 Mounting care boards meet board meeting of October 26, 2022 into session. My name is Owen Foster. I am the chair of the care board. And we have a number of important attendees and presenters today. We're fortunate that the panel today will be addressing the primary care landscape in Vermont. As most people know, primary care is critical to our goals as a state of improving not only the health of her monitors, but also lowering the system wide costs. Primary care providers treat not only our routine ailments and issues, but they also identify life critical conditions such as cancers and guide us through preventing and dealing with chronic disease. Not only that, but primary care providers are often our advocate and friends, but we're in trouble and navigating what can be a foreign medical world to many of us, myself included. Yeah, they're the reassuring hand in the medical experts that are there for us throughout our journey through treatment. So today I'm extremely grateful to our panelists for presenting. I'm excited to learn about the challenges they face, including the staffing shortages, administrative burden, health tech challenges, payment issues, and I'm sure a host of many others. One thing we as a board are interested in learning is how we can one understand those issues, but to what we can do with our authorities to try and alleviate those challenges for our primary care providers here in Vermont. You are our guests and we'll try and listen and absorb the information you have and we really appreciate you all being here and taking a time out of your very, very busy days to be with us. I recognize a few faces. I've had the pleasure of working with a few of these folks in the past and I'm excited to hear from everyone today. So with that, I'll turn it over to the executive director, Miss Barrett. Thank you, Chair Foster. I'm going to just start with a few announcements regarding open public comment periods, and then I will get on to the order of business, which is hearing from our esteemed guests today, our primary care providers. First, we have a couple of ongoing, a couple of open public comments regarding ACOs that we're looking at. So one care of Vermont is we're looking at their FY23 budget and certification, and they will be presenting their budget on November 9th, and then the GMCB staff will present their analysis on Wednesday, December 7th. Public comment can be submitted through Friday, the 2nd of December to be considered ahead of the GMCB staff presentation, or by Friday, December 16th to be considered ahead of the Green Mountain Care Board vote, which is tentatively scheduled for Wednesday, December 21st. On Monday of this week, we heard from Gather Health, another ACO in Vermont, and on their FY23 budget, and Green Mountain Care Board staff will present their analysis on Wednesday, November 2nd, that's next Wednesday, and then public comment can be submitted through Friday, October 28th to be considered ahead of the Green Mountain Care Board staff presentation, or, which is on the 2nd, as I said, or by Friday, November 11th to be considered ahead of the Green Mountain Care Board vote, which is tentatively scheduled for Wednesday, November 16th. We have an ongoing public comment for the potential next all-payer model agreement with the Centers for Medicare and Medicaid Innovation. Any comments that we receive regarding that topic, we share with our colleagues at the Agency of Human Services and the Governor's Office as they are leading those negotiations. And last but not least, in terms of an announcement on how folks can save money on their premiums, and I think the folks in front of us today, especially the primary care providers, if you're not aware of this, there was federal legislation that passed a couple of months ago that expanded and extended the premium tax credits for individuals and families buying their own insurance. And if you have folks in that position, direct them to our website. We're under premium tax credits where they can look to see if they qualify for more savings, even if they didn't qualify earlier in the year. So that's my public service announcement on saving money on health insurance. Please, please, please spread the word. So with that, I am going to talk about our order of business today, which is a discussion, and as Chair Foster had said, a group of primary care providers coming together today to educate the board on the primary care landscape in Vermont. We or I have put together some educational events. We had one on ACO regulation a couple of weeks ago. I wanted to get some provider groups in to share their experience with the board, and Chair Foster and I both agreed that primary care should be the first ones in front of us. So thank you again for coming to the meeting today. We have a range of primary care providers speaking with us, and the goal is really to inform the board of Vermont's primary care landscape. We have really three new board members, two very new, and then one who's been with us for nine months. So this is a great opportunity to educate them on your work. And I will echo what Chair Foster said. I know that taking time out of your schedule to be here with us today and in the prep sessions means taking time away from your patients, and I know that's what you're focused on. So we really do appreciate your time, and I hope that at the end of the day, this is beneficial to you as well as the board and the public. So with that, I'm going to give an overview of our agenda. We're going to start out today with an overview of our primary care advisory group, which is a committee of the Green Mountain Care Board. I'm going to ask Christina McLaughlin, who's health policy advisor, to give a short overview of that group and talk about their successes and some of their goals. And then it'll come back to me. I will introduce the participants on the panel. And then we've talked, I've put out some categories of focus areas that we're going to hear from the panel on, those being what Chair Foster mentioned, as well as value-based care experiences in that, workforce issues, wait times. And we will hear from the panelists on these issues. I will then turn it back to you, Chair Foster, if there are additional questions from the board. But I really am excited to hear from our primary care providers and the associations who represent them. And with that, I will turn it over to Christina McLaughlin to give you an overview of the PCAG. Thank you, Susan. So again, my name is Christina McLaughlin. I'm a health policy advisor here at the board. And I have been staffing the primary care advisory group, also known as PCAG, for a few years now. So first and foremost, the board's primary care advisory group was first established back in Act 113 of 2016. And that language had scheduled the group to sunset July of 2018. Although recognizing the importance of the group, the board decided to continue the primary care advisory group under Act 48, which allows the board to convene a technical advisory group to provide input on the board's work. Currently, the primary care advisory group consists of 12 active members, including NPs and MDs, Greenmount Care Board staff, that's me, and alternating board members attend those meetings. The board seeks input advice or recommendations from one or more participants of the group relating to clinical matters within participants' expertise to help inform our duties outlined in 18 VSA. Or to advise the board on the report required by the General Assembly or on a general matter of interest. The primary care advisory group has advised the board on various topics, including but not limited to the healthcare workforce strategic plan, the prior authorization and all-pair model report per Act 140 of 2020, the primary care spend report per Act 17 of 2020, and the health resource allocation plan. PKEG has also provided feedback on the health information exchange, Vermont's healthcare reform efforts. We have sent a letter to our federal delegation proposing changes, federal changes to support our healthcare workforce. They've testified to the Vermont legislature on various topics, including burnout and workforce issues and have done much, much more. The group currently meets by monthly, roughly, Wednesdays after hours, given that they are busy providers, so we start our meetings at 5 o'clock. In addition to advising the board, the primary care advisory group has set priorities to work on, and currently those include focusing on healthcare workforce, prior authorization, and primary care spend. The group is hoping currently, and I'll put a plug in now, to expand its membership to other clinicians, for example, PAs or others. So if anyone has a clinician to recommend or has questions about the group, you may reach out to me. My email is on our website, and many of the folks know how to reach out to me on this meeting already. So that would be great. That would be super helpful. We are always looking to expand our membership. As a side note, I do want to say that we have two PKEG members here. Eileen Murphy and Michelle Wade. So thank you for being here. While they're not here specifically to represent the primary care advisory group, they are members, and so I just wanted to mention them quickly. So with that, I'll turn it back to you, Susan. Thank you so much, Christina, and thank you for your great work with the PKEG. So I'm going to introduce the panelists today, and then I'm going to turn it over to them to provide a little bit of background on who they are and what they do, and then I will ask them a few questions in the discussion. So first, from Health First, we have Susan Ridsen, who is the Executive Director and Operations Manager there. In addition, we have Rick Dooley, P-A-C, who is the Clinical Network Director. From Primary Health Care Partners, we have Dr. Toby Sattkin, who is a family medicine physician, and we have also Dr. Dianne Haig, who is a pediatrician at Primary Care Health Partners. And they're joined by John Aslan, who is the Chief Operating Officer and Chief Fiscal Officer for Primary Care Health Partners. Next, we have representatives from the Bi-State Primary Care Association, and this is our FQHC group. We have Mary Kate Mulman, who is Vermont's Director of Public Policy for Bi-State Primary Care, and then she's joined by Dr. Melissa Velanski, who is the Chief Medical Officer and Physician at LaMoyle Health Partners, and Stuart May, who is the President and Chief Executive Officer at LaMoyle Health Partners. And as Christina mentioned, we have two PCAG members here and nurse practitioners, and they are Michelle Wade, MSN, ED, APRN, who is the Immediate Past President of Vermont Nurse Practitioners Association, and Eileen Murphy, MSN, APRN, FNP, BC, who is a family nurse practitioner. And last but certainly not least is Jessa Barnard, who is the Executive Director of Vermont Medical Society. So I'm going to turn it over to the panel now, and in that order that I read off your names, we'll have you share your brief introductions and background. So I'll turn it over to you, Susan Ritzen, from Health First. And I think you might need a little help with your slides, if I recall. Yes, Christina was going to help me. So thank you, Susan and board members. It's a pleasure to see everybody and to meet the new board members, Chair Foster, as well as Dr. Merman. So my name is Susan Ritzen. As Susan said, I'm the Executive Director of Health First. We are Vermont's Independent Practice Association. We've been around since 2010. We represent roughly 90% of the physician-done practices in Vermont. And collectively, our 26 primary care practices care for over 85,000 Vermonters. Many, some people don't realize that we actually had the first Medicare ACO in the state. It's called Accountable Care Coalition of the Green Mountains. It was way back in 2014. And we also had a commercial ACO called Vermont Collaborative Physicians. And that ran basically until one care became the only accountable care organization in the state. But we do have a majority of our primary care practices participating in the one care programs. And half of those that are participating are in the fully capitated CPR program. So we have embraced value-paced care. Just a reminder that our practices are also small businesses. They're weaved into the fabric of their communities, and they employ hundreds of Vermonters collectively. And for anyone who's interested, you can see our member practices on our website. Next slide, please. Here's the split of our practices. We currently have 63 with a 60-40 split with 60% of our practices being specialty care, 40% primary care, 130 physicians again with roughly that 60-40 split, and 70 advanced practice professionals. We actually have more than that, but we only count the ones who work 20 or more hours a week just because of our membership model. But it gives you an idea. And just of note, for a long time, we were running around 70, 72 practices in our network with a 50-50 split. But over the last, say, five years, we've seen a slow but steady decline with primary care being hit more acutely in the decline. And we do find that concerning. Next slide, please. Our network, we have experience, deep experience in a number of specialties. These are some of the board-certified specialties in our network. There are actually more. I won't read through these. I'll call out a few, though. We do have gastroenterology, dermatology, ophthalmology, and of course, you know, pediatrics, internal medicine, primary care, OBGYN in our network. We also have practices located in 10 of 14 counties in Vermont. 60% are in Chittenden County, as you might expect because of the population base. But we do have 40% of our practices located outside of Chittenden County and in more rural areas. Next slide. Just to reiterate, our 26 primary care practices care for over 85,000 patients. The 11 that are in Chittenden County care for about 34% of the Chittenden County population. And then the remaining 15 primary care practices care for about 28,000 Vermonters in more rural areas. We did have more, but various pressures did cause a number of our primary care practices to close. And the ones in the rural areas tend to close first because the margins are just so thin or nonexistent. So as prices of healthcare insurance for employees, increase in other medical practice costs increase while reimbursements largely remain flat or do not keep pace with inflation. It's an unsustainable business model and they ultimately go out of business, unfortunately. Next slide. Here's just a little bit more detail of the decline in practices and physicians that we've seen. As I noted, overall we've seen a 15% decline in the number of practices with a larger decline in primary care. A little bit less of a decline in total number of physicians, but again the hit has been more acute on the primary care side. And just a plug for independent primary care. We believe that they are very important model to be included in our healthcare market. The experience of care has been quite different in independent practice. They tend to be a little bit smaller, they're more nimble, you're not dealing with a lot of bureaucracy. So there's that more direct relationship that patients have with their providers, which many people prefer. We also, for many specialties, have much shorter wait times and consistently have shown that independent medical practices, primary care practices, deliver very high quality care for less money. These are the very types of practices that we need to be supporting and trying to maintain and encourage in our system. Patients want options for care, they need options for care, we have access issues. So doing what we can to really support these types of practices is warranted as the other practices, primary care practice types in our state. There's a place for all. But we do believe that the independent practice model is an important one. And it also helps to attract clinicians to Vermont when there's more options because not everybody wants to work in an FQHC or a hospital system. It's nice to also have the option to know that you can open an independent practice and do well and be able to make a living that way. So thank you. I will stop there and ask if there's any questions or maybe questions at the end. Yeah, we'll have questions at the end unless there's anything burning from the board. It would be great just to be able to get through the intros and then we'll have the panel discussion. Thank you so much, Susan. So