 Let's move to S 132 and 120 and yesterday we did not hear from some folks and they are all here. We have about 45 minutes 40 to 45 minutes and we have the green mountain care board is here with three people and I'm going to turn to Susan to you. I'm, I'm thinking that the best way to do this is to have a team presentation. Great. And I will turn to chair mullen to take this off. And so over to you. Thanks. And good morning everyone. This is a pretty fascinating conversation yesterday and a lot of extremely important points were brought out. And I just want to echo a couple and try to highlight them. Patrick flood talked about workforce and the real need for primary care and what we know is that in other countries in the world that have better health outcomes in the US. We have primary care doctors as they do specialists and we have the exact opposite in the United States. And I was hoping that somebody would quiz Patrick yesterday because he seemed to indicate that he had some thoughts on how that could be addressed rather easily. And this is something that we've been working on for a few years and nothing ever seems to be easy. And I can give you some of the things that we have tried we reached out to then Chancellor spalming to try to get a PA program started in the state of Vermont. For Cheryl, she'll know the history where the college of St Joseph and Rutland tried to start a PA program and it wasn't the wrong thing to do I think it would have made them sustainable in the long haul. Certainly they tried it at the end of really when they didn't have the resources to properly foot it up. And I know that a PA program sounds like a daunting task but when you're looking at the state college system in the situation that it's in, there would be some stiff up front cost to start that program but boy with that really bolster the college system in the future years. So, you know, I just want to point that out and also it's not just primary care doctors unfortunately it's everything from mental health counselors to especially nurses in my recent call with Northwest monitoring their situation. And Anthony Brio their CFO indicated that they have 21 travelers right now, and the price that they're having to pay for those travelers has gone up exponentially used to be 200% of what it would cost to, to pay to hire a nurse and Vermont. It's now well over 300%. So she said for the 21 travelers that they have right now, they could hire 70 full time Vermont nurses, if those nurses were somehow available to them. So, no system is going to be fixed if we don't address the workforce shortage. The network for shortage is driving up costs, you can see with the levels being spent. So, I just wanted to make sure that I threw that out there, and kept that at the front of all the work because a successful health care reform effort will only be successful if there's sufficient primary care and other providers to make sure the system works and right now it's going back up exponentially again, the problems that we're having with the workforce. So, a couple points to before I turn it over to Susan because Susan's really going to walk you through the comments and she's going to be brief, because we know your time is limited, but I just want to address one comment that was made yesterday. I don't lobby for things. What I do is I try to pursue the state strategy. You laid that out for the Green Mountain Care Board and Act 48 and in Act 113 and as a state regulator, we follow the statutes and the statutes right now are that the plan for health care reform in the state of Vermont is a move away from volume to value. And so I don't want anybody think that I lobbied anyone on anything other than we believe strongly that if the state strategy is to move to value, which we think is a very good strategy, then we as regulators are going to do everything that we can to try to make sure that we do move towards value. So, just a clarification I'm sure that it was really kind of a misstatement more than anything else that was made yesterday but overall I thought the conversation was great and Susan will get into the details but I just want to make sure that you do realize that the more clarity that you can put into the legislation, the much better off everyone is. And I just want to point out that and Susan will get to this in her testimony but the language around tying the compensation of the executive team to the median salary of primary care doctors would be problematic for us to currently certify the one ACL that we have in the state and just want to make that very clear to everyone. And with that I'm going to turn it over to Susan who will walk through the sections. Thank you Susan. Thank you chair Mullen and thank you committee for having us today for the record I'm Susan Barrett I'm the executive director of the Green Mountain care board. And what I'll do today is I first want to touch on S 120. And then I'll get into a general overview of the S 132 and then I can go into sections but you know I'll follow your lead. Madam chair, and we'll go from there. So, so Susan, do you have this and can we get this in writing. We do. Because I'm looking at our time and with, you know, this is it for us on this bill pretty much. Yeah, that's why we put it in writing writing that reason. So first in terms of S 120. We support the bill. We look forward to the insights and the information that you're going to learn potentially the bill passes. And we also want to offer any assistance to the committee that comes together, either in research or in data in the regulatory and evaluation work that we do around the healthcare system. So that's S 120 and I'll, I don't know if you have any further questions but but we do support that. Yeah, could I just ask quick, quickly. Sorry. I'm glad I'm glad to hear that and I think actually having your assistance would be really helpful. You're the data presentations that we've been getting from your staff and members have been incredibly helpful. I love them. And I see Elena, thank you so much. So do you, would it be okay to have you list, you know, referenced in the bill so that it's clear that that this committee would consult with you or like a sort of an in consultation kind of language. That would be up to you, Senator Hardy, but we would we would welcome that and whatever you need for research or anything that we can do to help you. We're always here. Thank you. I appreciate that. Great. And then I'll just give a general overview of S 132. And then again, we