 All right, so it's one o'clock on January 11th and we'll call to order the Green Mountain Care Boards meeting, I'm Owen Foster. And today we have a presentation relating to our health resource allocation plan. We have an update on that. Our director of health systems finances, Sarah Lindberg. We'll discuss the hospital budget reboot and consideration of changing the hospital finance reporting to a bi-yearly schedule. For logistical purposes, we're gonna take numbers three and four out of order today. So after we do the health resource allocation plan, we'll then turn to the consideration of changing the hospital finance reporting period. And with that, I'll turn it over to our executive director, Susan Barrett for the executive director's report. Thank you, Mr. Chair, and happy new year to everyone. I have a scheduling update. First, for next week, I wanna let everyone know that our meeting will be starting at 2 p.m., our board meeting. At that meeting, we're gonna continue the education that we're providing to the board, the newer board members and also the public on our regulatory work and background on that work. And next week, we're going to hear from some national experts on rural financial health. So that will be very interesting and very helpful to the board as you continue to do your work on hospital budget oversight. We'll also have our own Green Mountain Care Board staff update the board and others and the public and stakeholders on the work that we received last year as part of Act 167. And that presentation will focus on the hospital sustainability work, as well as some of the payment work that we received last year in reviewing the Act 167 language, as well as giving you any updates as to where we are with that work. So reminder, we start at 2 p.m. next week. And then also to remind everyone, as I do every week, that we are accepting any public comments regarding the next potential all-pair model. As I've mentioned in the past, the governor and the agency of human services are leading the work on the current all-pair model as well as the negotiations for the next all-pair model. So if we do receive those, we share those comments with those parties. And with that, I will turn it back to you, Mr. Chair. Chair Foster, you're on mute. Well, thank you. It's ironic because I was just asking people on that are attending to mute their phones. And meanwhile, I was muted. So yeah, if you're calling in or observing, for now, could just mute your phones because we're getting a little bit of background noise here and there. And later we'll have public comment. You can unmute if needed. And with that, our last board hearing was December 21st, 2022. And we have board meeting minutes to review and approve. Is there a motion to approve the minutes from December 21st, 2022? So moved. Second. Is there any board discussion? All those in favor, please say aye. Aye. Aye. Aye. Aye. And the vote is unanimous and the minutes are approved from December 21st, 2022. Next, I'll turn to two staff members, Jessica Mendesable, who is our data project director here at the Green Mountain Care Board. And also Veronica Fielkowski, who is our director of data analysis and management here at the board. Bissman Disable, I'll turn it to you. Thank you, Chair Foster. Can everyone hear me okay? I'm just gonna give a brief introduction and Veronica is actually going to present the slides today, but I have been with the board for just over four years now and started working on the health resource allocation plan when I came. So I have a lot of historical context and just wanted to set the stage for today. The purpose of this presentation today is really just an opportunity to provide some background on the work that's been done to date, provide some education to our new board members and members of the public as well as stakeholders that are maybe just tuning in or as we're all coming back to a new phase of this work. We have done quite a bit of work on health resource planning and that work is available and accessible on our website but I'll just emphasize that a revised health resource allocation plan is not complete. So no, there's no full plan. So I just wanted to say that upfront, but work has been underway for several years in various capacities and Veronica's gonna speak to that today. As always, we welcome feedback from stakeholders and members of the community that are doing work around resource planning. I think one of the things we learned really early on is that there's a tremendous amount of work taking place at the community level around resource planning and to the extent that we've been aware of that, we've tried to highlight that in the previous years. I'll just say it's probably not everything. And so if there's work that's underway and you wanna highlight that, please reach out to myself or Veronica or Susan and we're happy to highlight that work and consider it as part of our work. And we really trust the work that's taking place and wanna be a part of that. So and as Veronica will mention, we're continuing to engage stakeholders throughout the next phase of this process. And so I'll just turn it over to Veronica and let her kind of take it away. Thank you. Okay, thank you. So everyone should see some slides. So today we'll be presenting on the health resource allocation plan and throughout the presentation I'll refer to it as ATRAP. So the goal of today's presentation is really to provide an overview of what ATRAP is and the purpose, ATRAP evolution, what was ATRAP, what is ATRAP today? And then that will set us up nicely to talk about the ATRAP future in the next updating cycle. So 18 VSA 9405 requires Green Mountain Care Board to develop and maintain the ATRAP. It was established by legislature in 2003 and then updated in 2018, which we will review what those updates included later in the presentation. ATRAP legislation requires an inventory of specified services and resources and those include hospital, nursing home, other inpatient services, ambulatory care, mental health services, health screening, et cetera, home health services, emergency care, and then also health resources, which may include personnel, equipment, and then infrastructure for social determinants of health. Legislation also requires recommendations for the appropriate supply and distribution of healthcare services and for the ATRAP to be updated every four days. And I think there's some feedback, so folks from you. This is taken right out of statute, but I think it obviously summarizes really nicely what ATRAP is, so I just wanted to present it here. So the purpose of ATRAP is to identify Vermont's critical health needs, goods, services, and resources, which shall be used to inform the Board's regulatory processes, cost containment, and statewide quality of care efforts, healthcare payment and delivery reform initiatives, and any allocation of health resources in the state. And the ATRAP shall identify those Vermont residents' needs for healthcare services, programs, and facilities, the resources that are currently available, and then what additional resources would be required to realistically meet those needs to make access to those services, programs, et cetera. So ATRAP really should bring a variety of information from internal and external partners to provide the snapshot of our Vermont's health needs, what we currently have in terms of resources and equipment on those gaps. And it's really for informing the Board's regulatory processes, including certificate of need, hospital budget, et cetera. It's for hospitals and healthcare providers and entities to support of the legislative process, the public, et cetera. Many types of audiences for what ATRAP is. So I think that when we discuss the ATRAP evolution, it'll also help kind of define what ATRAP is and show. And so here's a timeline of kind of this evolution and we'll go through each of the kind of segments of this timeline. So first, as already stated, the legislature established ATRAP in 2003. The first ATRAP was published in 2005 and there was an updated ATRAP published in 2009. So the old ATRAP was a static report. The most recent of these static reports that was published in 2009 have sections that included kind of a general overview of what ATRAP is and then sections on ambulatory services, mental health services, long-term care services, et cetera. And then each of those sections included recommendation of resource allocation. And it was also almost 200 pages long. I think that 2005 ATRAP was almost 500 pages long. So a big report. In 2017, there was numerous stakeholder meetings in middle of the year to talk about kind of what are the visions for a proposal for revising ATRAP to legislature? And so from those stakeholder meetings, what was determined is that the proposal would be to move away from this static inventory and report and to also utilize more existing data sources. And so this was taken in and updated in 2018. And that statue went to affect them. And you will later see kind of the importance of utilizing all sorts of data sources for this. So this new kind of four-year cycle, I guess we can call it, started in 2019. There was stakeholder engagements, a transition to a web-based ATRAP and the ATRAP resources, healthcare resource inventories where the gathering was conducted, and then many different reports that kind of make the ATRAP were updated, including patient migration, utilization, assessments, et cetera. I think it's also important to show that in this timeframe, the COVID-19 pandemic response was happening and parallel to all of this work. And so just keep that in mind as we talk about all the work that has been done during this timeframe. So ATRAP today is really a series of dynamic reports, visualizations, and other user-friendly tools designed to convey information. These tools are all on our board's website, which I'll review in a minute. ATRAP identifies healthcare services and gaps and availability and accessibility and considers the underlying health needs across communities in Vermont. And Green Mountain Care Board continues to analyze healthcare needs and resources and utilization patterns to help support those regulatory decisions. So ATRAP data sources, I sometimes hear when we talk about ATRAP, like this one data source for ATRAP, but that's really not what we have. It's many data sources, health data sources across the state. So many entities like Jessica earlier