 The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you Mr. Chair. Happy 2020 everybody. The legislative session has returned. I feel like I've been in that building for six months. It's only been two days, so they've gotten things going very quickly. So thank you all for coming today. I do have a few announcements, very brief. Our schedule for January is up on our website. Please take a look at it. We have a very busy month ahead. We're obviously hearing from the Rural Health Care Task Force today. And next week we have a panel discussion focused on primary care. And I actually know that those participants on that primary care panel have been involved in this process, the Rural Health Care Task Force, and are actually building off of the recommendations for their discussion next week. So that should be interesting. I think that's all I have to report. Only the next Wednesday also is January 15th, and we have several reports due to the legislature, most notably our annual report. And so that will be posted on our website when it is completed, which is very soon. And I'll turn this over to you back to you, Mr. Chair. But I know Board Member Lunge will be doing some introductions for this discussion and then we'll get up and present to us. So we'll work through those logistics. Okay. Could you all mention the topic of next week's board meeting? Oh, it's a panel discussion on primary care workforce. Did I miss that? I'm sorry. Thank you for reminding me. Okay, the next item on the agenda are the minutes of Wednesday, December 18th. It's been moved and seconded to approve the minutes of Wednesday, December 18th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Okay, at this point in time I will turn it over to Robin. Okay, and I am going to move over to join my fellow task force members in a moment. But before I do that, I did want to just say a big thank you to several of our staff members who were very much responsible for making sure that we could get this report out. And that includes Abigail, who was our administrative support, was from the task force as a whole. Agatha, who are minutes, and it's a lot of research on various topics to help provide that background material and is also responsible for anything pretty in the slide. All the mistakes are mine, but all the pretty graphics are hers. Also, Patrick and Lori, as well as our member, Lucifer, helped us on the financial component of the report. Toby Howe, who works with Laura Colossi, did a heroic job on the workforce white paper. And then also we had assistance from several staff members at the Department of Health and our staff, Jess Mendesable and Donna as well, on the inventory. So this really was a group effort, among the task force, but also from a number of staff members from a number of agencies and departments. So I just wanted to do that thank you first. I am going to now shift over there. While you're walking over, Lucifer, can I add one other item to my executive director's report? Sure. I want to thank board member Lunge for leading this work over the last, I thought it was three months, but she reminded me it was starting in June. So thank you very much. You're welcome. Thank you. So why don't we just go down the row and introduce ourselves. Laura, do you want to start? Sure. Laura Colossi at MMR. Can you hear me? Laura Colossi at MMR and I represent the Rural Health Services Task Force, Vermont Health Care Association, which is the trade group for long term care facilities. Good afternoon. Jill Olson, I'm the executive director of the V&As of Vermont and I represented Home Health and Hospice on the task force. Everybody knows me. And I had the counselor staff of the Green Mountain Care Board as a support role to the task force during their work. Okay. So I'm going to actually put this in the stand. Make sure it's close enough. Can everyone hear me? Okay. We can. Okay. So we're going to get started. So before we jump into the slides, I did want to just do a very brief introduction. The board really started looking at the issue of rural health care issues last spring with our panel around hospital closures and some of the national issues that are presenting pressures for hospitals in particular at that panel. But I think the work that we did around that panel has really set the stage for the environment and some of the background information that we're going to provide today. This task force report advances the topic, although it is not the last stop in the journey around rural health issues. I think that really what the task force is hoping for is that this will be another step in the conversation about potential solutions. Also, the task force members, I just want to say thank you to them because they really diligently worked towards producing a comprehensive look at this issue with a shared goal of advancing shared solutions. And with, you'll see the diversity on the task force in a moment when we get to that slide. But it really, this task force really could have failed in terms of crashing and burning around, not being able to come to solutions. And everyone really did a great job of working together to find common areas and solutions. Can I have to point this out? Okay. You can tell I haven't sat over here with you. So just briefly on the table of contents, this report, this slide deck is the report that we will submit along with the workforce white paper to the legislature. So we aired on the side of including a broad array of slides to really tell the story and let it stand. What we're going to try and do today is give you the highlights and an overview. So we won't necessarily go in depth on every single slide. Otherwise our meeting would be 12 o'clock as long. And so there I've made sort of an executive decision in terms of areas where I felt the board in particular had more background that we could more quickly move through materials. With that said, please feel free Mr. Chair to slow us down on particular topics if you would like. And we're happy to either have you ask questions as we go or to hold them at the end, whatever you require. So this slide shows the legislative requirements from Act 26 of last year for the task force. And I just want to pause for a moment on this charge because it is extremely broad. And I think one of the areas that we were successfully able to tackle as a task force is finding a way to narrow our focus so that we could actually provide real recommendations in a short period of time at a very broad charge. So we were charged with doing an inventory of the current system of rural health care delivery in Vermont, considering how to ensure sustainability of the system, identifying existing barriers and ways to overcome them, and identifying ways to encourage and improve care coordination, and considering potential consequences for the failure in one or more rural hospitals in Vermont. Any one of these topics, quite frankly, could have been the only thing that we spent our summer all doing. So it was a broad charge, but I think we tackled it well. So this next slide shows the membership of the committee and several of the members are in the audience today and thank you for joining us. Act 26 set up the task force to have 14 members. There's representatives from Human Services, Green Mountain Care Board, Department of Health, Healthcare Advocate Hospitals, FQHCs, Free Clinics, Independent Practices, Designated and Specialized Agencies, Mental Health, Home Health, Long Term Care. And the point of this, such a broad membership is because it is addressing healthcare delivery in rural Vermont, which is more than just one sector alone. The style of the meetings, there were a ton of them. And first I should say that they elected Robin as the chair pretty much right away. And you're familiar with Robin, several people are familiar with Robin in the room, and she ran those meetings in a way that was formal. So there were formal votes, there were minutes, they were noticed, but they're also collaborative so that people in the audience that were on the task force were encouraged to participate and did contribute to the report. Also worth noting is that a substantial amount of work was done in subgroups, so outside of those 10 meetings. They volunteered from the task force to lead subgroups like Workforce, Laura led the Workforce, there was Care Coordination, to some extent there was a Telehealth subgroup and there were non-task force members on those subgroups. So it was truly a collaborative effort. The group also, some representatives of the group went to other meetings to talk about the work of the task force and solicit comments. So there was regular attendance at the meetings and the public truly didn't have a chance to participate outside of just a traditional public comment period. You want to add to that? No? Okay. So the next few slides are really trying to set the context and the environment within which we did our work. And these are the slides that I'm actually going to go through rather quickly because they really build off of the panel that the board heard from in the last spring. So the first area that I really wanted to ground us in is, as we know, Vermont is in the middle of the all-parent model agreement with the federal government. And this slide will be familiar to the board members because it's a common slide that we see in our ACO and all-parent model regulatory structure to talk about the reason why Vermont was pursuing the all-parent model, including the cost growth exceeding that of the economy and improvements that we could make in health outcomes or areas where we as a state could do better. I would like to start here because I think it's important for us to recognize that when some of the financial sustainability issues started to hit Vermont, we were already partway down this journey. And so it's an important contextual piece to how we would look at solutions to the issues and why we may take different approaches than other areas in the country. This slide, I'm going to skip for us because this really talks a little more depth about the all-parent model and having just come out of an ACO regulatory process, we really, for this audience, it doesn't need to be covered. So as we talked about in the spring, there are several federal and as well as state pressures around healthcare that is looking, which is causing changes in the healthcare landscape nationally. Those really span from some of the areas of focus and changes in the Affordable Care Act in terms of creating market instability. For rural areas, there is an aging population. Part of that is an aging workforce demographic. There are also Medicare changes at the federal level that are causing pressures. And so really, I think the takeaway there is that Vermont healthcare providers are not immune from national pressures, which have focused on reducing reimbursements and fee reserves and destabilizing the Affordable Care Act. And so in this slide, what we tried to do is just pull out for audiences that are less familiar with some of those national pressures, some examples of different areas of change that are occurring at the federal level that are impacting our Vermont providers. This is built up as a slide that Eric Schell used. I basically took his slide and Vermontized it. So since we had had a robust discussion about that, I'm not going to go through the examples with you today. Additionally, as the board is well aware, the Center for Medicare and Medicaid Innovation is continuing with value-based payments, and that is an environment which is going to remain a national environment into the future. So shifting