have everything in writing so we can send you a section by section after this. So we support the move to value based care. We're committed to an all payer approach to delivery system and payment reform. And we've experienced recently as everyone knows some significant data disruption in the model due to the pandemic. And that it's really unlikely that we'll be able to test the true value of this model as we get anticipated because of this disruption really for 2020 and really going into 2021 as well. So that said, we still sees that we're going to have some clear lessons learned and we're seeing that and we were grateful for those lessons learned. We know that we need to keep moving away from fee for service as I said, and that the volume based payment models that we're looking at and the model such as fee for service and towards value based payment and delivery system reform allows Vermont providers to focus on keeping people healthy and out of the hospitals and as addresses chronic illness, rather than just treating the symptoms and a fee for service way, we must continue to increase fixed payments the board has been committed to that from day one of this model. And we want to tackle the changes related to provider sustainability and I'm just going to put a plug in for Elena here that we did produce an update for all of you and for the legislature on the sustainability report. And whether it's over the summer or later on we'd be happy to come in and run. Actually, I'm offering Elena to run through that with you. She's the expert. So, we saw the value of the value based programs during the pandemic, and we saw those fixed payments really relieve some of the pressures that the providers felt as when we were shut down and patients couldn't come into the offices. And we also recognized that they weren't enough because our scale targets hadn't been met, because we need to do, we need to increase scale, and we need to do that substantially. The, the current model as we've said before and I'll just say it again, it is provider led and voluntary. We see the advantage is advantages in increasing equity and reimbursements that this bill addresses. Many areas of the bill do require the board to create a system that shifts from provider led and voluntary participation to one that is state led. So this is a big lift as you can imagine. We would really want to study that carefully and make sure any changes are done. Again, very carefully to ensure that we're attracting providers to these models, and that these programs continue to work for for the providers but most importantly for Vermont patients, because we need to keep talking about the patients and how this is affecting them. One thing, a couple of things on the ACO oversight statute, the chairman brought up Act 113. This statute, it's, it's already very difficult to document a lot of the results I would say or just document in general because much of it is very qualitative in nature. Many of the requests in this bill reflect work that's already been been being done in this statute. An additional statutory requirements associated with this bill would add to the administrative burden of documenting compliance with respect to the statute and add barriers, and that's on current participants I would say it could potentially add barriers to entry for other ACOs contemplating in the Vermont marketplace. So there is no requirement that there's only one ACO, there's nothing in the agreement that says that and and we would be very open to other ACOs coming into the market. I just closed by I mentioned the financial sustainability of our hospitals and the report that we just submitted as an update to you. We're considering a lot of the things in this, this bill, a lot of the things you talked about in S120 in that work as well. Just to tick off a few, we're looking at affordability, how are hospitals emerging from COVID. We know that there's really long backlogs of preventive testing that they need to get to so that we can make sure nothing is missed like mammograms like colonoscopies and we need to support them in doing that. We want to look at, we want to look at how the hospitals are looking at health equity. We know that that is something that is going to be really important. It's really important now. It's finally getting discussed more, which is really music to all of our ears. But we also know at the federal level, even at CMMI and CMS, they're also looking at this, everything they're going to do. They're looking at it through a lens of health equity, which is so welcome. And the last thing we're looking at and really one of the more important things in terms of sustainability is we're looking at how the hospitals are going to survive in a value-based world. So in our current system as we look at it now, how do they transition to more of their payments being paid for value? And that, I don't want to take Elena's thunder, but that's what she would cover when we do get a chance to update you on that. I have the section by section, which I can just run through quickly or I can just send it to you, Madam Chair, which would you prefer? Why don't you, why don't you send it to us just, and if we can come back to it today, we will, but I think it's probably best to do that. I do have a question for you. Sure. It's on S120, and there's a charge given to the committee that would include the efficacy of Vermont's all-payer accountable care organization model and changes that would be necessary to make health care more affordable for Vermonters or whether an alternative model would be more effective. So I'm just looking for your comments on that, given that the affordability relates more to hospital caps, budget caps, and long-term outcomes and quality, health quality outcomes. So, and it's sort of more Medicare, right now it's a Medicare agreement, Medicaid Medicare agreement with little participation on the private side. So I'm just wondering what your thoughts are on that. I'm going to start, and I think Chair Mullen will chime in here because I know we've talked about this a lot at the staff level. Let me just say that the board is committed to this model, to continuing this model. There is, as I stated earlier, we're learning quite a bit, and we know that it's not perfect. But we are making incremental changes. In terms of affordability, that is something that we look at, and again, I might just transition over to Chair Mullen here, but that's something we look at in our rate review process. It's obviously