 Michael Barber is on, so he must have solved his computer problems. Congratulations, Mike. Thank you. A little stressful. So good morning, everyone. My name is Kevin Mullinger of the Green Mountain Care Board, and I'm going to call this morning's meeting to order. We're going to dispense with any executive director's reports or discussion of minutes or older new business for this morning and save that for this afternoon's meeting. The sole purpose of this morning is really the collaborative surgery center's certificate of need application. And so for the purposes of this hearing, I'm going to designate Michael Barber as the hearing officer and turn the meeting over to Mike. Okay. Thank you, Mr. Chair. So this is a hearing in docket number GMCB-008-21 CON in the collaborative surgery center. The hearing is being held pursuant to 18 VSA 9440-D2 in Green Mountain Care Board Rule 4.407. As the chair said, my name is Michael Barber. I'll be the hearing officer. Representing the applicant today is Alexander La Rosa of MSK Attorneys and representing the Office of the Healthcare Advocate. I'm sorry. Am I the only one that he froze on? This is the reporter. No, he froze for us too. All right. Mike, we'll give you a couple seconds. If not, Laura, are you prepared to fill in as hearing officer if Mike continues to have computer problems? Certainly. Okay, let's give it a minute and see what happens. Mr. Chair, this is Susan Barrett. He is in our state office, I believe. So the internet should be fine, and I know someone is there to assist him, but I just texted him just to give you that update. If anybody's just joined us, we're in a little bit of a technical difficulty. We're trying to see if our hearing officer can get back online, and if not, we'll proceed without him. So I just got a text from Mike and he said probably the safest thing to do is turn the meeting over to Laura. So I'm here by appointing Laura Bellovo as the hearing officer. Good morning, Laura. Back. Can you guys hear me? We can. Okay. All right. I don't know what just happened. I'm sorry. You want me to keep going or you want Laura Bellovo? I'll resend the appointment I just made and then revert back to the hearing officer, Mike Barber. It's turning into a three stew. Just get here. I apologize. I'm having some computer issues this morning, it seems. So I think I was, I don't know where I lost you guys where I froze, but I was just a court reporter. Go ahead. You have it right there, Kim. Yes, you were introducing the health care advocate. And I had a question. I see Kylie and Sam Peesh. Who's representing the health care advocate today? It'll be Sam Peesh. Thanks. Thank you. So the schedule for this morning will be as follows. First, we're going to hear a brief presentation from the applicant, then the office of the health care advocate will have an opportunity to ask questions and board members will have an opportunity to ask questions. Then we're going to take a short break. After the break, the applicant will have an opportunity to provide additional information if they think that's necessary following the questioning. And once we've finished with that, we're going to move on to public comment and then I'm going to turn the meeting back over to the chair to journey. So in addition to the comments that it receives at the end of the hearing, the board will accept public comments on this application for 10 days from today. So through Monday, February 7th. And with that, are there any questions or issues that either party feels we need to address before we get started? I'm not hearing anything. I'll turn it over to you, Mr. LaRosa. Thank you. Good morning. Appreciate the board's time on this yet again freezing morning. And I am here with a number of really exceptional individuals to present the Collaborative Surgery Center's certificate of need application to this board. And we've structured our presentation today to highlight what we think is worth repeating. Obviously, there's been a fair amount of filing both in the certificate of need application that was filed and in responses to this board's four sets of questions that you board members all have. And as a board member myself, there's nothing I like less than having things repeated to me that are already in writing. So we've really tried to tailor it and highlight what we think is critical to discuss this morning with the board. I'm joined by Susan Ridson, Elizabeth Hunt, and both are founding members of the CSC. They are very excited to present this woman led initiative into healthcare to the board. I'm also joined by Amy Cooper. Amy Cooper is a manager consultant. She's not a member of the CSC, but she's been engaged based on her experience running a other ambulatory surgery center to help guide the development of this project. We've got a short PowerPoint presentation for you. It's maybe what 15 slides or so that we're going to run through. Susan's going to run through that to begin. We've structured it in a bit of an informal manner. We have both Susan and Liz have experience and expertise in overlapping, but also in distinct areas. And so as necessary to expedite the presentation, they may be both sort of jumping in and commenting on slides. Of course, you're welcome to ask questions at any time. They are happy to answer any questions the board may have. And with that, I guess let's just get started with our PowerPoint. If the board has any introductory questions it wants us to address, we're happy to take those. But as it is, I guess, Michael, how does this work? Do we, I use the term drive, each, do you want us to screen share the presentation? Do you want to go through it? How do you want to do that? If you can, if you have that ability to take control of the screen and share the slides, I think that'd be easiest. Okay, Susan, do you want me to run and you can just say next slide or how do you want to do it? You know, I'm fine driving. Okay, so you can go ahead and do that then. Yeah, I have to. Mr. Gehring officer? Yeah, I will. Yes, Mr. Chair, you remind me to swear in the witnesses, I assume. Yes. I remember. Pause for just one second, please. AJ, if you would drive, that would be great. I'm having some like privacy notices come up that I don't want to deal with. Okay, let me pull it up. Okay, thank you. Sorry about that. Not a problem. Mr. Barber, do you want to do that or? Yeah, while you're pulling up the slides, I'd like to swear in Ms. Cooper, Ms. Ridson and Ms. Hunt. So if you could please raise your right hand. I'm going to do it too, just in case. Okay, do you swear or affirm that the testimony you'll give today will be the truth, the whole truth and nothing but the truth? I do. I did not hear Ms. Cooper or Ms. Hunt's response. This is the reporter. Ms. Cooper, you're muted. Thank you. I do. Okay, and Ms. Hunt, you're muted also. Sorry. I do. Thank you. Thank you. Sorry, I had the wrong version open. Give me one second. Okay, I'm going to try to get this to work. Can you all see that? Yeah. Okay. Perfect. All right. So without further ado, I'll press on. So here, just a couple of things for the court reporter. You may hear me use some abbreviations. ASC stands for Ambulatory Surgery Center and CSC is the Collaborative Surgery Center. And as AJ said, we're joined here with Susan, with Elizabeth and Amy. Sorry, was there a question? Okay. Next slide, AJ. Oh, yep. Sorry, I froze. So why does Vermont need the Collaborative Surgery Center? We believe the most salient reasons are to help decrease the long wait times that patients are currently experiencing, as well to improve access to lower cost sites of care here in Vermont, on which we think there's not enough of ASCs. If someone is typing. Yeah, there's some background noise. Thank you. The other thing about ASCs is costs are knowable in advance. So patients will get estimates of how much their procedure is expected to cost prior to surgery, which is a huge benefit in the healthcare space. ASCs are less expensive on average, about 50% less expensive than getting the same procedure at a hospital outpatient department. ASCs are very high quality centers. They score well in quality measures. They have low infection rates. There's very high patient satisfaction, as well as surgeon satisfaction with ASCs. Such centers help bring physicians into the state. Surgeons and nurses, we believe the CSC will do that. This is definitely a labor of love for our team. We all have day jobs. Liz is 30 weeks pregnant. But we're committed, we want to really help improve the healthcare environment in Vermont. And we're taking that a step further by pledging to commit 50% of the center's profits to help support underserved areas in the healthcare space, such as primary care, mental health, and so forth. This project's very much in alignment with the triple aim of healthcare reform and healthcare reform in general. And last, but certainly not least, the CSC will help to diversify Vermont's healthcare system so that Vermonters have more options for care. And we're in a hospital-centric system that essentially forces patients to go to a hospital and pay high hospital prices for care that doesn't need to be done in a hospital. The other thing that having a diversified system is helpful for is you have redundancies in the system. And it's in making it more resilient so that when a pandemic comes along or a cyber attack and takes down, you know, the local hospital, people still have a choice of where to get a surgical procedure if needed. Next slide. So briefly, what is an ASC? Basically, these are modern healthcare facilities that provide same-day surgical services. Services are offered are both preventive and diagnostic in nature. These are highly regulated centers or facilities. They conform to state federal regulations. And in the case of the collaborative surgery center, we'll also pursue accreditation with the Joint Commission. As I stated, these are very high-quality options for care, and they are rated very highly by both patients and surgeons. And ASCs aren't new. They've been reimbursed by Medicare since 1982. But their numbers have grown. There's almost 6,000 now throughout the country. And a lot of that is just due to technological advances in medicine. We have faster acting, anesthetics, less invasive procedures. So more and more surgeries are migrating to an outpatient setting. And that makes a lot of sense because, you know, you're right-sizing the location of the care to be in line with the acuity and needs of the patient. And last but certainly not least, because these centers are so efficient and well run, typically they save money, cost people a lot less to get a procedure done in an ASC versus a hospital outpatient department. And they have saved millions of dollars to patients, payers, and just the healthcare system in general. Next slide. Yes. This is Amy. If I may just add a point. I think you said it on the first slide, but I think really a lot of the motivation for this project is just helping to position Vermont's healthcare system better for the future. There are some major trends in healthcare delivery that we highlighted in the application with more surgeries moving towards the outpatient setting, which ASCs are well situated to address and help meet that future need. We also have seen, you know, an aging population in Vermont, that's going to continue with that trend, one of the oldest states in the country. And this, they will require more outpatient surgeries. And this is really a cost effective and efficient way to provide those. And additionally, we have had, you know, a real burst of population growth in Chittenden County. So looking five years ahead, 10 years ahead, this project is really about helping to position Vermont to have, you know, the best healthcare system it can in the future. So I just wanted to make sure that that's underscored as part of the motivations. Thank you, Amy. Next slide, AJ. Great segue to this slide. To Amy's point, ASCs are definitely helpful to address some of the issues that she mentioned. Unfortunately, Vermonters lack access to these more affordable sites of care where Vermont ranks 50th out of 50 states for the number of ASCs per capita. You'll see that New Hampshire has 28, Maine has 15, we only have two. In most states with populations the size of ours have roughly 17 ASCs. For their residents to choose from. So not only, so where Vermont is already behind the curve and we don't, and we lack surgical programs in the state. And we expect that to only get worse, as Amy was mentioning, more and more procedures are moving to the outpatient space. We have an aging population, we have a growing population in Chittenden County. All these factors will combine to increase demand for outpatient surgical space even more than it is today. Next slide. So one of the major reason that we believe the CSE is needed is just the long wait times that have been a long standing problem. This has been reported on as early as January 2017. Green Mountain Care Board has reports that confirm longer than desired wait times and different specialties such as urology, ENT. You'll see a spokesman from UVMMC said it would take 175 days to see an ENT doctor. Just for comparison sake, if you look at the UK's national health system, they designate 18 weeks or just a little bit over four months as the maximum wait time for non-urgent consultant-led surgeries. So if Vermonters are having to wait over five months just to see an ENT doctor let alone get a surgery were well beyond what might be considered normal or acceptable for wait times. Next slide. So long wait times aren't without harm. It's not just an inconvenience for patients. There are worse outcomes and higher mortality rates for patients across a broad spectrum of diseases. You have slow growing cancers that continue to grow. People might be faced with chronic pain and could potentially become addicted or abuse opioids to manage that pain. Folks get depressed and in fact the really sad story in the Seven Days article talked about a woman who was incontinent due to a bowel obstruction tried desperately to be seen at UVMMC was told that she was going to have to wait three months and she wrote in her notes that she was in misery and that this was no way to die and she committed suicide because she was in such distress. So these are real world issues and some people can't work because of their condition needing attention. So you have everything that goes along with that unemployment, financial hardship, disability and just increased costs in managing a condition longer than it might need to be managed. Yeah and Susan if I may just add in here as well. We experienced this at our business last year where we had surgical tech out of work for six months, had a car accident and injured her shoulder but then was several months until was able to see a physician's assistant and then after that had to have a scan and then after that for surgery ended up getting the surgery after being out for five months but would come in and see her co-workers and talk about the mental health impact of the isolation that she was experiencing being out and not able to work. The painkillers that she was on in order to manage the pain eventually got the surgery after five months with some help from other physicians calling to get her in in an adequate time and it turned out that she had a little piece of cartilage or bone that had shipped off and was floating around in her in her shoulder that was taken out after surgery and she was back to work within two weeks as and is feeling healthier than ever. So had there not been such a long wait time before the surgery