now we'll turn it over to the folks from Primary Health Care Partners. Dr. Sackin, it looks like you're starting. Yeah, also I'm going to try a time to share my screen and do my slides but if this is not working we can we can change the plan. Okay, let me give it a go. Sure, this is going to work. Hold on. Christina. Christina, do you want to do a slide? I don't know. I'm sorry. Do you want to do it for me? Sure. No problem. I appreciate it. No problem. All right, so you're going to pull up our first slide there. Thanks. So first thank you for the opportunity to be part of this forum. I am Toby Sackin. I'm a family physician at St. Alvin's Primary Care and also the chair of Primary Care Health Partners and I'm joined today by Dr. Dan Hague, a pediatrician at our Monarch Maples Pediatrics Practice in Enosburg and by John Aislin who is our COO, CFO of Primary Care Health Partners. So we have a short time and we have a lot of information on the slides and I know that you can look at that. Mostly I just want to tell you our story, who we are, what we do, and some of the challenges that we face. You can do the next slide please. So Primary Care Health Partners is the largest physician-owned Primary Care Group practice in Vermont and our history goes way back. Our founding members started with Community Health Plan, Regional HMO in the 1980s. So our history always included a focus on quality and efficiency and we are no stranger to the concept of capitated payments and quality improvement measures. Then in the 1990s Kaiser Permanente came into the northeast and they sort of took over Community Health Plan and that only lasted a little while and when Kaiser Permanente left the northeast we were left with a decision. We could just all go and find a different job or we could try to stay together and do something different. And what a core group decided was to form a physician-owned independent Primary Care Group. And so Primary Care Health Partners started in 2000 and we're now going on our 23rd year and I've been honored to have been the chair since the beginning of that time. So we have all independent Primary Care offices so it's a mix of family medicine, pediatrics and adult medicine and as you can see on our map and on our chart we have locations across much of the state with offices in Brattleboro, Bennington, Burlington North End, South Burlington, Milton, St. Albans and Enosburg and we do have one pediatric practice in Plattsburg, New York. And the next slide. Each office has much autonomy but we are all bound together in one partnership with the common mission, vision and values which highlight our commitment to quality, efficiency, adaptability, the well-being of our patients and communities and our independent spirit. The next slide. Our structure is kind of unique. Primary Care Health Partners is led by the physician-partner owners in New York and Vermont and through an executive committee structure the physician partners direct the medical services organization which supports the medical practices with services such as billing, credentialing, finance, payroll, HR, risk management, IT and EHR support. And our structure is different from many other healthcare structures because the administrative office is responsible to the physician partners rather than the physicians being directed by the administrative office. And the next slide. So here are some fast facts. As you saw in the previous slide we have 11 locations, nine medical offices in Vermont, one medical office in New York and one central support office in Williston, Vermont. We have 31,000 active patients in Vermont and 3,000 in New York. We have 175 employees which includes 20 physicians, 23 of whom are the partner owners. We have 15 nurse practitioners and two physicians assistants. In Vermont 48 percent of our patient encounters are Medicare and Medicaid and in some of our offices this percentage approaches 70 percent. And the next slide. Our mission, vision and values guide our culture of quality, collaboration and commitment to our independent spirit. All of our offices are NCQA certified level three patient-centered medical homes. We're very collaborative and involved with OneCare Vermont and we participate in many of the committees including the Board of Managers, Finance, Comprehensive Payment Reform, Population Health, Clinical Advisory Committees and the Patient Family Advisory Committee. We support and advocate for independent primary care and we're always looking to bring in other small independent practices into our group and most recently we brought in the Monarch Naples Pediatrics. We offer administrative support to other independent practices with services such as credentialing and billing. And the next slide. But independent primary care faces some unique challenges. There's physician burnout. It's a struggle to try to meet all the overwhelming demands placed upon primary care physicians while trying to keep our practices afloat in a system where independent primary care has been underfunded for many years. It is almost impossible to compete with larger entities with regard to salaries, benefits, loan repayment opportunities. So it's very difficult to recruit and retain physicians, nurse practitioners, PAs and also clinical support staff. Negotiating with the commercial payers is extremely difficult and we have sometimes gone several years with no increase in reimbursement while at the same time the insurance premiums for our staff increase dramatically. We tried to explore a creative solution to that problem. We had an idea that maybe since through the ACO structure different practices have been allowed to share clinical information in ways that were not allowed outside the ACO previously. So we thought there might be some way through this shared ACO structure to allow ACO provider members to share in a large pool for health insurance and maybe other benefits without being employed directly by UVMMC. So we had some meetings with the UVMMC leadership about this idea and after looking into it for a little while it turned out that this just was not going to be a possibility. So the next slide please. So with no new great solutions in hand we recently handed out the information for 2023 health insurance to our employees and just seeing the expressions on their faces I knew that they would be struggling with being able to afford their share of the premium increase which for some of them would be an increase of up to 40 percent. I can tell you that every single year the physician partners in our group struggle with how we want to be able to do more for our staff in terms of salary and contribution to their health insurance premiums but with all our other costs increasing and little to no increase in reimbursement from the commercial payers we find that the math just doesn't work. Next slide. Yet there has been one bright spot in supporting independent primary care and that has been the comprehensive payment reform program through OneCare Vermont. We have been grateful for this pilot project which has provided some enhanced payment for independent primary care through a capitated model for a subset of our patients and this was an especially great support to us during the first months of the COVID-19 pandemic. The next slide. We believe there is great value in ensuring the viability of independent primary care practices in Vermont as an integral part of the health care system. Our independent practices have lower overhead costs in comparison to the hospital-based practices and as a perfect example over the past few years we have worked collaboratively with two hospitals, Brattleboro Memorial and also Northwestern Medical Center in St. Albans to successfully transition their pediatric practices which were not sustainable with hospital overhead to independent practice within primary care health partners. Our practices provide consistently high quality care. We are nimble, able to quickly adapt and implement changes which make us a perfect test kitchen for pilot projects and we offer professional satisfaction for clinicians and staff in small independent practices but the challenges we face threaten our very existence. While the CPR program, the comprehensive payment reform has been a step in the right direction and we've been grateful for the program. Further investment in independent primary care is essential. Next slide. So we thank you for giving us an opportunity to share something about our group and we'll look forward to answering some questions during the panel discussion. Thanks. Thank you so much Dr. Zadkin and with that I will turn it over to our next presentation which will come from the FQHCs and I have on my list Mary Kate Mullman from by state primary care going first. Hello, thank you. Let me put my put my slides up and Christina can help you if you run into problems. Thank you Christina. I think I got it. Got it. All right, excellent. I'm going to keep it on this main page because I just think it's easier to deal with in the slide presentation but so my name is Mary Kate Mullman. I'm director for Vermont public policy for by state primary care association and I first want to thank you for welcoming us here to give this overview of the primary care landscape. It's an important part of the system. So the first just before I get into this, I just want to give an overview of how we're going to work. I'm going to give a very high level overview of what a primary care association is, what FQHCs are and then how we serve and integrate into the state of Vermont and then I'm going to turn it over to my colleague Stuart May and Dr. Vilanski to talk about how that looks like or what that looks like an operation with serving patients. So the first thing is primary care association. This is an entity that is established by HRSA funded and defined by HRSA as an organization to support readily qualified health centers and other safety net providers. I provide support around programmatic clinical and financial performance and then in my role it's that facilitation and communication between the health centers and various governmental or partner associations. So we work with the legislatures, state staff, VMS as Jesse will talk about later on and these are present. There's one in each 50 states supporting the FQHCs in that state. There are three instances where they it's one PCA for two states or for example by state to New Hampshire and Vermont. There's Delaware and Maryland are supported by a single PCA and then the Dakotas are supported by a single PCA. So specific to by state. We've been around a while so I founded in 1986 as started out with two organizations and we've grown to represent 27 member organizations across both states. This is present in 146 locations and seeing over 300,000 patients between the two states. I'll get more into the Vermont specific numbers a little later on. Our members include FQHCs in both states, Vermont free and referral clinics and Planned Parenthood of Northern New England. This is a list of some of the things we do. I want to call out that second bullet point because I think this is something that the board is very interested in that workforce development. By state runs a recruitment center and this is really key in supporting our members in finding hiring and retaining. You see physician status nurse practitioners and physician assistants and we also work really closely with different educational partners to help really build up and develop that pipeline. We also work on data management and analytics. Again how this intersects with the board. We work really closely with Vital and Diva and the Agency of Human Services HIE team. We also work on food access in the intersection with healthcare and this is a key part of what opt-ins refer to as social determinants of health. It's really part of the FQHC's missions in understanding what are the factors affecting their patient's health and how can they get past or work through any barriers that might be there. So that's what the support staff does. Now what are the real entities do. Federally qualified health centers. These have been around since I'm not sure if they were put in statute in the 60s or 70s but it was really how do you support how do you provide care to especially historically marginalized marginalized populations serve individuals regardless of their ability to pay regardless of their insurance status and that's and then also look at them as a whole person. So that's really what drove the development of health centers. Each health center is required to establish a sliding fee scale. This goes towards there should be no financial barrier to care and so there is an income eligibility up to 200% federal poverty level and this is a sort of a stepwise support to reduce the co-pays or billings fees that patients might encounter. They are also really deeply entrenched in the community and in the patients and by when I say patient directed organizations in federal statute it is required that over half of their board members be patients. So that really creates the strong roots within the community and a real focus on the patient experience and like how are the services supporting the patients in that community and part of it is that integrated care that I talked about. So we've got the pharmacy, mental health, substance use disorder and oral health services often all in the same building with the primary care services and if they're not in the same building there is a strong communications and care collaborations across these different areas of care within the organization. So where are FQHCs in the state? As I mentioned there are 11 health centers in Vermont and these are manifest in 73 different sites and again they serve primary care, mental health, substance use disorder treatment, oral health, reproductive health and school-based services. All of our members are recognized as patient-centered medical homes and participate in the blueprint program. The community health teams are an integral part of the care that we provide and really bridging that social service, primary care, medical care. And you see there's a broad geographical presence. So who do we serve? We serve over 184,000 patients in Vermont that's meaning our FQHCs serve almost a third of Vermonters. In 2021 we conducted over 711 patient visits. Planned Parenthood also 600 or 16,000 Vermonters and the free and referral clinics over 10,000 Vermonters. On the free and referral they're seeing increases not just in the what you typically think of as going to a free clinic, the uninsured but underinsured. They're also seeing an uptick in Medicare who can't afford the Medicare co-pays and cost sharing arrangements. All right and funding. This is often a black box for many people looking at the FQHC worlds. So to become recognized as an FQHC members have to meet or have to go through a very competitive national application process and they must meet strict eligibility standards like serving in an underserved region. Once they are recognized as such they have nearly 100 additional regulations specific to FQHCs. This is in addition to blueprint for health requirements, ECO, care, all of those. They're additional and so we are well regulated. We have a regulator in HRSA who is very enthusiastic and robust. But with that robust regulation comes funding through the 330 grants. The 330 refers to the section of the Public Health Service Act that defines what the FQHCs are and then that grant that's awarded to them. I'll get a little bit into what that amount really goes toward. Then Medicare and Medicaid reimburse FQHCs on an encounter basis. You'll often hear this seen as a or referred to as a prospective payment system. This is basically a bundled rate for a number of primary care services available to patients of FQHCs. With commercial pay insurers we're reimbursed similar to other primary care. And then going back to that 330 grant funding and also our 330B savings from the 340B pharmacy program. These fundings really provide a required by statute and this includes the 340B funding. A required by statute to go back into operations and support expanded access and affordability. So for example on that sliding fee scale what a patient is required to what patient ends up paying and the difference with what that care actually costs. That's covered through the 330 grant funding or the 330B. We often use these funds for enhance for free dental care. This is a big problem in the state. Access to dental care is critical and often our members are the only source for oral health for Medicaid and Roles. It also goes towards translation services, care coordination, transportation services. A number of our members are starting to get mobile vans so they're able to go out to encampments or housing areas to provide care and meet people where they are. I could go into a lot more but I want to keep this as brief as possible and I've probably already gone way over time but I am happy to answer questions when we get to those and anytime I'm going to turn it over to Dr. Balanski and Stuart May to talk about what this looks like in practice. Great thank you Mary Kate. Christina if you could bring up the deck for me. I'd appreciate the assistance. Great thank you. We'll just jump right in and hopefully make up some time here. So next slide. Illinois Health Partners was established in 2006 and achieved FQHC status two years later with core services in family medicine, behavioral health and pharmacy and then from the timeline there you can see we expanded into family dentistry and pediatrics. 