now to other demographic factors, rural areas, including Vermont, tend to be older and thus less healthy. So Vermont is one of the most rural states in the nation. We're also the third oldest state, and we are aging at a faster rate than many other states. The percentage of Vermonters who are age 65 is growing while the percentage under the age of 20 is declining. And like most other rural areas, our most rural counties in Vermont are older and have poorer health outcomes than the less rural counties. I'll pause here just to say that the task force early on talked about whether we needed to have a definition of rural, and what we decided to do was really not limit geographically our look. And the reason we did that is even if you are looking at providers providing services in Chinden County, which is obviously our most urban county, they are seeing people who come from rural counties, particularly our academic medical center is an academic medical center for rural areas as well as urban areas. So we decided specifically not to limit our geographic look. Another piece of background is to think about how Vermonters are covered, as the coverage components do impact on reimbursements and other factors, what coverage is provided, and that kind of thing, that impact on sustainability issues. So what this slide provides as background is basically since 2000, the year 2000, the proportion of Vermonters who are covered by our public programs, Medicare and Medicaid, has increased, our uninsured rate has decreased, and commercial insurance market has decreased slightly as well. That's done with plans. And so that's really just meant as some background in thinking through some of what we discussed later in the report. So this is a complicated slide that is trying to tell a story about a piece of the report that we were hoping to make more robust. So what we attempted to do as a task force was collect key financial performance indicators from the entities that collect financial information today. And we did get a lot of information, but we didn't get information in such a way that we really could do an entity or sector level analysis of financial sustainability. So this slide really explains that there's a lot of data that currently is collected from providers. I think those two different agencies, many providers report to more than one agency, but the purpose of the reporting is often not a financial assessment or, and in most cases is not focused on financial sustainability in the sense that even if the agency is doing an assessment, they may or may not have a lever to then solve an issue. And so I'm going to turn it over to Agatha to explain the slide because it is a complicated slide, but that's really the purpose of why we wanted to show this because we thought it was important to show that there is a lot of data, but that data is not really looking at what we were trying to look at. So it was of limited usefulness. So we'll go through the details. I'll just basically give you some shortcuts on how to use this slide. So the top parts, the dark blue boxes are the agencies that are collecting the information. In addition to those top four boxes on the top are these two bars that span the length of the diagram on the bottom, which is DEVA and the federal government. The reason why DEVA and the federal government, who are agencies that are collecting data on the bottom, is because so many of the healthcare sectors that are represented here are reporting directly to DEVA and the federal government. So for simplification purposes, we drop those two collecting agencies down to the bottom. And then right here are the healthcare sectors that very much mirror the membership of the committee, and you'll hear us refer to these sectors throughout the report. The lines that are drawn with a dotted line, so as not to sort of misinterpret this as an organizational chart, but this is a reporting chain, show how the entities are reporting to these agencies. And then the key on the bottom shows for what purpose the data that's being collected is used for. Like Robin said, if it's one that looks like a piggy bank, that's a financial assessment. Whether or not they're actually assessing the financial health or sustainability. The institution is another question, but they are collecting the data for purposes of financial assessment. If there's a dollar sign, it's for reimbursement rate setting purposes. And the one that looks like a chart is for key performance indicators, which may or may not be financial or quality. And then one other note for simplification purposes, independent providers and FQHCs on the right-hand side. Like I said, there are lots of sectors that are reporting to DEVA and the federal government for those of the two that we highlighted their relationship with those two entities. The only other thing I would add is that if the symbol is in the chain of higher up, it means it does apply to all the entities. And we did that just for readability. There we go. So one other piece of background that we looked at early on was a report by the Bipartisan Policy Center, which is a center which was looking at rural health care at the national level. And I just pulled out their priority areas and recommendations as a point of reference. And you will see when Agatha goes over the task force priorities that there's good alignment between what our task force focused on and what this national Bipartisan Policy Center report focuses on. And those are built or retained in a rural workforce, expand telemedicine services, create appropriate payment models and value-based care programs that account for lower patient volumes and a reliance on Medicare and Medicaid, and allow rural communities to adjust their own health care services to better fit the community's needs. And a lot of the recommendations in that area focused on federal designations, which may require certain types of services to be offered in order to maintain that designation. So an example of that would be the critical access hospital designation. So I looked at this report really basically to get a sense of what was going on at the national level and to help us think about any areas that maybe we as a task force hadn't independently identified, but we were able to do that. So then in terms of the task force, the rural health services task force, as Robin said, there was a need to narrow the focus of that large legislative charge. And so the task force did this by early on doing a priority setting exercise where each member of the task force came to one of the first few meetings with a list of what their priorities were for their health care sector, what the issues were, what the solutions to those issues were. And from there they found commonalities, common grounds, and prioritized. So with all the issues that were identified there were several. The group limited themselves their work to workforce care management, which was actually one of the requirements of Act 26 and revenue stability. Sort of one topic that touched all of those three that came up in the conversation of potential solutions was telehealth. So the group did decide that they wanted to address that issue in their report. The task force in setting those priorities also set some principles for themselves in addressing those priorities. Because they worked for a very short period of time, a relatively short period of time, six months with 14 members for 10 meetings, they wanted to stay focused on those three priority groups including telehealth. And they wanted to work with materials that had already been produced and were consistent with the work they were already doing. So they were looking at what was happening from that report or what was happening with the oral health task force or what was happening in reports that were published previously. So it was really using the materials and the resources that were already at our fingertips. They wanted the recommendations to be inclusive of financial and non-monetary solutions intending that this report was to be submitted to the legislature so in order to give the legislature options on the recommendations. And they wanted the solutions or the recommendations to be beneficial to all healthcare sectors. So that was the purpose of a 14-member group that is at digress to not just fix one sector or address the recommendations for one sector but for all the sectors. And I should mention that all of the recommendations that are in this report are consensus. If there wasn't consensus on a recommendation then it didn't make it into the report. The only thing I would add is that you will see later in the back a list of other work routine reports that we looked at. Some of them, people brought up a lot of the other reports that are to be submitted next week so we weren't able to align with absolutely every relevant legislative effort and there are quite a number of them but we did our best. So you can't really have a discussion on rural health care and delivery in Vermont without talking about some very critical barriers to rural Vermont. In that priority setting exercise that they did the group did focus on the three workforce care coordination and revenue stability but also spent some time discussing these economic barriers that no matter what recommendation is put forward they will continue to run up against some underlying infrastructure issues that affect all of Vermont's but particularly rural areas. So the task force again early on recognized these as being beyond the scope of their work but did want to make mention of them in the report. So we're going to the next section of the report now which is rural health delivery. It's just a few slides and we can breeze through them because this is stuff that should look familiar to the Green Mountain Care Board. This slide is a little bit a little bit different but it's a little bit different this slide comes directly from the expenditure analysis Lori Perry from our office works very hard on this and it's a very valuable resource but the purpose of this slide is to as we're looking at the healthcare sectors long term care, nursing, hospital this is a resource that was at our fingertips to sort of show the scope of each of the sectors now it's not an apples to apples but it is showing that in 2017 how the $6 billion in expenditures was spent by healthcare sector this is showing the resident analysis which shows spending by Vermont residents regardless of whether or not they got their care in Vermont and then the next slide which is the $6 billion pie but it's divided up by the provider analysis so this shows the spending at Vermont providers regardless of where the patient is at so it could be that's out of state this next slide is the last slide in this section shows just three inventory maps there are several inventory maps that are in the last section of this report but this is sort of a preview for the inventory the substantial inventory work that was done predominantly by the Vermont Department of Health and the Department of Health John Olson was a task force member worked with some of the staff at the Green Mountain Care Board just known as Donna Jerry and putting this together the full version of these maps in the back of the report are also someone to find narrative that describes the map so we're not going to go through the inventory section we can schedule another time to come back if you're interested in that which is to show that this is a sample of what those maps look like the only thing I would add to that is that we will be using the inventory maps as our first basis for each trap 2020 and