you know that whole episode could have lasted a month or two and avoided the sort of extra problems that Susan talked about on this slide the isolation, the loneliness, the pain medications if we could only somehow increase the access to the surgeons. So CSC will help help get patients quicker access. Okay next slide you're good. All right so care at ASCs is more affordable and this is an important consideration in light of our high healthcare costs that continue to grow at an unsustainable rate. Vermont spent six and a half billion dollars in healthcare in 2019 and that constituted over 19% of the state's gross product and we have frankly some of the highest healthcare costs in the nation here in Vermont despite a very healthy population. So it makes sense to take advantage of the lower cost that can be realized by utilizing ASCs and this chart demonstrates that on the left-hand side you'll see a number of procedures that we expect would be performed at the CSC and the second column is the rate that Medicare would pay in ASC and then the column next to that is the rate that Medicare would pay to a hospital outpatient department and you'll see that the savings is significant anywhere from 29% to 66% savings and a lot of that is due just because ASCs are more efficient operations they don't cost as much to run as a hospital outpatient department. So there's you know good reason to take advantage of that. The other thing to keep in mind with this chart is only shows the difference in the reimbursement rate for the different codes. Hospital outpatient departments as well as inpatient settings they are permitted to charge for ancillaries things like time spent in recovery medications gauze and other things whereas ASCs cannot legally charge for those items everything's bundled in the code and reimbursement rate that they receive so the savings is likely to be more. So this really makes care more affordable to a larger part of the population and these prices will be available to all patients including those with Medicare or Medicaid commercial insurance as well as self-pay patients so we should take advantage of that as remonters. And Susan if I can add in there just again reinforcing the affordability here and that when we're referencing that these are the codes this is strictly for the facility fee that is charged. This doesn't include as Susan mentioned the ancillary charges such as time and medication. I personally have done a couple analysis of procedures that friends and family and myself have had comparing an HOP in hospital outpatient department procedure compared to an ASC procedure and the savings shown here again is for the facility fee but I was incredibly surprised about the savings that comes from not being able to charge for the ancillary charges in the ASC setting it does add up and unfortunately it's very hard to materialize because each site of care and incident of care is different of course for medication and needs but I think it's important to highlight that we are not able in an ASC to do that and it kind of moves in the way of health care reform in the bundled payment of it's a single charge for one instance of care. And again just bouncing back to the triple aim I think that this this fee schedule and the ability to clearly state prior to a procedure how much a patient will be willing to pay based on their insurance plan benefits is right in line with the triple aim of reducing per capita costs of health care improving the experience of care no patient wants to walk into a procedure not knowing what their bill is going to look like at the end of the day and that's something that we'll get to further on in the slideshow but it is something that we're very passionate about at CSE to ensure that there is no surprise billing and that patients are aware of what their cost of care is going to be once their healing is done and they're getting anything in the mail. And then of course again just to highlight the triple aim is this is all improving the health of populations by getting patients seen faster. Thanks. Yeah, thank you. So we actually have real world data in the example of the Greenmount Surgery Center and the Vermont Eye Laser Center in terms of the savings that Vermonter has realized through these centers. So this is from the Greenmount Care Board's annual report which I'm sure all the board members recognize. On the left hand column you'll see all the state's facilities, hospitals and ambulatory surgery centers minus two that were excluded for data reasons and the charge that each facility charges for different procedures and in all cases the ASCs are less expensive than the other option in Chittenden County which is UVMMC which is where the Greenmount Surgery Center is located and where the CSC will be located. Also the ambulatory surgery center is also among the lowest cost option relative to the cost at hospitals outside of Chittenden County. Next slide please. So drilling down a bit more that average savings of $2,000 per case it can be annualized to over $5,000 or I mean $5 million per year or for the year of 2019 when the Greenmount Surgery Center opened. So just orienting you to this chart you'll see that hospital average price which is basically the average price that we saw on the previous slide of all the hospitals in the state compared to the Greenmount Surgery Center price and you'll see the statewide average compared to the ASC results in a savings of 39 to 52 percent but if you look closely or drill down to the Chittenden County which is where the CSC will be and where the Greenmount Surgery Center is the savings is even more dramatic 35 to 70 percent and that's real money in an individual's pocket basically especially if somebody has a high deductible plan and they have to pay this money out of pocket $2,000 is a lot of savings for them and this is a lot of savings for Vermont too and this only reflects commercial patients savings to commercial patients in one year it does not include the savings accrued to Medicare or Medicaid. Next slide please. So as Liz mentioned earlier we will be providing patients with estimates of what their care we expect their care to cost prior to surgery we'll post all our prices on our website we're really committed to price transparency and it will be individualized according to the patient's insurance status as you can see here yeah go ahead. I was just going to add in regarding the patient estimates as I mentioned just before this is something that as Susan said is something that's very important to us to ensure price transparency within the healthcare setting we think in the ASC setting that this is something that's very doable and it doesn't create any sort of administrative burden or anything due to the size of our planned facility and one of the big benefits of doing this is we are talking about if a CON is issued of having a policy in place that we make sure that all estimates are sent within two weeks of the procedure longer if possible we would then rerun the patient's benefits. So what you're looking at on the screen is a mock of an actual procedure that could be done and we use a clearing house system that allows the patient's real-time benefits to pull in so if a patient were to call and say got this benefit but you know I had another procedure I had an ER visit we would be able to give them a real-time cost it would literally generate within 30 seconds and we had had the ability to work with them that if as Susan mentioned there's a high deductible plan that would allow a patient to say look I can't pay a $2,000 outpatient fee right now in our various policies that we submitted to the board one of them is payment plan policy that would result in zero interest payment plans so we would work with the patient to ensure that it's a payment plan that's affordable to them we don't ever want the issue of payment to deter someone from receiving the surgeries that they are in need of and then of course if there is a payment plan issue or they're saying there's just no way I can pay that we have a comprehensive financial assistance application that we would send out to the patient that would allow them to base on based their income on the poverty level in the state of Vermont compared to the national level and that would allow us again to make sure that the patient can be seen at the right time without any delay in care of their surgery date. Thank you. All right important consideration of the CSC or unique feature that we think is really valuable is just the unique environment that an ASC will offer to Vermont's healthcare workforce these are lean and efficient operations they need to be in order to stay in business so they are really fast-paced close-knit tight working environment that's really employee-driven I know this the CSC team will work very hard to make sure the environment is very positive and just inclusive of the employees ideas to improve just the flow and care there's minimal bureaucracy at an ASC which is just a nicer place to work for some people some people want to work in a large institution some don't so it's nice to be able to offer them that balance another huge perk to some is that you don't have to work nights or weekends or holidays so you have more work life balance and it tends to work really well for workers with families and small children and things like that and there's also plenty of opportunities for cross-training you don't need to spend years to move around and do different positions and Liz and Amy can tell you about you know Green Mountain Surgery Center employees who've done just that and moved around and really expanded their skill set. Yeah Susan I actually I have quite a few examples that I'm currently the Operations Manager at Green Mountain Surgery Center and I have multiple examples that in our short time here since opening in July 2019. Just some examples we've had a receptionist we helped her get into nursing school I personally wrote her a letter of recommendation so she is now at Vermont Technical College pursuing a nursing degree. We had a nurse who moved here from out of state and she was raising her family and took time off and she asked if she could get some clinical hours through our facility to get her Vermont State licensure back which we happily helped her with and that did not we did not require her to continue working with us in fact she's now working in the public school district but we wanted to help her by way of letting her get her licensure back. We have a receptionist that was trained into a technician role so she has worked up in her career rank. She's very quite happy and one of our very valuable employee here. We have a medical assistant who's currently training into a scrub tech role and that's medical assistant is more people that help patients get in and out of bed clean stretchers insert IVs. Scrub tech is an OR actually assisting setting up of procedures and working in a sterile environment different level of responsibility and she's doing fantastic. We have a technician who is currently training through a structured education system that we are covering and full for her to become a first assist so that works directly hand in hand with a surgeon to assist in things such as laparoscopic cases and things like that so we have sent her off to training and we are supporting her fully in her education there and then we have multiple business office staff who came on board here and I personally am working on getting them into different management skills in order to progress in their own personal career as well. Again as Susan said working in a small ASC is a different healthcare working environment for both clinical and non-clinical staff. Prior to working at Green Mountain Surgery Center I worked clinically both in first person experience within the healthcare system in Vermont and then I worked outside of it as a vendor and I do know the different environments you work in do impact your day-to-day life balance and I have seen just what a positive impact working in an ASC in our environment really can do to a person and then retain a lot of employees. Next slide. So we believe that those features of an ASC will help to recruit and retain valuable healthcare workers in Vermont. First of all we believe that our women-focused and or women-led and strong community focused organization will actually attract workers by itself. This is important to workers today what their employers are doing for their communities and we are firmly committed to our community. The another ASC in the area will give Vermont workers more choices as I stated before not everyone wants to work in a large institution and that's fine some do but many don't so it could help it will we believe it'll help recruit workers to Vermont and keep them here. Having another ASC in the area will also help to lessen the monopsony power that's in the labor market that often exists in a consolidated system which some would argue we have here. For those who are not familiar a monopsony is when a large buyer controls the market and can set wages for area workers who have few or no other choices to work in the area and this can lead to you know job dissatisfaction in fact there was a recent commentary by Richard Davis that talked about nurses feel who work in large organizations or hospitals they feel sort of institutional servitude and the CSC will not have that kind of environment we will treat the staff in a way that we want them to treat the patients so with lots of caring and so they you know pay that forward so to speak. And another CSC as the Green Mount Surgery Center demonstrated will help attract more independent surgeons to the area you know a American Medical Association survey showed that 66% of sub specialists are actually independent physicians and we do have a shortage of some surgeons and some specialties here in Vermont so attracting them with the Collaborative Surgery Center will help Vermont with you know having more surgeons in needed areas. Susan if I may add just a few examples there it's very common for physicians to be married to each other they're in medical school together and residency and all of that and there are several examples just in the last few years where a physician couple moves to Vermont one of the physicians works for the academic medical center one of the physicians is in private practice and operates at the surgery center we have examples of this in general surgery attracted a general surgeon and a geriatricist a physician who focuses on the process of aging one of them works at the hospital the other works in independent practice utilizes the surgery center we have recently had a gastroenterologist in independent practice married to a pain management specialist another really area where there's an acute need for more surgeons there one of them works at the hospital one of them works in independent practice and a couple of other examples we fully expect that CSC will help us recruit new independent surgeons to the state but also help the hospitals fill their needs with surgeons that they need as well so it's a very complex process recruiting physicians to the state and having those options as Susan talked about for different physicians to practice in different ways at the same time we think is really critical to helping Vermont attract and retain the kind of medical workforce that we want especially when you consider they that the physicians have these options in every other state in larger numbers we need to be able to compete with that I think too to add to that when it comes to staffing of the ASC itself Governor Scott most recently