said across the state are conducting work that help us understand the current resources, needs, and gaps that we have. And so the ATRAP should include reports from many partners, including us here at the Green Mountain Care Board, the Health Department, BAS, EVA, et cetera. So Vermont has many data resources, databases, et cetera, which can be used to measure and evaluate the supply, distribution, and cost of healthcare services in Vermont. Just to note, Green Mountain Care Board has two or two of those health data resources, the hospital discharge data set, and the all-players claims data set. And those two data sources can be used to understand some of these, but it has to be supplemented through other health data resources that we have in the state. So it really is a collaborative process. The Green Mountain Care Board has worked stakeholders throughout this whole process. Early stages included conversations on statewide planning already underway, priority areas to consider, as well as format and presentation discussions. We learned very quickly that measurement of need is highly nuanced and often the gaps lie with workforce and care coordination. And we realized that planning for these areas during the pandemic is highly challenging. And so we focused our efforts on analysis relevant to the board's work related to sustainability and utilization patterns, which was a lot of what the ATRAP work was during this four-year cycle. This is a pretty simple visualization, but it's how I like to think of what ATRAP is. It's really all these data resources, health resources, equipment, inventories, needs assessment, community profiles, healthcare utilization analysis, patient migration, et cetera, that kind of come together to make what we refer to as ATRAP. This is our ATRAP website, which can be found on the Green Mountain Care Board pages. It's currently organized by healthcare resources, which include the inventories, community needs, and assessments, many of which are conducted by our partners at the health department, AHS, et cetera. And then a number of public reports, many of which are done by Green Mountain Care Board. The resources that are currently available are kind of a mix of static maps and reports. So for example, this took a random example, oral health care inventory. And so here's a static map on the left of just the dental care services across the state. And then a couple of snapshots of more interactive or dynamic reports in dashboards for patient understanding, patient migration, and then primary healthcare access. The recent updates for this kind of ATRAP cycle, and this list is not exhaustive, this is just a few things that have recently been updated. Includes the patient migration analysis, which is done by Green Mountain Care Board. There's a new hospital market report, which formerly was the patient origin report that the Green Mountain Care Board did, but now the hospital market report is done by VOS. Blueprint community health profile data is updated. And then the healthcare inventories, which were conducted in 2019 and 2020. Again, this is not an exhaustive list, just an example of a few items. So that's where we're at today, and kind of looking, and so we're gonna start talking about the future. There has been work that started in 2022 to think about the future, which is requirements gathering for the ATRAP update, for understanding how our Green Mountain Care Board regulatory processes use ATRAP and how their work kind of can influence or update what ATRAP is as well. It's definitely a kind of goes both ways updating. So ATRAP future vision process and goals. So the vision, I wouldn't say it's different than what we already know of ATRAPs to be, but I think it's important to consider it as we think about the future. So ATRAP should capture what is happening in the state in terms of healthcare accessibility, quality and cost and how we wanna allocate our healthcare resources. We wanna deliver up to date sustainable and dynamic resources that enables more informed health resource allocation decision-making across Vermont using data. We wanna focus on the needs of each regulatory process at the Green Mountain Care Board, for example, a certificate of need. We wanna provide ad hoc analysis for different needs and questions that are arise, that are not captured by the current ATRAP. It's impossible for us to be able to tie a nice bow about every single need or resource or gap that we have in healthcare in Vermont, but having the ability to do ad hoc analysis to fill those as needed is important. We wanna foster a collaborative process. So this goes back to that collaboration of all the partners that we have to work with for ATRAP. Many of the work is being done outside of Green Mountain Care Board. So we just wanna have a process that is inclusive of using and leveraging the work that's already being done and then develop a tool that allows for navigation to a variety of reports completed by all these partners, by a health service area to understand the resources and needs. So how do we package that data or information? I think it's important to think of this whole process as ongoing. There's not really a, we start here and this is the final product. It's always an ongoing updated process. So we can start with requirements gathering. For example, what we're doing now is the Green Mountain Care Board regulatory processes we need to do stakeholder engagement. We need to consider data collection analysis reporting and then how are we gonna visualize and package that information and then keep going. This is true for all of ATRAP. This is true for specific priorities of ATRAP, et cetera. So some considerations, so kind of the structure in terms of how are we gonna update or choose priorities for the next ATRAP? So there's gonna be a new state health improvement plan. So that should be utilized to guide some of those decisions. Again, those Green Mountain Care Board regulatory needs that are happening through the requirements gathering. That stakeholder engagement, we wanna revise the process to ensure work across the state is included. We need to ensure that we're providing recommendations for resource allocation and then the visualization, how to package the data on the webpage to make sure it's meeting the needs of everyone. So this is just a little bit of a kind of, if you will, a roadmap, a light roadmap, maybe of goals and next steps. So some of this will be a little repetitive, but we wanna finalize the Green Mountain Care Board regulatory process requirements gathering. We need to communicate the stakeholder engagement process, determine a process to enhance the ability to provide ad hoc analysis, not captured by the ATRAP. I think this one is really important is to explore more sustainable ways to update resource inventories and collect data from hospitals and the least burden some way. Not only do we want this to be useful, but we also want it to be sustainable and everyone is busy, pandemic response or not. And so, how do we collect this information? Develop process for providing resource allocation recommendations who's gonna provide those recommendations, how, how will they exist, when will they be updated? And then map when and how ATRAP components are updated. So because the ATRAP includes many different resources, analyses, assessments, et cetera, all of those are updated on a different cycle or for a one-time analysis and are not recurrent. So I think understanding that and being transparent and mapping it out will enhance what ATRAP is. And then just a reminder again that this is an ongoing process and there's really not a finish line, but we can continue to work to make ATRAP as useful and sustainable as possible. All ahead. Excuse me, Chair Foster, this is Susan Barrett. Apparently there is a problem with the link and there are folks who are on another link. So I was, I was hopeful we could just pause here. I have a staff member trying to get them on the correct link. Sure, of course. Okay. You mean a link to this, to this webcast? This board meeting, there's another faulty link and I have Marissa Malomet over there who's trying to get them over here. So maybe we can just pause for a moment. Sure. Marissa just gave the right link. So I was, one of the people over there was clicking on the link in the monthly agenda as opposed to the link in the daily agenda. I am so sorry. We will make sure that we address that. Chair Foster, should we just give it a few moments for folks to check in? Yeah, we'll just give it five minutes. We'll give it five minutes. We'll come back at 1.30. Okay. Okay, hi. So we had a technical issue with one of the links and some of the folks who wanted to hear and potentially public comment on the ATRAP presentation weren't able to attend and we think it's important that they do. So we're gonna take a little out of order today, even more out of order and we're going to do the hospital, sorry, the consideration of changing hospital finance reporting to buy yearly. Then we're going to do the hospital budget reboot and then we will have round two of the ATRAP update. And we apologize for this, but we thought that given the number of stakeholders wanted to participate, it was important to do it and give them the opportunity to hear it and comment. And so we're gonna do that. And I apologize again for the glitch, but thanks for your patience. It's a new year and we had vacation and getting back up to speed here. So thank you. And with that, I will turn it over to Sarah Lindberg, our Director of Health System Finances. Thank you, Sarah. Thank you. Are folks able to see my screen? Great. So I'm here to chat with you about the upcoming or a proposed change to the reporting for fiscal year 23. So we'll just kick it off here. And the current way that we're doing the reporting is we have three financial monitoring, I'm sorry, we're proposing three financial monitoring periods essentially a two interim and a final. Right now we're requiring five within the fiscal year. And because the even now that we're post COVID, the numbers are just looking a little bit more stable. We feel like that might be overkill and it's might be time to flex back to kind of some of that earlier timeline of further reporting. The advantages of this proposal would be reducing some of the burden of these filings on our regulated entities. And also as we look to make changes to our budget process, it might free