something we look at in our, it's written into our rate review process. It's something we look at in our hospital budget review process. It's something that I actually, and I think it would be very helpful if you, the legislature could define that. We would be open to that process and work with you on it, on affordability, because it is the affordability in our rate review process is very un-defined. Let me just ask this question, because I'm getting more information than I asked for. I'm asking, if you think that this committee is the right committee to do this assessment, that's all I'm asking. If the committee is reaching out to the Green Mountain Care Board for the data, there are implications here for the workload for you to do this. So I'm just asking that given that we currently have a CMMI evaluation and that we recently got a letter back from the CMMI, and we also have the AHS involved here. So I'm wanting to know your opinion about, and your thoughts about, not an opinion, but a measured response to this particular number. I would say that there is going to be, and it currently is, a federal evaluation of the all-payer ACO model. That's number one. That is being done currently by NORC and the University of Chicago, and they have a contract with our federal partners, and they were delayed a little bit because of the pandemic, but they are getting out now to start getting information and evaluating this model. So then the question arises for me whether or not this is a valuable experience when perhaps some assessment of premiums and co-pays and rates might be more appropriate in determining affordability. So that's all. I go in a different direction. Chair Mullen, did you want to comment? On your line of thinking, Madam Chair, when you talk about the premium rates and things like that, the statute in some respects is conflicting because it's designed that DFR offer a solvency opinion and set a range for the RBC, which is a measure of solvency. So oftentimes we don't believe that a premium increase is affordable, but at the same token, we're kind of locked into the statute that sets that range for the RBC. So it's a conflict, and we wish we had some magic wand that we could meet both of those at the same time, but it's very difficult. But so I guess, but I'm going back to the task or the charge given to the committee here on the efficacy of Vermont's all payer accountable care organization model, given to the legislative committee, and I'm wondering, given that you may be included in this bill. And so that would be a request for your input on this. I'm just wanting to know, is this something that's going to happen between now and November? Do you mean the federal evaluation? No, no, this is that I'm looking at the bill. This is a task for six legislators. What I'm hearing you say, and maybe this is a good way to communicate is to report back to you and what I'm hearing you ask. So are you asking, do we think it is appropriate for the s 120 committee to be evaluating the efficacy of the all payer model over the next four or five months. That's exactly what I asked you. It's a very large task. So, but answer the question, is it something they can do? I, you know, I look at this and I think going out to visit with people in the, in the state to talk about affordability and this one is just layered on as almost literally and and something the CMM I is currently doing. So I don't, I don't. I think if you wanted to evaluate in the terms of like the federal evaluations, they evaluated the state innovation model bill and evaluate the all payer model. Typically they are done year, like they come out a couple of years after the model finished. So, sorry, Susan. Now go ahead, Elena. And I think it also depends what you're defining the evaluation. So the federal evaluation is, is, you know, a comparison, it's a statistical comparison of outcomes and inputs. If you're thinking about stakeholder process to learn how it's affecting Vermonters I think that's a kind of a different task, and that could perhaps be done over a series of months but I think if you're really looking at kind of understanding statistically if it's had an effect that I mean, number one the data aren't there. So I think that's one challenge in of itself but it also usually takes quite quite a bit longer to do. So the word that's in the bill and then we'll move on because we have two other witnesses but the word that's in the bill is the efficacy of and so that's that's significantly different from. So what do you think, you know, it's significantly different and so please think about that. And, and let us know your thoughts on that. I see two hands up. I'm hoping that they are quick questions and because we need to move on to two more witnesses, Senator Hooker. Thank you. Thank you, Kevin and Susan and Elena. I guess my concern is that with this question of efficacy and the upcoming renewal of the contract, how can we enter into another contract without knowing the efficacy of the program that has been in effect. And so that's what I think we're trying to get at or at least my intent in this bill is to find out if we're doing if the ACO is doing what it's supposed to be doing. You know, fine, go ahead, move on. If we find that it isn't then we need to cut our losses. So that's where I'm coming from. Thank you, Senator Hooker. I would just say that the problem is because of the pandemic. It's hard to say for sure. And so I don't think that the state of Vermont should be rushing into a large multi year extension but I do think that there would be the need for a bridge period to actually give the current model a chance to work. And unfortunately, you know, that might take, you know, a one or two year extension or something to try to really get the facts on whether or not this is doable or it's a waste of time. So, and I appreciate that and I'm wondering is there that is that a possibility we don't have to enter into a five year contract. Everything's a possibility. The way the current agreement works we at the Green Mountain care board have to submit a report. I think it's December 21 maybe Susan. Does some end of this year. Yeah, that we may. Yeah. So, I don't want to I do, I do need to interrupt the conversation it's, you know, yet again it's an excellent conversation. But we have two folks who were here with us the other day and who need to testify. And so I'm will move on and if we get a minute or two at the end we'll come right back to this I know how important this is to everyone.