms that do this and and whether you require an actuary or not is something to talk about you could do it with an actuary. You could do it with just a data, a data firm that really, you know, does this a lot and specifically in this area. You could do it with some of those names but but Dale. I suspect they have someone on contract that could do that could do this for them. A Milliman, for example, could do this. Right. Right. Okay. Are you there. Joshua you're frozen. Are you frozen. No, no, no, I was going to ask a question so I was lost. If I could, are the people you talked about waiting lists are these people in these lower age groups part of that waiting list. Where are these people know that you're looking at they could be but the vast majority of them are not on a waiting list at all right now. They are just individuals that we have identified as having the same clinical conditions and patterns of utilization within the system, as the folks that are on the modern needs group today. And so therefore we know that they have the same level of care needs and how they're getting their care needs met might be from a relative might be that they're higher income and paying cash out of pocket. They may not be even aware of the modern needs group in some instances. And so those are all possibilities. Yeah, Senator Hooker just I'm sorry to interrupt but the example that I gave earlier about that my constituent is exactly that her mother it's early onset Alzheimer's her mom is like 53 or something like that. So, and she's not getting any support, you know, financial support to do what she's doing so this is exactly this is why I like this one. Well I like it as well I also have taken care of her partner, and not getting any compensation for it. This absolutely resonates with people and that and it's, it's so important so. Okay. Yep, next slide. Here's the, here's the big, here's the big sort of, I'm going to caveat this with these are the most aggressive numbers so the highest numbers that you could possibly see. And I think we need to think about this. And we did that on purpose because we wanted to, you know, not underestimate and have a surprise on the other side. And I think that the way you manage this, quite frankly is to the dollars that you have available in the end. Because that's that there's there's a if you if you open the door, it'll go wherever it goes right so but that that's how almost that's how every state manages this that I'm aware of which is there's a wait list once we hit our dollars and that's what we have in this place today for that first line here those 500 to 700 folks. That would that that could come in right away. And let's be clear that these folks are not static when we're talking about folks they're actually equivalent to an individual year for a year right it's not. It's not that Josh necessarily some folks need ongoing so that early onset Alzheimer's will need ongoing and ongoing, but a lot of folks need three months and six months and it there was an event of some sort of stroke that you recover from and then you don't need three or five more years right and maybe you need something more than and so these individuals both the thousand that are on the MNG the moderate needs group today and any additional that we would add. They, they're very there's all kinds of folks in there right and so it's it's it's parts of Josh and parts of Beth and parts of Tim not not. Josh all the time, in some cases it is, you know, a Josh or a Tim all the time for the full year, but in other cases it's not. We then broke out Medicare folks right so here's our either disabled Medicare folks but primarily above 65 Medicare folks so eligible by age, not by getting on to SSI and SSDI. And, and then there's the commercially insured folks the commercially insured folks are smaller group. But it's a, it's a totally unrepresented group in our pantheon today of folks that we really target with programs, and they're there folks that I would just point out that end up in one of those other two groups when we ignore their ADL needs today. We get them one way or another. And the argument here is that it's one you know well right which is that getting upstream on this and providing a little bit of support can miss some of the more expensive things later on. Next slide please. This we talked about already which is in order to add it to the global waiver to the 1115 that we have in place you need to do a little financial analysis. And I think that's the last one is there another one. Oh, okay. So that's where we are modern needs. So the total number of people affected can be up to 18,000. Right so. And if there were. So what we did what we didn't look at was how many Vermonters would be affected by a cap on cost by a cap on how much we gave each for monitor or on yeah or the total. Yeah, so if we can go back to that dollar slide for a second. Yeah. The next one. Yeah. So, down one more. Very good. Thank you. So, so if we, if we. So, let me just talk a little bit about this. Let's use the Medicare number that's the biggest scariest number on the page right because there's the most people right above 65 in Vermont is 140 plus 1000 individuals of those individuals. There are 14,715 who are not on are not in our modern needs group today, and not known to our, not known to our department of aging independent living today because they haven't come in through an eligibility door, right. The same clinical characteristics as individuals who have come in through the through the eligibility door. Some of them are are higher income, right. And one of the ways to manage that $20 million down to five very quickly is to set an income cap on there, right. And currently the mng the modern needs we've cut off is that $2523 per per month per person. So, the analysis. We do break down by income level in the paper, how many people there are in each category and we have the dollar amount per person on average that it costs today. You can provide a slimmer benefit than there is today so a smaller dollar amount per individual on that would provide some benefit to a broader group of people. You could provide the same level of benefit that's provided today to a smaller group of people right though that's the playoff there on the dollar front. I think we're good. We get it. Yeah, yeah, no. I actually asked a different question so I'll ask it another time, but