addressed this about we need to retain employees not just in healthcare but in the entire workforce within Vermont again it's it's having those options for our healthcare professionals or administrative professionals to seek a working environment outside of the standard practice within Vermont which is in a hospital setting and we have examples of that currently at Green Mountain Surgery Center where we've had multiple nurses who were actually went to nursing school at University of Vermont or Vermont Technical College sought work elsewhere outside of the state because they wanted to be in the ASC environment and have since moved back with their families spouses and partners to seek employment here which then of course brought in their spouse or partner to work in the workforce of other sectors within Vermont and their children into our daycare and school system so again it's creating that option for people to make a decision for their career and not be forced out of our state borders which we know is very important right now and how the state is trying to figure out ways to retain people of working age in Vermont next slide then of course we have the Collaborative Community Foundation that's our commitment to funnel 50 percent of the center surgery centers profits to associated charitable foundations that would support things such as primary care mental health child counseling services and just general health care reform efforts and the way that we envision this happening is we will make grants available to health care related organizations throughout Vermont we're really excited about this feature of our project next slide here's some key stats our project will cost just under 5.3 million location we are seeking an unrestricted multi-specialty license with a minimum of four core procedure types as you see there and it will serve the northern Vermont area primarily but also counties in New York and central Vermont as well next slide and this is the last slide just showing that the Collaborative Surgery Center does have broad community support people would like more options for their care and more affordable options and we believe the CSC will provide that thank you okay thank you so next we'll move to questions from the Office of the Health Care Advocate Mr. Peisch thank you very much no worries no worries just a record my name is Sam Peisch IUT him pronouns I'm a health policy analyst at the Office of the Health Care Advocate also known as the HCA so just want to say good morning thank you chair Mullen members of the board I don't believe I've had the opportunity to say welcome member Walsh great to have you literally and figuratively on board so specifically the HCA has comments solely on three points and we love to hear from the CSC as well of course there on the proposal to donate 50 of profits commitment which we just heard about the their patient financial assistance policies and making the case for requiring implicit bias training for staff and leadership at the CSC so on the first point we want to recognize that the CSC is proposing donating 50 of its profits to support the community which is obviously a substantial commitment and the HCA recommends that the board require the clavator surgery center to report the board on the use of their donations for the sake of transparency and to ensure that the money is being spent as described so the first questions area for the CSA in this regard to be good to know what criteria you plan to use and determining how these monies are going to be distributed to support community health as you stated in the application and today and we'd also be curious to hear how you arrived at this policy rather than an alternative such as charging lower prices for patients so that's the first comment any question so who on wants to take that so I can start out and just say that as far as how we will identify the needs we anticipate looking at several sources we would there's community health needs assessments there are different regulatory and legislative reports that talk about different areas in health care areas of need we would speak to you know area patients area surgeons area primary care physicians but we do anticipate doing it in some sort of structured way yes Susan I'll just add to that you know we have talked about the doing maybe a grant sort of program for organizations who are focused on the key areas that we've identified the primary care mental health counseling services health first itself when I was there which Susan now runs was the beneficiary of the SIM grant program and really enabled that organization to be involved in health reform and connected to a lot of the other organizations working on improving health care in Vermont so the one idea that we have talked about is structuring some sort of similar grant program obviously in a much smaller scale but to have organizations with ideas about innovating and improving services that relate particularly to primary care which is an area that has really always been a challenge to try and figure out how to get enough and the right kind of funds to support primary care so that we can continue with population health and with the goals of providing more care at the preventative early stages rather than later on when its conditions are more advanced and it's more expensive so I think these are all conversations that we've had about how this foundation well function so these these ideas are all on the table. Liz do you have anything to add on that? No I was just in that that I would be most likely in the form of grants and that you know CSC the foundation itself is not yet formed but we did mention in our application that the CSC foundation would be a separate entity within the actual structure of the business meaning that the board members for the medical portion side of collaborative surgery center would not be those that are running the foundation side just to make sure that there is no conflict of interest in where the money should go and I think that that's important to highlight. Thank you appreciate it. On the second point it'd be great to hear a bit more about the development of your patient financial assistance policy probably comes as no surprise given at the age that this is something that's important to us it's our position that we think it would be useful and beneficial for the CSC to be required to have a patient financial assistance policy that aligns with UVM medical centers given that they both operate or would operate assuming the in the same service area and the level of generosity of financial assistance policies at smaller hospitals does vary significantly but I think that the standardization would provide a more level playing field so I'm just curious to hear your response to that position and hear a bit more about how you developed your patient financial assistance policy. Sure Sam I can take that so our financial assistance policy for patients is actually completely comprehensive and in line with the University of Vermont Medical Center and we do that just to ensure that a patient isn't going to be dinged financially for showing up at our center versus theirs regardless of the ASC fee structure being lower we still want that same poverty level to match the same discount of care for for when they do arrive through our doors. Great thank you and on the final point so this is regarding implicit bias for training for staff and leadership at the CSC this stems from the clear data documenting racial disparities and access to care and care delivery for people of color this is obviously a national and statewide issue and I just want to make folks aware that there was a recent piece that I recommend that everyone read from researchers at the University of Chicago publishing health affairs documenting how racism and racial bias can be institutionalized through EMR or electronic health record so their analysis of patient notes were represented a sample of nearly 20,000 patients found that black patients are more than twice as likely as white patients to have at least one negative descriptor added to their history and physical notes and this is important as there's similar data to suggest that these descriptors lead to lower quality of care from providers people of color are also far more likely to experience discrimination when receiving health care services and Vermont is obviously it's a growing and diversifying state as for the last census count and more immigrants and refugees are coming to the state so it's a virtual statistical certainty that Vermonters of color would consider seeking care at the CSC assuming that the CON would be approved so to best serve these patients we believe that requiring implicit bias training at a minimum is an important step to help CSC prepare to treat a diverse population of patients with differing needs means experience and characteristics so we're hopeful that CSC will be willing to commit to this at a minimum and we're happy to work with the CSC leadership to provide resources about effective training and corresponding literature in this area this is something that we do at our office and at Vermont legal aid we're a project of Vermont legal aid it's an area of growth for all of us I think and if the CSC doesn't commit to this recommendation we would ask the Green Mountain Care Board to consider issuing that as a condition if it decides to approve the application so we'd love to hear you respond to that and those are the end of my comments thank you thanks Sam I can speak on that as well just on behalf of Green Mountain Surgery Center again as the current operations manager at Green Mountain Surgery Center we do perform implicit bias training with our staff currently and so that is something that we have spoken about as the CSC group that that is something that is absolutely vital to care for our growing population here and again we have a comprehensive training program that has established a Green Mountain Surgery Center that works very very well to educate staff and all diversity training language barriers pronoun you and all of those different factors that really does impact a patient's level of care level of comfort and our ability to serve them properly so we have full intention of doing that at Labrador Surgery Center. Yes thank you I would also add the racial disparities were talked about which we're certainly aware of and doing training on there also is a lot of nuance that goes into caring for patients who have our gender non-binary and identify in different ways there and what sort of pronouns you use there's different points from check-in through the procedure where it's very important to make all staff aware of what a patient's preferred pronouns are how they want to be addressed and we had a surgeon who treats these patients we actually treat a lot of these patients and particularly patients having gender affirming surgeries which we do a lot of at the Green Mountain Surgery Center particularly for patients on Medicaid one of the surgeons who takes care of a lot of that patient population actually gave us all of the training materials that we use videos online with you know quizzes and role plays that we then distributed upon after her recommendation to our entire staff tracked compliance with completing it and talked about it at our staff meeting so that everyone from the front office to the pre-post area to those operating in the surgical suites knows what our expectations are and has been through role play to try and make sure that their language and their respect for patients is demonstrated at every point along the way so that is something that I know the leadership here on this call of CSE Susan and Liz have already been involved with and certainly would be sure to bring that into the new center as well great thank you so much that's great to hear back to you Mr hearing officer okay thank you so now we'll move on to questions from the board and we'll start with board member homes great thank you so much thanks for the presentation I can really appreciate all the hard work that went into submitting the application addressing all the interrogatories I think it's a thoughtful application and I want to note that I really appreciate the charitable component that you just described about the proposed center um my questions are are going to focus on quality I think for the most part so you're requesting a CUN for an unrestricted multi-specialty outpatient surgery center I don't know if you have the application in front of you but on page 70 that is helpful to you you mentioned in the application that one issue with hospitals is that surgeons must cope with delays when nurses who are inexperienced with a particular surgery are staffing the ORs and one of the advantages of an ASC is that nurses are trained on a specific set of procedures so my question I guess one of my start of my questions is you only plan to hire six surgical RNs far less than what hospitals would employ so I guess my question my first question to you is what is a reasonable number of procedures that each RN could realistically be trained in and master so if they're experienced enough to ensure quality in a multi-specialty center I can take that one um so the so the reasoning behind requesting an unrestricted license is to allow for CSC to grow as the outpatient surgery population grows a CMS gum moves more procedures into the outpatient setting that's not to say that we're going to welcome 500 surgeons into the in our doors and allow 500 different procedures to be done we understand that within a four OR capacity fiscally calendar year wise everything that that's just not reasonable so um our quality measure and need of understanding that you want to have nurses who are specialized to certain specialties and then having an unrestricted license they are kind of separate issues because it allows us to recruit and meet the need of the community by bringing in surgeons and whatever specialty feels necessary at that point in time and that allows us for instance here at Green Mountain Surgery Center we have multiple specialties going on at this moment and our nurses are able to focus on various areas meaning we have a core GYN team and again we don't have we don't have an abundance of OR nurses we have just the right amount and it's lean staffing but they specialize in these procedures and that is all part of the operational kind of background work that goes into the ASC is understanding what our current needs are understanding the type of staffing we need to recruit and hire and that is based on what type of surgeons would say I'm going to come on board I want to start doing procedures there and then there we would match for the type of nursing that we would need staff so do you have any specific policies in place to ensure that the staff that you are hiring has the clinical expertise to support the diverse set of procedures that you do plan to offer what policies in place do you have yeah that's I mean that is part of our hiring criteria as of course like extensive background check into their personal history what their clinical history is what type of cases they've served which is very standard in any healthcare setting of understanding what type of background they have personally from their own training Liz I would also add that in some cases it's the surgical technicians not the RNs the nurses who are really the experts in terms of the equipment and the support that the surgeon needs during a procedure so an example is retina surgeries it was actually our surgical technician who really the surgeon interviewed food and determined was excellent at what he