that we will continue to work with the Department of Health to build on that as well my turn so headed on to workforce this is something that I've spent the last two years working on I started working for the long-term care facilities in 2009 and on my first day on the job they said to me that my number one priority is to help them deal with their regulatory challenges and that was consistently the top priority for them until about three years ago when they said our single biggest problem is that we can't get staff what are we going to do about this so the workforce white paper that you see attached to these slides is a really deep dive into a lot of the challenges that we're going to run through here pretty quickly today I would really encourage you to take a look at that there's a ton of research in there and a lot of data that I think is really important the task force and the workforce of community in particular felt pretty strongly about developing that as a way to say to the legislature this is a priority area particularly in the healthcare workforce sector we have a lot of challenges with workforce across all sectors manufacturing, construction we have a real economic development challenge in this state we need people to take care of people when we started looking at what are our real challenges and barriers the aging population stands out as a tremendous tremendous challenge when you look at the percentage of our workforce over the age of 60 this presents itself with a couple of challenges as our population old ages they need greater healthcare they have greater healthcare needs greater needs for long-term care and our workforce is aging out across the various levels of the healthcare professions when we look at data from other areas we see particularly at the board of nursing level that we have had a significant decrease in the number of licensed folks in the nursing professions as well as with our primary care physicians there are a lot of factors involved with that but the bottom line is that those numbers are steadily decreasing that shows up when we start looking at what are our vacancy rates and what do we need for staffing in 2018 the Vermont talent pipeline management project surveyed all the hospitals three long-term care facilities and one home health agency to get a sense of what are the nursing needs between 2018 and April of 2020 and they identified 3900 nursing related job vacancies when I say nursing related that's personal care attendance, licensed nurse aids licensed practical nurses registered nurses, advanced practice nurses we knew that that wasn't comprehensive so the associations got together through this process and did a survey of long-term care facilities, home health agencies we worked with the designated agencies and you'll see some additional data presented here with respect to what we need for primary care long-term care facilities, home health agencies just in the short-term and when you look at the turnover rates we have got significant turnover rates the reason for that is we don't have enough workforce folks are working on double shifts we're dealing with a burnout situation at the provider level at this point we started talking about what are all the barriers to getting greater numbers of people to enter healthcare for a career student debt rises to the top you'll see in the white paper some of the challenges for our institutes of higher education and the increasing tuition rates that we're dealing with that's laid out there pretty well education credentialing challenges this really references the challenges with making sure we've got enough clinical nurse educators that are able to educate the qualified applicants that are applying to our nurse education programs right now our institutes of higher education are enrolling 50 to 60 percent of qualified applicants because they don't have enough clinical nurse faculty so we need to find a way to increase that pipeline of clinical nurse faculty some licensing challenges which we'll go through in the recommendations provider burnout which I've already referenced aging workforce which I've already referenced really trying to help folks outside of Vermont realize that Vermont is a great place to come and live and work and how do we market ourselves for the quality of life that we do have the fact that Vermont really is an innovative place to be a healthcare provider given all of the efforts we have going on the housing child care and transportation issues that Agatha mentioned this really came out in the context of the workforce discussion we've got a significant number of folks particularly in the personal care attendant licensed nurse aid even our LPNs who really have challenges accessing child care particularly if they're single working moms affordable housing and that cuts across affordable and high quality housing when we're trying to attract folks coming into Vermont with that in the old housing inventory and then reliable transportation for folks in rural areas to be able to get to work the trailing spouse I'm sure you've heard a lot of the challenges around getting folks to move to Vermont when their spouse can't find an appropriate job and the fact that we're dealing with a tight national regional and local labor market so we have providers competing across the same pool of potential employers we're competing with what's happening regionally in New England and particularly at the physician and nurse level it really is a national market that we're up against and then one of the things that folks felt strongly about was that Medicaid rates tend not to be able to cover the significant wage increases that providers are having to invest in to be competitive that all translates into extra cost in the system when we're talking about a workforce shortage I know the Department of Labor doesn't like me to use the word shortage but it's the easiest way for me to describe it but it's technically not accurate so that results in the significant need to utilize traveling temporary and contract employees and some of the data that we have you'll see down below hospitals 11 of the 15 hospitals reported a spend of over 56 million dollars home health in hospice over 10 million skilled nursing facilities 12 million and I can tell you at least on the skilled nursing facility side and that the data is all in this white paper over a four year period just for the skilled nursing facilities it's a 158% increase in what they're spending on traveling their staff as a general rule facilities are spending twice what they would if they were dealing with having employed staff we wanted to make sure that the board and legislators understood the types of initiatives that providers have really been implementing for a number of years to try to deal with the workforce challenge and as we surveyed providers across the various sectors some best practices really kind of were highlighted that many many of our providers are doing and you'll see those listed here we also wanted to make sure that we were pointing out all of the good work that our legislature and our other non-for-profit partners are doing in this case around loan repayment scholarships and grants and the work that the legislature's done to kind of move the needle over the last few years and helping us address our workforce challenges so you'll see some of those how they did here as well then we got to what are our recommendations going to be and you'll see that they fall into those buckets of non-monetary solutions as well as monetary solutions and we tried to identify whether it was an initiative that needed to be led by the legislature the administration and in some cases particularly around the licensing issues the office of professional regulation so the first is entering the interstate nurse licensure compact that movement is already under way at the legislature changing the clinical faculty requirements and this gets to the nurse educator challenge that we discussed the office of professional regulation has just recently submitted a report to the legislature agreeing that we need to make some changes to allow a greater pool of nurses to perform the services of clinical nurse faculty create a pathway for military medics to LPN the legislature put in place a direct pathway for licensed nurse aides for military medic to licensed nurse aides two years ago this would expand upon that effort removing statutory barriers to physician assistant employment aligning mental health clinician licensing requirements accepting certain licenses as immediate pathways to licensure of dentists exploring licensing pathways for foreign dentists and foreign physicians and then exploring the possibility of joining the psychology inter-jurisdictional compact which is similar to the interstate nurse compact so those are some of the non-monetary more regulatory type changes that we think would at least help it's a tool in the toolbox to try to bring more folks into this pipeline higher education reforms lower the minimum age of admission for the LPN program which is currently 18 the idea here is if we could lower that entry level age to 17 then students could take advantage of at least the prerequisite courses in their senior year in high school as part of the dual enrollment program which would really cut down on the cost of obtaining the LPN certification re-open the UVM psychiatric mental health nurse practitioner program which is something that UVM had proposed to do a couple of years ago it was an appropriation issue expand apprenticeship programs for non-degree allied health careers the Department of Labor currently has apprenticeship programs so we'd like to work with them to expand those to areas where we feel that there's greatest need and then on the financial side increasing scholarship funding and loan repayment funding our loan repayment program has been relatively level funded for the last seven or eight years it's just under a million dollars New Hampshire for example just appropriated 6.5 million dollars to its loan repayment program when you look at our nursing shortage in particular over the last handful of years we've only been able to support 57 nurses through our current loan repayment program so the task force felt pretty strongly that we needed to boost that funding and then the task force agreed that there were a number of tax incentives that we would like the legislature to consider to promote health care workforce in our state main nearest neighbor in the oldest state is doing some pretty innovative things when it comes to their opportunity tax credit program which is much more broad based in the health care sector but we felt like we needed to do something here to attract folks into Vermont and to stay in Vermont they also have in Maine a rural practitioner health care credit Oregon has similar programs so we're asking our legislature to take a look at some of those ideas continuing on telehealth which we'll talk about was again a cross cutting issue and we see maximizing telehealth opportunities this is a way to help us deal with the stress and strain of not having enough bodies to provide the service in every location that we'd like them to be at every minute of every day and then reducing administrative burden obviously rose to the top of the pile because of this provider burnout challenge that we're facing so there are a number of recommendations here around streamlining quality measures reducing and eliminating prior authorizations and then recognizing some of the real challenges around having an adequate mental health workforce and substance abuse workforce really