because I think we probably should move forward. I apologize. No, that's not a problem. So, I'm going to turn it over to Tim for public public option. So happy to be here this morning. I'll kind of go through these at a high level, just to kind of set the stage here now we're kind of talking about a different set of proposals and a different attack on accessibility and affordability if the cost growth term was about overall aggregate spending and restraining costs and the moderate needs was about direct service delivery and finding ways at a very micro level to be sure we're delivering services this is about creating more coverage options coverage options in terms of insurance and further monitors that might be more affordable than what they're facing now and in particular and we'll talk more about this folks who are in the individual and small group market. So a little different part of the of the economy here but that's kind of what we're talking about so just to kind of back up a public option as I said really is an insurance coverage option, you know, designed to leverage the state's position as a payer and a regulator to create something that might be more affordable than otherwise would have been available to Vermonters, either through the commercial marketplace or on the exchange. Typically, when I say typically because much of this is conceptual, when people think about a public option there's three ways to deliver it. Right. You can create a new public program like a new Medicaid or a new state employees program something analogous to this to actually go out and compete in the market, try and get people to enroll. You could leverage existing private plans or Medicaid plans to administer benefits sort of a public private partnership overseen by the state. However, you can expand an existing state program right open up the employee health, the state employee health system or the retiree system or Medicaid to folks who otherwise wouldn't be eligible and leverage that delivery system to provide care. So along in the short, every state that has considered this and kind of move forward and there are, I would say I would characterize it as two and a half states have done the second option which is public private option where you're leveraging existing networks and insurers to deliver a public option services so that's kind of at a high level, kind of what a public option is and kind of what every mechanism might be so if you could go to the next slide. So, who will it affect for Vermont if we were going to do something like this when you talk about consumers as I said, this is largely a small group and individual market combined kind of thing, right this is who it's going to affect mostly 29,000 people in those markets, there's an additional, you know, almost 4% of Vermonters who are uninsured. So, you know that's a significant chunk of folks who could potentially take advantage of it now I recognize, you know that 3% number on the, you know, pretty big number I don't know that we're going to move that too much with a public option, given churn and whatnot but the Vermonters in the small group market and the individual market I think, you know that's a place where it can help you think about what other states have done in terms of the savings that they've targeted for people who are implementing a public option. We could be talking about, you know, if you think about a silver plan premium as much as $1300 a year that you could save an individual in one of those two markets by depending upon how you implemented a public option. The Vermonters obviously are another large stakeholder here. Obviously they're never going to be on board with a state run government run program in direct competition with them. But clearly if there's a public private partnership where they are being leveraged in Vermont it's really to commercial plans that are being leveraged to deliver services I think that they're likely to work with the state to understand how that's going to work. The Vermonters are the other big stakeholder here right because we're going to talk about this on the next slide. They're the folks actually delivery care the ones who are ultimately getting paid for care. And depending upon how the same how any savings are derived in a public option. It is their ox that might end up being gored and so they're going to have a say and they're going to worry a little bit about how that all gets structured. Before we move on to the next slide. So before we move on to some of the real kind of nitty gritty implementation considerations. Let me stop here and talk a little bit about how do you pay for it. Right. There's a lot of other policy levers, but overriding everything is, you know, how do you how do you make it work from a financial standpoint because at the end of the day, to make the option work it's got the coverage option itself has to be kind of more affordable than what they would then what a consumer or a small employer could direct their employees to on the marketplace now. And there's a couple of ways you can get there right you can sort of per my prior slide. You can reduce or hold provider rates to a level right you can benchmark them against commercial rates you can benchmark them against Medicare rates. But try and use Medicare rate provider to the provider rate reductions as a way to drive premium reductions that then might be creating an option that's more attracted to consumers. Depending upon how those structured, you're going to, you're going to get provider resistance right to the extent that they're baselined on commercial rates, probably less so. The more the more you think about the baseline against Medicare or Medicaid rates, probably more resistance to provide from providers on that standpoint, but again, limit provider rates that's going to turn into premium savings. The second option or a second conceptual source of savings if you will is competition right just established by establishing the benefits by establishing provider networks by creating competition amongst insurers, you can drive premiums right that's the theory of the marketplace now is if you get standard benefits of standard set of plans and you get plans to compete you're going to drive rates down relative to what they might be. From my perspective that's a pretty conceptual argument particularly for a state like Vermont, where there's pretty