up some time for them to deal with some of those changes to prepare for the fiscal year 24 reporting. The potential con that I see is that there is a possibility that it would increase the time that the Green Mountain Care Board would learn of a financial problem. We do have plenty of other resources and are using those for our financially vulnerable hospitals. So I think that this is probably a low probability outcome and would violate other conditions of the budget order. And we'll walk through that together. So the leftmost column is showing some things that won't change based on this proposal. We get updated hospital budget filings in October. We get audited financials in January. We will get the next fiscal year budget filings in July. And right now we're expecting those federal 990 filings as well as the community health needs assessments in September. So this proposal would not touch any of that. But if you look at how the current proposal does, so the October, November and December, the Q1 filing, as well as the prior year actuals are currently due January 31st. And then we have filings April 30th, July 31st and October 31st. And as you can see, there's already filings due for some of these same time periods. What it would look like to change this to kind of bi-annual monitoring with the final report would be have them report their October to February actuals by March 31st, having those prior year actuals due in December. And that would include the July through September months. But we would see the March through June, July 31st, which would be kind of integrated in the hospital budget proceeding. So July, there's a big filing usually July 1st. And then that would give a little time for them to focus on that, for that second filing. Just to remind you folks, these are some of the other conditions that allow us to do additional monitoring as needed. So telephonic check-ins that we have discretion to schedule. Right now we meet quarterly with the UVM Health Network and we're meeting monthly with Springfield Hospital. And so, you know, if there are other hospitals that seem to have some financial vulnerabilities, we can call regular or ad hoc meetings as needed. Hospitals are to advise the board of any material changes to its budgeted revenue or expenses or assumptions in its budget. So they already are supposed to inform us about that off cycle if there's a material change. They also are going to be participating in our strategic sustainability planning process. And that's going to start to ramp up here. And so I think that that also will involve a lot of data attention that they might be better spent on that project than quarterly filings. And then, you know, we also have a very broad condition about timely filing of all forms required by us. So, you know, that's one of the things that we are going to be thinking about for the 24 guidance is making sure that we're incentivizing timely filings. And if we're getting them less often, that timeliness becomes even more important. So that is the proposal. Thank you, Sarah. Thank you very much. Thank you very much, Sarah. With that, we'll turn it over to any board discussion or comments. Do any board members have any questions or comments? I have a couple of questions. You go ahead. Okay. Thank you. So my first question is the, the con that you mentioned, Sarah, you know, that it may increase the time before the GMCB would learn of filing. It may increase the time before the GMCB would learn of financial problems. And I'm wondering if we can mitigate that risk somehow. And I recognize that we have these alternative methods for monitoring, but I'm just wondering would it make sense to impose a day's cash on hand trigger that if the day's cash on hand falls below some critical threshold, then that specific hospital might have to revert back to quarterly reporting. Until the day's cash on hand and then exceed that threshold. Does that make sense to mitigate that risk of the con? I think you might be on mute though. Going around today. I think of that scenario that, yeah, the additional oversight is warranted and whether that be through financial reporting on a quarterly basis or something similar to the monthly meetings we have with some hospitals. Yeah, I think that makes sense. And then my second question just was with that timeline that you laid out, we put the non-financial reporting on quality and access on the back burner during COVID to alleviate some of the admin burden for hospitals that were trying to manage the pandemic. And I'm just wondering what's your current thinking on what non-financial data the board might resume requesting monitoring and how that might fit into this new timeline? Yeah, I think that's a really good question. And I think that that's part of what we'll talk about in the next presentation, but like, yeah, let's make sure that the things that we're expecting through the financial budgetary process are related to those decisions. And let's figure out a more appropriate avenue for the other important things that we need to know about hospitals, but maybe not are directly related to a budget decision. So I think that we would want to think about that in terms of any additional requirements in that timeline. Okay, so maybe we'll visit that as we're rebooting the hospital budget process where that non-financial reporting will be in there and when and how it fits into this new reporting timeline. Okay, thank you. Those are my questions, Chair Foster. Ms. Lynch, did you have any questions or comments? Sure, I had a comment. I like the idea of moving back some of the quarterly reporting. I think to just this point, there are a couple of things that we've instituted pre-COVID to mitigate that same risk of not getting timely information which has occurred once before. And that included ensuring that we had both the executives in the board chair attesting to the information and also I think this requirement about reporting, we got that a little more strict in the budget orders than it had been beforehand. So I feel comfortable that we have the protections in place that should we not get information that we need, that we have ways we could react to that in between these reporting periods. Any other board member questions or comments? I had one which was relating to Member Holmes' suggestion about a potential days cash on hand trigger. Sarah Lindberg, do you have a sense of what that number would be or how should we go about assessing or thinking about what that number should be if it's something the board wants to consider? Absolutely. I think that that's exactly the kind of like objective financial benchmark that we're looking to build into the new process. So I'm hesitant to kind of shoot from the hip and just set something here. But I think that that's something that we can take as homework and bring back before the board or just I think the tricky thing at the moment is the entire United States hospital sector is in really rough shape. So what the right relative indicator is might be a little more challenging than your average fiscal year. So, I didn't have any other questions or comments and I'll turn it over to the health care advocate for any questions or comments they may have. Happy New Year, Sam Pysh off to the health care advocate. It's good to be with all of you. It's been a little while. I've definitely missed the board meeting after that. But we don't we support this. I think it's a reasonable change. And I think the concerns that I think you already prepared for the potential concerns around reporting outside of that time. But I think those are mitigated. And that's Shiloh my young one. So I think we're I think we're supportive of this and thank you to Sarah for all the work you've done on this so far. Great. Thank you very much and hello to Shiloh. And with that, we'll turn it over to any public comment. Again, as usual use the raise your hand function and I'll try and call people in the order in which their hands are raised. Miss Jennifer Bertrand, please go ahead. Can you hear me okay? I apologize. I don't have my camera today. Yep. Perfect. Loud and clear. How are you? I'm good. How are you? Nice to meet you. Chair Foster on Jen Bertrand on the chief financial officer at Givert. I just had a quick clarifying question. You don't mind for Sarah just just for the purposes of when our final audit is and what this is applicable to. And is the December 31st deadline applicable to just our preliminary financial reporting? Okay. Thank you. That's just what I wanted. And our actuals would still be due on January 31st. Correct. Perfect. Thank you. I just wanted to clarify that and that's great because our audits are still kind of, you know, in process at that point. Thank you. Great. And nice to meet you too, Miss Bertrand. Hopefully we'll get to meet in person sometime. Does anyone else have any questions or comments? I guess I have a question for the board, which is would the board members prefer to take up the motion now or have further consideration of the potential trigger relating to days cash on hand or would the board members prefer to incorporate that in the hospital budget review process? I guess my question for Sarah is timing. So if we don't vote on this today, does that mean there's a quarterly filing that comes in in the meantime? That's my concern. I think we kind of owe this to the regulated entities. Yeah, I do know that we're going to start talking about guidance in the very near future. I don't know if it makes sense to formalize that kind of indicator into a more official framework in the future or that's what I would recommend. I want to be, yeah, that said, the hospitals I think that we are, yeah, we also have an actuals of fiscal year 22 coming up. So that might be another opportunity to think about a principle here. If I'm the one who raised it, I will say that that's fine with me. I just wanted to raise it as a potential mitigating strategy so that we don't have to worry about your con that you proposed. So I'm comfortable with this motion language here today and as long as we kind of put a pin in it and think about are there circumstances under which we would want a hospital to report more frequently if the financial vulnerability reaches a particular level? So I think we can put a pin in that and find a different avenue to explore that. I'm comfortable with it as well. I mean, of course, it's good practice and good judgment