looking at the Medicare credentialing restrictions and seeing if we can adjust those so that we can have greater access to those services across our continuum and then increasing state recruitment efforts establishing a state led immigration and new American initiative to try to connect health care providers with this population establishing a statewide marketing campaign assuming that we can do some innovative things not just around licensing but also on those tax incentive and financial incentive ideas that we've put out there to really market Vermont as a place where folks want to come get their education and stay and live and work and then asking the administration to prioritize health care on the Vermont workforce development board which looks at workforce development across the state across the economy and in all sectors we also tried to identify what the federal issues are and we've already begun conversations with our federal delegation on these issues which is trying to find a way to maximize national health service core and nurse core program funding really having a better approach to implementing the public service loan forgiveness program I'm sure you've heard a lot about how people thought they were eligible to have their loans forgiven because they then turned into public service we need a more robust effort so folks understand what those requirements are and how to access those programs because there are people who would benefit from that certainly in our state we've asked the delegation to increase the federal share of our state loan repayment program funding and then raise the H2B cap to alleviate shortages so the H2B visa program is the program where most nurses would enter the state and be able to work there's a cap, a federal cap amount or the number of folks who could enter and it's a national cap so there's a lot of activity in Washington a lot of provider organizations at the national level asking for that cap to be increased which would help with the flow of folks does the national cap get allocated out to the states or how does that work that's my understanding is that there is there is an allocation and so we've been talking with our congressional delegation on how to maybe address that for rural rural states so those are our workforce recommendations again I really encourage you to take a look at the report and we certainly appreciate the board's attention to this really important issue okay so we're going to shift now to the section of the report that really documents some of our efforts to look at revenue and expense issues across the sectors as I said earlier we didn't get as deep into this area as we had hoped to do the data limitations but really what we started trying to do in this area was to bring things down closer to a sector or entity level because when you're looking at financial sustainability as we see for example in our regulatory process with hospitals you need to look at it in terms of operating expenses and revenue sources and so this slide is really showing that for many of the sectors there are issues with operating expenses growing faster than revenues and as Laura mentioned in the workforce area reimbursement rates not covering inflation or personnel cost increases and so this slide just basically provides some examples of pressures on the operating expense side and pressures on the revenue side as an example of what we were hoping to be able to at the level that we were hoping to get to but did not. This next slide has a lot of words on it but this is one that we can probably read through pretty quickly because of the work with the Green Mountain Care Board that as you're familiar with these topics this is about the financial health metrics that we were measuring but before talking about the financial health metrics a little bit about the task process if you recall that slide that showed the reporting channels from entity to agency we were trying to collect financial data from those agencies that are collecting the data. The task force got together to set some background they invited the Green Mountain Care Board hospital budget staff to come in and member Yusuf was there to talk about how the Green Mountain Care Board looks at the financial health metrics of the hospitals and which ones of those could then be used by the task force that would apply to all health sectors. So the task force members got together and they narrowed a large list down to a smaller list and even from that smaller list of financial health metrics selected the three that are up on the screen which is margins, operating margin and total margin, days cash on hand and pay or mix. We put together a financial workbook that had more than just those three metrics on it and several metrics on it and sent it out to the agencies that collect the information. We did receive most of those workbooks back, most of those workbooks back some of them were more complete than others and the information that we have we tried to analyze and aggregate into the slides or the deck. We're not going to go through each one of the sectors individually each sector does have a profile slide so to speak in the next few slides. We won't spend time on each individual sector but those profile pages really are meant to do what Robin was talking about which is to look at an entity level. So system wide looks are great. You can look at the hospital system and see what the average operating margin is which you really need to look at the 14 different entities to see what the financial sustainability of those institutions are. So quickly I touched on some of the limitations of the data but I'll get the one that I missed which are that financial years may be different for example for home health agencies they're not all reporting on the same year fiscal year or calendar year not all of the agencies were able to provide audited financial statements and audited financial statements are preferred because those are the months that have been through the auditors. We couldn't get data for all the sectors and we only asked for the most recent three years of data so three years of data is a great start to looking at trends but three years of data is not a trend in and of itself. And then lastly which Robin mentioned is the system wide analysis which is useful to look at in terms of how the sector is doing but you really do need to do a deeper dive by the entity level. Anything you add? The other thing I would add is and you'll see this as we go through the different pieces we weren't always able to show a range so when we talk for example about today's cash on hand slide we have the average that doesn't show you the variability so it's important to remember that even in the data that we're going to show there's more under the hood than what you can see in the slide. So I'll spend a little time on the next two slides and then I'll raise through the rest in this section. This shows payer mix and we know that payer mix is important because it shows the percentage of revenue coming from each of the payer whether it be commercial, government, self-pay. And you can see so here's hospitals home, house and hospice, nursing homes FQHCs and designated and specialty service agencies. There's variability where their payers are the amount of money that's coming in from each of the payers. So for the hospitals it's worth noting that this information is coming from the Green Mountain Care Board so these are the 14 hospitals that report to us this does not include the Broward Borough Retreat. Whereas earlier in the slide that Laura showed about the travelers that did include information from the Broward Borough Retreat and we were not able to get information on payer mix from independent providers and substance use providers. I just wanted to comment that the payer mix is also can have some variation within sectors and particularly if you have a really large organization such as One Large Hospital that their payer mix will influence everybody else's and we certainly see variation in the home health industry in terms of payer mix depending on the location the more rural places tend to be more medicated. Thank you Jill. That sentiment is exactly true for day's cash for using designated agencies as an example. They had an FY 18 although their average was 51 days cash on hand the minimum that year was a designated agency that had 8 days cash on hand and the maximum was a designated agency that had 102 days cash on hand so you can see there's a big difference between 8 days and 102 days. So on days cash on hand we display a multi-year look from 2016-17 and 18 and this was one where we had limited data. We weren't able to collect days cash on hand from all the healthcare sectors but we are able to post the ones that are on the screen. So I said I was going to re-screw these sectors profile by sector but I'm just going to pause for a second to know how to use these slides. Using home health as an example we tried to profile one of the financial health metrics that does show the difference in the entities. So using home health as an example this is showing operating margin. So here is the percentage of operating margins from positive all the way down to negative and then this access here is showing the 10 home health agencies in Vermont that reported. So we tried to on each healthcare sector profile an entity level look. We also on each one of the slides show the days cash on hand the payer mix and highlighting any sort of limitation to the data. Thanks Ron. Do you have anything else you want to add Jill? No, I actually think you've covered it well. So who's the agency that has over 10% So actually my members are pretty sensitive about talking about who's where but I will tell you that some of the variation comes from decisions about how much to invest and how much to keep in cash. And so it's actually can be a little bit hard to make sense just looking at the dots without understanding that those deeper questions there are agencies that are actually pretty similarly positioned and it's still a bit of choice about investment. So we have a profile for the FQHC's profile for the designated specialty service agencies and thank you to CND and Heidi for all your help with that. They came and presented to the task force a very nice presentation on the financial assessment of the designated and specialty agencies. We have a profile on the long term care facilities independent providers and the free clinics. I could just make a quick note about independent providers and free clinics. So the reporting that independent providers do is related to those who are at part of the blueprint and do the reporting that is required to be a blueprint practice. So on the independent providers we looked for external sources to provide information about the financial situation. So it looks quite different from the other sectors because of the information that we had available. Similarly with free clinics free clinics of course don't get reimbursed from payers because people are usually going there because they either can't afford their deductible or they are uninsured and so this slide will also look a little bit different but try to provide some relevant information about that sector. Yes. Just commenting on this is the nursing home slide. So the division of rate setting within DEVA collects Medicare and Medicaid cost reports audited financial statements payroll based journals and a lot of other information. They did not put it really in the context of some of the others that I know Robin asked for but I think it's in large measure because we just spent last year