limited commercial engagement of insurers I don't know that competition alone is going to drive premium to a place where you're going to get savings or at least measurable savings that you can articulate. And I'm going to tell you in a minute why it's important that you have to be able to articulate those savings. So it is, it is an outcome you want to achieve I'm not sure it's an outcome or something you need to hang your hat on to say yeah you're really going to get savings here. The third source, obviously is you can, you can appropriate money you can put state dollars and subsidize premiums or subsidize the plans to such a degree that they look more attractive to what consumers otherwise otherwise might see and I, I don't need to tell you the implications of what that means and sort of how you get those state dollars becomes complicated. The financing considerations are important. Because you another source is federal dollars right you need, you can, if you generate savings in a public option, and you generate savings in such a way that what the federal government might otherwise spend on premium tax credit subsidies for people who are in the public option place right if you drive premiums down enough that the federal subsidies go down, you can submit a demonstration waiver to the federal government and be able to recoup some of those costs. Right so for able to put together a package if you're able to show in an actuarial way to the federal government this, this public option scheme that we and I don't say scheme in a bad way this public option program that we put together is going to reduce across the board for beneficiaries who are going into it and then subsequently they're going to reduce the, the amount of money that the federal government has to pay for those folks who are otherwise subsidy eligible, you get to get some of that money back. States that have proposed that some states have proposed to take that money and put it back into the public option you could take that money. And I think that's the one I think has taken that money to subsidize other programs right then have to go back into the public option but there is opportunity here to claim federal dollars to the extent that you can structure this in a way to save some cash. Go ahead, go ahead, I just wondering if you were finished with that slide because I'm going to move on. And just a comment that I think it was pretty unanimous and a part of the task force that provider reductions was not something we wanted to pursue we've been trying to improve equity of payment for our providers so just a comment on that from the task force perspective. Yeah, and I think, and we can move on to the next slide I think center lines that gets to your opening point like right what is the thing then that you can do. What are we as a committee how do you how do you want to legislate or direct or kind of advance this policy conversation and I think what we had recommended and I think what would be what could be a next step. That's probably a bridge too far at this point to say you're going to legislate and throw say you're going to a public option. That's probably a little too aggressive off the bat but I do think there's a bunch of implementation considerations that it is worth doing some more work about right and so the financing considerations around provider rates is one of them right if there's a if there's not an appetite appropriately so to to sort of threaten access any greater in the state of Vermont, you know one of the considerations are so the implementation considerations I'm going to talk about now kind of come in the context of perhaps asking the state whether you want to go to the DVMC or the, the Medicaid agency, or the health department to go out and do some more work, particularly actuarial work, right that we can't provide here to really think through the implications of how this would work and whether or not it's an option to the state that could advance this access and affordability issue. One of the questions is we've talked about that you'd want to think about is what type, right, public private partnership we've talked about like Washington, Nevada have done, or a public program buy in state run plan. I think we've talked about that. Another consideration is benefit design. Right, obviously, or maybe it's not obvious but I think it, it would have to be a plan that would meet the requirements of a QHP in order to sort of generate savings or be able to say you generate savings because it's got to be a plan. Tim. Yes, sir. Tim, and Senator Lyons, would it be helpful just to for Tim to talk briefly about the interaction between the exchange and QHP and so and this concept. Right. Okay. Yes, why don't we do that, but I don't want to lose sight of the time. Right. So, this would be the, so in order to claim savings right the third to go to the federal government and say you want to get some of these savings back to the extent that we can calculate savings. The public option would otherwise need to be a comparable benefit a QHP type benefit that you then what you'd get on the exchange right you couldn't offer. For example, a limited benefit or hospital only or long term care only it would have to be a benefit that beneficiaries otherwise could get on the exchange for subsidy so that's why it's important that the benefit design kind of match what we start with a QHP, so that then you can then say you've got a comparable plan that you're going to go back to the federal government claiming savings. The other benefit that you get when you think about benefit design the other lever that you get to tweak and I think this gets some of the questions that Senator Hardy was asking earlier, was you can you can roll in or analyze whether you want to create a network requirements or cost sharing requirements that might address other disparities or economic or racial or other access issues that are occurring in the state by putting requirements on the plan, or adding benefits. Just, just to emphasize again I mean this then goes back to the comments I was making earlier around transparency contract transparency openness of rates and claims data that we don't have access to today. Yeah, okay but it has huge implications for access and affordability. Right. So, right so so it's I think you can see here that it's more than just kind of benchmarking huge pieces and opportunity