by any entities that have acute financial distress to keep us informed regardless of whether it's formalized. I suspect that that would happen. And nonetheless, we're going to have an opportunity and guidance in connection with our hospital budget review process to formalize it should we need to. So I'm comfortable with the motion language as well at this time and I'll go ahead and make the motion and the motion is I moved to modify the hospital financial reporting schedule to require hospitals to report mid year actual results twice per year instead of quarterly with mid year reporting deadlines at the end of March and the end of June as presented today by Green Mountain Care Board staff. Actual year end reporting will continue to be due on December 31st. I'll second that motion. All those in favor, please say aye. Aye. Aye. And the motion is unanimous and carries. Thank you very much, Miss Lindberg. And next we will stay with Miss Lindberg, who will discuss the hospital budget reboot, which is somewhat related to what we just talked about. So, Sarah, please go ahead. Let me get myself off mute and. Okay. I'm coming through. Okay. Okay, great. So I'm here to just kind of brief the board about our current process underway to review our hospital budget regulation. And so the first I get a lot of comfort from reminding myself of this and it helps me remember to have a lot of humility with the problems we're grappling with. But if this is a chapter of what that has a brief history of health care reform written by Mr. Hamilton Davis back in published back in 1999. And it's summarizing findings from a report produced by the Daniels commission looking at Vermont back in 1975. And some of these findings we're still grappling with, you know, not too many specialists, not enough generalists practicing in our state, but we're still seeing a lot of complex administrative structure with high cost devoted to administration. Having money flow out of the state. In that case, they were concerned about insurance company profits flowing out of state. Wide spread variation and utilization patterns of health care resources and costs. Yep. Is there a. I'm still only seeing the first slide. I don't know if that's true for others, but it sounds like you might have moved to it. There we go. Thank you. Yeah, I am. I always appreciate a technical correction. Hardware is not my jam. Okay. So yeah, so a lot of variation in utilization patterns and the resources and costs associated with those. So, um, defensive medicine was on the rise, which was, um, uh, leading to some malpractice costs. Uh, then, or to mitigate against malpractice costs. And there were, uh, not a regard to cost and the demand for some of these resources, fragility of the healthcare system in rural areas and, um, a dearth of data to plan and monitor the system. So we've certainly made progress on since 1975, I would say that there's still lots of work to do on these topics. And so, um, I always try to keep a long view because I know people much smarter and more equipped and probably more powerful than me of have tried to solve some of these really intractable issues. And, um, I just want to be mindful about kind of the importance of incremental progress in my own work. Um, so as far as the regulation of hospital budgets, I always find it helpful to kind of remember, um, from once we came. So, um, there was plenty of activity prior to 1992, but that's kind of where the, the modern reform machine, uh, came together by merging the health, uh, policy council and the data council, as well as the certificate of need board. Um, and that all came under the healthcare authority, which was, um, then moved over to at the time the department of banking's insurance and security. And that's what, how Bishko was born. Um, and that is when the real authority to limit the hospital budgets came in. So that's really when the state's, um, leverage over this process, uh, came to be. Um, and then back in 2011, the HCA portion of Bishko kind of broke off to, to start the Green Mountain Care Board. Um, and that's the point where Bishko renamed themselves as the department of financial regulation. And so, uh, we've been regulating hospital budgets in a pretty similar way. Um, in the, since the nineties and, uh, you know, a lot of the metrics honestly are the same. Uh, however, the whole delivery system is not. So we just need to try to remember that. And so that's what part of why, um, in taking on this role back in June, um, one of my first, and I think I was pushing for this in my prior role even, but, um, just a dedicated scope of work to really take a hard look at our regulation of hospital budgets and figure out how we can achieve some, in my judgment, really important goals. Um, and I've listed what they are here and, and that is developing objective metrics for hospitals, financial health, um, improving the way we evaluate hospital performance. Um, things like care quality, the access to care, um, the cost efficiency associated with our hospitals. Um, looking for additional opportunities to align our regulatory duties. Um, and this is, you know, most painful, I think when the QHP rate review process and the hospital budget process, um, are trying to run on, uh, I don't know, not quite parallel tracks. Um, and then really importantly, just make sure that the process is consistent and predictable on both sides of the equation. So it's only fair that people know how they're going to be judged and that we're, um, you know, true to that, um, guidance. Um, and if wherever feasible, reduce some of the administrative burden, I'm, I'm a strong proponent for better regulation and not necessarily more regulation. And so getting that right amount of oversight, I think is just going to take some, some careful thought. And so just to lay out some of, um, the term I've stolen from a colleague here, but essential questions like, what are we really kind of trying to do here? Um, this is the list, um, that, that is just a smattering of many very difficult questions that we're grappling with, um, some of the ones that I wanted to highlight for you today are that, um, how can we better assess access affordability and meaningful outcomes? Um, what do hospitals look like when they're healthy from a financial perspective? Um, what is the information that we should be using to make hospital budget decisions? Um, and what makes more sense, um, from a regulatory monitoring perspective? Um, and for those indicators, um, what is it that makes sense to look at a corporate level versus at that individual hospitals level? And what are the benchmarks that we should be comparing them to? And while we're on that topic, what are the comparisons that make sense for all our hospitals and which ones really, um, have designated peer groups and do those peer groups change depending on the question that we're looking at? Um, I also think, you know, it's really important to be, um, thinking long-term about what we do in hospitals exceed or are unable to meet a budget. And so how does that kind of fit into the framework? And if we're going to be entertaining ideas of hospitals bearing more risk, um, what role is there as a regulator for assessing, um, the appropriate amount of risk and assessing solvency for a hospital? That's kind of a new topic. Uh, to delve into. And so I feel very fortunate that we were able to, um, award a competitive bid to Mathematica Policy Research, um, and they have a lot of experience, uh, that's related to this effort. So they've been working with us on our all-peer models since 2019, working in that same time period, um, in Pennsylvania, who's looking at, um, paying hospitals in a different way. Um, lots of experience from the state of Maryland who has a much different approach, um, since 2014. Um, that's not the approach that's necessarily going to make sense for Vermont by any means, but, uh, it's good to have kind of a landscape of experience. Um, they also, uh, are helping out in Washington state, uh, with the chart model, um, or had been, um, as well as some help to HRSA, um, with their, uh, rural emergency hospital, um, work, which is a new designation that CMS is going to be rolling out that might make sense for some of our hospitals here in Vermont. So I think that's another really important piece of their experience. Um, so we were working with them to outline the goals and methods, um, identify, um, process improvements, and really think of some of these key benchmarks. Um, and so this really just says that in a different way. So they're really chunking this about what's really about process, and that's such like our document management has a lot to improve. Some of the things we talked about in the, um, feedback from the last, uh, process, uh, debrief of the last process. How can we make this more efficient, get stuff to you all faster? How can we do a better job of kind of giving you, um, executive level information so you really know where to focus your attention? Um, kind of some of the methodological questions that are highlighted here are, you know, really what are our goals for hospital budget regulation and not for board member A, B or C, but what's the role of the Green Mountain Care Board? And what is the goal of that process in the current landscape? So a lot's changed. So it's, I think it's a good time to kind of think through what that, what that's going to be and how we therefore want to regulate based on those goals. Um, and then there's just some data questions. So, you know, what data are we collecting? What data should we be collecting? Uh, what, what are a better or less burdensome data sources so that we can, um, reduce some of the administrative burden on our regulated entities, as well as for staff members. And so, um, they are kind of breaking it up into these pieces. They're all interrelated. Uh, and they're, uh, very mindful of our moving timelines, which time feels like it's moving faster every single day for me. But, um, in March is when we're going to have to finalize the guidance for the hospitals so that they, when they turn their budgets in on July 1st, we know what to expect and, uh, we'll have the hospital budget hearings in August, most likely. Um, I mean, we're likely to have hospital budget hearings. And when we do, they will be in August. Uh, and then October is when we, of course, have to issue the orders, um, for the decisions we made by September 15th. So this, this