going through a task force process on nursing homes including financial sustainability and a lot of that work was done then just so you know that that data is collected and analyzed within DEVA. Yeah actually that's similarly for home health. The data that's collected by Dale is on a state fiscal year basis and is unaudited but our audited financials are also submitted to DEVA for separate purpose which is for our provider tax it's part of why we have some concerns about that Dale data because it's not audited and it's really off the right fiscal year. We are definitely not going to go over the hospital slide because we've all seen this information before in the hospital budget process but I did want to spend a little bit of time just touching on the issue of hospital closures one of the specific charges in the legislation was for the task force to look at the potential consequences of the failure of one or more rural hospitals in Vermont I think is we all know hospitals provide critical services to patients as well as other healthcare organizations and all of the sectors in a particular community do need to work together for the care of their patients. What we found when we did research on the closure hospital closure financial impacts was that there are two areas that that's been analyzed so this is data based on what we could find in our research that's out there it's largely not Vermont specific so it's the studies that we were able to define on a more national level so when a hospital closes there's an economic impact due to the hospital being an employer and also a purchaser of services in one of the studies we looked at in northern New England healthcare workers were about 10% of each state's work force and the closure of a community sole hospital is estimated to reduce per capita income in that community by 4% an increase in unemployment by 1.6% so what that really is looking at is acute care hospitals just to be clear it's acute care hospitals where there is one hospital in the community so that's very similar to I pulled those statistics out of the that I could find out because that's similar to the way Vermont's hospital system is structured where we typically have one hospital per county the statistics are different for counties and other states where there's more than one hospital in the county so I tried to pull out what I thought was the most relevant and I'm not going to go through all of the statistics because you can read as well as I can I'm just going to highlight a few things also when an acute care hospital in a county closes again when it's the sole hospital there's a little bit less than a 20% decline in the physician supply which also includes primary care so it's not just general surgery for example and I think that's no surprise to us looking at how much primary care is provided by Vermont's hospitals we give an example of maternity care as a reduction in service largely because that was what we were able to find in the study so again I'm not going to go through all the details but it gives you some examples of what is going on there and I just also wanted to note that one of the in the federal bipartisan policy where they have a section on right sizing of care and so I think it's important to acknowledge that aligning services is complicated and trying to figure out what right sizing means when you have a declining population and an aging population is hard and that there's also impacts on access and travel times outcomes and community preferences so that's not an easy analysis to do we did not attempt to tackle that in this section of the report and then lastly I think it's important to recognize in this section that for our hospitals they are in the middle of a payment reform where which at least theoretically could provide more revenue stability over time but we are really on a shaky page that Eric Schell talked about where not enough of the revenue is in the fixed prospective payments to provide that stability and they're really trying to span and manage to both a fee for service environment and a fixed prospective payment which of course is both of the systems are meant to drive different behaviors so we just wanted to acknowledge that that's firmly where we are right now in our aging so turning back to the task force discussion we do not have consensus recommendations in this area what we basically decided was that in looking what data we had that there really was not the ability with the data available and with the time available to do as I said before a real deep dive on the financial sustainability of each sector and certainly there are priorities that are used by both our legislature and the administration to allocate state funding among the sectors that largely has not focused on sustainability of the particular sector in the past it's really focused more on community needs other pressures of variety of factors so we wanted to acknowledge that but basically indicate that we felt like it made more sense in the task force to focus on the other areas where we had the ability to find areas of consensus across all the sectors rather than offer non-consensus recommendations in this sector but nobody thinks they don't need more money that's true so that's the question the task force did identify two broad areas around sustainability as dill mentioned targeted increases in reimbursements and reduction in administrative burden to the provider burnout and other issues so the way we've structured this section is to include two slides which have examples that were submitted by each sector with an example of either a targeted increase or a reduction in administrative burden that that particular person representing that sector thought would be helpful they again are not consensus they were not, people did not were not asked to discuss or debate or agree on those persons saying this is what our sector thinks would help us in these two areas I did want to note that in the national conversation there is a real focus on telehealth and moving from fee-for-service to value-based payment as a way for rural providers to weather national pressures increase revenue stability and improve value so I think that is also worth noting that Vermont is on a journey securely trying to move towards the value-based payment so I'm not going to go through all of the details of these slides I think people can read the examples I did want to note on administrative burden that the independent providers suggestions on reducing administrative burden are included in the consensus recommendations related to workforce so you don't see them represented here but that's that's why and these are all different from the consensus on administrative burden recommendations okay fine I have the floor it's a long way to wait a slide 53 Jim and I had the same problem we had the same silence so care coordination so this was absolutely one of the topics that we talked about I think in some ways we came up with fewer recommendations I think you'll see in part because there's a lot of work already happening with the provider space on care coordination much of which has been driven by various policy changes like payment reform but there aren't as many I think policy recommendations to make as we've been going through this evolution okay so I call this the spirograph chart and it is if I'm the only one who remembers spirograph okay so this is really a visualization of all the different connections that there are between the various provider types who are provider services and support to folks and I think this is from a particular community from Ben and Tim so what I think all of this says is that really what we're trying to do as providers is work together to make sure that people are getting the right care in the right place and that core role of home and community based services as a coordinator particularly for services that impact health but aren't healthcare is really strong and was strong before we started healthcare reform so I feel like that was really a theme that we heard a lot but care coordination is something we're talking about a lot in healthcare reform conversations but it's not a new idea in fact one of the things that you'll see on that last bullet on the slide is that in many ways initiatives like the blueprint or like the one care Vermont work are really ways to increase our effectiveness and efficiency in doing that care coordination and providing tools at least in theory that's what we're hoping for not so much the idea or the way for us to talk to each other I think that part is well known from others so we identified various issues that I would say are pretty consistent with other meetings that we all go to where we talk about care things that are related to care coordination so one is really making sure that we find a way to invest in that coordination work some of it is not really reimbursable necessarily in the old environment and so that's really important to try to find a way to make that possible we have this bullet that I think is really right on which is that the transition and payment and delivery reform is both too fast and too slow so in some ways I think for providers who are trying to change how they are paid it feels pretty fast and pretty scary for those of us who are hoping that those changes will drive some real change in the delivery reform and what an entity like a hospital might want to invest in it feels slow and so it kind of depends on your lens and your perspective about how it's feeling there are some real limitations this is where telehealth comes in where there's actually quite a bit of telehealth that lots of providers think would be really beneficial and approve our coordination and also improve our workforce issues and yet that's not reimbursable under most payers so there's some real payment barriers to providing those services and you know it really would be great for people to have to move around less to get their care and also for the providers to be able to access places that are rural and far away even with their critical expertise so we also talked about the more evolution of the data tools or the technology tools that we're working with as especially community providers on care coordination it's been talked about a lot but there's some real barriers the thing that I hear about the most we talked about is there's no integration with electronic health records right now and so for most providers who are trying to now talk to each other in a new electronic way through Care Navigator about care coordination there's double data entry people are working through their medical records and they're working through Care Navigator it's something that I think everyone is well aware of as a barrier and a concern but it's definitely a complex problem to solve we also talked about the variation in how the care management work is happening in different communities and this tension that we always have we see it in the blueprint between sort of local control or sort of local realities and then the need for there to be some standardization and consistency so I would say I've seen that tension through the whole implementation of the blueprint that's been over the last decade plus and then that has sort of carried into the work that we're doing today we also identified that there's some coordination that providers would love to do but it's illegal and that's an ongoing concern that came up when the Affordable Care Act was passed where there's this tension between how the justice department type folks think about these issues and how providers think about the issues and the barriers