did and he has really trained the circulating nurses and another surgical tech to be real experts in that service even at the Green Mountain Surgery Center you know we have as Liz mentioned not that many surgical RNs who work in our ORs less than six but we also have a team of three or four surgical techs and on a certain service you might only have even half of that team I just meant mentioned that always covers that one service because they're the real experts in it so we do have a lot of surgical policies written by our OR nurse manager in terms of what's required to know for each service on the tech level and the RN level but the way that really gets taught is sometimes through experienced nurses but also sometimes through experience surgical technicians who are a real valuable piece of the puzzle okay um let me probe a little further um CON standard 1.4 specifically addresses the volume quality relationship which I think is related to this conversation and it requires that applicants have to show that they'll be able to in this is direct quote maintain appropriate volumes for services for which a higher volume of service is positively correlated to better quality so in the application itself on page 42 you know there's a space for the applicant for you all to address that and I just want to you know the first sentence in your answer says we do not believe that our application proposes services for which there is a unique positive correlation between volume and quality but then the next paragraph says while there's a demonstrated positive correlation between quality and surgical volume so I guess what I'm trying to understand here is how can both statements be true um that there's that your application doesn't propose services for which there's a correlation between volume and quality but yet there is a demonstrated correlation between volume and quality so I'm I really do want to understand this because it's a standard that has to be met so I think I can help clarify some of that um it's a turn of Barossa so I think the intent of the answer just in that section on page 42 on CON standard 1.4 is I think there's a um there's trying to be a disassociation between any individual procedure which is why the FOSA decompression is referenced versus the overall quality of care provided to the community when there is adequate volume to provide those services I think you heard Susan in the PowerPoint talk about how long wait times and inadequate access to surgical procedures has negative outcomes negative health outcomes and so the intent of the answer I believe is to is to express the the point that you know there are of course procedures where the more you do the better but that that's not really what we're trying to get at with this application what we're trying to get at I believe is the concept that by having and providing adequate capacity the overall surgical community and surgical field and meeting the community's needs you're improving health care to the greater community population and I think if Amy or Liz or Susan want to further comment on that they should but I believe if if I'm looking at the the response on page 42 in the CON application as to CON standard 1.4 that would be the intent to articulate that um the higher volume and service is positively correlated to better quality I think what you're talking about is quality of outcomes it's we understood it to be and that by having adequate staffing and adequate provision of surgical services across broad spectrum of surgical need you're able to provide better quality care to the community. Okay I understand that interpretation but I think actually really what's meant here is that the volumes are high enough for which there's a volume quality relationship to support the outcomes and so I'm just going to do one more question then I'll let this go but um you know you're proposing ortho surgeries and you know in slide seven you actually do mention total and partial needs and surgeries that you might do that's an area where we know there's a relationship between volume and quality the leapfrog group that you actually cite elsewhere in your application as a source of quality data on ASCs has actually developed minimum volume standards of 50 needs per facility and 25 per surgeon and 50 hips per facility and 25 per surgeon and I think the reason this is kind of my line of questioning is all around this because the reasoning for two of those metrics is that the support staff has to have enough practice to support the surgeon so maybe I'll just ask it more simply will you use um evidence-based research to develop for example minimum surgical volumes like those proposed by the leapfrog group to ensure that you have that minimum number of surgeries to ensure quality care for your patients will you impose have some sort of minimum volume standards where there's evidence that it there's thank you um board member home that's actually where after um attorney Larosa finished speaking I was going to mention as well that when it comes to minimum volume standards those um are um identified by right now we also have those at the green mountain surgery center they are identified by the medical advisory committee and that's the group of the medical director and then surgeons from each of the representative specialties and then our nurse managers they meet quarterly and determine what um you know all the credentialing goes through them which surgeons should be credentialed and part of the credentialing pot process for certain specialties one would be ortho which in gastroenterology is another one they set up minimum standards that anyone who becomes credentialed has to have done at least this many surgeries and if they are close to that number they actually have a process that's developed to observe have observations by more experienced surgeons before they can start doing surgeries on their own if they're anywhere close to the minimum number so there are actually policies that exist currently at the green mountain surgery center in response to these standards and guided by them and I think at csc the intent would be to develop a similar process there okay great um and then let me my last question actually involves something that you just mentioned um and I'm interested in the governance structure and particularly how it relates to quality assurance um in non-profit hospitals right trustees to comprise patients and members of the local community typically have seats on the board and they typically have seats on the quality committee so your governance structure was a bit unclear to me um in the governing policy submitted in response to the first set of questions it says tbd for governing board membership so and then in in exhibit six I think you outlined that the quality committee will be comprised of a center administrator nurse managers and members of the center staff so then every member of the quality committee as it's currently comprised has a financial stake in the center and it doesn't seem to be any community or patient representation in the way your governance structure operates which is different than how hospitals operate so my I guess my question is really twofold who's going to sit on the board of managers will it include any community members patients and what role if any will patients and community members play in quality oversight so uh the the governing um board has um yet to be uh constructed um Susan and Liz um would be leaders on it and then the surgeons who operate at the center would also be members as I think we described the um medical advisory committee then will be the medical director and then as I mentioned members um surgeons who operate across the different specialties at the center and then um the nurse managers the head of the post department and the or department um and um and then someone from the front office staff as well then the quality assurance and performance improvement committee which is the one that you just described which has um really the working members of the staff so that has um technicians on it that has um medical assistants that has nurses on it um it's really interdisciplinary group including um the administrator or director of the center what that group does is um looks at the feedback from the patient surveys and Liz you can talk about how the patient survey feedback um how um constant it is how consistent it is um how widespread it is how it gets incorporated into staff meetings into quality assurance and performance um improvement committee meetings um all of that Liz I know you're very familiar with that and running that process so maybe some more and that would be helpful yeah and part of um as Amy said with the quality assurance and performance improvement and then also the environment of care committee um as mentioned on our organizational chart that was submitted with our application that all goes up into our medical advisory committee it's also reviewed by the medical director and the administrator um but one of our key initiatives will be to ensure that patients feel heard one of my current roles here um again as operations manager is I am consistently looking at patient feedback receiving and from calling back patients um positive and negative and you know we work through it all um even if it's from a billing perspective or care perspective um we have we plan to have very robust processes in place of follow-up procedures for those patients um I I reassure patients currently at Green Mountain Surgery Center that their um concerns or compliments will be addressed in our upcoming meetings and um all of these things take place weekly daily um I send out a message to all the nurse managers to ensure that they're aware of this and they always bring any of these to both the medical advisory committee and medical director and administrator so the community is heard by way of feedback and our um patient feedback survey currently at Green Mountain Surgery Center goes out um post-operatively via a link um and our use our utilization rate is quite high for that and we do review that consistently um monthly in our staff meetings I plan a collaborative surgery center to um go through all of those and any sort of um issue that arises will be spoken about in a way that can be constructive um and again there's always follow-up so while our structure does not have any community members outside of the facility directly on any of these committees their voice is heard um and that is by a very robust system that communicates comes constantly with our patients okay thank you those are my questions thank you the next we'll move to board member lunch you sound like a shipment on helium not working great yes we'll just give Robin a sign back in yes yes yeah did you already move to somebody else or shall I begin no we didn't okay well good morning everyone I'm glad I could lend a little levity with my technical difficulties um so I had a quick follow-up for from um board member Holmes's questions related to minimum volume standards Ms Cooper you talked about the credentialing process that was helpful my follow-up was obviously you'll do that before uh someone comes on board how frequently do you assess the minimum volume standards after uh the person is credentialed um currently it's every two years thank you credentials okay great very helpful um so my first question is related to the utilization assumptions that you included in response to the first set of questions which is on pages 1-2 of your response to that inquiry um in response to our staff question related at least I thought that's where it was um but now I'm looking and it appears to be later hold on just one second let me see if I can find it it was in response here we go it's in response to question set three um and it's the assumptions for four operating rooms versus three operating rooms with a low medium and high in your application it looks like the four operating rooms low assumptions are consistent with the application and you explained your assumptions I'm wondering if you could just briefly indicate to us how you arrived at the medium and high assumptions so we can understand what went into those estimates and that was in question set three I'm just just for clarification yes question set three and it's uh there's not a page number on it I'm sorry to say but it's after the patient estimate example it's the charts with the assumptions for four and three operating rooms I think it may be in response to question seven that's maybe where we reference chart the charts the assumptions for three and four yes but you did not actually let the assumptions were the difference for it sorry Amy no that's okay yeah the difference in the high medium and low um assumptions the variable that changes in each scenario is the procedure time the time that it takes to do the procedure and um this are the low assumption is just using what um you know real data that we have available which I think is mentioned which is the the procedure time including turnaround time in the OR so not in the procedure rooms but only in the ORs at Green Mountain Surgery Center and I think that was 105 minutes total um we do um a lot of um you know relatively quick procedures in the OR right now hand surgery procedures um retina as I mentioned um plastic surgery procedures um which can be long or short but a lot of ours currently are shorter time relative to procedures that might be done at CSC in the future so and um Liz has a lot of experience with this having worked in orthopedics ORs in particular but those cases themselves might take two hours or 120 minutes and then you have a lot of cleanup because of all the equipment so then you're looking at 150 minute procedure time plus turnover at least and then again depending on um urology procedures was also have a lot of equipment involved in them and imaging as well within the procedure so those case times again are going to be longer and I believe that in the medium scenario um I don't have the table in front of me maybe we used 120 or 150 um but 120 120 okay and then I think if you look at the other data that was submitted by the local hospitals on their procedure length that the high scenario is maybe um close to those hospitals in procedure length time but below them even um considering that um the turnover time likely will be more efficient and faster but I think the range ranges from the low end what we do at Green Mountain Surgery Center which are probably going to be shorter procedures than what is planned at CSC um to sort of the long end the high end if we did um you know have surgeons who are doing more of the total joints in the future that take and other surgeries that take a lot longer. Liz is that um do you have something to add there is that a good description? No I think that's a that's a very accurate description um based on it's really based on the specialties that come on board again with with the proposed unrestricted license depends on which surgeons come on and of those surgeons what what is their concentration of case type and I have yep sorry go ahead Amy. No I was going to say a point that you raised um about just the variation even within a specialty um the sports medicine procedures in orthopedics are totally different length totally different payer mix totally different patient population than joint replacement procedures also orthopedics but fully you know much older patient population much different payer mix much much different equipment and time um you know Liz is really an orthopedics expert if there's more questions about that area particularly but the um projections and the predictions