here to sort of say, you want to build into the benefit design some outcomes that are, you know, priorities for you all in terms of disparities access and quality. Next slide. Can I can I just jump into here just for one second. Just, I wanted to point out who this helps. Again, we have before and I don't want to spend a lot of time on it but I just want to point out that we are talking about the small group, small employers and individuals. We have seen those rate increases go up, right, aggressively in that in that market and, and in what might be called a death spiral to that market by some. Right. And so the the issue here is, is when you think of these different options this one is targeted at that group of folks that is is not represented in any of the other options. Well, the cost growth target everyone's represented in, but this, this is targeted at targeted at reducing the costs in that area specifically. So I just wanted to say that one more time. And could I ask, what happens to people who aren't associated with these small groups I mean individuals who are looking for help. They can, they'd be this would be an offering on the marketplace they could enroll just like they could anything else on the marketplace that this would be an option for them. Thank you. Yep. So more implementation considerations, we've talked about the premium savings and financing right how do you get there and I think it's pretty clear that rate reductions are not something that the committee wants to pursue and we've talked about the 1332 waiver, I think it's also important. If you do further study and to think about is the impact of the ARPA premium subsidy rights and there's an extension or an increase under the various cover relief bills of the premium subsidies and the person, the amount of premium subsidies, which are expected to expire I think understanding what that expiration is going to do the market and how that's going to look is going to be important consideration. And then, as Joshua said the impact on small employers and what this might do for them. And then finally right tying this back to best point on the broader scheme of growth limitations and cost rate kind of how does that all play together. Next slide. And then finally in terms of just implementation considerations, right being very precise and understanding the impacts on the resident eligibility and marketplace, you have this obviously from the time being have a combined small individual group market. That would be something you'd want to think about. There's a fairly stable market there's only two issuers kind of understanding how that all plays to kind of how a public option would be put together. Who who and then another consideration would be kind of who and we've talked about this in terms of some of the other options we've talked about today right who in the state would be best position to oversee and run a public option whether it's the health board or the state insurance agency kind of how that all plays together. And then executing agency here in timing really are to speaking to who you would want to do this further analysis not so much how you would implement it but kind of who would you want to direct to to go off and think for another six or eight months in more detail about a public whether it's for my health access or not. I think the point is it's got to be coordinated amongst the Vermont Health Access Green Mountain Health Boarding and the Department of Financial Regulation because they all have a play. And insurance regulation overall. And I would just point out here something that you will hear and have heard which is that the departments are heavily stretched and every, every new thing is is an issue. And I don't want to gloss over that. But to the extent that there are one time funds available to support the analysis here. There is, and I think you'll hear this from the department and the agency that that their appetite for doing this might be timed to coincide with the expiration of the subsidies on the on the exchange or the reduction in the subsidy levels on the exchange, because there will be a greater need then there, I would say there's a significant need today. But there, but the need will be greater than. And so, as you weigh out things those are, there's some timing and issues there. Can you remind us of when the drop dead time is are for the subsidies. Okay, they go through the end of 2024, but I will double check. Okay, so I think I thought that as well but so if you look at your last timing issue there there's some coordination. Yeah, so when one ends the other gets teed up. Okay. I don't want to take it too complicated but it's healthcare to all make it a little more complicated right with all the unwinding that's going to occur on Medicaid eligibility and maintenance of effort there's just going to be a lot of excitement in the market for for this kind of set of folks over the next 18 to 24 months. Okay, thank you. Thank you. Thank you. Thank you. Go ahead. Go ahead. Just a quick question on the timing. I definitely understand that the timing related to those are both subsidies, which is something that my other committee, Senator Cummings and I talked about a lot in finance last year, because I think we split out those markets temporarily they're not combined. And also timing pressure or coordination desire with our waiver extension, I know that our overall global commitment waiver. We asked, I believe for a one year extension because of the pandemic and then it's going to come up again. So, is there urgency to do this. I don't see right I don't see and Joshua should stop me if he thinks differently because he's closer at the state. This would kind of be on a different track than the global commitment to help waiver right this is not a Medicaid only problem or issue that's being addressed I think it is quite frankly, it's a different set of folks at CMS that are going to deal with that. Clearly there's an interaction there and we need to think about it but I don't think one informs the other in terms of timing. Okay, that's actually good to know because if there was some urgency with that that it would be a little bit more short on time. I think it's actually a different waiver the all payer waiver and the interaction with with how we think about rate setting timelines for the small group market, which is those. I think it's not