are real certainly reimbursement limits for this kind of coordination work and then another piece which is that we don't have enough people necessarily to take care of everybody and so it's really hard to find enough people to also coordinate the care of everybody when that person might actually be able to provide a direct service so that that can be really challenging as well these are some really great examples of success that I'm not going to read to you I'll let you take a look at those but a couple of things I wanted to just know these are very human heavy initiatives so they are really focused on real people, real providers community health workers, other types of folks having relationships with people with complex needs and really assisting them in a pretty deep way and that's really the work that's required to reduce emergency department visits and hospitalizations which is what you see carried out through most of these initiatives as a sort of outcome but to me what I was struck by as I read through these was how much interaction, live interaction between real people and the folks that are trying to serve how important that is and I don't think we're going to get away from that it's always behavior change is really complex people have some pretty challenging life circumstances that take quite a bit of effort to work through so some themes and you're going to see these carried forward in the recommendation there's a broad continuum of care coordination providers there's more we're going to do to develop and mature our care models and then one other thing that we talked about and that I definitely feel is important is that we spent a lot of time focusing on primary care as a critical service and it is a critical service where we need to go next I think is and actually we should probably change that to an and, isn't that the way you're supposed to do it but and there are other places where primary care is essentially happening and where primary care can be extended so into the home, into nursing home, using telehealth so there is I think we just need to sort of think more broadly about what we mean when we say primary care because if we mean office visits that's pretty limiting then we talked about how designated agencies other community providers are already doing love care coordination but we've got those workforce vacancies we talked about there for some smaller independent practices some of those models are requiring some infrastructure that they may just not have in those practices and then the last thing is there's this is definitely a theme that I fear among the home and community based providers is making sure as we change these models and do our innovation that we look first to the provider community that already is providing some type of service before we start building new things and I think that's a little bit challenging in some ways partly because an entity like a hospital might be used to a home health agency saying no on certain things because they're not covered by Medicare and to remember that we've actually got this incredible capacity in designated agencies in home health that might not be currently reimbursable but that we could do with some other changes so I think that was the last key thing that's the last oh no we keep going to the recommendations so I'm not going to go through the recommendations because I actually said almost everything that is in here the themes are pretty familiar there are a few items to highlight we certainly highlighted the need for those delivery system reform dollars and efforts I know I don't need to explain that in this room and then there was also at the end of the next slide there's one about just aligning that reporting the screening, the performance indicators all that stuff that can really take a lot of time and effort there's a lot more work to do to get those things lined up to make it more usable for providers with less duplication so this is the last full section of the report before we get into the additional resources which we won't go over today and this was when we started off we talked about the three priorities and that one of the potential solutions to workforce care coordination and revenue stability is telehealth and we've heard it mentioned several times already today this section not only includes the recommendations but it's also sort of an educational piece because as we did the work in telehealth it became apparent rather quickly that there's a lot of misinformation old information about telehealth so the task force section of the report is part recommendation but part sort of educational reference so firstly when people talk about telehealth there's a lot of interchangeable words and so this slide is meant to kind of capture those words and it's structured by talking about the three very common modalities the ways that telehealth is delivered so this first column is telemedicine which is also referred to sometimes as synchronous telehealth and synchronous means live so this is the kind of telehealth that's happening in real time there's two ways that it's done there's from provider to patient and the provider is at what is called a distance site and the patient is at what's called an originating site so this terminology is important especially when we talk about originating site because depending on where the patient is and depending on where they get their health insurance they may be eligible to receive telehealth services and they may not be able to receive telehealth services and this conversation comes up a lot when we talk about patient's home or home life setting whether it's a nursing home or hotel wherever the patient calls home the second kind of synchronous real live our live telemedicine is video console so this is from provider to provider so this is when one doctor is talking to another doctor usually in an emergent type situation like in an emergency room so that's what is referred to as telemedicine synchronous telemedicine the second modality is called store and forward often referred to as asynchronous so this is not live this is a passive transmission of information it might be an image but it could be text it could be a question and this is also often referred to as an e-consult and there are going to be recommendations about store and forward and then the last is remote patient monitoring which is also referred to commonly as telemonitoring telemonitoring so again that relationship is provider to patient where patient can transmit health information to the provider from their home now while telehealth definitely has been identified as a potential solution to some of these barriers that we've been discussing the task force wanted to make it clear that it is not meant to substitute the face to face interaction between a provider or patient it is meant to enhance that relationship so this next slide basically takes what you saw on the first slide with the icons and gives a picture and an example so when we talked about telemedicine synchronous live being able to talk directly to you or doctor an example is telepsychiatry so being able to call your psychiatrist from home or from a hotel room also in that first modality the provider to provider consultation telemergency so if you're in an emergency room and the emergency room doctor is having a patient that's suffering from a stroke and needs to contact a neurologist they can do that through telemergency and we heard about this when we heard from Southwestern Vermont Medical Center it seems to be a relatively robust telehealth program and they are using the telemergency services we're starting forward there'll be a recommendation here if if you're in some of the circles that are talking about telehealth you've heard a lot about teledermatology teleoptimology those are the two forms of storm forward that are available at least under Medicaid in Vermont so this is an example of taking a picture of something that could be an issue sending it from a provider to another provider a primary care provider for example to a specialist and asking do you think this person needs to come see or do you think this is something that can be handled by us or will this go away and then the last example is the remote patient monitoring so this is a patient at home can take their own vitals their own blood pressure and send it to their provider so I just wanted to put up here these FAQs about telehealth in Vermont these questions came up a lot as we were kind of researching the topic here in Vermont so it's important to know that there is parity in Vermont for approved telehealth services in other words if I'm going to the doctor to receive a service in person and it's covered by my insurance then I can also get that service for telehealth but it doesn't mean there's pay parity there's coverage parity the service must be clinically appropriate and within the provider's license scope of practice it would be if it was person to person the patient must consent to the visit being done through telemedicine and there's consent form that needs to be filled out this consent can be bypassed if it's an emergency prescriptions can be prescribed through a televisit and telehealth consultations are not recorded that question came up actually quite a bit is whether or not they're reported and they're not reported even talking about telehealth the reason is because telehealth there's lots of research that shows that telehealth when we've heard it from different sectors that it can have a substantial impact in rural communities it can mitigate access issues specifically ones that are related to wait times telehealth saves time for the patient in terms of traveling to the doctor's office having to hire a babysitter to go to the doctor's office but it also saves time for the provider if a patient can forego seeing a specialist for example through e-console the dermatologist looks at the picture and says no they don't need to come see me well then they just save time to see a patient who has a more complex a more complex case so it helps save time on both the patient and the provider time but essentially the reason we're talking about is because it supports these three private areas and some of the research it shows that some effective telehealth programs for rural communities are chronic care management intervention, emergency care home monitoring, intensive care units long term care psychotherapy, remote counseling and interpreter services so we don't have a lot of information about how telehealth has impacted Vermont we can read the studies we do have we have pockets of information about how telehealth is working in Vermont so this map this chart shows information that's coming to us from the University of Vermont Medical Center and they have recently really beefed up their telehealth department and the head of their department Todd Young took a lot of time to meet with me and some of the members of the task force and the hospital budget team to talk about not only how they're doing telehealth at the Medical Center but about how it could and should work in Vermont this map here is showing the regional impact so of course this is sending into New York because this is the network and it's showing where the patients were living when they received their televisit so you can see how big that map is so these are all patients that are receiving services from the University of Vermont Medical Center and to sort of kind of calculate one lens of looking at the impact of this is through the savings in time they evaluated 561 video visits in 2018 and the Medical Center assessed that they saved 