38% of our patients fall under the Medicaid payer classification and you can see almost the same amount on the commercial side so 60% of the patients we serve come out of our governmental payers. Next slide please. Briefly here what I wish to point out and part of our approach is how do we maximize health status for our patients and we do that through a integrated team approach that looks at whole person care. Next slide please. These nine segments are key in maximizing health status so through our integrated team we bring the resources to help our patients address these nine segments in order to maximize their health status so it goes beyond just that medical encounter for providing all of the resources to these patients so as I said it's key to maximizing one's health status. Next slide please. Just briefly a list of all of the services we provide as Mary Kate mentioned under the blueprint program the community health team which has our health navigators, social workers, dietitians and we also participate and most of our family medicine physicians are part of our medication assisted treatment program. We next slide all of these services are located in four different locations primarily in Morrisville and Stowe although we do serve the entire Lemoya County. Next slide please. Some of our strategies that are associated with the Swedish services in that premier comprehensive healthcare are listed here and do require community engagement. Very briefly I'm going to run you through these five initiatives that help to maximize health status. Ultimately Ben that medical loss ratio curve and we believe this is the right approach and helps us also in the positioning for various advanced payment models. Next slide please. First there's something called the Lemoya Health Collaborative and our vision is to create a seamless continuum of care that aligns our residents and patients with the right care with the right partner at the right time. We believe that primary care serves as that solutions integrator for that continuity of care so if you will quarterbacks the continuum of moving the patient to maximize their health status. Currently the collaborative insists of 10 partners so nine of our partners here in the Lemoya County healthcare ecosystem. Next slide please. We were able to launch this Lemoya Health Collaborative under a HRSA grant from the Federal Office of Rural Health Policy and from there since that launch in 2020 we've created three community collaborative teams. Members of those teams are stakeholders outside of the 10 that I referenced earlier from our healthcare ecosystem. All of the funding behind this collaborative is part of our overall run rate here at the FQHC but it's an important piece. Next slide. This is just a list of the current 10 partners that meet on a monthly basis and continue the identification of other cohorts and how we look to tighten up that continuum of care to ensure that our residents get the right care with the right partner at the right Next slide. Another piece that we're looking at expanding is our pharmacy service line and as the tagline there says it's not just about the prescriptions. 2008 we were part of a joint venture that created community health pharmacy. Our patients under that 340B program currently see those savings through a direct mail option. In about five weeks we'll be opening the first Lemoya Health Pharmacy which is actually bringing a pharmacy into our practice sites. So it's creating value there and by introducing the clinical pharmacist as part of that integrated team they're there for that collaboration and support the treatment plan with those providers. This extension we believe will continue our work in medication compliance and refill rates. Also helping our clinical teams with med reconciliation and adverse drug events and lastly will help in improving health outcomes by already knowing those patients that are having compliance issues in getting those prescriptions filled ahead of that next visit so that information can be introduced during that visit and identify those barriers for that patient. Next slide. Another program that we're participating in that we believe is also innovative if you will partnering with our PCA. We were able again through the Federal Office of Rural Health Policy are participating in a four-year grant. The only grant awarded to applicants in the states of Vermont and New Hampshire to use food as medicine. So currently our cohort that we're addressing in the medically tailored meal program is cardiovascular. Those patients participate with our team and receive the either prepared meals or staple grocery boxes and our greatest challenge there is around the logistics and distribution and that's key to making this program successful. We've been fortunate through a good partnership with Meals on Wheels since they are the subject matter experts for logistics and distribution. We have plugged into their model so our patients then for those getting the prepared meals submit under the same type of infrastructure their meal requests and those get delivered. Next slide. Outside of that food security is huge like many other primary care providers here in the state. Food security ranks very high and the social determinants of health is a barrier to maximizing health status. So we have built in a screening and referral process within our practices to work with those patients that have food security issues. We have partnered with the Bounty Share and everyone eats programs along with funding grocery cards for a number of our patients so they can use that to purchase their own groceries. We launched this in the fall of 2020 and since then have provided solutions to approximately 2,000 of our patients. Next slide please. We have also this past year looked to expand primary care into the schools here in LaMoya County for starting with the LaMoya North School District and the Johnson Elementary School. The town of Johnson ranks highest of all our towns here in LaMoya County on the Vermont Department of Health's Health Fundorability Index and there we're bringing core services to that student body so those core services are defined as behavioral health, oral health and pediatrics. In working with both the school and our designated agency have been able to identify those students needing behavioral mental health services that don't have access under existing avenues. Launched that in the second half of the academic year of 2022 and prior to the end of that academic year started delivering services to 52 students. We're back obviously in Johnson Elementary this academic year 2023 and we're looking to expand the number of students there. Have also introduced oral health hygiene services. We started out last academic year once a month with just cleanings and serviced approximately 20 students at the elementary school. At the start of this academic year we'll be up there twice a month and also have expanded the services meaning besides those hygiene services we actually now have the ability to conduct x-rays and apply sealants to those individuals. This academic year will be the first year of introducing pediatric services and primarily they're working with the school of the parents and the students initially around asthma and other respiratory diseases. Next slide please. Our future outlook is recognizing the need to continue to grow primary care family dentistry and pharmacy services as outlined key pieces in improving the health status of the residents here in LaMoya County. We continue work on positioning ourselves for a move into advanced payment models. We are a participant in the one care ACO. We believe that the LaMoya Health Collaborative Model is the right model for improving health outcomes and finding ways to lower the overall health care costs here in the county. So continuing that development which includes the group is looking at now a referral software tool if you will. How do we with disparate systems share the key information to follow that patient across that continuum. And we continue to build out our strategic initiatives around whole person care and being able to afford our patients and residents an opportunity to maximize their health status. Next slide. Our headwinds are pretty much the same as everyone else work for sustainability. Not going to go into that too much access to capital to fund that growth be it hard capital or working capital. And lastly as Mary Kate talked about while we do have some governmental funding outside of payment fee schedules it's important to note that on the federal side our and this is nationwide our 330 grant funding has been flats in fiscal 2015. And here in the state outside of the 2000 statute for the Medicaid FQHCs to receive a PPS prospective payment rate the state has been using a proxy rate that is actually less than that. And with a significant amount of the patients we see that are under Medicaid that further puts additional systemic structural pressures on supporting the organization. That concludes our presentation on LaMoya Health Partners and thank you for your time this afternoon. Thank you Stuart. And we will turn now to Eileen and Michelle. Thank you. My name is Eileen Murphy. I currently work per diem two days a week in the Gifford FQHC and I'm president of the Vermont Nurse Practitioner Association and I co-teach one course each year in the UVM Nurse Practitioner Doctorate Program. I'm speaking today as a family nurse practitioner for over 20 years having worked on both sides of the Connecticut River in primary care. One purpose of the primary care advisory group at the Greenmont Care Board is to highlight opportunities for improving access to primary care. As nurse practitioners in primary care and hospital care Michelle Wade and I ask you to listen to a story today that can be a typical patient care experience. Patients want and need timely access to efficient and effective care. We also want patients to have safe high quality evidence base care. An 82 year old female your mother your grandmother your aunt your neighbor is tech savvy and contacts her primary care provider office using the patient portal. She is some nausea and abdominal pain. She's scheduled for an appointment the following week and the next day she calls the office as she doesn't think she should wait a week with the pain she has. The secretary says there are no openings so the patient asks to speak with a nurse. The LPN writes down the story consults with the patient's PCP and schedules the patient to come to the office that afternoon as an overbook. The PCP obtains a history and physical exam. Orders an ultrasound for right upper quadrant pain and puts in referral for surgical consult. The patient is seen by surgery with the ultrasound result. The surgeon notes the patient is not a surgical candidate at this time prescribes and requests the patient call to be seen if worsens. The patient does get worse in the next few days feels sick has increased pain. Contacts origin office and can't get in so contacts the PCP office and a scene. The PCP has no notes for review of the care provided or follow-up plan does not have a current medication list except with the patient reports. Patient is known to the PCP appears ill and is a bit confused and has a fever. Besides being sicker one of the antibiotics has affected her anticoagulant which the surgeon was not aware she was taking. The patient is admitted to the hospital for management. Another brief example is a patient seen by their PCP for regular diabetic follow-up. One of the components of diabetic follow-up is a foot exam and that assesses for skin changes and vascular and neurological changes. Patient has a foot wound enough to need referral to podiatry for wound management. Podiatry manages the wound sends the notes to the PCP and sees the patient through the wound healing process. Podiatry then schedules the patient for follow-up every three months. Patient is lost to follow-up with their PCP as the initial podiatry note was scanned into the record but did not get to the PCP for review. Patient contacts the PCP office months later for medication renewals. These patient care experiences demonstrate how care is affected by healthcare workforce issues that would be appropriate staff and training care coordination to triage and schedule patients for care by communication of follow-up plan details between healthcare providers specialty and primary care offices by medication reconciliation updated medication lists monitoring for potential interactions and by the public perception of healthcare there's a culture of seeing a specialist. The electronic health record is a tool yet is the clinicians who provide the informed evidence-based care and oversight for complex patient care. Primary care sees the whole patient the person it's hard work it's complex work a patient with a primary care provider whether a PA APRN or physician is much more likely to receive coordinated safe cost-effective high quality care and this takes a team and it takes time. Some colleagues on the primary care advisory group are not present today as they are providing that primary care to patients and families while we are here. Improving effective access to primary care requires culture change that incentivizes the patient Vermonters to see and appreciate and experience the benefits of primary care communication and provider neutral language and healthcare and state organizations and in all forms of media as to the concrete benefits and value of primary care inclusive and respectful of all clinicians who deliver that care and leadership demonstrated by empowering patients and families with information as to all the options available for them for primary care and access to healthcare. Sometimes it seems we have little effect on improving the care of patients given we only have influence in certain areas. We need to incentivize high value primary care and improve the health of the population and place the current system which rewards practices for the volume of patients seen. In primary care we continue to be the change we want to see in Vermont healthcare and I turn Michelle way to continue thank you. The stories that we're telling you today are legitimate patient care stories and we knew that many of our colleagues today we're going to present you guys with a lot of PowerPoint slides and data. So we wanted to bring it home a little bit and what I want to add on to the bottom of this is when Eileen starts talking about value-based care and patient care holistically we have to realize that the world is coming to value-based care I do believe and as the and as the Green Mountain care board and as the state of Vermont starts working on what this next ACO is going to look like our ask as clinicians to you is to make sure that we are using every clinician to the highest of their degree. We need to make sure registered nurses are working to the highest level of a registered nurse and aren't handicapped by a silly ruler regulation. We need to make sure that the nurse practitioners the physician assistants are also working to their highest. There is an ACO reach model out there that does this that several states currently are a part of and it has worked well and has excellent data. So our ask is that we help provide better holistic primary care to Vermoners by providing the care that we can provide at the top of everyone's license as well as affordable primary care that holistically takes care of the patient. A little wrap around for