process won't be changing. So it's a very, uh, challenging timeline to make some changes. So just to kind of give you a framework for what we're thinking. So right now in the current fiscal year, we're developing those performance measures, including, uh, relevant benchmarks and, uh, other, uh, kind of data sources. Um, and some of those are alternative data sources of particular interest are, you know, are there ways that the cost report could give us what we need to know with, um, reducing the burden on some of our regulated entities. And I think this last one in my mind is probably the most important. And that's just like really standing up some more, um, broad based systematic monitoring of our healthcare system here in Vermont. So, um, kind of go into a one stop shop to kind of get out the lay of the land. Um, and so for fiscal year 24, um, the name of the game will be focused like really what are the, the key inputs we need to, to make these budget decisions. Um, and making sure that we're, we're staying on tap on target with that. If there's other data collections that need to be stood up, um, that maybe aren't as related to the budget, you know, working on that kind of operationally. Um, and then, you know, doing our part and keep, uh, assessing the budget filings as they, as we say they will be assessed in the guidance. Um, so I think of 24 is, um, really a bridge year. Um, and then in fiscal year 25 is when I picture kind of a more, um, significant change in the process. And then the next couple of fiscal years are going to be about refining the methodology until we can get to something that, um, is, um, established. And so, you know, parameters might change, but the process is, is clear. And the guidance is, um, you know, not going to be changing materially year over year. Sounds like a long time. Um, part of the reason for that is we envision, uh, definite need for a rule change, which is not a fast thing to do. We also may need, um, some statutory changes. We're still trying to kind of explore that, but, um, that's part of what the, the timeline is. And also I've worked for state government long enough to know that, um, that, that I should not over promise anything. It takes a long time to move some of these measures and, and, uh, things along. Um, so, uh, Mathematica has, uh, had one-on-one interviews with all the board members at this point and are currently engaging with all of the CFOs for confidential interviews to get their feedback about the current regulatory approach. Uh, we'll be sharing kind of some, um, preliminary feedback early next month, um, with you board members, but also with the, um, the CFOs just so they can kind of, um, see where, where things are kind of sugaring out at that point. Um, we also, uh, I don't know if that's happened yet or not, but, uh, there's an interview with the healthcare advocate as well. And we will be collaborating with, um, all sorts of folks in this endeavor, including the healthcare advocate, um, the Department of Financial Regulation. We're hoping to try to, um, learn from some of their expertise in financial regulation in the state to see what lessons we can apply here. Um, the Agency of Human Services, um, both, um, from the healthcare reform standpoint, but also from their, um, health insurer, um, role as a payer for Medicaid. We'll also be working with other health insurers. And then healthcare consumers because those, those, um, outcomes that matter, um, obviously they have a say in. Uh, we do, I think I already said this, we're anticipating, um, some changes to the rule. Um, there's some things in there such as, you know, the current rule, um, says if we have hearings, we can only exempt up to four hospitals. Um, that may or may not make sense. It may make more sense to have hearings when there's, um, you know, an issue to deliberate and have that not be the, the standard rule, but that's the type of thing we're going to be delving into over the next three months, uh, and beyond. Uh, and so there's this little old Act 167 that also has some related duties, um, to this work. Um, so the first one is the development of value-based payments. Um, this is something that will be completed in collaboration with, uh, the agency of human services and, uh, must, uh, leverage a stakeholder process that they're already using, um, in terms of the next, uh, all payer model work. Uh, we also are on the hook to determine how to incorporate value-based payments into our hospital budget regulation. That's something, you know, we ought to do anyway as a regulator. Um, financial health, um, theoretically should be agnostic to where the money's coming from. You know, that, that, that should just to, but, but if there are other things that we want to think about doing special about alternative payment models, we need to think through that, um, as part of that work. Um, and just an important bullet in that statute is that, um, that work must include an assessment of how this regulatory process will impact Vermont's hospitals, um, from a financial sustainability standpoint and also says that we're looked, we are to look for opportunities to improve their financial health. So that, that's, uh, that's one that was in there. Uh, we also, uh, our need to recommend a methodology to determine an allowable rate of growth for hospital budgets in Vermont. And finally consider the appropriate role for global budgets, um, for Vermont hospitals. So, um, all this seems pretty easy and straightforward. Now I'm just kidding. This is an incredibly challenging amount of work, um, that, uh, I look, it's exciting work, but it's going to, you know, thinking back to 1975, like, you know, I don't expect to solve this in my 20-year career, but I hope to make a dent. Uh, the rest of, I have 20 years of my career theoretically left, uh, unless I get hit by a bus. So anyway, I'm sorry, I'm very rambly today. Um, what questions can I answer for you, board? Ms. Lindberg, we're not letting you out of here in 20 years. Your, your, your sentence is a little bit longer than that, unfortunately for you and good for us. Um, thank you very, very much for your presentation and your work on this presentation. Um, so yes, any board questions or comments? I don't have any myself. Um, go ahead, Tom. Thank you, Owen. Um, so I just want to take a moment to say thanks. This is really strong work. Uh, your depth of experience and thinking here, um, is just a real asset to us. And I wanted to call out a couple of places where you mentioned, including, um, Vermonters in this process and I just want, um, I think that's really important when in other roles, I've made an effort to always include patients if it's clinical work or, um, just the other people, whether they're business leaders, municipality leaders. Um, I think about trying to find the missing voices who will be affected by the work that's underway and making sure that we're reaching them or reaching out to them. Um, it sometimes doesn't always feel that appropriate or that necessary, but when we've made the effort, it changes the conversation in a good way. And so I really hope that we, um, renew our efforts and strengthen our efforts to, uh, expand the perspectives that we listen to, um, in these processes that we're listening to business leaders, we're listening to municipality leaders who are making decisions about, you know, uh, how healthcare affects their city budgets versus how many teachers they can hire. And so there are a lot of perspectives that we don't routinely receive with the board and I'd like us to keep trying to find them and bring them in. Um, and you mentioned that in a few places. That's also a big deal when it comes to value-based payments. Getting into the nitty-gritty with value-based, I think of value as outcomes that matter to patients. That's the, that's the numerator. And so making sure that we are, um, getting outcomes and making sure that they do matter to the people that we serve. Uh, I think, um, that hasn't been, um, as strong as I'd like. So I hope we continue to move, uh, toward getting better outcome information. So just wanted to, um, reiterate some of the things you said and try to, um, add on top so we keep moving in this, the direction that you're outlining. Thank you very much. Chair Foster, can I ask a question related to, um, board member Walsh's comment? Please. I'm just actually wondering, Sarah, how we're going to go about, um, do you, um, do you know the process yet by which Mathematica is going to be reaching out to consumers to get that patient feedback? Will we be working through the healthcare advocate or is there some other mechanism to get that insight? Yeah, I think that's a, the healthcare advocates kind of my place to start. And I think from there, if there's other resources or individuals that we tap into, like, yeah, I think that makes all the sense in the world. Okay. Thank you. And I, you know, I just have a comment actually after that. I just, you know, I really want to tell you thank you also as well. And I'm really excited about this hospital budget process. You probably know that I'm very excited about this. I really think it's time that we, you know, find ways to streamline it. And, you know, to the degree that we can limit some of the data requests of hospitals, if we can otherwise obtain that information through the cost reports and other sources, that's really helpful. Um, it also allows for what I like about that is it allows for some standard across hospital, you know, the same source versus some interpretation of what the data request is. I understand there's still some, there's still interpretations when hospitals submit information to cost reports, but there's a bit more standardization potentially in some of those vehicles. And, you know, I think as we're really envisioning potentially new payment models as this slide indicates it makes sense to revisit how we're doing assessments of hospital budgets. So I think what I'm most interested in is hearing what Mathematica's recommendations are for these objective benchmarks, right, that we can start to use to assess and compare hospital efficiency and cost and price and affordability and access and quality. Looking to their insights as they've scanned the landscape out there for how we assess hospitals on a comparative basis. I think it's going to be helpful. And to the degree I know the timeline looks long, it looked long to me. I will say it