47,000 driving miles for the patient and 1,000 hours of driving time which translates to about 6.6 tons of carbon emissions so that's one way of looking at the impact and of course the next question is what's the financial impact what's the access to care impact and those sorts of analyses are still happening right now my understanding is the network is focused on just getting telehealth integrated into their services and with that they'll start to track this information we asked them about the no show rate trying to get at the access the access issue and they did say that for for specialty visits in person there's about a 30% no show rate so this is your going to see your specialist, you've been on the wait list for 4 months your appointment comes up and 30% of people don't show up whereas with a telehealth visit for specialty care the no show rate is 2% and when those 2% don't show up they have a process by which they try to figure out why they didn't show up was it a technology issue was it a scheduling conflict I think there's an argument to be made there in terms of access and using everyone's time efficiently but there are limitations to how telehealth is implemented in Vermont and when we spoke with various people providers, stakeholders, policy people the barriers are who can be paid to deliver telehealth services what services can be reimbursed what services can be used and how can provide our best incorporate telehealth into their regular workflow and in kind of teasing these it became clear that a lot of these are about information it's about having the right information timely information and sort of dispelling some maybe misinformation about telehealth services we can't talk about telehealth without talking about broadband limitations this will particularly undermine the modality of telehealth where people are using services from their home so this timeline kind of shows progress as of 2014 progress that's been made to expand telehealth we've been chipping away at making telehealth more available reimbursable when you see a green cell that means it was a state of Vermont initiative when you see a blue cell that means it was a federal initiative but between federal and state initiatives we're starting to chip away the hold out as is most always the case is Medicare Medicare is the one where a patient cannot receive services from home we're starting to chip away at that with the Medicare Advantage starting in this year Medicare Advantage members will be able to get services from home and through the all pair model it does two big things one is that Medicare patients who are attributed can receive services from home and the second and actually have this on the next slide but I'll say it now is there's something called a health professional shortage area it's a federal designation it happens all over the country but in Vermont there are parts of Vermont that are identified as a health professional shortage area and the second thing is that it's not all over Vermont in fact there are big pockets that aren't considered this health professional shortage area unless you live in a health professional shortage area you aren't eligible to receive the telehealth services under the all pair model that designation is waived so this chart is labeled draft and it probably always will be and I will just say I encourage anybody who has suggestions or corrections to this chart or if you know of people who might be able to help us develop this chart please do forward this along and ask them to contact us but this chart was trying to address those first limitations where who can provide telehealth services and what services are reimbursed well this chart is trying to get at that the columns are payers there's commercial, medicate, medicare and medicare advantage and then the all pair model and then the rows are the biggest kind of barriers to telehealth the first being whether or not a patient's home is an improved site the second is that health professional shortage area I was talking about the third is who's a qualified provider who can give the services the fourth row is about store and forward the fifth about remote patient monitoring and then the last is just to catch up or other limitations so I'm not going to go through the details of this but just basically how you would use this is for example if you were interested in how commercial reimburses for telehealth you could look down here and say yep I can be at home it depends on your who's providing your insurance but yes and yes it does extend beyond the health professional shortage area I could live in a place that's not in the HPSA and still receive the services one thing I will note here down on the bottom line is for FQHCs this is kind of a special problem for FQHCs is that medicare does not reimburs FQHCs as a distant site period so if an FQHC provider is having a video visit with one of their patients that is not reversible this is the last page before we get to the recommendations and it's the second to last page of the presentation so before talking about the recommendations first one is to talk about the expansion initiatives that are already underway on a federal level CMS is doing some things and congress is doing maybe doing some things to chip away at the medicare stronghold to chip away at the medicare looks a little bit more like medicaid for storing forward the state is sorry I have a very small type here this is about teledentistry so the dental access and reimbursement working group published their report in November and there was a signal there that when the department of health presents their budget to the legislature this year so in the coming weeks they will have a recommendation on teledentistry one of the sort of low hanging fruit so to speak is on storing forward right now in vermont storing forward is limited to teledermatology and tele-optimology and sort of a next natural step would be to extend that to teledentistry we have recommendations that go beyond teledentistry but that would be a next natural step I did forget to say when I was on this chart that the recommendations that you're about to see basically are just like the extension of this there's been a lot of work that's been done to expand reimbursement for tele-health and the recommendations are basically just continuing the timeline and then in terms of planning initiatives the EPQHC the vermont program for quality and healthcare has convened a group of stakeholders it's a very large group there's about 30 people that attend and I would even go as far as to say as regularly attend these meetings to talk about best practices to talk about planning to talk about implementation and it's a diverse group providers, policy makers and really just kind of a special thank you to Hilary Wolfley and Kathleen Holtman for their work on that they do this at the EPQHC underfunding from their 9.416 contracts statutory funding which is which is limited funding so they're doing this on a funding source that's limited so last thing to add for recommendations so the recommendations there's four of them basically the first is for storm forward e-consults to expand it expand this beyond the tele-dermatology and the tele-optimology the bullet points sort of recommend think of them as like tiers of expansion so the first would be low-hanging fruit to expand to teledentistry ultimately the goal would be in the second and third bullets which is to extend storm forward e-consults to services between primary care and specialty care so anytime a primary care doctor needs to consult with a specialty care doctor to have that thing allowable if it's clinically abbreviated the third bullet point is to expand reimbursement from Medicaid and commercial insurers to align with Medicare and reimbursement and I always have to read this one to myself three times because Medicare is typically the holdout when it comes to tele-help except when it comes to e-consults when it comes to e-consults it's allowable and so the goal would be to bring Medicare up to speed with Medicare Medicare that's why I was afraid to tell you the next topic is remote patient monitoring so again the bullet points are basically like tiers of expansion so the goal here would be to expand Medicaid coverage beyond congestive heart failure I haven't talked about this much but under Medicaid and Vermont a patient is only eligible to receive remote patient monitoring at home if they've been diagnosed with congestive heart failure and we asked why why is it limited to that and there really is no good reason and not because of lack of information but it's most likely because it's just ready to be updated some examples from other states are that they allow remote patient monitoring for anything that's clinically appropriate allow remote patient monitoring for commonly accepted applications such as COPD, asthma and diabetes and then the third bullet point are those examples from other states which are disease specific the third recommendation is for the ACO waiver to ensure that ACO telehealth waiver supports primary care and mental health at skilled nursing facilities and that word ensure is really what's important because there's just a lack of clarity on whether these services are available under the ACO waiver and then the last recommendation is on funding which you can see in the box is action by the legislature action by administration action by the all peer model action by private peers action by federal everybody and anybody who wants to contribute funding towards grants for telehealth planning and for programs so that covers the priority areas and telehealth any questions? it felt like we'd relived six months I'm sure I felt that we're not going to walk you through the additional resources but just wanted to tell you what's in there we have more definitions about telehealth because some of the recommendations would require new definitions being created in statute we have a section on related task force reports we have the inventory of course a bibliography of the articles and other materials that were circulated in the task force that we used to create the report and then a summary of the public comments and of course all of the information is posted on the task force website super are there questions from the board? a couple of things the first one is just to make sure I heard it right it was Perlora the slide 20 yes workforce biomex and challenges and I wrote down that you said that that was the number one concern and I'm just wondering whether this inventory is kind of prioritized from top to bottom yeah it is when you look through the report I'm just going to find the page in the actual report it is page 4 of the report and those are really by priority identifying the things that we can't do anything about first right the tight national labor market the aging workforce these are things we can't do provider burnout and then when you start to get to what are some of the real barriers in terms of access to the profession we heard loud and clear across the state that the rising higher educational debt was a primary barrier so you know in terms of things that we can actually tackle that rose to the top of our recommendations is that necessary no yeah correct the other is kind of like looking at the page 3 just these simple boiling down to the five questions that you're actually going to pursue and you've given them a fire hose of information I mean this is really a kind of a wonderful document because I think everything is is in here but you know if I was a legislator I'd you know I'd be sitting there saying be careful what