these patients in case anyone was wondering the first patient did end up going to surgery and actually had a prolonged heal time due to the anticoagulation and the second patient thankfully healed well and did get back into primary care but could have been lost to primary care because primary care initially was doing the foot exams which is well within their scope of practice and referred out appropriately at the appropriate time but what didn't happen was the patient didn't get referred back to primary care at the end of that acute episode. Thank you. Thank you both. And now we'll turn it over to Jessica Barnard to round out these presentations then we'll get to some panel discussions. Good afternoon. Thank you very much. Let me get my screen up here. Okay. I think I'm going to follow Mary Kate's lead and keep the presentation in this form so I can see where I am. Thank you very much. I'm Jessica Barnard. I'm the executive director of the Vermont Medical Society and I'll tell you a little bit about who we are and what we are working on in primary care. Let me make sure I can go to the next slide here. There we go. So we are a membership service organization founded in 1784. We are currently have physician, PA and medical student members. We have about 2600 members around the state. So a little bit different than some of the other associations you've heard from this afternoon rather than representing sort of an employment or practice type. We represent certain professionals, healthcare professionals. We are about two-thirds of practicing MDs and DOs in the state. And as I said that's across all specialties and then also all practice settings. So independent practice, FQHC, hospital-based. We have individual members and also some medical staffs or group or practices do join as a group for their physician and PA clinicians. And as a staff, so I'm a staff member, but we are physician and PA led. We're led by a board of our members and then also our members elect a our officers, our executive committee currently made up of a psychiatrist, ED physician, pediatric intensivist and surgeon. And then our full board seeks to be inclusive of specialty, geography, practice type and other demographics. We currently have four family practice, three adult internal medicine, two pediatric and two psychiatric and one OB member on our board. So a fair amount of primary care representation. And another way we hear from our members and hear especially from primary care is through the work we do with medical specialty societies. So we offer administrative and for some of the specialties policy or advocacy support to their own associations. So these are a list of those that we support. They're all independent membership associations with their own boards and own agendas. But we do then contract with them to provide administrative and advocacy support services. And for the pediatricians, family physicians and psychiatrists, those are some of our more most active specialties. And then we have a shared staff. So my co-worker Stephanie Winters is the executive director of those organizations, but also a staff member of VMS. And so we have a really great communication and collaboration between VMS and the specialties. So we may bring ideas or legislative proposals to the attention of the specialties. And then sometimes the specialties bring requests or information our way. And we work together on advocacy or other programs to move those forward. We also get feedback from our members through typically an annual member survey. And I know this was shared with the board. I shared it with Susan a couple of weeks ago and I think it was sent around. But I wanted to just highlight it again. I encourage you actually to follow that hyperlink in the middle with the full results that pull some more quotes. But I think it gives a really both stark and realistic picture of what it's like to be practicing medicine right now. We received almost 300 responses, which is pretty good, especially considering this was not a click the button survey. It was all, you had to fill in free text. So both the highs and lows of practicing medicine, our members are extremely committed and dedicated to caring for their practice. They love their relationship with their patients and families. On the other hand, we got quotes back like the overall morale of physicians is as low as I have ever seen it. And I just don't have time to be human. Here are some of the other challenges. And again, I won't read these all and the full results have more quotes in them. But here was one I'm a first year medical student looking at family practice. I am most concerned about being able to spend meaningful time with patients and being limited by the policies of insurance companies and health hospitals that require lots of paperwork and short visit times. So that's a new somebody considering whether even to go into primary care and not sure that they're going to be able to sustain that practice. On the other end of the kind of experience practicing, one thing, another comment was what impacts their ability to practice medicine too many work hours, too much administrative work after a 50 hour clinical week. I'm a director of clinical service and have no administrative time. All I do is put out fires and not improve anything. And then another about the deluge of EMR messages that's taken on their own life. So what do we do with that information and that feedback we get from our members and our board? Well, we work with our board to translate that into legislative and regulatory advocacy into education and outreach to our members on topics of interest. We run a program under a contract with the board of medical practice that works on practitioner health and wellness. And as I mentioned, we support our specialty societies. And for the purposes of this afternoon, I will highlight how we've taken some of that work to strengthening primary care. We made this a big policy priority last session and had a whole and had had and will still have a whole campaign around making primary care a Vermont priority. Again, I included a link to the full campaign brochure with pictures and more stories and quotes from primary care clinicians. But our advocacy efforts focused on five elements, strengthening Medicaid payments, increasing commercial and Medicare primary care spend, support for participating in payment reform, strengthening workforce, and reducing administrative burden specifically around prior authorization. And fortunately, we had some successes in 2022. So I won't read all of these, but just so the board is aware of some of the movement we did see. So Diva has did increase the primary care, one of the primary care fee schedules to the 2022 Medicare rates, which it resulted in a fairly significant increase. And the 2023 budget for Diva has to fund the primary care at 100% of Medicare rates or report on if they are unable to do that what that funding would require. There was a study required of blueprint for health funding for community health teams and quality improvement. And then there were some significant investments in workforce. So there is a fairly new scholarship in its second year of funding 10 primary care physicians who graduate from the Larner College of Medicine and commit to practicing in Vermont after they finished training. There was an increase in loan repayment for primary care and PAs and nurses. And there was 15 million possibly more than that to be made available this fall for workforce recruitment and retention. And then also some strengthening of coverage for primary care. So that leads to what we still have on our agenda from 2023, what we have some unfinished business retaining Medicaid payments at at least 100% of the 2022 Medicare rates. So Diva has sort of agreed to try to stay at 100% of Medicare rates. The problem is if Medicare decreases their fee schedule, which is currently slated to happen, then if we're tied to Medicare, that could actually be a significant decrease to primary care in Vermont and a huge problem for primary care practices and independent practices of all types. We would like to see the report back on funding increases to the blueprint for health and implement those recommendations as well as possibly look at other elements of blueprint funding. We still support working towards minimum primary care spend by payer types, including Medicare. And this is something we'd like to take a look at in future all payer model negotiations. And those increased investments we think are a strong way to both support the blueprint and the CPR program that you've heard mentioned through the ACO. We have not accomplished paying for audio only telehealth services at the same rate as audio visual telehealth services, which we think is a big equity issue for Vermonters and the more rural parts of our state or who don't have broadband access. And we're working on updating the Vermont's workers compensation fee schedule, which has actually not been updated in 16 years. We need continued support for workforce loan repayment scholarships, the recruitment and retention payments. And we're also we've been in touch and maybe they could say more about this, not to put them on the spot, but by state primary care has been doing a lot of research around establishing a family medicine residency program in the state. And we think there are more steps to take around decreasing administrative burden actually a lot more steps, but one small element in that direction would be expanding what are called gold card pilot programs that were created by Act 140 of 2020. These are exempting folks from prior authorization if they have a very high rate of having their prior authorizations approved. So happy to discuss more of those in the panel. Maybe that kind of tees up more specific panel discussion and we look forward to it. Thank you for having us here today. Thank you, Jessa. And thank you to all the panelists. So now I am going to direct some questions to the panelists. We had a pre meeting and realizing that to go through each individual person or group, we would probably get repetitive answers. So I'm going to direct these the question to specific groups. I'll call you out. And of course, if there if there's another person on the panel who wants to add please chime in. So my first topic is on workforce shortages. We heard that from all of the presentations from all of you. And I think it was I know it was present before COVID, certainly COVID exacerbated that. So I'm going to direct this question to Dr. Volanski and Stuart May and also to primary health partner folks. So how have your organizations and your practices been addressing the workforce challenges and shortages? Thanks, Susan. You know, recruiting, it's not easy for anyone. A lot of other people have alluded today about how difficult that is. You know, being in a rural setting, we are competing with folks and, you know, a lot of folks have choices of other areas that have sort of more spouse employment opportunities, more varied education and other cultural opportunities. So that already puts us at a disadvantage. But for people that really get it, you know, want to enjoy what it's like to be here and live in a rural place, you know, they find their way to us. But sometimes it's hard for them to choose to join us. Housing is really challenging in our community. It's hard to find housing of any kind affordable or otherwise. You know, and unlike UVM, we can't just, you know, build buildings and put nurses in them. So we're having a hard time with that. I have nurses that really commute from a very far distance. So that's something we don't have a lot of agency over, but is a real significant headwind for us. And, you know, Vermont is short on all kinds of providers. So there's just so much pressure on all parts of the system. So we have, you know, had to kind of join the arms race of salaries, which is really, you know, we've had increased what we're offering, which is not easy for us to do. But I think that has somewhat helped us. We had, we help people with relocation and try to offer them as much other enticements as we can. We are have been able to combine our call schedule, which really I think has improved the quality of life or at least the frequency of call. So that now we can have small groups like pediatricians who don't have to cover their practice 50% of the time at night, because we can help each other out. And so that's, I think, been really helpful. So even though the call is heavier, you take it a lot less often and it allows you a little bit more quality of life. As far as, you know, we've had an issue, I think it's hard to see. Sometimes retention is difficult. I think the transition from residency or practicing in an area where you have a lot more collegial interaction and a lot more, you feel more supported and feel a little scary sometimes for people, particularly if they're new in their profession. And we hate to see people kind of float from front, you know, from one, two or three jobs before they really get their feet under them. So we've become very mindful about creating a very high touch, very close onboarding and orienting process so that we can make sure that people have the support they need, you know, particularly for folks in the advanced practice realm who maybe don't have a residency but probably would like to have had the opportunity, that additional training we try to create enough support so that they really want to come here and they really want to stay here. We've actually retained some of, you know, we've had a lot, we've had a couple of people in their 70s retire this year, we've had a couple of other people who sadly leave primary care, used to have people leave our practice to go to primary care elsewhere. Now I'm starting to hear people say, I just can't do this anymore. But we have managed to retain some of those folks to help us with the onboarding and mentoring process, which is kind of a, I think a creative way to utilize folks who are, you know, just not willing to take on that full workload but are still incredibly valuable to us. So we really use them in that, to retain them in that capacity. We have actually hired a lot of physician, a couple, two or three physicians who thought they wanted to retire and then they wanted to keep working. They just couldn't handle all of the responsibilities after hours that come with the heavy impanelment, you know, of having to follow somebody through every realm, you know, place of care that they go through. But they're still really happy to come see patients and help us with capacity issues while we work on our recruitment and building our workforce. And we've really become really excited because we've been developing over the years a real team-based approach to care. If, you know, because they've done research showing that for a primary care physician to do everything that needs to be done for their patient population would take a person about 26 hours a day and nobody has that kind of time. So rather than, you know, working faster and just working harder, we're trying to work smarter and we're trying to make sure that we have a really robust team support system with everybody working up top of their license so that when you're here, you can go on vacation and not have to take your laptop with you. You know that people are going to support you. You can enjoy your time off. You know, and you're not there holding everything by yourself. And I know hearing from all my other colleagues today, it's just really a treat to hear what everybody's doing because everybody's doing such great work and everybody's involved with the blueprint, which I don't know what we would do without the support of the community health team and the math team because I started doing substance abuse treatment work about 20 years ago when I was sort of doing it all by myself and watched the sort of math and blueprint grow up around me and I just can't imagine how anybody ever did it like that now. So, you know, we are really working hard to leverage the full team to make sure that when you work here, you have the support you need and you can actually stay. So I don't know if you want to add anything. Just briefly around creativity, we've been working with our university and colleges to expand internship opportunities and then hopefully being able to convert them, if you will, to full employment. Also, within the nursing shortage and challenges there, our clinical leadership has developed a clinical ladder. We believe we're