a diva global waiver it's it's the other waiver. And I don't think again though that it necessarily has to move concurrently with that waiver there are just some interplays from a regulatory perspective with how we regulate insurers and where this would be placed and timed to I don't believe that if there were something that needed to be changed in the all payer waiver. That waiver is more urgent than at this moment I think because that's the place where that regulatory stuff is happening. Okay. So I know there's so many waivers, one starts to wonder, you know, should we just not have the system we have if everything we're doing is waving what the requirements of our current system are just a thought. Well I will send it as a form of that. Technically they are not waivers they are demonstration from projects. We all call them waivers. Maybe not you but we all mix them up and then Nolan has to tell us, you know it's this waiver, and it just becomes like this ridiculous thing of we're always asking to change the rules and order, you know, as we're, as we're looking at this it comes to mind that it would be helpful for us to understand what the 1332 waiver is. So we'll, we've put that down for an agenda item and a Tim, I don't know maybe perhaps when you're back at some point are you and Nolan can guide us through what that waiver is and who's responsible for it and how what what has to happen to do things. Yeah, that'd be great. Okay. So I think that's the end on public option. Okay, well, it's not the end of complexity. I'm not feeling too cheeky I need to ask Senator Hardy if she liked this one, because she was rating the other two. This one. I do like this one but I also understand that that it may be an uphill battle at least for now I think Josh's point about the overstretched state agencies is a really good one. But I feel like we could maybe get the ball rolling in some way. So we'll see what happens, Senator, good suggestion. Yeah, at the end, you know, on a 10 point scale, just for feedback purposes. Yeah, okay. All right, let's, let's, let's expand our horizons. Okay, one more. So we'll try and keep this to our last 15 minutes here. So, I think this one at the end makes sense I think it's perhaps the most well known of any of the options it's been around a long time it's highly successful from a national perspective it's been lauded. Our community health teams I think everybody's had some constituent who's had some interaction with the community health team at some point. The key key components to this are again it's an it's an existing program in Vermont. It is funded today. You know, and it supports community health teams. It's funded so by our commercial insurers today by Medicaid today by Medicare today. And it's funded on a community health team basis so you pay your share as a payer, you pay your share based on an attribution method for the employees and you don't pay based on units of service. How many of your, how many of your insurers actually use the community health team, you pay based on the primary care medical home how many of their patients are your insurers. That's the basic model and we can get into a lot of detail on how the attribution happens. It's timing wise and all of that but it doesn't matter too much. It matters to Blue Cross or to MVP or to Medicaid on a monthly basis but it doesn't matter. It doesn't matter for this conversation what matters is that we're attributing lives based on their primary care medical home and getting a payment for those community health teams today to support those individuals who need support from a community health team. How do they get to that community health team they get there exclusively by referral today so the primary medical home says hey Josh needs some help coordinating care needs some help with their substance use needs behavioral health support that they're not getting from me or that needs to be better coordinated and the community health team steps in and provides supports either in helping folks get from one place to another to find the rights of providers for them or to actually provide some services on an interventional basis. And we have allowed in Vermont that that blueprint for health to grow at the local level the way it needs to so teams are not identical. And they're based on what the local providers believe they need support from a community based team to do. And it's been very successful on that front because it meets the communities and the individuals where they are and provides supports for them how they need it right so really care focused. And so much so that we believe that we could expand this offering in Vermont by doing some identification and stratification of the population to I to make sure that we don't solely do referral but allow individuals to be identified and offered services through the community health teams that are identified as needing those supports so currently all the big payers and providers UVM Dartmouth blue cross MVP Medicaid have programs where they do this where they identify individuals who are high utilization, who are, you know, utilizing services say in the emergency room much more often than, than is normal, and they outreach and they say, you know, can we help you. Here's the all kinds of sports we have for you. The community health teams don't do that today the blueprint doesn't do that today. But we're paying for that as a state in our commercial rates. VCCI, the Vermont chronic care initiative is doing its day you're paying for that explicitly by appropriation. In addition, as rate payers we're paying for the community health teams. And so this, this would say hey we have a very successful community resource. One last piece on this. The, the, the risk of payers are not participating community health teams today, because that no one they're not required to, and we haven't demonstrated the value to them explicitly for participating. Adding some identification and stratification to to who could be enrolled or outreach by the blueprint and expanding the blueprint teams to meet those needs. And following up with a how these needs have been met. So improved outcomes improve consumer satisfaction and reduce use of the ER for as a, as just an easy example for those teams would allow us to to demonstrate to blue cross to MVP to UVM to Medicaid and Medicare that our blueprint teams are actually more effective