we asked for because we got so much that is it so much that we don't know what to do with it and this is the end of a biennium there's so what's your take on the linkages with this report as it goes to the legislature and legislator leadership that can step through this to sort through with just the kind of priorities that Laura was just talking about where things that the legislature can take action and how do you go through that sorting process with the committees to to get as much out of it as you can by the end of the session I'll speak of it from the workforce perspective then others certainly chime in there is already underway significant activity on the workforce recommendations the legislators have been paying attention to this for the last six months they've gotten drafts at the committee chair level so we already have bills that have been introduced around interstate nurse licensure compact they're already working on the clinical nurse faculty credentialing challenges they are fully aware of where we are with respect to recommendations around tax incentives I think that certainly as you know the robust conversation and the legislature I think to the extent that we can get some of the lower hanging fruit we'll get some significant movement this year recognizing that this really is a multi-year approach and that the workforce issue really it's an economic development challenge that has a lot of larger issues that are certainly much bigger than this task force can take on that the legislature has to deal with but I think just trying to highlight for them what we see as the areas that we would like them to focus on and really I would say what this has done over the last six months is raise awareness of this issue for the legislature and the critical importance that this workforce shortage has with respect to our ability to afford to provide the services that Vermont is asking providers to provide it affects access you can't admit patients if you don't have the staff available to meet those patient needs so the ripple effects across the system I think legislators are really starting to understand but I think certainly on workforce it's a multi year issue so as I was listening to us give this presentation and this is the first time we've tried I here's one of my notes highlight items that legislature can do something about because there's a lot in here that actually isn't a legislative initiative and so I think that as we think about our different audiences we need to maybe highlight but I also just wanted to say I was really supportive of having this more detailed full reports or white paper version on the workforce issues in particular because of the probable need for multi-year focus on those issues and so I thought it was important to have more of a document that we could hold on to stand alone start to work through so I think you've raised a really good point that we're going to need to address but yeah we'll have to be thoughtful about that Just a little more generally what I would say is that we've been scheduled in one committee so far health healthcare next week and to Jill's point the task force met most recently yesterday so we did a quick turnaround to try and get this draft out but we still need to do things like do a full proof read and finalize any typos or last minute errors before we submit late hopefully later this week but I think what I've been trying to suggest to the committee chair that one approach they could take is let us do an overview so they kind of see the full scope of the work and then let's pick out the areas that they really want to do a deeper dive because I think we tried to kind of balance both of those approaches today but I think for a committee they really could take a very much higher level than we did today and then follow up and do okay today we're going to talk about workforce next week we're going to talk about telehealth or whatever so I think that's an approach that they could take that would really allow them to work through it in a more systematic fashion very comprehensive report and obviously there's been a lot of work behind this a couple questions on as you're going through this were you able to identify maybe like the most vulnerable areas in the state you know because we know we're all throughout the whole state and I like how you dealt with the Virginia County because a lot of people that are coming in there are from rural areas as well but was there any prioritization or looking at areas that might be more vulnerable longer term? Yeah I think we do know from the demographic information that the more rural counties do tend to be older so Northeast Kingdom, Bennington come to mind but the task force did not prioritize the recommendations by geography because the idea I think was that the policy change would benefit all geographic regions I don't know if Laura you had anything that came up related to that in workforce in your subgroup meetings? I think you know I've spent the last two years actually going around the state talking with facilities in every pocket of the state I think I've been to probably between nursing homes and residential care and assisted living 50 different homes over the last two years and I hear the same story no matter where I go obviously you know it is more of a challenge maybe in the Northeast Kingdom there are very very rural parts of the state and you have greater challenges around things like transportation in those areas and the ability of folks to get to work and to find child care so those I would say are maybe more significant challenges in more rural areas but the same story was told wherever I went whether that was Burlington or Derby so that's why I think we really tried to take it to how can we do this in a way that benefits everybody and benefits every sector whether it's a designated agency a home health agency, a nursing home, a hospital the unifying issue of workforce this has been really an incredible process because it is truly the one thing that cuts across every single provider group across every county in the state Next time you two are sitting next to each other okay maybe note that the other thing I would just say about the geographic issue is that I think part of the reason why we didn't focus on that is that on a policy level for and I'll just speak to the area that I know probably the best which is Medicaid I think it would be very difficult to target your policy recommendations by geography because there are sort of federal limitations in terms of having uniform rules across the same provider type so that would get very complicated very quickly and I think quite frankly if the financial deep dive had resulted in a different result and resulted differently then maybe we would have gone there but kind of where we ended up it didn't really make sense to and I think one of the areas that isn't really fully addressed right now is resource allocation kind of across within different areas of the state and that's probably a harder one to address with that just talking about consensus recommendations and you obviously had a pretty wide representation on the committee which is great but when you deal kind of with consensus sometimes that might limit some of the maybe tough topics because there's not consensus on things and so I guess maybe if there's something in the future I mean how do we overcome that because that can be a barrier sometimes if you're dealing with consensus to move forward that's some things that might be more controversial so one comment is that actually there actually wasn't that much trouble with it we had very broad agreement on almost everything that the conflict was around the margins if we had tried to maybe array which sector was in most need of more financial resources that would have been impossible and I don't think there's any environment where that could be made to work but I think we agreed to sort of set that piece aside so that we could work on everything else but I don't really feel like it was hard to find consensus because the issues were so cross cutting I guess one area we didn't get a lot on was the financial metrics in general and we don't look at half the hospitals are in the red and half the Home Health Agency that you showed and the hospitals were losing money and we don't know the full financial pictures elsewhere and it's just I guess the key there is time and how quickly are we going to be able to implement these things whether it's between workforce or telemedicine because you've certainly identified a lot of the key issues it's just hard to solve it's not something that's going to solve quickly and we're already losing money across the state in a lot of areas so hopefully the infrastructure will be there when these things go forward I think there are a lot of challenges I did just want to make a comment that what you saw was charges operating margins not total margins and so many Home Health Agencies actually have long standing expectation that they'll have an operating loss and they have been able to make it up on fundraising that's getting harder there's more and more organizations trying to do fundraising but I just want to clarify that it's actually really important I think for those agencies to be it's important for them to be portrayed appropriately in the public space it's actually hard to raise money if people think you're falling apart so that's where the sensitivity can come from and that's actually always our challenge and advocacy is how do we describe the challenges we face and yet make sure our communities know we're going to be there for them it's a real tough balancing act we're interested to see how this moves forward okay at this point we'll open it up to the public for any comment thank you it was a great afternoon I know that it was a great six months for team rural health task force so I'm going to move back to my chair and then that would be good would anyone on the board we should make a motion we should make a motion and Robin you may want to abstain from this I don't know well the big mountain care board is not studying the task force's recommendations in depth we support exploring solutions focused on improving the recruitment and retention of the health care workforce expanding access to telemedicine and allowing care models to mature the board understands that payment and delivery system reform is the path forward to financial sustainability and a retrenchment to fee for service payment is inconsistent with federal policy and will only result in greater financial distress for Vermont's health care providers is there a second is there a second is there any discussion if not all those favor signify by saying aye aye and I will abstain what the record show that it was a three zero vote with one abstention and one absence I should have probably we should have probably let you know that in terms of the task force report it was a unanimous vote of the members present and I abstain because the board had not discussed it yeah probably was a sad vote knowing that you lost a member of the task force just recently so yes we luckily had a we were able to substitute Steve Meyer so he was the official secondary designee for Tony Morgan who did pass away which was a sad day but we do want to recognize Tony over the years for the state of Vermont's is there any old business to come before the board is there any new business to come before the board seeing none is there a motion to adjourn to move it's been moved in second to adjourn all those in favor signify by saying aye aye any opposed thank you everyone have a great rest of the day