the first FQHC in the state to have that outside of the traditional acute care settings to help that. And then just briefly, as Jessa kind of teed up, this is more of a long game approach, but HRSA has announced a planning grant application process for Teaching Health Center Graduate Medical Education to bring in rural primary care residency programs, which the 11 FQHCs are very interested in. We've started this work about a year ago of which LaMoya Health Partners is the lead organization on that. So actually that work has begun and we will be submitting an application to bring additional slots to the state for primary care residency. Thank you. One of the things I wanted to just thank Jessa for mentioning that scholarship program because when I was on the Rural Health Care Task Force, that was one of the main things we really wanted and we really need more things like that, more opportunities for loan repayment, more opportunities for other kinds of professionals because we're not short just on providers, but also nurses, MAs, physical therapists, psychologists. You name it, we have a lot of issues with workforce there. So that's really a wonderful thing that has come to pass. Thank you and I'll turn it over to Primary Care Health Partners for your input here. I guess I can start just make a couple of comments and then hopefully, Dan and John, you can add on to this too. I alluded to in our presentation that this is a really serious problem for us. We just cannot compete with the salary and benefit and loan repayment options that potential candidates are able to get from the hospitals or the FQHCs. We just do not have the financial resources. So there are two buckets here, right? I mean, there's the practitioners that we need to recruit, whether it's a physician, nurse practitioner, or PA. We have had just a really impossible time recruiting physicians. People are coming out of training with so much debt that we cannot even begin to help them. To try to get some of these grants for loan repayment, we're required to match $10,000 or more, which we do not have. If we try to use a recruiter, the recruiting cost and John can add to this later is just exponential. And that's assuming that the person stays with you once you bring them. So on the practitioner side, it's extremely difficult. On the staff side, nurses, medical assistants, receptionists, it's hard. Again, we're having to compete with larger organizations that can offer much more than we can. We basically are looking for kindred spirits, right? People who have the independent spirit, people who want the flexibility that we can offer a sort of like truthfully a small family within the office where we can really be so flexible on schedules and time off and various needs that people may have in their personal lives. We depend upon that a lot, but we're struggling. So John, I know you may like to add, and Deanne, you may like to add. Deanne, did you want to go first or when we say something? Sure. I'm happy to go first. I think one of the reasons that are, well, when I reflect back on where myself, where my practice was a whole year ago, we've come certainly full circle. I've been in my particular site for 20 years, but this is my third iteration of practice. And in order to do that has been, it's required a lot of assistance. And so we are here because we want to be here. And because the 8,000 kiddos that we take care of, we can't imagine that being absorbed by anyone else. They're medically very complex and, you know, it just we're committed to them and we're committed to this area. So that's how they were able to recruit us. We want to stay here. It would have been far easier to leave. So we have a group of very committed people, and I think that drives being able to entice other people to come and join us. We love what we do. We do a lot in terms of quality. We can feel good about the work we do at the end of the day. That's our mission. It's so easy in primary care because it's absolutely overwhelming, all that you're expected to do, to feel like you're never doing enough. But we take opportunities to celebrate the things that we are doing well and to cycle it back around and remind ourselves of the good work that we're doing. And I think that's very powerful. Having the extra support of the MSO who can help us with the business aspect of like we don't learn this in medical school. As you know, we're not business people, but we want to be here. We want to stay here and we need to be able to have the proper amount of staff to be able to continue to function and to continue to work hard like we've been doing. So all of the things that people are talking about are struggles across the board, and any help with any of those things would be very much appreciated. So I was just going to add sort of a personalized comment to the question. As it was being asked, it reminded me of one of our physicians whose response to dealing with his shortage was to work more hours. And you know, it's not physician burnout, it's physician inferno, right? I mean, he's working 1.2 FTE and you know, in independent primary care, there's nobody nobody else covering your bottom line except for the physician themselves. If there's a loss, it comes right out of the pockets of the physicians. And so he's the one who's working those extra hours. And I got to tell you sometimes I don't even know why he why he continues given how much stress he's under. I don't know why except I know the answer because he's that passionate about delivering care. But and unfortunately I said it's it's how are they dealing with it is just more time more time. And it's like how long is this going to last as far as recruiting mentioned to before. These recruiting firms are looking for $25,000 for a physician or $19,000 for a nurse practitioner right on top of we've got to offer these loan forgiveness is which require match on our side for being an independent. So it's a huge investment hoping that when they come they'll stay. So it's it's a challenge. Thank you. Thank you all. And I see Susan Ritzen from Health First you have a comment as well. I just want to punctuate what Dr. Sacken and John Aslan have said recruiting physicians and being able to pay them competitively is one of the biggest issues we see. And I just want to point out that you know the other like FQHCs they get grant money the hospitals you know they have 340B money so the FQHCs independent practices their only source of revenue is reimbursement by payers. So when that remains flat or does not keep pace with the expenses that are practice you're looking at an unsustainable paradigm basically and that is one of the key reasons why we just can't compete. The other thing that would be extremely helpful you know when you have these physicians working day and night to you know get the work done is you know they're burdened with so much administrative work. So steps taken to decrease that would help free up the clinicians to actually see patients and would potentially reduce burnout. So I think that's an area we can work on. Thank you. Thank you. Thank you all. I know it's a challenge and if I had a silver bullet I would share it with all of you but thank you for your perseverance. Oh and Jessica Barnard. Sorry to jump in I just had to add one piece of actual good news. That's wonderful. Thank you. Especially in the area of workforce I feel like any good news is important that this that AHEC the Office of Primary Care and working with HRSA expects to receive about triple the amount of loan repayment funding the state has gotten historically for I think the next three years so that will not only allow the state to offer more loan repayment slots but also to put that HRSA funding towards some of the sites like FQHC sites where I think they're obligated to prioritize but then state funding for loan repayment should be more available for independent and hospital based primary care because I know that's been a frustration is kind of how not all primary care practice sites are equally eligible for the state's loan repayment program. So if you were trying to recruit in the next few years keep your that more information should be on the AHEC website in the next I don't know maybe month or two it's going to be opening up probably around the beginning of the year so share that with any new new primary care clinician. Thank you. Thank you for sharing Jessica. Okay so we're going to switch topics here to value based care a few of you touched on this in your opening remarks and I'm going to direct well this is the same group so so maybe maybe I'm going to hold that question because I want to I want to get other folks involved here so why don't I talk about telemedicine I think that is something that I'll start with now and then we'll get to value based care and and this in Jesse you touched on audio only as well which I think both of those were used so much during the pandemic and I'd like to get some feedback on how are you doing with that what lessons have been learned from using telemedicine and audio only during the pandemic and what are the challenges and opportunities and I'll direct this to VMS and Dr. Velansky and primary health partner so Jessica do you want to start here? I'm happy to start on the more technical I'm sure the physicians joining would have more to say kind of how they've used it in their practice and how beneficial it's been for reaching patients I'll say kind of on the policy side when I want to I think one of the really big challenges has been how much it's been the landscape has been changing you know not only sort of because of the federal public health emergency there have been permanent changes there have been temporary changes there's been state temporary and permanent changes and it as a practice I think it's just been extremely hard to keep up with all of that changing landscape what is getting reimbursed in terms of codes at what amounts so I think ideally reaching a steady state would be very helpful I think we're getting closer to that but it's been it has been hard and I think also the fact that there were there was such an expansion right after sort of right in the beginning of the pandemic and now we're sort of seeing a gradual ratcheting back of what's covered where Medicare has not yet finalized their 2023 fee schedule but we're expecting that there will again be some further kind of reductions of what's covered especially in terms of audio only and we just see and that that is such an equity issue for Vermonters I attached it as another handout some comments that a number of our organizations submitted together to the Department of Financial Regulation when they were looking at this issue this summer which has I think some really useful data from both UVM health network and Dartmouth who just have as large entities better data collection capabilities in terms of where you know sort of what some of the why patients are needing audio only so where their calls are being dropped where they do or don't have broadband access so this is often this is a patient sort of request and a patient need it's not that often the sort of first line option but it's really needed so I think that's been the challenge and we're at this point really concerned that also with the end of the federal public health emergency which we expect to be coming kind of in the early part of 2023 that that may also have sort of a trickle down effect on what Medicaid is reimbursing for audio only so if Medicaid makes that cut I think that's going to be really hard for especially low income Vermonters who are even less likely to have broadband access so that's kind of the big policy piece and I'd love to hear from some of the clinicians in terms of how they're using it and what the benefits to their practices. Yeah I think that thanks just so one of the things I really love about about telehealth you know there's so many benefits there's so many ways to look at it but the bottom line for me is if I can provide the right kind of care to the right person in the right setting the right platform at the right time like if you let us kind of figure that out we'll cut costs we'll prevent unnecessary VR utilization we'll provide access for people that really has a lot of difficulties her mount barriers and when it comes down to it it's really good for the patients. Patients really like this they almost like it a little too much because sometimes it's a little hard to get them to come in now but like at the pandemic when you know all at once everybody stopped coming to see us right it allowed us to sustain ourselves it allowed us to be able to help people that weren't able or were not willing to come in we you know we didn't close some places did close which I think you know was a tragedy for patients accessing their primary care providers it was not easy to stay open because the in-stream income stream just vanished and we had to really get creative and this was really a helpful tool but for people who you know don't have transportation have lost their driver's license but need substance use treatment who can't afford the travel time off from work who can't afford the gas to get here they don't have a job either or they don't have childcare resources they can't bring their children via RCT it was an incredible expansion of access for so many people that had struggled and our behavioral health mental health and substance use encounter rates and at the pandemic went up so they were like at a hundred and twenty twenty five percent of what they had been before because all of a sudden the patients that really needed these services could finally get that and that was just an incredible boon for them I think for us we have spent years giving people free care at night over the phone and now I a lot of us still do that but you know you have this option now that you you can decide to pivot to a telehealth encounter if somebody is really getting basically everything they would get in the office they just decided to call at night out of convenience they were at work they can take time out there's all kinds of reasons that patients do that but instead of just like okay I'm just going to give them this prescription you know you can actually say hey why don't we do this visit right now I can actually make a video link with you it's fairly easy I can take a look at your child's rash or I can you know we can actually conduct the visit now and then you don't have to come in tomorrow which is great for my receptionist they don't know where to put the patient tomorrow anyway so you know that's great so we can actually make a little rain when we're up at night doing this work that was previously completely unpaid you know and as far as you guys all know that you lose money on these visits they're not paid the same and you know and for us we have a lot of enabling services and I guess you could some people might say well you're not using all those services on your telehealth encounters but actually we love using our community health team our MAT team and our embedded mental health clinician via telehealth and patients love it too it just gives them so many more opportunities to interact with those folks and to try to get my diabetic patients to come back and see the nutritionist on a different day if she didn't if she happened to be with another patient while they were here or I have if I I've had periods of time where I've only had the one nutritionist and I've got these different locations well now my community health team my MAT team my expert mental health clinicians they've mastered the art of being more than one place at at one time so if I have somebody who's expressing suicidal ideation or is really in the mental health crisis and Riches and Morrisville they'll just bring in an iPad or a spare laptop and I'll send him a little fuse or a zoom message and then they'll bring him virtually into the room with my patient so that my patient gets that care when they need it so it's really increased their their opportunity to engage with patients so so having that in our repertoire we've gotten creative about using it in a lot of other settings I think for patients to lose this access would be really tragic I think that you know for them it's been a really good thing I think that you know the equity piece as Jessa mentioned is is is hugely important and I think if you want to cut costs if you want to you know just if we just had capitation and we could just decide like what is the right time what is the right place what is the clinically