about this are are difficult when even within one specialty the range um in terms of procedure times payer mix etc a patient age population targeting um can range can vary so widely. Absolutely and I think um just sorry and that not to keep dragging that on but um another area within orthopedics that obviously will have a huge impact on time is the patient condition um you know I've been in knee replacement surgeries where it's uh it's a younger athlete with um slight degenerative disease um and then I've been in a knee replacement of the same age patient with severe disease um and it can go from an hour and 20 minute procedure to I've been in a five hour total knee replacement procedure um and um again as Amy said within the orthopedics realm um spine um does fall into that the orthopedic spine type cases and those were of course um while it sounds quite intense as I'm sure all of you know there are some very quick spine procedures and there are some very lengthy spine procedures so again it's that fluctuation of you until you know the exact surgeon and their specialty that would be coming on board um it is hard to estimate a really kind of like pee in on what their case times would be. Great thank you thank you that was helpful. I also wanted to draw your attention to a public comment that we had received about your characterization of PCI um surgery says preventative um and I was wondering if you would like to respond to that. Sure I can respond to that um first I'll just say we're super impressed that an interventional cardiologist had the time um to read through our application and comment on it and I'll just say our inclusion of um even mentioning PCI in our application was really stemmed from a desire to try and um plan for the future because cardiology is one of those areas or specialties where um they very recently started approving some procedures to be done in an ASC setting and it seems to be growing so we really just wanted to include it to show you know that things are dynamic and change and things are added all the time. Not being cardiologists we did um obviously make the incorrect assumption that getting PCI in either a hospital or ASC setting that the patient would experience the same sort of improvement in their health with respect to you know future heart attack and mortality risk. We didn't understand that a patient who would qualify for their PCI procedure in an ASC setting has different you know outcomes than that same patient than a patient who would qualify for it in the hospital setting. So we stand corrected and we're actually happy to get that feedback and would love to have someone like Dr. Go-Go consult on with us should we ever include cardiology procedures at the center. Thank you. Next I wanted to talk a little bit about your service area um it's and confirm what I believe is the service area you are uh asserting which is that your primary service area would be Chinden Franklin and Grand Isle with a secondary service area of Lamoille Washington and Addison in some upstate New York uh counties which I won't list and then the tertiary service area would be the rest of Vermont is that accurate or uh did I mess that up? That's accurate it is and we also anticipate some patients coming from Canada. Okay thank you. Okay and in your application you discussed um the potential impacts as you've assessed them to UVMMC what would be the impacts to the hospitals in the secondary service area and in Franklin and Grand Isle which you've listed as a primary service area if you know. Well I'll just start and um you know I think the literature shows that the biggest impact is for those that are closest um proximity to the ambulatory surgery center so we in the impact there is projected to be quite small I believe is two to four percent um so we do not anticipate that the impact to um hospitals further away would be significant. Okay and I would like to add to that just um again and on behalf of Green Mountain Surgery Center just living through this ruthless pandemic that won't seem to give up these days um we have um been able to actually collaborate with surgeons from area hospitals such as Northwest Medical Center um when their staffing needs got to um dire levels that they were having to reschedule their patients um that those surgeons were able to call us they were already credentialed here mind you but they were able to call us and ask for increased capacity um for operating time here to not have to push those patients that were already waiting or possibly rescheduled multiple times and of course we accommodated that we made things work we pushed things around um we split rooms in the OR whatever we had to do to get these patients seen so I think that redundancy in the healthcare system has been seen in real time and we hope that that can continue happening at Collaborative Surgery Center. Thank you Liz I was also going to add on the that's one way that um the existence of the Green Mountain Surgery Center has already supported surgeons who primarily operate at Northwest Medical Center when the OR time there got crunched due to COVID and staffing and other concerns um they asked if we had extra time we had it available and we were able to maintain um continuity of service and access to elective surgeries that would have otherwise been canceled at the small hospital um there are at least two surgeons that have moved to Vermont to operate at Green Mountain Surgery Center who when they have patients who are higher acuity older needing um or just live up in the Franklin County area um those surgeons um are preferred to operate at a small hospital where they know the staff and it's more um um familiar and um they know their equipment sometimes they bring their own equipment but instead of opting opting to maintain privileges at the big medical center in Chittin County they actually go and seek privileges at Northwest Medical Center and now have brought new surgeries that wouldn't have been here um had these surgeons not move back to Northwest Medical Center um and that's happened in at least two different specialties already so um just um things that have happened in terms of our relation to the other smaller hospitals that no one necessarily anticipated um before the project was approved but now have actually managed to have that sort of collaboration in real life. Thank you and um if you are approved as an unrestricted multi-specialty surgery center what would the impacts be to the Green Mountain Surgery Center? Currently the Green Mountain Surgery Center so part of our application if i can step back a little bit part of our application is that we would not have overlapping shareholders meaning that the current physician owners at Green Mountain Surgery Center um by way of of sharing the pool if you will would not be able to be in best conditions over at Collaborative Surgery Center um the Green Mountain Surgery Center is operating at right at our sweet spot um quite frankly we are we are unable to continue accommodating new surgeons at this point because our calendar is quite full and we always like to keep open that 10 to 15 percent a minimum capacity in order to accommodate those urgent cases so that being said we are um there's a couple services of course with an unrestricted license that would be overlapped but it would not pull from any one practice um and to compete one of the services that we hope that we currently provide here at Green Mountain Surgery Center is pediatric dentistry it was primarily a Medicaid group um Medicaid population i'm sorry and that is something that we really hope to provide at Collaborative Surgery Center solely because using or working with these dentists at um Timberlane pediatric dentistry as well as other dentists around the service area that have reached out to us personally um there's such a significant wait time issue with these children um upwards of 10 to 12 months um resulting the children going into the emergency room so there will be some overlapping of services um and that's planned for and that's noted and again the physician owners at Green Mountain Surgery Center are completely aware of this and um there is no um hesitation or hard feeling that there will be any sort of pull from either way okay and how about the eye surgery center impacts to the eye surgery center if it's unrestricted well currently the cataract cases that were um previously done i believe at Fannie Ellen um aren't aren't currently occurring um and so of course there is the possibility of that of those services being able to be performed at Collaborative Surgery Center um we've worked well with um the Retina Center or I'm sorry um the cataract services to date knowing that Green Mountain Surgery Center cannot perform those cases independently um but we don't foresee that being a large spectrum of care as we've mentioned our four core does not include the cataracts um so that is not something that we would be focusing on but as we said throughout the application if there is a community need if there is a significant backlog if there is a cataract surgeon who is seeking to be able to provide these services then we would of course accommodate and at least speak to them about how we could accommodate these procedures for them okay thank you um in two places in your application you referenced that most large commercial payers um based their contractual reimbursement on a percentage of Medicare are you aware that Blue Cross Blue Shield of Vermont does not reimburse as a percentage of Medicare yes and they are Vermont's largest health insurer yes okay thank you um could you explain your assumptions for bad debt and charity care in the financial table six as it was revised please take your time and pull it out if you'd like thank you Liz I know you're looking for it um on a high level I believe those were based on um the experience of the Green Mountain Surgery Center with bad debt and charity care which is our obviously um only comp and closest comp so just okay one and a half percent generally so that was um I'm sorry this is the court reporter I didn't get the percent that someone said one and a half percent one and a half percent thank you and um as Amy mentioned that is based on true numbers and really our only kind of data point for real-time numbers um that's below market standard in health care um but that is an analysis that we did in real time for a Green Mountain Surgery Center over the course of operating months um that's a number that Amy and I have worked on together um to estimate a true number um to ensure that our revenue is accounted for appropriately um and the 1.5 percent is accurate great okay and that you know in Vermont in Vermont we're very um there's been a lot of work on ensuring that a high level of the population has health insurance whether it's an adequate or it's commercial insurance so compared to national comparisons you know the bad debt and the charity care is lower um in some cases I mean um but part of the reason for that is just how much access there is to health to health insurance sure um I had a question uh related to that from um Elizabeth's testimony earlier uh when I looked at the charity care policy that you provided to us um um in your submission uh it was not clear to me that it would cover something such as an unpaid deductible uh but it sounded like Elizabeth that that was the intent is that correct sorry I'm pulling it up just so I can see the exact wording on that or yeah and I'll get it up too so on page two of the charity care policy under eligible services towards the end of the paragraph it says services reimbursed directly to the patient by the insurance carrier or covered by another third party are not eligible for financial assistance um and it's the covered by it's the covered by language that is confusing to me because certainly like a deductible would be related to a service where most of the cost potentially was covered by the insurance carrier but the deductible itself would be the patient's share that was obviously not covered um so I I think your charity care policy could use a little bit of revision if the intent is to cover the patient cost sharing and you could be a little more explicit about that so I wanted to understand what the intent was versus what I had read in the document from I'm having trouble finding that exact document right now I apologize um but one um our financial assistance policy does outline that regardless of the ability to pay um we would work with the patient um and so I'm not sure if that answers your question entirely I agree that that wording might not be entirely clear and that is something that we can work on to ensure um and again it's our goal is to be in line with area hospitals um and to ensure that they have the same opportunity for access to care um regardless of ability to pay okay and the charity care um and bad debt policy I presumably uh applies to the facility fee only since that's what you would charge is that correct correct okay and do you know or would you know what type of charity or or bad debt policy the physicians the physician owners would employ I mean obviously not specifically but in general how does that work there is um at at least how it works at the Green Mountain Surgery Center is when we have a patient who applies to financial assistance and qualifies we also pass that patient to the physician office and oftentimes it's the physician themselves who reach out to the patient and come up with a um agreed upon amount that the patient is able to pay after us having given the physician the information that we have thank you and then lastly um related to charity care if um if I assume that at some point you potentially will refer cases to a debt collection um and I wonder if you could speak to how you would anticipate that working um I can speak to that and we um we actually currently um just speaking in practice for on behalf of Green Mountain Surgery Center we do not use a debt collection agency part of our ethics and standards are that we do not believe a patient should go into any financial stress based on an inability to pay for healthcare so we do not incur any um any sort of collections agency that can dang a credit or um God forbid for someone's housing a situation or anything like that so that is not something that we would ever intend to do we just we don't think that that's ethical great thank you I am coming to the close um I had a couple of other questions that you've provided us with information on uh slide seven related to Medicare prices which I is it a correct assumption that you pulled those from Medicare's price compare tool on the their website correct okay um and then I'm wondering if you could speak to Medicare's policy of site neutrality and how that might impact on uh differentials between ASCs and hospital outpatient departments and if you're not prepared to answer the question you can you know certainly let me know that it's a good question um I'll admit that I haven't uh updated my knowledge on where CMS is at with the site neutrality policy okay thank you um and then in terms of Medicaid's reimbursement for ambulatory surgical centers how does that compare to hospital outpatient departments Vermont Medicaid specifically so and again totally fine to say if you're not if you can't answer the question sorry Amy let me interrupt you no that's okay I was just gonna ask Liz and I have both been um very involved with Vermont Medicaid over the last two years on helping them to develop and their consultants to develop a fee schedule for for ambulatory surgery centers when the green and so Liz I'll just start and