than some of the other interventions that may be happening in the system and would allow for the community health teams to do the thing they do really well, which is they're fully embedded and engage at the community level. That's the whole spiel on that at a high level about why we believe there should be some additional expansion of the blueprint explicitly tied to identification of individuals using another pattern on top of the referral based pattern that's there today. And so that would allow that would not just encourage it would explicitly put in place. The process necessary to demonstrate the success of the program empirically. So, next slide and any questions as I before I keep talking. I'm looking at the number of slides that we have so probably good for you to keep going. So we can get to a place where we can have a additional questions and conversation. Sure. And as I often do I talked through this slide on the first slide without moving it so this has some of the details around the dollars that we spend on those community health teams today in the report there's a full appendix with the with the 2020 spending on the blueprint. Overall, and you'll see you'll see that in your budget materials when the state comes in as well. Next slide. I think you probably we probably should emphasize the significance of primary care practices within the the concept of medical home or our health care team community health care teams. They're integral and embedded and have been part of since the beginning the development of the community health teams and and continue to have the primary role in in identifying what their needs are and the community health team, how the community health team can be integrated with the practices and utilize so this is a this is a care management first this is a clinical improvement. First, and it was actually started at the very beginning to help those primary care medical homes move forward on their accreditation status and improve their heated scores and those things. So it really is a clinical first and program. Next slide. So, I think what we want to point out here is that they're there have been some analyses done that demonstrate what really is powerful in improving outcomes for individuals. And that's where we have demonstrated success and important to that demonstrated success are a few things. One that that you're addressing behavioral health to that you're including telehealth and information technology as part of your strategy, and that from an organizational characteristic perspective that we have prior to the blueprint has that we target patients with substantial non medical needs in addition to medical problems. How much we do that is an unknown at this point and could be part of and should be part of, you know, identification and stratification and the, the, the vendor that we brought in actually does that so mine that we showed at the December 15 meeting actually does that pulls in those medical issues very robustly and combines them with clinical data. And that it's focused on individual patient care rather than transforming provider practice so it's important to transform provider practice right practices don't change how they do stuff, you can't change what the outcomes from the practices are. But the, in order to have an intervention that is successful clinically and for the individuals in their outcomes across social and medical outcomes really has to be focused on measuring the individual patient care, and then using non clinical staff to provide the blueprint does some of these and not, not all of these and the ones where we've were suggesting here, we would add to the blueprint would be that identification and stratification and that so that individuals are assigned to the blueprint for outreach in a pathway other than just for referral through referral, and that measuring those outcomes would also then allow for the case to be made to the ERISA employers in the state and particularly to SIGNA for example as their ASO their administrative services organization or sometimes it's called the TPA, a third party administrator that they should participate in funding those community health teams explicitly because hey, we enrolled two dozen of your folks and and they had these outcome improvements as a result of it. And so, I think demonstrating that explicitly would be would be very helpful to the cause. Can I just ask if of the, on that previous slide, you said that of the 23 program features exam and seven were associated with favorable estimate costs and quality impact. Do you have a list of those that were not. Yes, I don't have it on this slide but yeah we can get that to you yeah absolutely. Okay thank you. Sure. Lorraine back down now. Yeah, I think we can move. We don't have to spend time on Maryland today we can come back and talk about other states if folks are interested so I think we have Maryland Washington. Yeah I think we can skip those and go right here to the. We can come back to the other states. Just briefly on CPC recognize we're at the very end of our time here today together so what we wanted to point out here is that the innovations and the practice transformation delivery functions so the bullets at the bottom of the page here. Help us to compare to our existing blueprint what's being done and perhaps what could what could be added or included that isn't being done today, and that health information technology vendor support I would point out, not available today to the blueprint robustly or to our other initiatives robustly. Our health and health body. And has been increased and decreased over time. Our actionable feedback reports again, not standardized our definition of care management, not standardized across the state for all the different care management case management and care coordination activities. So today, how many folks are enrolled and say a UVM for different UVM care management programs, and how many of those same individuals are enrolled in the community health team, or in a blue cross blue shield or MVP intervention and so the ability to put those and to keep track of who's doing care management for whom when is something that would benefit the blueprint and all of our other care and case management programs, and that can be done and is part of our how you do comprehensiveness and and planned care and population health at a statewide