appropriate way to meet this patient's needs this including audio needs to be part of the package so many patients cannot manage the video they don't have the bandwidth they don't have the technology in their house or they don't understand it they don't have the tech literacy they just don't have the ability to manage that most people have a phone and it's really important for them to be able to include that when it's clinically appropriate great thank you and um primary health partners I you may want to add to this I'd love to where I have found the most helpful is in the mental health arena primary care physicians provide a lot of mental health care and this is one area where it really benefits to have that option of telehealth some patients have a hard time physically making themselves come into the office or their schedules don't allow that they can come into the office for many different stressors transportation issues and that is certainly one visit where just a conversation after hours where I can send my nurse home and I can give the patient as much time or as little time as they need that's been invaluable I've been able to connect with college students who are away make sure that they're checking in regularly it's it's been really helpful so I would very much hate to lose that ability as we know mental health is a is a really big issue right now post pandemic has been prior to the pandemic but I think it's really important to maintain that excellent thank you and I see rick duly you have your hand up yeah thanks I just want to sort of point out there when this really interesting position sort of stuck between fee for service and this goal of shifting to value based payments because in essence what we want to shift to is we want to shift to really audio only or audio video or it doesn't matter as long as we can take care of our patients and and give them the care that they need so but unfortunately we're in this fee for service system right now where primary care is already so underfunded and we're so on the cusp that when we get less payment for an audio only service we were penalized for it so it's hurting primary care now even though our goal is to increase primary care spending and increase our longevity so I think yeah we I appreciate that you know the goal is we're gonna you know make this big shift down the road but I think there needs to be real significant change you know now to supporting primary care especially with these audio and audio audio video visits I echo everything everyone else said about my patients I mean there's no doubt that the folks who are least able to afford broadband least able to have access to a car have you know patients who can't travel to see me because they literally can't afford the gallon of gas it's going to take to get there and back you know these these visits are life changing so so we absolutely do need to make sure that they're supported adequately and not on the backs of the primary care providers getting less reimbursement for them thank you thank you thank you and I see Mary Kate Coleman has her hand up yes hi thank you Susan I just want to add to what people were saying and just with a comment that this is not less work for providers to provide care by an audio only it's not like oh let's do a quick call and call it a day no no no it's still you're still going through all of the conversations the labs the patient education changes in treatment plan you have to identify any care coordination next steps prescriptions so the idea that it's just a phone call is not true oh and then there's the follow-up then there's their documentation of all the conversation that happens so this is not a sub-visit this can be for most cases for clinically appropriate visits by telehealth and audio only it is a physician visit thank you that's that's really good information I appreciate that so this actually I'm glad I started with the telemedicine question because it kind of led into the value-based care question and in terms of value-based care we we really want to know you know what has worked what hasn't worked you touched on that a little bit with telemedicine with value what has or hasn't worked with value-based payments in your practices and for your patients and we have health first and primary care partners as as teed up here but certainly others chime in and I'm just aware of the time so I just want to probably wrap it up with this question and I'll turn it back to chair Foster and see if board members have any additional questions but this is a big one so I can take a stab at starting it I guess um thank you you know I think as as we said we all believe in in these quality improvement projects and in value-based care I think part of the issue is in order to really achieve these goals and to get the outcomes really it requires some upfront investment and to be to be able to implement the changes that we need to get to where we should be and where we want to be and where you can like tap into the value-based payment so um that this is like this vicious cycle that we're constantly in in talking about these programs and and when it comes to you know the idea that value is necessarily less expensive that may or may not be true so this is a it's a really complicated topic I think it's not it's not it's not simple to say oh there's quality and there's value and like we pay you for it and that's it's more complicated than that I feel really strongly that investment should be made upfront and then we'll see the outcomes so um in a sense the concept is a great concept and in little tiny pockets it is working but if what we're really looking at is sort of transformation of healthcare and what's been said by others right you need an entire team in order to make this work the majority of what's going to make these things work is not the physician it's the entire team around us that entire community health team and we just don't have enough of it right now so I'll leave it at that and let other people chime in I'll go ahead and chime in I agree with everything Toby said um and I know someone had earlier mentioned that robust team uh you know sort of supporting uh you know supporting your practitioners um you know and all those things that that team does you are are generally not reimbursed um in a fee-for-service model so you know there there is no real payment and one care does pay us for you know some money for care coordination but even that care coordination payment doesn't fully pay for the entire cost of the care coordinator so we're still paying half the cost of the care coordinator to provide this care that isn't reimbursed that I'm I'm certain saves hospitalizations and you know decreases readmissions I'm certain my patients overall have better health because of it but I'm not convinced that necessarily it's a dollar-for-dollar savings in the long run like Toby said and I know it's not a dollar-for-dollar savings for our practice I I know it's it's a money loser for our practice but still something important for us to do I will say the you know the idea you know we are in the CPR project like um you know like um primary care partners um and certainly through the pandemic fantastic you know one of the practices we're really struggling you know having that that dependable income for for us it's about 30 just just over 30 percent of our patient population was really helpful that part is great the problem is that the the promise of value-based payments is that you know you'll get this upfront payment and then you'll be able to do all this great care and life will be easy because you'll have all the resources you need but the payment has to be high enough to for that to make a difference and the number of patients covered by it needs to be high enough that you can change your practice model so for us it's 30 percent of our patients that's great but 70 percent of my patients are still fee-for-service which means I can't change the way I do business I can't change scheduling or you know all the things that people say are going to make you know create these efficiencies that honestly I've done this for 25 years I've yet to see anything that has created efficiency and any of the stuff that we've done but um you know I feel like we um have this have this thought that we're going to suddenly make this big transformation but it has to be um with a lot more patience than we have in the system now because otherwise we got that whole you know put into a news analogy that we've all talked about for 10 years um and I don't know how to make that that next jump to get us to get us beyond that that's the biggest fear that I see in trying to trying to get to value-based payments thank you anyone else in terms of your experiences value-based payments season also add that um in the experience across our primary care practices who participate in the one care programs is um the programs don't work for every practice like for some practices it does not it's actually money losing for them if they were in the fully capitated program so there is some personalization that needs to happen I've also heard from practices about um some pretty serious attribution issues so um you know where practices haven't been at the practice for a couple of years and when their payment and um performance is tied um to you know the patients they're taken care of or attributed to um if you know something is falsely attributed that could mean real money for them or take some down a level on their goal and so you know there there's some kinks to work out um but in general I do think that the one care programs have been by and large beneficial for our primary care practices so we are thankful for that thank you I see John you have your hand up I do so um going back to a comment Susan Risen had made earlier historically in terms of funding primary care it's really been uh what you can get from the government payers and you basically subsidize it with what you get from the commercial payers and so the more government you have the basically the worse off you work and so I gotta tell you in 2017 I I would have foreseen the same thing that Susan was saying earlier about some of our practices probably would end up closing financially the numbers just they didn't work and when you have physicians who are cutting their salaries to be less than the office administrator how long can that go before yeah you just it their survival was was at the brink I was so disappointed in terms of where we were at I you know Toby you know the story that uh I I strongly felt that PCHP needed the next Lee Iacocca but I wasn't it and to the point that I even said you know I should resign because I don't know what the minivan is I don't know what's going to take this thing to help these practices survive I had been to realize that in 2018 there was a minivan that's being delivered and that was a CPR program the CPR program isn't perfect right just just like if if Chrysler left the the same 1984 minivan unchanged all these years it would not have been a success right just like the CPR program cannot be left alone and it's evolving through the years to be something that that intended to really help primary care right we're moving to those next stages of of the value-based concepts and supporting mental health and and and we're appreciative of of the commitment at at at one care and the hospital the table that all the comments here about investing in primary care they're all saying it they but they also being fiscally responsible that we're making this investment then that how do we prove there was success in doing it and and we're appreciative to be at that at the table I got to tell you that that one office in particular that I thought would have been gone by now the reinvestment from the CPR program helped to to to strengthen his financial office he's not walking away a rich man but at least he's making compensation or he can hire practitioners at competitive marker rates that he couldn't do under the old fee for service model so boy I can't imagine the day that we would say that the CPR program she would pulled the CPR programs needs to evolve and I so supportive of wanting to continue to see that thing develop further and and further into all the value-based concerns you know and I said they they're at the table and everybody's talking about driving it there great thank you so much thank you all oh jessa I just thank you and thanks john for those great comments I just want to sort of add a plug for those green mountain care board members or staff who I know a number of us are participating in the meetings that AHS is bringing together around kind of the future of payment reform or a next all-payer model and I I have said this several times in those meetings but I am a little concerned that this message of the CPR program is not getting through and that if we don't have an ACO we may not have a mechanism for a program like a CPR program so again not saying it's necessarily every detail of it is perfect but I think if I have fears that if we are totally starting over with something completely new in our state that we may lose something that is at least supporting a number of primary care practices so that's just a collective request that we all continue to discuss it in those meetings or in thinking about a second all-payer model great and I'll turn to you rick in a minute I'll just say you know it's it's also great to hear from providers about what's working and what isn't working about programs and while some programs like the CPR program may not be perfect it does sound like it is working in in a lot of ways so that this this feedback is very very helpful to us rick you have your hand up yeah I just want to point out that in terms of the evolution of the CPR program I totally agree with John you know one care does have this sort of CPR group I know John's been there Toby as I have you know where we meet with Derek Rainson the director of payment reform and you know Tom Boris or CFO and really they have they have really reached out much more so now than I think they did initially which is great you know to really get provider impact and and they said repeat I heard Tom say I can't count the number of times say you know I don't know this I'm not a practitioner tell me what I'm missing tell me tell me what I need to know to make this work tell me why this wouldn't work and so they they've actually been especially in the last year so I've been really responsive in that way and I think that's going to help drive this evolution of making the program work more folks you know and and they they were respectful when they were practices of ours who would loss lose money you know first they were a little skeptical they're like oh no this model worked for everyone and when they sat down with you know one of our practices and looked at and were like oh you're right this model would not work for you okay we'll we'll try to figure out how to make that work so you know so I think there is there is an evolution happening which is which is really helpful great thank you so in the interest of time we're getting up around three o'clock and we've been talking quite a bit I I I want to just thank all of you again for being here today and for the work you've put into um the preparation and also for being um just for sharing your your lived experiences with the Green Mountain Care Board I will turn it back to you Chair Foster if there are other questions from the board or you thank you I will turn it over to board questions this time if there are any we can go in sort of the usual order if people would like is that me I don't know what our usual order is anymore so it's you now all right um I actually don't have any questions I thought it was a great uh discussion and I really appreciate everyone's comments and thoughts and it's nice to see many of you who I haven't seen in a while so thank you very much for coming can I make me next Owen please go ahead okay and can you hear me okay is my audio working right now okay perfect um again I want to echo um Robin's you know gratitude thank you so much it's really informative it's always helpful it's nice to see your faces again um I actually just have two questions one was I was wondering if folks might be willing to share any updates or any information on specialty wait times um you know we had obviously done some work over the in the winter months um had some focus groups and and learned a lot about specialty wait times and I'm wondering if there's any relief there any relief