looked long to me, but I think, you know, thoughtful evaluation and improvement takes time. So we have to be patient if we're going to get it right. And I imagine we'll have some changes already in place in March when you come back with some of the staff recommendations for the guidance. So we're already moving down the path of improvement. So thank you for your hard work and for the team's hard work. I know there's a, there's a village back there that's helping you. So thank you to the entire team for this work. I said it quick comment as well. Just somewhat echoing Tom and actually reflecting on it while he was speaking. I was going to comment on a, you know, with regards to all the questions that you put up on that slide, Sarah, the goals that the Green Mountain care board should have with regards to the hospital budget review process. I think that this, my thought on seeing that is this is an area that I'd like to crowdsource some other people's ideas on that. And it sounds like mathematics is doing that in somewhat of a private, anonymous way. But I would, I would also love to use our public comment process and really seek public comment from, you know, reminders, legislators, business owners, you know, providers, you know, individuals in a, you know, hospital systems, individual hospitals, practice groups. I mean, there's so many different, you know, AHS, DFR, payers. There's so many stakeholders in this patient advocates, mental health advocates, other, other advocates, as much public comment as we could receive on this, I think would be really helpful to start to shape how we think of, of our role. I think we all have ideas as to what that is, but adding that input would be so helpful. So anyways, that's my one comment. Thanks so much for this and all the conversations. I think member Walsh for raising that point because it's actually something I saw was that the interviews are with us, the regulated entities and the healthcare advocate. And then the next point on nine mentioned substantial collaboration with some of these other parties. If there's a process, Ms. Lindbergh, by which we can ensure that we're getting that broader spectrum, including even, you know, independent practices, primary care, because they all have views too as to how our hospital regulatory process plays out. The ACO, I think that is really important to get the right balance. So thank you member Walsh and the others for highlighting this. I think it's a really important point. And I, of course, echo everyone's gratitude for your great work and your team's great work. And I'll turn it over to the healthcare advocate for any questions or comments. Yeah, I'll just say thank you again, Sarah. We look forward to working with you on this process as we have been over the years. And I just want to raise up, I want to pine at length because I think I've made this point before, but the theme of humility throughout this process, I think is really critical. And I think it, I hope it instigates a chain reaction amongst all the folks that are involved in this process. And I support any type of effort to increase community engagement. I think that's no surprise that our office would be an advocate for that. And would also just put out there that I think if there's any opportunity to expand the form by which public comment is given, not just in a written form, but whether this is town meetings, potentially that are able to include interpretation services as well to get as diverse of a range of spectator and stakeholder engagement as possible. So, but again, thank you, Sarah, for all the work on this and look forward to work with you. Thank you very much. And finally, we actually have an opportunity for some public comment, which is one of the best parts of these board meetings. We don't have the entire University of Vermonters here, but there is a substantial number. And so with that, I'll turn it over to public comment for any thoughts on this. Sir Walter Carpenter, how are you? Good to see you. Please go ahead. Hey, hanging in there. It was a struggle to join this today, but welcome to 2023. My how many years on this board? I just have one sort of general comment question and then a general comment. I echo the humility, the comments about the humility part. We talked about affordable. I'm curious, and this is nothing to do with Sarah's report or anything, but how do you define affordable and what is affordable to whom? And I don't hear that. Everybody says it's affordable, but to whom? You know, because what's affordable to someone on the board is not affordable to someone on the street. I don't know. That's just a general question and comment. Yes, I think it's an important one. And I do think that it's a concept that I feel strongly needs to be applicable to each regulatory process, but not confined to it. Because I think it is a, you know, there's a lot of complex relationships. So yeah, if someone, I don't need to get into a lecture about it, but I think those are really, those should be essential questions on our slide. Walter, they are, they're really important questions. Thank you. And that is an important point. Is there any other questions or comments at this time? Okay. Miss Lindberg, thank you and your team very much for your presentation and your work on this and have a good day. Thank you. All right, great. And with that, we will get to go back over the health resource allocation plan update with Veronica Fielkowski, our director of data analysis and management and Jessica Mendesable, our data project manager here at the board. And board members, if you could act really surprised when you hear things just to keep it more real. I'd appreciate it very much. Okay, so hi everyone. My name is Jessica Mendesable. I'm a member of the data and analytics team at the Green Mountain Care Board and just wanted to give a brief introduction before I turn it over to Veronica. So the purpose of our presentation today is to provide a review of the work that we've done on the health resource allocation plan and just really educate new board members, new stakeholders and members of the public coming into this work and discuss the next phases of this work. And so work on the what we like to call HRAP is not complete. It's definitely been underway. And as we've completed assessments or projects related to resource planning, we have posted those to our website and shared that information. We would definitely welcome any feedback on the information that's been provided to date, but also acknowledge that we have more work to do going forward and would engage, you know, our partners that we've worked with in the past as well as any new partners that are doing resource planning around the state. And we definitely look forward to that work. So I'll go ahead and turn it over to Veronica to present the slides and I'll be here after to answer any questions. Thank you. Great. Thank you, Jessica. Good afternoon. My name is Veronica Falkowski. I'm on the data analytics team. And I've been with the board for a little over a year. And we'll provide an update on the health resource allocation plan. So the goal of today's presentation is really to provide an overview of HRAP and what its purpose is a trap evolution. You know, where were we, where are we today and how has it evolved and then talk about a trap future, a vision, a process and goals. 18 VSA 9405 requires Green Mountain Care Board to develop and maintain the HRAP. Legislature established HRAP in 2003. And it was updated in 2018. And the legislation requires an inventory of specified services and resources, which includes hospital, nursing home and other inpatient services. Ambulatory care, including primary care services, mental health services, health screening and early intervention services and services for the prevention and treatment of substance use disorders, home health and emergency care. Other health resources may include personnel, equipment and infrastructure necessary to address the social determinants of health. The legislation also requires recommendations for the appropriate supply and distribution of health care services and for the HRAP to be updated every four years. The purpose of HRAP, this is taken straight out of the statute. It's obviously written clearly and well, so just read it. The purpose of HRAP is to identify Vermont's critical health needs, goods and services and resources, which shall be used to inform the health care services, regulatory processes, cost containment and state-wide quality of care efforts, health care payment and delivery reform initiatives and any allocation of health resources in the state. And it shall identify Vermont residents needs for health care services, programs and facilities, the resources that are currently available, and what additional resources would be required to meet those needs to make access to these services. HRAP should really bring a variety of information from internal and external partners to provide a snapshot of health needs, resources, equipment, gaps in Vermont. And it's for informing the board's regulatory processes, including certificate of need or the hospital budget process. It's for hospitals and health care providers and entities. It's to be a support of the legislative process. It's for the public. It's for many different uses. So now, excuse me, we'll review the HRAP evolution. So here's a timeline of HRAP. And so we'll go through each period or segment. So as stated, legislature established HRAP in 2003. The first HRAP was published in 2005 and then was updated in 2009. And those two HRAPs were static reports. The 2009 HRAP had sections that included a general overview of HRAP. And then data on ambulatory care services, hospital services, mental health and substance use services and long-term care services. And then within each of those sections, provided recommendations of resource allocation. So then kind of moving ahead in time. In 2017, there were numerous stakeholder meetings to determine how would we like to revise the statute to for HRAP. And so in those stakeholder meetings, it was determined that we would like to move away from static inventory and reports, and also utilize more existing data sources. And we'll review those data sources a little bit. And so those proposals were accepted and updated HRAP statute went into effect in 2018. So in 2019, and kind of through 2020, 21, 22, there are many things done to kind of have what