then you can chime in on things I'm forgetting um the when Green Mountain Surgery Center opened um the Vermont Medicaid was paying Green Mountain Surgery Center off the physician fee schedule um so Vermont Medicaid up to that point had a physician fee schedule and a hospital fee schedule and that's all um and and um historically I think that may not have been a problem I don't know the details but for the surgery center that existed because their patient base is primary in Medicare and Medicare has a fee schedule so we started seeing um Medicaid patients from the time we opened a Green Mountain Surgery Center and realized that the facility fee that we were getting paid um was not near covering the cost of the drugs in the room time and the nurses and everything else and we said where is this coming from you know it was a 10th um in some cases of what the hospital payment from Vermont Medicaid was um and then we realized oh I think they're paying us off the physician fee schedule got in touch with folks at Medicaid say do you realize this is happening maybe time to relook at this um and they said oh that's a good point we do we ought to relook at this and develop an actual um ambulatory surgery center fee schedule instead of um you know just using the physician fee schedule to pay surgery centers particularly you know planning for the future um if this becomes um you know future ones so we went through a lot of um back and forth um advice studies how other states are doing it they brought um their fee consultant in we had um conference calls with them we brought the dentists in because uh you know we were about to bring on the Medicaid dental service um so they gave us um their views on how things work Medicaid listened to that went away and um did some research on all of it came back and created an ASC fees schedule which was just implemented in July of 2021 and Medicaid is now paying um from my understanding you'd have to confirm this with them that they pay surgery centers the same rates that they pay um hospitals in surgery centers in other states outside of Vermont which is lower than the Medicaid rate paid to in-state Vermont hospitals and we do in-state Vermont medical centers um but is similar to how they would pay if Vermont Medicaid patients went to out of state surgery centers that's my point of understanding um of how that works and now typically oh I'm sorry Elizabeth typically their fee schedules are posted publicly so that is something we can take a look at to confirm and I was sorry to add that within the Vermont Medicaid ASC fee schedule um a lot of the surgeries as we've mentioned um our gender affirmation surgeries of um breast reductions of um self-injected means of things of that nature GYN procedures um there's a whole plethora of them um but there is what they call a grouper um for ASCs which allows reimbursement only on the primary code so that is kind of more of that bundle payment service that um that we've agreed to and that we are performing current thank you for explaining that that was helpful okay I have just one more question um could I you explained in the application your current roles and relationship to the center could you please explain your what you would anticipate your roles would be with the new center once it's if it is approved and opened yeah I can start um as as is very evident um I am operations manager at Green Mountain Surgery Center currently um and I run our business office here as well um and we have been in um you know we've of course spoken about future roles um at collaborative surgery center um knowing that it definitely will take full-time human to do this same role in another setting um that's not probably realistic to think especially as Susan mentioned I'm 30 weeks pregnant um so we are um that's all in the talks and that's something that Amy and I are consistently kind of looking at and analyzing of what the future will bring should a CUN be issued um but just reassurance that we are aware of any sort of overlap of interest and that we are taking that into strong consideration when we are thinking about future plans and I think Susan just to mention you know your experience and knowledge and expertise really comes from being involved in Vermont's healthcare system more broadly and all the reform um and efforts that have been going into improving it um and so I think you know the idea top level is that is that Liz would be in charge of operations and Susan would be in charge of um the foundation and the community partnerships um and then I'm a consultant um offering my guidelines and advice on how to develop it thank you um I'll turn it back to you hearing officer Barber thank you so this might be a good time for a five-minute break if anybody needs a break sure why don't we come back at uh 10 15 thank you all for your uh it's amazing to me that this is like a 5.3 million dollar investment in the level of detail um that that you folks have come to understand is is is impressive and so I thank you for all that work um my first question has to do with the real estate transactions and um so the the application profile the letter of intent to lease between CSC and the Colchester real estate company holding an option to purchase a 5.25 curriculum drive um and but it seems uh there are filings at the Secretary of State's office that dissolve um LR and W effective 12 3121 and the Colchester real estate company effective 1 13 22 and so I'm just wondering if uh you can clarify whether this is so um and tell us the current status of the entities involved with the real estate supporting CSC's application so um I'll comment on that I don't think any of the witnesses specifically know about that transaction I believe um that the Colchester real estate company has closed pursuant to its option and has uh acquired the subject property so um but if if the filings at the Secretary of State's office have the Colchester real estate company um dissolving what what has taken its place uh that may be an error I don't know I don't really represent them there's I'm not entirely sure what if there's a new entity that they've assigned their rights to um we can certainly confirm that we don't we're not them okay so I mean so uh I mean that is important I'm just wondering whether or not you know there's changes to the to the financial arrangements here whether there's a new landlord whether there is um a new letter of intent and obviously the option to purchase probably is is null now if if the purchase has been made but uh I'm just wondering if if um we can get some update on this situation to make sure that um because a lot of this rolls out into the next 10 years and uh you know whether or not the profile of the deal that's presented to us is still the deal that um uh exists if if that's all right with you folks sure we understand that if there is any change in the technical nature of the landlord's name and entity it uh would be a full assignment of the letter of intent to lease our understanding is that any future owner would be subject to the lease in the terms of the letter of intent to lease and that if there is a special purpose entity with additional real real estate investors we don't know about uh who would take it over um well I also don't have reference to the dissolved I'm looking at the Vermont Secretary of State and that may be a filing error based on the timing so we'll certainly check confirm with the board not an issue well we can send you a copy of the filing if you'd like well I have it I see it oh okay um so assuming that um that situation basically stays the same um the uh and you know there is a change I mean the landlord uh was to deliver the fit up premises as per the plans prepared by Wyman and Lanfair and architects initial fit up costs uh were estimated or are estimated at 2.4 million landlord will incur initial fit up costs and said costs will be reimbursed by tenant through the payment of the base rent of $64 per square foot so my question given the prior arrangement was if the fit up as per the plans prepared by Wyman Lanfair architects cost more than 2.4 million is that the landlord's obligation to cover these costs with the rent remaining at $64 per square foot and I so I think that question shows why it's important for us to understand what the real estate deal is here because uh the landlord might be different I mean um um the landlord might be now coal chester real estate company um and so until we can see kind of what this deal is it's kind of hard to assess you know the underlying relationships sorry can you ask that question again I'm not sure I'm not sure I understand it so it so um in the the original arrangement or the land ward was to uh um do 2.4 million dollars of fit up specifically um um aligned with Wyman Lanfair architects uh 2.4 million dollar costs and so my question was if if the um that fit up as as designed by Wyman Lanfair architects is cost more than 2.4 million dollars who's who's on the hook for that uh it you know would it be the um the tenants or would it be the landlord and I'm not quite sure who the landlord is now um but um you know who's bearing the risk of a fit up going beyond 2.4 million like a cost overrun yeah because because there's a provision later in in the uh in the document that says that um that if the deal closes uh basically I can read it it says immediately following the receipt of a certificate of need tenant will have 10 business days to determine additional work tenant requires above and beyond the landlord contribution all additional work will be and that's additional to the Wyman's work all additional work will be considered tenant fit up and as such the tenant will be responsible for the cost so I just want to follow me yeah yeah so the so the intent of that in the negotiation early on uh to come up with this letter of intent to lease was that if the 2.4 million dollar number was I mean obviously there's a contingency built into that initial estimate um as any large construction project has the the intent and understanding of that would be if the fit up was you know reasonably greater um then that would be rolled into the overall cost of the lease but it's really not expected to be much overrun given the sort of high value estimate that was placed on it and sort of the retainage that was included in the 2.4 million dollar number um our understanding that if there was exceedance that would be included in the cost of the rent which is sort of how this is all paid back so would that be that the rent would go up beyond 64 dollars a square foot or that the um the rent in the future um to the landlord would would effectively be diminished because because uh you know part of the the cash flow went for these added tenant fit ups I guess I'd like to see this this I don't know I don't know how to ask ask the question now because I don't know what the arrangement is but I my concern was or my question was it's a 64 64 dollar per square foot rent part of that was to pay for the 2.4 million dollar fit up and the rest of that then fell to the landlord and so if you're telling me that um that uh if it's significantly above the 2.4 million dollar it will be the tenant that will pick that up and I think that then does you know uh have some impact on the um collaborative surgery centers finances I don't know but it's it's just a kind of a change that we just I think we just need to make sure we understand it the um well that's sort of I mean those are two two different questions right so um the first question is does then if there is a new business holder if there's new real estate entity are they inscribing to the terms and conditions of the lease intend to lease second if there's a cost over on how is that allocated right those are the sort of two issues you're pointing out right our understanding of the cost over and we're happy to confirm it for you is that it would be yeah amortized and spread out accordingly um which is the intent of this provision so yeah so so what you're saying is that it would be uh spread out over that 10 years and the uh because it was a fixed amount um every year for the tenant to pay back that um that fit up investment so what you're saying is that the amount coming out of this um collaborative surgery centers budget would be more um than is what profiled now because the cost would be more I mean I think it's sort of axiomatic that if costs that if the cost of construction somehow for any project exceeded the initial estimate that that would affect the overall bottom line of the project I mean I certainly can't say that any construction project is guaranteed to hit its bottom line number certainly not today and certainly not ever in the future or in the past um this number though is based on you know uh pretty conservative estimates based on current material costs which as we know are very high and I think there's a fair to high degree of confidence in speaking with Wyman-Lampier and um uh the people who built the Green Mountain Surgery Center that this is a pretty reasonable number construction wise um for this project okay so if there's any update for us you know that you can submit to us so that we can see this um on the financials for example that were submitted with the uh the application if we can see it it would be helpful just to understand it um my next my next question um kind of was a rollout of that that that the way that that uh the cash flows worked um out of the $64 per square foot rent netting the $2.4 million out of that on an annual basis that left um about a $37 per square foot uh for the landlord and I'm just wondering if if any research was done to to figure out whether or not that first year uh based um uh amount going to the landlord at $37 a square foot you know was within the marketplace just you know is that a number that that that is comparable to what's going on on the control Colchester real estate market for the Colchester real estate market is charging even higher premiums for space right now okay um my next question was had to do on the income statement um where the annual growth of the net patient revenue for years two three and four were 7.7 percent 10.4 percent and 10.1 percent respectively um relative to the expenses um against against that revenue for clinical personal clinical personal costs clinical expenses non-personnel and administrative expenses those grew exactly at the same rate you know as the net net present revenue on an annualized basis um and you know I such fiscal cemetery is unlikely to occur and um so I'm wondering since uh last July when you made this application whether or not um there's any kind of further insight into the growth rate expected growth rates for clinical personal costs clinical expenses non-personnel and administrative expenses Amy or Susan I didn't do the baseline projections sorry I was on mute all right can you hear me now yes so um the revenue per case is um one key driver of that is the case mix and how that changes um so through the projections you know we had projected cases by specialty and what we've seen is if you move your mix from you know lower lower revenue per case services to higher revenue per case services you know for example from GI cases um gastroenterology cases to more um plastic surgery or OR cases your revenue per case increases so that's some of the case mix shift there in the four years out is driving that revenue increase whereas the um clinical costs are um are staying consistently growing they're growing but they're staying consistent I mean one thing that we have found at the Green Mountain Surgery Center that inform these projections is how