level. We know how to do it in fact. We again not not the people on this phone, necessarily not myself doing this, you know, but that there are population health. We know how to do it from a population health perspective. And with that, I'm going to recognize that it's 11 o'clock, and I'm happy to talk more. Joshua right work. Our committee actually goes another 15 minutes today. And so I the hard stop at 11 was so that we could have an opportunity for further discussion and questions if you're still available. I can, I can be on for for the next 15 minutes I believe we lose Beth right at right now though. Okay. Oh, any quick questions from that. Okay. So, so Beth I think you've heard the questions regarding the cost growth containment piece and trying to see the value of that to improve patient quality I think that's one that we all have but we also did talk about collecting claims information and claims database and utilizing that for clinical improvements. So maybe at some point we could get more, you know, a more robust discussion about that going forward because I think we are our goal here is access that is quality based and affordability that is downward trend. I'll say two things before I the one is that you know that the cost growth should be seen as sort of an umbrella strategy that helps support, you know, an overall target it is not supposed to answer all of the questions. But there aren't pieces of it that can help to improve quality and that you can't include as part of the overall strategy, additional initiatives that would do that so that's the first thing. The second thing is I checked on the number of Vermonters that were in self insured plans and those are the ones that are not in the v cures system and it looks to be about 20%. So, 20% of the total. But I think what's important is that it sort of sets the tone and to have everybody in and to have have the cost growth benchmark be something that is applicable across the state. Regardless of what the insurance is and that there's transparency and publicity really about what how insurer rates are growing or not growing. All right, thank you. All right, so I'm sorry that I have to run but but I knew. Josh and Tim can answer any other questions while I'm gone. Thank you very much. We really appreciate your time. Thank you. Have a good day. You too. I do have one question for Joshua before we change course here on the blueprint and that the predicted number of people who would be affected through the identification process. We do Lorraine I don't know if the numbers that numbers on one of these slides. I just don't remember. It is it is in the report that we could impact up to 65,000 individuals. We don't know today how many individuals are rolling through the blueprint on a monthly or annual basis. It's nowhere near that number. That 65,000 numbers taken from some national studies that have been done on the percent of a of a population that at any point in time could benefit from some level of care or case management or care for the population. I'll say that that's a gross number right like it's, it's, it's certainly overstated at any like, we wouldn't enroll that many people, right. So how many would be enrolled is somewhere is something that we would limit here in the same way that we would for the moderate needs group based on what the resources are available right and today. I think that that's what I can say about that. Yeah, well, and if since the risk is not included in that and we're seeing that a risk is 24% of the total. And if a risk did begin to cover, you utilize a blueprint that that would be a significant number. So those are the kinds of things that we would like to understand and then obviously the return on investment is so critical here and what value the blueprint brings or has brought and continues to bring so those are kinds of things we need to look at but in terms of moving forward. There are some very discrete things that you've identified. Senator Hardy. Thanks I'm just going to get out ahead of Tim's question and say that this one seems super vague to me. It's hard for me to tell what this would do. I don't think you make the case very clearly. And the sort of trying to sell it to a risk of plans is kind of a chicken and egg thing because it's pretty hard to sell it to them if they're not part of it. And a lot of those orisa plans have similar programs built in that are sort of behavioral health and care management things that they offer to their, their participants I know that based on my own experiences being in an orisa program. So I think it might be really hard to prove to them that getting rid of what they're already doing and doing the blueprint and paying for the blueprint instead is going to be better for them. And I mean I think in general the blueprint is one of those things that is a is a good thing but it's really hard to explain to people what it is and how it's helping. And so I think needing to be able to be more explicit about that. And, and even still I'm, I'm still it seems very vague this proposal. Yeah, so let me share some of the, the concern that I've always had about blueprint, I was, I was part of the whole development process and legislatively with that, and feel that it's such a critical part of our health care. But for me it's a model, it's a model for care delivery. You know, rather than paying into it's not an insurance. It's not insurance necessarily, but it's a model for how care is delivered than the question that we would have is. Are we improving the quality of care for patients through this and making things less stressful when they move from a care service to care service, or from medical care to behavioral or other care. And are there cost savings when patients are treated utilizing this model so that's the kind of thing I think needs to be demonstrated when any insurer is going to invest in this care model for their consumers we use the word I'm using the word consumers for assured so. So, yeah, and Senator Alliance thank you for that reminder, the, the program that we are proposing. This is an enhancement rights when existing so I can take a one minute stab at being more more precise. And that is that the current program is by referral only and payment is made using a different mechanism, which pays for the teams, but doesn't connect payment for the teams with savings to the insurer employer