our HRAP is today. There were stakeholder engagements conducted. There was a transition to web-based HRAP, which provides HRAP resources versus that static big report. Healthcare resource inventory gathering was conducted. And then just the updating of many reports and analyses including patient migration, utilization and others. I think it's important to address that in this time, the COVID-19 pandemic response started. And so many of those stakeholders and hospitals, the people that we work with to understand our needs and gaps and inventories and equipment were devoted to the response from much of the whole stateless. So HRAP today, it's a series of dynamic reports, visualizations and other user-friendly tools designed to convey information. And these tools are found on our website, which I'll show in a little bit. HRAP identifies healthcare services and gaps in availability or accessibility so that JMCB continues to analyze healthcare needs, resources and utilization patterns across hospital service areas to support regulatory decisions. So HRAP data sources, I think I often hear the HRAP data as if it's one source. It's important to understand that it's not. It's working and conducting analyses that help us understand the current resources, needs and gaps. And so it's really the HRAP includes work from JMCB, the health department, VAZ, DEVA and other partners. There are a number of healthcare data, stats, databases, resources which can be used to measure and evaluate supply distribution. But they're not just at JMCB, even though JMCB does do two of those health data resources, the hospital discharge data set and the all-player claims data, but although those are useful to understanding some of this, they're not, they don't tell the whole story. And so it is really important for this to be collaborative and use all the work happening in the state. The Green Mountain Care Board has worked with stakeholders throughout this process, early stages, included conversations on statewide planning, already underway, priority areas to consider, as well as format and presentation discussions. We learned very quickly that measurement of need is highly nuanced and often the gap lie within with workforce and care coordination. But we realized that planning for these areas during the pandemic is very challenging. And so we focused efforts during this timeframe on analysis relevant to the Board's work related to sustainability and utilization patterns. This is a simple graphic, but I think it's a nice graphic to kind of just understand what ATRAB is. It's really, you know, health resources and equipment inventories and needs assessment and community profiles. It's different analyses from healthcare utilization to migration to whatever and coming from all sorts of different data resources to make ATRAB. So the ATRAB website is housed on the Board's web pages and it's currently organized by healthcare resources, community needs and assessments, and then a number of other public reports. Here's just a few screenshots of some of the data that's available under the ATRAB pages. Some like the map on the left are more static reports or images. For example, this is from the Oral Health Inventory, so dental care services across the state. Other resources under the ATRAB pages are more interactive or dynamic dashboards. These two examples include a patient migration dashboard or primary care access dashboard. So just wanted to highlight a few recent updates for what ATRAB is today. And this is definitely not an exhaustive list. It is just a few highlights. So the patient migration analysis was recently updated and that's done by the Green Mountain Care Board. The hospital market report was recently updated. It used to be the patient origin report, but GMCB was recently updated. It used to be the patient origin report that GMCB conducted, but with this new hospital market report, Laws NSO conducts the analysis. Blueprint community health profile data by HSA was updated by DIVA. And then these healthcare inventories that were done in 2019 and 2020, right at the start of the pandemic as when they were being finalized, those were conducted by us and partners. So as we kind of come to the end of what I'm going to consider this cycle for the four years, we can start beginning thinking about what is the next four years going to look like as we think about updating ATRAP. And some of that work has already started. So this year we began doing requirements gathering for ATRAP specific to the regulatory processes and the teams on Green Mountain Care Board. So so far we've talked to the certificate of need team and the hospital budget team. And it's really to understand how do they use the ATRAP but then how does their work that they do inform the ATRAP as well, so the future. So these are the visions. None of this, most of these are not new, but I think they're important when considering the future. So ATRAP should capture what is happening in the state in terms of healthcare accessibility quality and cost and how we want to allocate our healthcare resources. It should deliver up to date sustainable dynamic resources that enables more informed healthcare or health resource allocation decision making across Vermont using data. Focus on the needs of each regulatory process of the Green Mountain Care Board. Provide ad hoc analysis for different needs and questions that arise that are not captured by the current ATRAP. I think this is important. ATRAP can't answer everything. And so if the questions arise because things change, we need to have the ability to be able to do ad hoc analysis to answer those questions. We want to foster a collaborative process. So as hopefully I've shown that this is a collaborative process. It's a collaborative tool. And so we need to be able to share, kind of capture other work that other entities are doing and have a process in doing so. And then develop a tool or tools that help that allowed to navigate these, the variety of these reports by HSA or whatever other topic or geographic area to understand health resources and needs to support our regulatory process. With the change of in statute in 2018 going from a static report to more dynamic reports. I think it's important to remember that this is now an ongoing process. There's really not a start and a final. Here's a report. It is kind of a cyclical process that will never ends. So there's requirements gathering, there's stakeholder engagement, there's data collection analysis and reporting and then visualizing and packaging that information. And it keeps going. These are just some considerations by like high level topic areas. So kind of the structure of ATRAV in the sense of how our priorities going to be developed or decided on. And so using the new state health improvement plan that will be coming out in the next year or so by our regulatory needs at GMCB. I've said this already, but revising the process to ensure work across the state is included in terms of stakeholder engagement having recommendations for resource allocation, how do we determine how to best use those resources in an effective and efficient manner. And then visualization, how to package data on our webpage. Is it going to be dashboards? Is it going to be by topic HSA? What is the most useful for our audiences? So this is a roadmap if you will of goals and next steps. So some of this will be a little repetitive to what I just said, but I will review them. So we want to finalize our GMCBD regulatory process requirements gathering. So finish talking to everyone to understand how they use ATRAP and how they can inform ATRAP, communicate the stakeholder engagement process, determine a process to enhance ability to provide ad hoc analysis, not captured by ATRAP. I think this is one of the more important ones, which is explore more sustainable ways to update resource inventories and collect data from hospitals in the least burdensome way. Regardless of COVID-19 response or not, where everyone is busy, hospitals are busy, providers are busy. We don't want to be burdensome. We want to have useful information. And also, you know, not only be sustainable on how we collect it, but up to date, you know, if it's a resource list from five years ago, is that useful? I mean, maybe it is. Maybe it's not. And it probably depends on how quickly things change, but we do know things change. So we need to explore that. Develop a process for providing resource allocation recommendations. So who makes those recommendations? How are they updated when, et cetera? And then this is a relatively simple one, but I think provides, will provide more transparency, which is just map when and how ATRAP components are updated. So there's so much, so many reports that kind of feed in to what ATRAP is, and they all are updated on a different cycle, or maybe they were a one-time report. So just having that and understanding that and went to anticipate some of those updates, I think would be important. And then just a reminder that this is a cyclical and ongoing process. And we welcome feedback like Jessica had said in the beginning and wanted this to be a useful tool for everyone. Take questions now. Thank you guys very much. I'll turn it over to my other board members for any questions or comments they may have. I'll jump in. I just want to say thanks to Veronica and Jess. Having been involved in this in the past, it's, you know, the inventories in particular are a lot of work. And a shout out to Donna for that as well, because she worked hard on those. I think it's good to reboot and take a step back and try and figure out how to move forward in a useful way, because I think that's quite, frankly, always been a challenge with the ATRAP since the beginning is how do you ensure that you're not duplicating efforts that other state agencies are making? Certainly the Department of Health has, you know, terrific data capabilities and does a lot of analysis on needs and they're in charge of doing, you know, certain needs related assessments. We don't have the people or the capacity to duplicate everybody else's job. So I think you've done a great job of trying to pull in what's happening in all the different agencies in one place. So thank you for that. And I look forward to hearing more as we move forward with the next cycle. Ms. Walsh, go ahead. Thank you, Chair. And thank you, Jess. Thank you, Veronica. Second, what Robin was saying. You