much space there is to control costs um one of the rules we have and Liz can talk to this as well but anytime we purchase new instruments or equipment at the Green Mountain Surgery Center or even disposables um is we have to get um three different um quotes on it and negotiate before we decide what to purchase um this is really a lot of what Liz Liz's job is um and the um ways that you can control costs um by really being focused on it and making an active part of your sourcing and procurement in a surgery center um I've really been astounded by how much um how much ability there is to do that and to instead of paying $40,000 for a piece of instrumentation that um doctors have requested you can get quotes and find someone who's selling it who only used it for a year get it inspected and then save $30,000 I mean it is um and those kinds of savings if you're looking for them are available regularly that's how we've managed to keep clinical costs um below um what the budget is at the current Green Mountain Surgery Center and that sort of um work has also informed the projections for the Collaborative Surgery Center. Well thank you for that I just um I mean I fully understood that the expense profile is a you know work in progress and and is an estimate it just seemed uh so spectacularly aligned that revenues were perfectly aligned with these expenses um in terms of their growth rate and uh and you know a lot of things have changed since last July and I'm wondering whether or not you're more worried or less worried about um you know the the financial future given that um so my last question kind of has to do with not not the case mix in terms of procedures but just the the payer mix and um you know your application says that the Collaborative Surgery Center will accept all forms of insurance including Medicaid and the Collaborative Surgery Center will require all physicians performing surgeries procedures to sign a document agreeing to serve Medicaid patients if the board determines it necessary to conject for as a condition in the CON. There is a difference between agreeing to serve Medicaid patients and actually serving Medicaid patients and so say we agree that the Collaborative Surgery Center's estimate of a payer mix of 12 percent Medicaid is appropriate and reasonable reasonable if the Collaborative Surgery Center doesn't experience an actual Medicaid payer mix in that vicinity might what might be some remedial conditions the board could impose for example would it be reasonable to restrict distributions to members until a payer mix in the vicinity of 12 percent is achieved. I think just a comment on the Medicaid population that we plan to serve at Collaborative Surgery Center as mentioned pediatric dentistry is one of the core four specialties that we are requesting be able to serve in that there is a significant wait time issue as we've spoken about as well and given clinical history here at Green Mountain Surgery Center we could serve pediatric dentistry patients if we had the capacity five days a week and that would that's not going away anytime soon and we also so that being said the 12 percent Medicaid will be I believe really a large portion of that will come from the pediatric dentistry population. The remainder of the population that we'll be serving again is within the Medicaid population that we see here we do a lot of again the gender affirmation surgeries we do not restrict or limit based on the patient's payer quite frankly in the business office we other than verifying that their benefits are live we do not look at their benefits for any other reason other than to make sure that we have a plan on file to bill or that we have a self-pay policy to put in place to let the patient know what they owe. So just commenting on the actual volume I do not foresee a 12 percent Medicaid population being an issue whatsoever for our future collaborative surgery center to serve given the specialties that we are hoping to bring in here. Okay that said what what what if what if it is a problem though what what if we're down in the two to three percent range in terms of serving Medicaid patients. Do you have any suggestions as to a remedial action that the collaborative surgery center could take to fix that problem. I mean I view it as a problem I think you know serving Medicaid people is very important and so if if if circumstances drift such that that number is down in the single digits low single digits what should we do about it you can ponder that and send us your thoughts that that's one I came up with just because you were tying this to physicians agreements and and so restricting distributions to those same folks might be an encouragement to to spend more time with some Medicaid patients and I think that was it for me. I would like to if there are any updated real estate documents I would like to see those because that's it's fundamental to how the shift leaves the doc and who's paying for what and I think that we need to have a clear picture of that and if and in my mind right now that even the ownership isn't clear I don't know given those you know those findings at the Secretary of State's office there's it's an unknown to me at this point in time so thank you very much and thank you for all your effort here. Thank you. Okay now I'll move to Board Member Walsh questions. I'd like to join my other board members with thanking you for the work to prepare for this CON. There's a lot that goes into it and I want to recognize that and thank you for it. Could you confirm for us that there are no there'll be no diagnostic equipment no CT MRI scans in the facility and if not where will patients receive those services? So there will not be any CAT scan or MRI services within the facility. There will be other imaging tools such as large sized C arms and many C arms which is typical for any surgical facility just for localization and understanding visualization. There we haven't truthfully we haven't worked through where that would be but that would be something that we would work through with the physicians that are credentialed at the collaborative surgery center to ensure that there is timely access of course to the radiologic procedures that are necessary for diagnostic purposes. Currently there are multiple independent physicians who work or who provide outpatient surgical services at Green Mountain that you utilize University of Vermont Medical Center Northwest Medical Center and all the other various COPLI all their imaging departments for their diagnosis needs prior to booking or performing their surgeries. So it is utilizing other hospital sources and their radiology outpatient departments. Understanding those relationships can be insightful and of course given the procedures that you're planning to do the vast majority require imaging and so that's going to be a big component of this. My second question I want to understand the facility fee that we've discussed a few times already there were part of your presentation was to show the Medicare fee versus Medicare reimbursement fee for hospitals versus ambulatory care and there was a slide about the Green Mountain Care Board's analysis last year with commercial payers but I wanted to ask a little bit more about the commercial side because you're estimating that over 50% of your patient volume will be commercial payers and and how will you be able to maintain your cost advantage? How will you know your facility fees are on the lower side in the in the area among commercial payers? So a lot of commercial payers a lot of to Ms. Lunge's point Blue Cross Blue Shield being one of the major payers in the state of Vermont but those payers such as Etna and Cigna are based off the Medicare fee schedule so in a relative system of percentage of Medicare for those payers that are based off Medicare of course if you're starting with the lower rate that is shown from our example on our PowerPoint of the ASC fee schedule that relative percentage increase for commercial that we've spoken about of whatever percent that may be would of course be that relative savings to commercial in an HOPD setting. When it comes to Blue Cross Blue Shield speaking on a level of just experience personally with Blue Cross Blue Shield as spoken about earlier they do not contract based on the CMS website and their fee schedule they do it on an individual basis which you know of course is quite time consuming as but it's it's what it's what works for them and they do that in a way that makes sure that our we are not being reimbursed higher than a hospital and so that does assist in ensuring that our price is lower than the outpatient services that are offered in the hospital setting. So it is on a fee by fee basis that we contract out directly with a Blue Cross Blue Shield rep for that large commercial payer portion. Okay. Please go ahead. I would just add to that and say that you know MVP and Blue Cross Blue Shield did write letters of support for our application. Blue Cross Blue Shield Vermont while they are local to Vermont is part of the broader Blue Cross Blue Shield Network nationally and all payers nationally Blue Cross Blue Shield United at MVP's regional but they understand surgery centers there are you know it is a big care provider part of the healthcare industry throughout the country and they expect that prices at surgery centers will be well below prices at hospitals and that's where their negotiating starts. So the payers themselves ensure on a commercial level that the prices are in line with other surgery centers as opposed to with hospital-based prices. Great. Thank you for clarifying. I just wanted to you know value-based environment moving more toward that I'd like you to be able to maintain your advantage and understanding your plans for cost allocation and monitoring your costs in order to be able to succeed in those arrangements. I think it's an important thing and I couldn't quite understand typically the commercial reimbursement or commercial payments are proprietary and I wasn't sure how you were going to be able to know maintain your the advantage that you're talking about. So thank you for clarifying where you're at with that. Next I'd like to turn to my last question with it's with the CON standard 1.6 about collecting and monitoring quality and outcome data and Ms. Hunter mentioned earlier it seems like you have more going on with quality improvement than I saw in the application. You talk about maintaining the ability to assess as required by Medicare but again kind of think forward in a more as we move more toward a value-based environment. Can you say some more about your plans for collecting outcome measures analyzing those and how do you see that changing over the near term? In regards to CMS there is I'm sure you're well aware that there is ASC specific quality measures reported by ASCs to CMS for benchmarking purposes. There's also the ASCQR which is another benchmarking criteria that's met and those are things that we have instituted here at Green Mountain Surgery Center that I fully intend to do at Collaborative Surgery Center. I think that it's vital to understand what your quality standards are to a national basis. The nice thing about those benchmarks is you can hold yourself up to comparison of like surgery centers all surgery you can sort down to really understand to get a better understanding and then have a better high-level look at how things are operating and where you see that there is room for improvement. I'm sure you're also aware that there is the percentage increase to your CMS fee schedule that is accounted for with this benchmarking and the outcome of outcome variance of your benchmarking so that is something that we strive for at Green Mountain Surgery Center of course to always make sure that we are meeting or exceeding any level of care in all of their quality measures and that's something that we pay attention to consistently. Internally we make sure that we have multiple sources within our QAPI and our EOC groups working towards quality improvement plans and it's forward thinking it's not issues that have come up yet but it's just maintenance to make sure that we aren't ever falling behind. I think that the redundancy in that system is very important and that's something that I will institute at Collaborative Surgery Center to ensure the quality of care doesn't lack. I appreciate the more detail and that's what I'd like to see with the response to that question is you understand what the quality the existing quality requirements are and have a plan for collecting them analyzing them and distributing them in the center and have that a bit more spelled out because it's difficult, right? It requires time and it requires effort and it might be wise to have dedicated staff for it, a quality director or something of the sort. Perhaps you're already doing it sufficiently but I couldn't tell from the application. You can see a budget for it and the trend is also toward more patient reported outcomes and you talked earlier about the surveys that you're doing that seems like you're building the infrastructure for those type of outcome measures but I would have liked to have seen a little bit more detail of how you plan to do those going forward. Right now what I read just said you're going to meet the existing requirements so sharing more of what you're already doing would be helpful. Sure, a couple things there. One of the things that we do internally and I appreciate the need for quality and someone, a person in the role of quality and compliance. Personally I wrote quite a lengthy paper on the importance of that in undergrad and I understand that completely. That is something that in order for us to remain nimble and to maintain our low cost and overhead as we've all seen on our balance sheet for personnel cost there are redundancy and roles that occur at ASCs so we can't just have, you know, of course I would love to have a quality and a quality person in place. Currently at Green Mountain Surgery Center that falls on to a nurse manager who completely encompasses that and I'm part of that team as well with the quality reporting. And then the outcome variance we have and I'm sorry I did not explain this well in the application but an outcome variance that we have is monthly having physicians report to us on every single patient that was seen within the surgery center. They go in and they follow up with anything. Was there a hospitalization? Was there an ER visit? Was there a phone call? Was there unexpected pain that occurred? And they allow that to it's part of our procedures or part of our policies to have a physician perform here to report that monthly and that is something that we do in-house and that again I fully intend to have. I believe that it's going to be incredibly for us to have full transparency into that next door especially without having employed physicians so it allows that transparency level that you would see in an employee physician setting and then we can follow up with the necessary parties whether it's the doctor the admitting doctor or the patient themselves or whoever it may be to ensure what the outcome variance was of the patient to ensure that we fully understand how their level of care was suited and how it was post-operatively. That's terrific thanks for the added information. Developing the ability to aggregate those outcomes and learn and rather than one by one looking at it in in totality would be it'll just be required in the future. Thank you for answering my questions I'll turn it back to Mr. Barber. Thank you. Okay and last Mr. Chair do you have questions? Thank you