in sight are there any you know anybody willing to share anything about uh the difficulties or or not in getting patients in to see specialist I guess I can say I think it's the same there's a long wait and um the hardest part about it is the patients are told um that they can get in faster if they make us like page the specialist which but I can guarantee you those people do not want to hear from us and I basically have to tell our patients that is for like serious emergencies and I know that you want to get in but I I cannot in good conscience page this person for this but that's what they're being told yes sometimes they're told that by the specialists and when I when I hear that I'll actually give them that feedback like please don't tell them that I I know that I can call you if I need you but please don't don't encourage my patients to do that I'm not going to abuse the system and you're just pitting me against them I think that there's another angle to the scarcity of specialty services I mean there's a very real problem with the supply we really do need those providers and we don't have enough of them but I think that there's also an ability for a lot of primary care physicians to do more of the kind of care that tends to get referred I mean we have a lot of training and we can do things like skin biopsies and joint injections but not when our schedules are under such terrible strain and so a lot of times I think to make to try to make room in our impossible schedules we are referring things that we would have enjoyed doing ourselves but we just can't find time and that just makes the problem that much worse and I think if we had enough of us having the time and the availability and to work at the top of our license and provide the care we've been trained and we have experience in providing that would actually take a lot of the burden off the specialty referrals the other thing I noticed and I honestly don't know what's driving this but that a lot of the specialists don't act as consultants but rather keep our patients and continue to follow them for a long time rather than put sending them back to us saying okay yes I agree this is Parkinson's here's what I think you should do let me know if you need any more help instead they just create follow-up visit after follow-up and I lose my patient I want and I may want them back I usually when I refer them say I want you to manage this take this off my plate or I'd like your diagnostic impression and advice for management but I don't necessarily want you to keep this patient and I'd love for them to you know create that you know enable that capacity for other consultations by acting as consultants more often letting us do the management that we can do and actually just follow up with that because that's something that we heard that from both sides so basically from primary care providers we heard that specialists were hanging on to their patients too long and from specialists we heard that they're you know being referred patients that should be treated in a primary care setting and so I'm you know your your comments are something that we've heard and how do we start to make that cultural change what you know what are some opportunities to do that where does it start well you know Dartmouth has I'm sorry I mean the Dartmouth has right on their referral form if any of you have ever filled out the Dartmouth referral form you know it says you know do you just want a second opinion do you want us to just manage do you want us to evaluate like so so it's right on there's a actually over the three or four options are but you know and they think great about the folks I say look I just want you to just evaluate and give me give me your opinion they'll do one visit send it back and say here's what we think and folks who I say I want you to manage they hold on to so so it can be done you know it's not rocket science you know I think it requires I don't I think there are also those patients who get who who maybe get referred you know because they I don't want to say because they want to but there are patients who certainly I could manage their thing their condition and but they are insisting that they need to see a specialist and maybe those people do end up on the you know no matter you know for better for worse those people sometimes do end up on the specialist roster just because you know they squawk and you know it's it's very hard to prevent that but that's not the vast majority the vast majority is is I think appropriate referrals I just want to put a plug for the child site program if any of you use that this new child site program through the I don't even know who's funding it but it's it's a telephone referral service it's fantastic I used it three times in the last week you call you they call you back as actual an actual child psychiatrist like a real live one calls you back you know within half an hour or so spends 15 minutes taking the whole history of your patient and then they just say okay here's what I do here's what I recommend here's some suggestions you know if you want to schedule for child psych it's probably going to be 12 months down the road but in the meantime here's what you could try for medicines it's fantastic I think if we had those resources for you know endocrinology for rheumatology that would be fantastic because oftentimes I don't need the patient to see them I just need that for are the providers I just said the provider just say hey okay here's my next steps here's what I do we can do the work we're trained at that we just need some direction so and sorry Melissa I didn't mean to cut you off there that's perfectly fine I you raise a really excellent point in that phone consult service that or e-consults or telehealth however you want to call it I've heard them starting to talk about developing that EVM and it would be great I just still think that for all the reasons there aren't enough primary care physicians it just feeds this problem and creates this I don't want to call it a myth of scarcity there's a real scarcity of specialty care but and and there's the reasons there aren't enough primary care physicians it's so complicated from the way people are selected to get into med school of the way graduate medical education is designed and then how things are reimbursed and it's all upside down there's a couple of hands raised I'd like to turn to if if we can it's miss Murphy and then miss wait after miss Murphy is commented this is exactly a thank you this is exactly the conversation we had in the primary care advisory group when the specialty wait times came out that a good chunk of it maybe patients who are referring themselves because this is that culture of you need to see a specialist and not understanding that there's a lot of ortho that can get done in primary care PAs and NPs physicians everybody does skin stuff everybody does ortho everybody does the basics these are some of the basics of primary care that can be done some of it is that mix of are there enough primary care providers it's the scheduling onto the schedule is the patients not knowing what can be done in primary care and then the other pieces specialists some of them and that's not specific to a specialty or an individual but there are those who keep the patients and have them come back every several months it used to be years ago that you'd send a patient to cardiology for a hypertension management consult and they would do the consult but then they'd see the patient every three months then cardiology got to where they can't keep those patients and then they'd come back to primary care so how much of it is dermatology cardiology neurology keep going down the list of specialists keeping those patients versus sending them back and how much of it is patients and families for monitors not knowing what can get done in primary care thank you miss murphy and miss weight I think you were next I think thank you very much for recognizing me and I would tag on to what Eileen murphy had to say and it was an excellent segue something that we have also discussed at pcag is about the culture change that needs to happen and around an education campaign and I think that is where our leadership across the state whether it's at the department of health whether it's at the gree mountain care board whether it's through blueprint whether it's through cht we need to educate our patients that they don't have to see this specialist and we need to also educate our patients for for everything they absolutely need them for certain things we also need to educate our patients though that the primary care provider is the person who needs to be that gatekeeper because they're the ones that know everything that's going on with that patient and when they're seeing six different specialists their care is so fragmented that that's where problems happen that's where accidents occur and that's where care gets in trouble and so it's so important that the primary care provider is that gatekeeper and is making sure that all of the specialists when they are needed are looking at that patient holistically that's an education area that we need to get out to the general public thank you jessica do you have any other questions at this time I actually said a quick one more question um you know we obviously we've seen and heard about hospitals divesting of their pediatric or under primary practices because they weren't viable and we've also heard about reimbursements being higher for hospital-owned practices so I'm just trying to reconcile the two and then wondering how those practices then become viable when they are separated from the hospital what's happening in those practices that makes them viable outside the hospital setting when the reimbursement rates as we hear are actually higher for hospital um employed physicians I'm just wondering if anybody could speak to that it's a curiosity for me john you might want to chime in on this but you know for us and then and diane can talk about it too you know the overhead of the hospital versus the overhead at the independent primary care practice and it's a huge discrepancy so we are able to operate more efficiently from overhead we don't have like you know all of the hospital regulations that they have to do but we also um you know probably staff more leanly right we can only afford what we can afford and so we we share medical assistance at least in our practice you know we we don't have our ends we have a couple of lpns for triage and we use medical assistance for everything else and we share support staff um and so a lot of those things happen but the salaries and the benefits are still an issue right like you you heard diane and i'll let her speak for herself but you know when when that pediatric practice you know they were independent years ago as mousetrap then they went to the hospital when they left the hospital to come to primary care health partners they took big decreases in their salaries and benefits in just because they they shared our you know they had a kindred spirit with us they they had been in an independent life and they wanted it back and they wanted to take good care of their patients and they wanted to make a go of it but you know financially for them this wasn't was not a good thing because in primary care you have to live within your means you know they were basically you know honestly like being overpaid for what they were able to bring in to cover their salaries and somehow that cost shift was happening at the hospital so they agreed that they would pay them and benefit them at a certain level but in real life the you know what i said before the math doesn't work john did you have more i think you you've summed it well right the hospitals have a lot of overhead to apply to the individual segments of their operations and that doesn't exist and to that to that degree in our organization i don't you know i don't know the all the reimbursement rates for all of the hospitals i i've had insurance carriers commercial insurance carriers tell me it's the same it's it's no different i i don't know but um but i do believe it's the the the overhead is one of the big elements that is the difference and we'll turn to tom walsh and then uh dr david merman unless uh jess you have anything else okay um tom are you are you there do you have any questions or dr merman i'm here this is tom i want to second the other board members and i'm saying thank you for spending time with us this afternoon um as a relatively new board member one of the things that i'm constantly trying to think about is how to um listen and learn about the issues in the provider community and then think about what levers we have through statutes in our other responsibilities where we can take action that would affect that i like um staffing within your facilities is something that i think about a lot after listening with everybody um but i'm still trying to learn what levers we have to push on to to be able to help with that and one area that comes to mind and i think it was toby that that was talking about this the the pricing of benefits and um particularly health benefits and that made me wonder about for your practices are you do you group together to buy insurance are you self-insured how do most of the independent primary care practices organize their business to be able to offer benefits could you help me understand that yeah i mean the issue of one of the biggest challenges and john you'll help me here but you know we're not allowed to band together with other practices with different tax id numbers in order to to pull together we're not allowed to do that so we're really at a big disadvantage when when it comes to something like that that's why i had that idea like well why couldn't we do it within the aco structure it sort of made sense to me that that there could be something like that but when we sat down to look into it further it turned out that there are all kinds of reasons and regulations that for the purpose of health insurance only you're not allowed and and everything else but you know that's where you know in health care because of all the laws were not allowed to sort of you know have you know like a union and we're not allowed to to collaborate together for the purposes of of group purchasing and the independent practices even even the larger ones are not big enough to self-insure so um john did you want to add anything or or rick it just too too small to self-insure and it's been known that health care workers are users of health care services and so it's a higher cost group to ensure they're human too right it yes and and so i think that that's important um i'm trying to reflect more on that and i think it's important for uh board members when we're thinking about uh small group and large group rates and the effect our decisions have on those that that affects the people you employ absolutely if i could just add i think you know this whole idea of the the health care workforce and how we're struggling to have enough people to take care of everybody if we don't make sure that we take care of the people providing the care there's going to be nobody to do it right so i appreciate that and that's what i'm i'm trying to flesh out and with my own thinking a little bit but also share it with everyone when we're when we are doing our rate review right the independent primary care practices are a big part of the small business community yes and and you all are affected by those decisions hugely affected hugely affected in a couple of ways not just in higher premium costs pardon me for interjecting but also you know when the hospital gets a budget increase i mean that and the payers get a rate increase i mean there's less money available in the system to reimburse the independence there's nothing left so it's a double whammy yeah sure i'm i'm seeing that more and more and just thank you for talking me through it and making sure um i was i was wondering to um i think it was stewart okay one second i just want to turn there's a mary kate moman raised her hand i think it's gone the point that you raised before so i'm sorry to interrupt i just didn't want to ignore her thank you thank you chair foster uh remember walsh i just wanted to add the fqhcs are feeling that same pinch as well some of ours are self-insured but many are not and so those premium hikes are really hitting a lot of our fqhcs their budget thanks mary kate any other um comments on that question around before go ahead dom i think you're good thank