individual. It doesn't connect outcomes directly to those he just measures that they insurer in particular would be very happy to have better he just outcomes. And so, in doing those things. This goes back to that sort of that statewide pop health. And identifying individuals who need help and following up with that return on investment analysis, which would include both the, the clinical outcome improvements those he just metrics that have a dollar value to insurers. So they can put a dollar value on on what a good he just measure means to them. And where there is an improvement in health outcomes that reduces medical utilization for individuals or increases less expensive utilization and decreases more expensive utilization to the extent that we can as part of the blueprint and the modeling for that both for identifying people who are more likely to have a beneficial outcome, and then measuring what those outcomes are, we can do several things. We can get CMS Medicare and Medicaid to continue to pay and to increase their investments based on what we're doing for those community health teams, based on demonstrating that, and we can make the case to, as part of a rate setting process with our insurers that we do set rates for that we can include an additional amount downward based on on their rates in roll that a higher level in the community health teams. And third, we can make the case to the ERISA employers that they, here's the benefit, like we'll show it to you in in number of people and in dollars and cents, and in, and in health outcomes. That's the idea. I hope it's not so clear as mud. If it's still clear as mud, we can come back to it. Oh, I'm sure we'll be back to it and I'm sure we're going to hear a lot of comments from other folks who are very interested in. There are a number of folks who are interested in this expansion, but there are folks who are interested in other areas. I guess, as I look at some of the options that are before us. I want to think about touching as many Vermonters as we can with reduced out of pocket and reduced costs so that they and increased access so when whatever decisions we make, looking at and making as many people as we can, and ensuring then that we're keeping money in their pockets. If, even if, if we had a, if we said we want the umbrella, you know we want to hold down costs whether hospitals or others. We want to make sure that when we're holding those costs down that we're putting we're keeping the money in Vermonters pockets for not having them pay for that reduction somehow so there is a lot here. Senator Alliance to your point just I forgot to make this point, which is that the Vermonters who access community health teams there's no cost for Vermonters who access those community health teams. Right. That's important. Which is why the greater the emphasis we can place I think initially on primary care and then having that primary care be accessible. Then would allow for greater access to those behavioral and other need social service needs for folks. Committee questions. I don't think I'm ready I don't think we can make decisions now to throw out or keep in any one or more of these I know that some sound more appealing and simply because we're more familiar with them and that's okay you know that the the moderate piece I think resonates with everyone, but then some of the other pieces I think will begin to resonate. As we look at combating opioid addiction or substance use disorders and making sure that folks are getting the type of care that they need comments questions. Madam chair. First of all, can we take the slides down so we can see each other. Well, there's a thought. That's a good one. Thank you, Senator. I just want to thank everybody for the presentation today was much clearer than the other day. And there's a lot to think about. And I also am going to leave early today because I need to sort of get in my headspace to report a bill on the floor. So, yes, and so Senator, we're going to finish in about a minute. I wanted to give everyone extra time and especially you and wish you good luck and and well on your floor report. Thank you. So I will see everyone again I'm sure. Thanks, Josh. And Lorraine and Beth, Beth who left. Okay. Bye everyone see you on the floor. So, committee question questions. Senator Hooker, Senator Cummings. Senator, Senator Carby, ledge counsel Carby. I'm going to start. Yes, please. Okay. Thank you. Jennifer Carby legislative council. This is just a brief. clarification I had wanted to check in with diva folks to confirm but the, the increased advanced premium tax credits from ARPA are only in effect through 2022 there is a proposal in the federal build back better bill that would increase would extend them through 2025 but that has not been enacted yet so just so we're all operating under the same information. So what do you know is that is the, oh the 2025 is in the build back better that's sitting there on the wall. Okay, and whatever form of sitting on the wall they do. Okay. I'm not sure I want to say thank you for that but thank you for that. Senator Hooker, Senator Cummings, Senator Taranzini. You've been soaking it in. Any thoughts or questions. Too much to. There will be questions. Yeah. That's good. You know, and this is a Friday, any time that you have during the cold weather over the weekend to take a gander at the report itself, or at the information you've received today and bring questions in or the things that you think would be helpful taking steps so are the things legislatively that you think we might do to move forward and any one or more of these areas would be very helpful we're going to have to narrow ourselves no question, but there are some things I think we can do. There are bills that we have in committee that could serve as vehicles. I'm thinking we should use an S bill I'm not interested in tacking things on to an H bill at this point unless unless we get desperate. Okay. Joshua and and and Tim and Lorraine and Beth who's not here. We appreciate your time and clarification. We will come back to this we will have you folks in as we go forward we'll start talking amongst ourselves and then looking to see how we want to move forward. And then we're going to need additional support as we do that. So, thank you. Yeah, we'll be around easily reachable and happy to take Nolan Nolan has your number. Sure does. So do you.