Mike. It's always good to go last because a lot of the questions get answered and I've been trying to scribble off anything that's been answered whether through a previous question or in your testimony today and so hopefully I won't be repetitive but forgive me if I am. As far as the fees and charges related to physician services will they be billed through the collaborative surgery center or will they be billed by the physicians themselves? The physicians themselves. And do you have any type of agreement with them that would mirror the type of charity care that you discussed with the health care advocate? Not formally no. I mean you you heard the process that I think was Liz that explained that there is a handoff of the information to the surgeon and you know the explanation of the charity care policy and so forth. We haven't discussed anything beyond that. It might be good to at least have a conversation so that monitors aren't left behind in this scenario. You talked about lowest cost but I think you did qualify it several times. We've seen in the past where people claim to be lowest costs that oftentimes they weren't that in fact critical access hospitals were the lowest cost just a couple of them and I'm just curious if you believe that you will be lower than all hospitals or just UVM? I think it's really still not possible to know what the cost is at all hospitals for all procedures without knowing exactly which procedures the surgeons that will recruit are going to be doing and then what the price is at every hospital it's really impossible to guarantee that will be lower than every hospital will certainly make efforts to the I'm sorry I think you froze Ms. Cooper about price we will certainly make efforts to to through our conversations with payers and the way that we think about our cost and setting our prices to ensure that we are delivering substantial savings based on the care being delivered in hospital outpatient departments but we can't guarantee because we don't have the information available to be able to guarantee that we would be lower than every hospital on every procedure but I would like to remind the board that we're talking about the cost for the actual procedure and there's still the issue of ancillary charges that hospitals can and do charge that ASCs will not so there will be savings from that certainly. So likewise with the previous question is there any type of agreement with the physicians who are providing services that their charges will be less or will they be the same regardless of the setting? Typically if you were to look refer to that CMS fee schedule that we've been referring to kind of as a cost basis for a lot of our analysis that's used widely to compare HOPD to ASCs the physicians fee for those are typically identical based on the CMS reimbursement. I mean Susan you can speak to just from my experience running Health First the independent physician network the physicians don't have power a lot of power over setting their rates with the commercial insurers here the commercial insurers decide what the community rates are and tell the physicians what they'll be paid by and large I mean Susan you can comment if that's different. Right and it's typically quite a bit less than hospital employed physicians. Okay. Member Pelham asked several questions about the ownership and it is somewhat confusing at this point because of the filings at the Secretary of State but who do you understand the principles to be for the landlord entity that you'll be dealing with and what's their other experience and development. Mr. LaRosa you're on mute I believe can't hear you. So as I understand it LR&W held an interest in this property has two condominium units unit one and unit two and this is LR&W held rights over the unit two. Cultures to real estate company had whose principal was Taylor Harmeling had rights over had an option instead of exercising that option or in the process of exercising that option it proceeded to purchase out the shares in interest of LR&W and now Mr Harmeling is the primary owner with additional investors of this property and has confirmed that the terms in condition of the letter of intent are part of the purchase out of LR&W and CREC. So CREC was closed out and our principal will be a new special purpose entity with Taylor Harmeling as the member. So just to be clear there is a cross relationship between landlord and tenant? No. I'm not talking about ownership interest but I think there probably is a relationship interest is what the point I'm trying to make. Yes Mr. Harmeling and Miss Cooper are married. Correct just so that's on the record. Yes. You know like everyone else I'm thrilled that you're talking about 50% of the profits going to such worthy causes but of course I also worry what type of constraints could be placed to make sure that there are profits so I'm curious about what type of promises have been made to owners to guarantee them a return and also what type of commitments are there to make sure that management fees and salaries don't eat up any potential profits. So aside from the obligations to pay your rent which obviously is you know contractual obligation I'm not aware of any other promises that would be made or have been made and certainly wouldn't the lawyer inside me stress that none are being made to guarantee profits to guarantee profits to investors or anybody else as to the management side I'll let Susan, Amy or Liz speak to that. We have the budget we have the budget for the personnel that will be running the center that's based on good comparisons so we think that will be the budget we think that the center will generate a profit you know it's typical in ASC arrangements throughout the country for a management company and there are several large ones in the country to put up upfront money to build a surgery center then they own half of it and receive half the profits and the physicians who are operating there own half of it and receive half the profits so we think that in terms of physician expectations the physicians expecting to own a minority share of the center and have 50% of the profits go somewhere else will be a normal expectation we think that we would be competitive in having physicians see this as they would in ASC opportunity in any other state but what we're just doing here is replacing the sort of national management company who helps set things up and help front the costs with with ownership profits going not ownership but profits going committed to be going to a foundation and all of the stuff that would normally be done by the management company we think that between Susan and Liz and myself as a consultant we can provide that guidance we can provide the templates around policies and ways to do things because we have that experience already having built a successful surgery center so I hope that helps give some color on why while this is different and innovative having only half the profits of a surgery center available for the physician owners is is somewhat normal in a different way throughout the industry okay and one last question for Mr. LaRosa you said that $37 was typical for the Colchester area and the way I understand this deal it's the remainder of the $64 that is paying for the fit up or all the space is $37 typical for a space that has no leasehold improvements I'm sorry what is $37 typical for a space that has essentially raw space pre-fit up right I mean I think you're I think you can get even higher rates than that at like warehouse space it's I mean recently warehouse space down the road on exit 16 which is this area is going for even higher rates so that's the best I can offer it 740 Hercules Drive which I think it's just up the road is was like $80 a square foot recently for raw warehouse space I think I'm turning into my grandfather when I think that prices are too high no I mean look it's hard to build things and and there's not a lot of space okay those are all the questions I have Mr. Barber okay thanks um I have one follow-up if I may um chair mullin asked about um that the commercial price negotiations and I was into and I was wondering if you're anticipating that the collaborative surgery center if approved and gmsc might negotiate separately or together with Blue Cross or other pairs that allow for negotiation separately thank you okay um instead of moving to public comment at this point I think it might make sense to talk about post hearing uh whether there's any follow-up or any any additional written material be that briefs or written follow-up I did hear a couple questions that I think board members were looking for some additional information around the real estate deal potentially around Medicaid rates things like that um and I think it might make sense for the board to put that in writing and get that to you guys because we don't have a transcript yet and won't probably for at least a couple days so does that sound reasonable that the board would issue some limited questions that that arose out of this hearing that needed follow-up and get responses pretty quickly from you guys it's the board's decision you know we'll do what the board wants okay so unless they hear any disagreement from board members I think that's the easiest way to do this um and then the next question is whether either party feels like there's a need to submit a post hearing brief uh at this point I think that's unnecessary but like to hear your thoughts yeah we don't I at least on behalf of the csc I don't think we really intend to submit one I don't think there's legal issues that need to be substantially briefed I mean there may be some fact questions I suppose that the board wanted follow-up on but that's not really briefing the hca do you agree hi everyone we do plan to submit a written brief but I believe that some of the questions that we have will likely be answered um by the csc if the board submits questions that came up during the hearing okay and what um let's talk about the timing of that brief and what are you thinking that would be filed so we can be flexible um I'm happy to work with the csc and the board to come up with a good timeline but um if sooner is easier um which I would expect to move things along I know that this is a long process already um so I have to do it this week because that's um beneficial sorry did you say this week I did yep uh yeah I think that I mean that would be appreciated if you could submit that by the end of the week uh or at least no later than one day and then Mr. La Rosa you're welcome to submit something too uh sounds like that's not of interest I understand that uh and then the board will get out a set of limited follow-up questions probably early next week that works for us yeah we can do it by Friday okay then at this point um we'll move to public comment unless there's anything else from either party okay so if you have a public comment um to make please raise your hand on the teams app um I see start with hand Davis and then go to Rick Julie thank you Michael um I don't have any questions for the applicant I've got some questions for a combination of the board and the staff first one is when the original Green Mountain the uh the Green Mountain Care Board the Green Mountain Surgery Center was open um it was uh a for-profit at the time that we talked about how many I'm sorry Mr. Davis you're cutting out a little bit I think somebody's shuffling papers or something I'm sorry um yeah in the uh in the original the questions about the Green Mountain Surgery Center because the question got raised uh so how many um how many of the large number of uh ambulatory surgical centers in the United States were for-profit as opposed to non-profit has Donna Jerry have still have that number I don't know him um this is not really an opportunity to ask questions of board staff for this kind of hearing um you know that number you know that number I don't know that number okay is that that's that's a question and I think that's an important question um is there any way that the board would answer it yes I think not it's sorry if I wasn't clear at the beginning this is a opportunity for the for public comment um not not really questions and so I'm just gonna ask you to keep it to comments I can't ask questions okay wow that's new um the the question one of my questions is um well I'm not supposed to ask questions I'll forget it I'm done okay we'll move to Rick Dooley uh thanks so much um I just want to I know this is is a certificate of need um uh hearing and so I just want to just sort of reiterate the need with the patient experience that I had actually just this week or evolving into this week um I just want to share this with the board to give a little perspective so I had a gentleman who had a rectal fissure a young gentleman as you can imagine rectal fissures are very very painful I hope that none of you have had the mis-pleasure of having them but it's not a pleasant thing and we've exhausted pretty much everything as an outpatient that we could do the next treatment is a is a pretty simple outpatient surgical procedure done by a colorectal surgeon um and I set him up last Friday or Thursday we tried to give him a colorectal surgery for what should be a quick procedure and was told that as soon as they can see him and talk about doing this simple outpatient procedure would be um May which is a long time from now their solution is you know you can send him the ER and maybe depending on who's on they could potentially do it in the emergency room the gentleman now it's after January 1st of course he has a high deductible so if he goes to the emergency room it's going to cost him probably two grand out of pocket for them to potentially say we can't help you just follow up with the colorectal surgeon folks when they can take care of it in May um so I just want to reiterate to folks that that brings to you know brings to home the the need for high lower costs better access easier access those are very real um concerns for all of our patients this gentleman is insured um you know with a commercial insurer but a very high deductible so you know he's not a medicaid patient or uninsured but there's a very very real need for these services in our community um so I just would uh encourage the board to you know keep the patients at your forefront as you're thinking about about the need for these services in our community thank you thank you I'm not seeing any other hands raised is there anyone on the phone not on the teams that has a comment okay uh not hearing any other comments um but like I said at the beginning of the hearing um we will keep the public comment period open for 10 days following this hearing so if there are any additional comments um welcome to submit them to the board information about how to do that is available on our website and with that I'll turn it back to you mr chair thank you mike great job running today's hearing and thank you to the applicants for getting us through this process and getting us the information that's required to make a decision um we do have a board meeting this afternoon so I don't see a need to go through old or new business unless any board member has a desire to do that at this time I see shaking of heads no so um mr hearing officer would uh the proper motion for me just to be to um recess the meeting to one o'clock or would it be to adjourn um I think recessing makes sense so I'm going to recess the meeting of the green mountain care board until one o'clock this afternoon um where we'll be talking about different topics so thank you everyone and have a great lunch hour thank you thank you chair thank you