know, listening to this, the thought occurred to me that we hear sustainability a lot. And I think that that's a very important aspect. One thing that I haven't heard a lot, but I've seen great examples of in other places where it's not so much. It's responsiveness and agility, right? During COVID we saw how adaptable and responsive our healthcare system can be. There were pop-up vaccination clinics. People mobilized in a way that I think as time goes by, we'll look back and see, you know, it wasn't perfect, but more and more it was incredibly impressive. Right? And given that, that's kind of juxtaposed with this slow epidemic of mental health stresses, substance use disorders and suicides, that prior to the pandemic, those were all on the rise. During the pandemic, they did not abate. It got worse. As the pandemic is fading, it continues to worsen. The data in our state is that we're on track this year to eclipse the record we set last year. We have no pop-up clinics for mental health services. We haven't built our capacity, changed on a dime to try to address those concerns. And so I think of, we've said, we've had during other parts of the presentation, like a slow, steady approach is needed, particularly from regulators. But I wonder if part of the HRAP, what we could be looking at is how do we improve our agility to meet the demands of promoters, the needs of them? Because those are changing faster than our healthcare delivery system has been able to change. And it just seems like that could be, there could be some paragraphs about that and some thoughtfulness about it. So that occurred to me while listening to you and I thank you for provoking my thinking. It was an engaging presentation about something that could be a bit dry. So thank you for your work and thank you for sharing it with us. Any other board member questions or comments? Ms. Holmes? I can answer two quick questions. Thank you also. We always echo each other's gratitude, but I mean that sincerely here. I think you mentioned that the HRAP team was working with the hospital budget team to optimize this tool, understand how the information was flowing back and forth between the two. And I'm wondering, given the presentation we just had, whether Mathematica is also exploring how this HRAP tool could potentially tie into the hospital budget reboot. So I'm thinking, for example, of the patient migration and hospital market reports feeding directly, how can that feed directly into the board's assessment of hospital budgets? Ken, in the opposite direction, will we use the hospital budget process to request the HRAP inventory updates that we need to keep that data dynamic and up to date? So I'm just wondering if Mathematica is also involved in thinking about how to optimize the use of this tool to improve the hospital budget process. I can answer that. And I don't know if Sarah Lindberg had to run, but she can chime in. It's definitely a part of that contract work. We considered it when we wrote the contract. And I think that's exactly right. Like how can we automate some of that data collection around services, where that was very manual process with hospitals in years past. And we've definitely asked them to have a look at that. I don't think that that work has started yet. Sarah, you can correct me if I'm wrong. But one other thing that I just wanted to throw out there is, Jess, you mentioned the non-financial reporting requirements. And that's an opportunity to maybe reduce the burden at time of budget submission, but turn back to some data collection that could help support HRAP. So I just wanted to, I heard that. And I remember that's when we used to ask for that information. And so maybe we could consider that as well. Perfect. That sounds great. Thank you for that. That's helpful. And then I guess my last question is really, I'm wondering, you know, in this process, as we're reimagining what this HRAP looks like, and it's a dynamic process, and we're kind of rebooting this as well coming out of COVID. I'm wondering if in the staff's research, we've come across any other states that do anything similar to HRAP. And is there a source of inspiration out there that we could be using to come up with a really dynamic, useful tool for resource allocation? Or is Vermont really just out ahead of all these other states and trying to do this? So that's a great question. And I'll let others answer as well if they know. I did Google, you know, a whole resource allocation planning words around that at a state level. And there really isn't anything quite like this that I could find, which makes it challenging because it's thanks to bounce ideas off of other states. So if others do know of other states doing something similar and maybe are using different language, and can't say I spent a ton of time looking, but I think that would be helpful. Great. Thank you so much. For what it's worth, I've never heard of another state doing it. I mean, certainly countries do like real resource planning, which this quite frankly is not. I don't think this is meant to be that otherwise, quite frankly, it would be staffed and funded. But I think so. I think it is kind of a unique animal. Yeah. Yeah, it's more of a resource of resources of understanding what we have and where we're at and what our needs are. I have a few questions, comments. One is I think it's great that this is merged into or morphed into a far more dynamic document. I mean, health resources are not static. So a static document every four years seems archaic in this day and age. So I'm very happy about that. It sounds like there's going to be some complexity with its being dynamic and how it's then applied into standards. But that seems something that should be worked through because of its necessity that it is dynamic. So the other question I have, and maybe for this is for Jess, is what's the relationship between the Act 167 Hospital Sustainability Work and the HRAP? Seems like there's some overlap and scope there. Maybe different ways of looking at similar problems. Was that this, Jess? Okay. Well, I think that's exactly right. And the more we dive into the Act 167 work, the more I realize that HRAP might inform that work and vice versa. Act 167 received funding and to the extent that we look at services and capacity by hospital service area, that's exactly what the HRAP is. That was the hope. And to have that work take place now, it would update any of the work that we had done earlier on. And so I do think that there's overlap there. Other folks, feel free to chime in. I guess the reason why I ask is, is there a way we can leverage to use them together in a sustainable way in the future? But I don't think that's really, that's more of a rhetorical question, trying to figure out how those will blend over time and ask you that specifically now. Thanks. Thank you both very much for your time in the presentation. Every time I hear some of the work of the data team, it reminds me I want to go speak with the data team more and there's a lot to learn. You guys do really phenomenal work. I've been on the website and I encourage others to go on the website because the data information is really interesting. I have it up now. And it gives you, for example, primary care access data, including how many physician assistants or primary care providers there are per 100,000 people. It gives it to you for each health service area. It gives it to you on a statewide average basis, the maximum, the minimum. So you can really compare and see what we have available in different parts of the state. The patient migration report gives you the last five years of what costs have looked like for commercial Medicare and Medicaid. It gives you a sense of where costs are going up and for which payers. So it's really fascinating data. And I can see, I think I forget if it's just a robin, the point about considering this or looking at this data in connection with the hospital budget process is really a good point. So I encourage the public and everyone else to look at it because it's very, very informative about the state of our state's health care system. And I'll turn it over to the health care advocate for any questions or comments that they may have. Thank you, Veronica and Jessica. I appreciate all the work on this. One quick question and then a brief comment. The question is, I wonder how feasible, and I imagine you've already thought about this, but I wonder how feasible it would be to look on the back end to see what reports and tools are being used most frequently through the ATRAC and which ones are maybe less frequently utilized as one of, I'm sure, many metrics thinking about rebooting and reforming. So I just wondered if that was possible. And then the comment, one just brief comment is during COVID, the Oregon Health Authority did a health resource allocation plan somewhat. It's much more narrow in scope. It's not, I mean, I agree that there isn't really another state that I've seen that does this type of work, but they did have an interesting tool, particularly about prioritizing health equity during kind of a resource scarce environment. So I would just recommend that tool. It's interesting. And they also do a really great job with language. They've translated it into like 30 different languages, which is pretty impressive. Yeah, so I just wanted to make those two points. Thank you. Okay, thank you. I'll have to go look at that. And in terms of the comment on looking at, you know, the utilization of some of these reports, I'm not exactly sure what our web page capabilities are. I'm sure there's something, I think the challenge with that is some of a lot of the resources that we do provide are not our work. It's we're linking to other people's work. But when we're thinking of stakeholder engagement, we can consider, you know, what is up with these reports, the most looked at, most useful that we can leverage more. So thank you. Thank you. And I'll turn it over to public comment. Please use the razor hand function. If there's any public comment. Great. Well, thank you very much, Veronica and Jess. Nice to see you both. And with that, I'll turn it to the board to see if there's any old business to come before the board. Any new business. And is there a motion to adjourn? Promote. Seconded. All right. All those in favor please say aye. Aye. Aye. Aye. Aye on the motion carries and the meeting is adjourned. Thank you everyone. Have a good day.