you thank you yeah yeah um i think it was this stewart may may who um pointed out in one of the outcomes slides he was talking about one of the aims is for for zero suicides and toby another note that i took about them met at the pchp medical service organization um i've i've worked with quite a few of those in different parts of the of the country and and um have experience with them doing a lot of data collection and this um data collection and using a goal often unattainable of getting to zero are two things that i've seen in a lot of places and in in vermont i think when we when we think about outcomes um and quality data we sometimes get into uh worries about small numbers and how they can be misinterpreted and so i'm i'm i would like your all feedback not necessarily this afternoon but over time about the possibility of of monitoring data with questions about ambulatory care sensitive conditions and in particular use diabetes as an example because it's so prevalent but if we were able to review outcome data that looked at um what proportion of your patients in your panel had diabetes of those who have it i'll make what proportion have an a1c level greater than nine and of those who has not been seen in the past six months and of those who haven't been seen how many end up in the ed or with an inpatient admission and how many end up dying and the goal with that type of review would be how can we get the ed visits and the inpatient admissions and the deaths to zero and what we'd watch we could watch that over time right knowing that zero a consistent zero is impossible but in high reliability organizations we think of things like zero harm and trying to get to zero but so then you're not benchmarked against somebody else you're benchmarked against how your how your practice is performing over time and you can think about this with patients with depression too like what proportion of your patients have a positive screen for depression and what proportion with the positive screen see a psychologist then how many are admitted and how many suicides and deaths when I was working at Dartmouth-Fitchcock and we did the we had the multi multi-specialty care at the at the spine center we we ran into our outcomes were abysmal in the beginning when it came to detecting depression we were expecting 2.5 percent of our population but when we started screening people we had over 13 percent we thought wow this is a big a lot more than expected we need to do something we had a psychologist in the hallway at the at the time but we found that of the patients who were screening positive less than 10 percent were actually seeing the psychologist that we had there so that was a big you know kind of a shock to see that we weren't doing very well and then we had to go through a lot to try to get those numbers up but I'm sorry I digress a little bit but I just trying to show that I know how hard this type of work can be on on some levels but that type of data does a medical service organization in Vermont in your area provide data services and would they be able to do something like report the number of patients with diabetes a1c greater than nine not seen in six months who goes to the ed who goes to admission and does that seem like I want I hope to hear from people beyond this meeting like what are the holes with that type of thinking where are the problems how could it be better um so um that's the last that's the last thing that I had I was hoping for some help thinking and there's a hand up but I can't see who's it is so Dr. Sadkin and and then Mr. May great thanks um just want to let you know that we actually are working on all of those things that you talked about um we're collecting that information in our independent practices and also through one care and we're working on that together through one care so um a lot of the committees that that Rick and I sit on together like population health and there's a value-based payment reform with the CPR program we're looking at a number of measures including the ones that you talked about and trying to sort of devise processes by which we will make improvements in those numbers so that is in progress and so a lot of that so he's going through one one care a lot of that data collection okay yeah thank you and I'll say also Tom for um for medical home certification and I think almost every practice on this call is especially with the medical home um you know one of the medical home certification um requirements is that there's a series of QI projects that get done each year based on data so you have to you know pull this data have a project that your that your practice works on and then you know report out at the end and so these ongoing so so the request for data is not you know and practices want that data I think one of the tricky parts is we do a lot of our practices need to get that from one care because they don't have the staff or the knowledge or the facilities to actually pull that data themselves and I think you know one care you know sometimes you know we can certainly pull who are a 1c's are better less than nine that's the easy part um figure out who was you know potentially admitted not admitted yeah that's really claims based data that we need to get from you know from an organization like one care um and you know they've been working hard on coming up with a plan for that and and hopefully we'll start seeing you know so far it's been sort of more aggregate data and and we've been advocating for a couple years now to get more practice specific you know drillable what can we do with this data and and that's the sort of the direction we're headed so I don't think you're off off track at all I just do want to point out that the zero suicide is um is actually that's a project of the suicide prevention resource group um so so it's not that everyone is I mean ideally we're all targeting you know the goals to get to zero but but it's you know the that's the name of a project the zero suicide project that's a nationwide project it's not a you know not an unattainable goal necessarily set by by the Vermont practices if that makes sense yeah it does Rick and I appreciate you um sharing that with me I thank you and Mr. May I see that your hand is raised yeah just as a very briefly Tom um we've over the past year and a half invested internally in improving the data intelligence um so as Rick mentioned part of that sustaining level of PCMA is to use evidence-based data but we do mine our own data then set those internal metrics how we're going to measure it use various implementation tools through outreach with those cohorts to mark that measurement and report out actually on a quarterly basis all the way up to the board but happy at a future date to dive a lot deeper in and continue that conversation I appreciate that too I think it's you know when you think about it's what proportion of your patients or my patients right when I was seeing patients what proportion of my patients have a positive depression screen what proportion are seen by the psychologist what proportion end up um admitted um that type like it's it's just it's division right we don't we don't need an algorithm or artificial intelligence the hard part is how do you gather the data right but but so many organizations in some of my different roles in the past spend a lot of money on artificial intelligence intelligence and um fancy regression models but it's it's division the their rates so the hard part is how do you bring the data together um and it it proves to be really difficult but but that's yeah and yeah and just briefly right it's been it's in disparate repositories and then what do you do when that data is actually in a flat file type of format right extracting that but like I said happy to have the conversation at a later date all right thank you sir thank you everybody I'm I decided taken enough time okay it's um 327 in the meeting scheduled to adjourn at 330 and I want to make sure that there's time for public comment and the health care advocate um I I have a number of questions which I'll forgo I think a number of might can ask later but I did want to give Dr. Merman a moment in case he has any um questions oh thanks so much um you know it's it's I'm new to the board and my my vantage point in health care has been through emergency medicine so it's it's really um interesting and helpful and uh just really illustrative I think to get the vantage point that you guys have from both the standpoint of you know challenges but also some successes and where you're going in the future and so I took a lot of notes and I have a lot of things that I would love to reflect on uh three minutes is going to be tight but I I I do want to just sort of bring up a few things which this might sound like almost a silly question to ask but of Susan um I just was wondering if I could ask you this question which I feel I feel very strongly about this and I think everyone else does hear but but I want to ask you so what do we lose as a state as a community when we lose an independent practice like what what can you just I don't know just flush out a little bit more that that loss so we can yeah thank you for the question we lose some very high quality health care options you know there's ample data that shows that independent practitioners provide very high quality care they frequently keep their patients out of the hospitals they're not going to the ed they see them quickly they have that often have a really close relationship with their patients so they know them so that results in more responsive care that helps to avoid problems down the road so and they you know they are more efficient they do have less overhead so they the cost is less so they're they're the high value practices that we need and it's just options for Vermonters um you know the wait times are often shorter for some of the specialties that we do have um specialty care um you know such as dermatology some reproductive endocrine chronology gastroenterology they're there are shorter wait times there so it's access it's access it's choice um and it's it's just the ability to have a diverse health care system in options you know what you also lose is i think primary care independent primary care providers are really really entrenched in our patients care and so as an example i got a call at quarter of six one of our patients called and he was feeling mentally unwell you know maybe suicidal one of my partners harlow down the hall and say hey i know you're on the way out the door could you chat with them you know i talked on the phone to 6 30 i came home i called him at 8 30 at night to make sure he was doing okay my nurse called them again at 10 to make sure he was doing okay we agreed he could stay home we were both off the following day we agreed that i would call him at nine she'd call him at 12 i called him at three so that's what you get you you get for independence we are it really is i know toby said it's like it's a kindred spirit um you know i don't want to say everyone is altruistic but i've got to be honest to go primary care independent um you're pretty damn altruistic i mean you're not getting a lot of money for a lot of a lot of time a lot of emotional investment um you know a lot of caring we do it because we we love our patients and that's what you lose when you lose these independent practices is you get people who are you know maybe a little more jaded as they as they leave the practice just saying i just can't do this anymore because i'm giving everything i'm not feeling like i'm valued for that and i also add that you know um for the independent specialties there seems there's more of a way to get in to see a specialist urgently whereas i think you know the hospital system with the specialist they don't necessarily have a way to see people urgently it's through the ed that's not the case with the independent specialist i i just wouldn't if you would let me pipe in a little bit this is melissa um i just feel like yes for some people it's a choice but there's also a lot of communities where there is no choice right and so there are some places where the you know we don't need any fewer primary care physicians i i always hate to hear us being pitted against each other because honestly we all are doing really good work um and i would like to see all of us survive you know and i'm i'm happy to bring people under the fqhc umbrella if they want to be there but at the end of the day we don't need fewer primary care physicians than we have now dr haig has her hand raised so please go ahead doctor thank you i just wanted to point out you know in our personal experience last year we came dangerously close to losing over 82 years of collective pediatric knowledge and expertise from our area 57 of those years were in this very area developing trust developing relationships seeing now second gen um patients and it just you cannot replace that you can't replace that thanks are there more are there more hands up i i can't tell if everyone has had a chance i think everyone's had a chance that sure foster i can i i mean i there's a few more things i'd love to bring up but i know i know we'd like to give uh like fischer chance yeah i just want to be mindful of those folks time um unless they have to jump at 330 and would miss an opportunity um we could actually take it out of order um mr fischer and the health care advocates officer do you guys have time if dr murman continues on with some questions or do you need to go now no that's totally fine chair foster and i'll just be me i'm from the health care advocates office this is a great question great yeah thank you sam thank you all right go ahead doctor i'm sorry thanks i thanks uh thanks sam too um can i just touch on a few things that i just really thought were really poignant to me which are um stewards comments about the meal delivery systems and how from again from my vantage is an emergency physician this is just so profoundly important in our community not only do people get meals which is a struggle for a lot of people um a lot of people live alone and are profoundly lonely and don't call family when they need help because they don't want to be a burden and so what i find is the meal delivery person is often the early detection system for somebody who's who's clinically sick you know and so if they don't come for three days sometimes you find someone's been on the floor for three days and they end up with me in the emergency department horribly sick going to the hospital but but those those frequent meal checks are it's so profoundly important so anyways i just wanted to bring that up and i really applaud your work there um i lean with you know really focusing on access to care and the role of you know the whole all of the various providers that we can we can bring in and improve access to care for primary care is really important and uh and michelle the comments of working at the top of your license is sort of like you know i think also um that was mentioned by several other people is a common theme within my workplace too and trying to figure out how to how to do that so those resonate um jessa i wanted to ask you a question and i probably should know this on the care board now but i'm still in the phase of a lot of a lot of learning but when you say increase primary care spend to 12 percent do you know what primary care spend is now if she's still on i yep i'm still here and i was just the green mountain care board um helped lead a report investigating that very thing um i think it was a 2019 report at this point my time is all collapsed with covid it was before the pandemic um looking at the most recent data they had at that point um and it depends on the payer so i'm sure i can send it over i'm sure that your your staff could could get that to you to take a look at by by payer where we were at that time um but but but yours we are not as a whole we are not there yet i mean again it varies by but as a whole we are below actually medicaid um is one of the best and they are actually over 12 percent the commercial if i recall and boy i don't have it right i think was maybe around nine or ten and then medicare was the lowest around maybe five or six and then and then this is as much of a question to you as it is to my colleagues on the board but do we have insight and i again i'm i'm new to the board and i'm trying to learn everything that's occurred but do we have insight into the differential of reimbursement between uh you know independent primate care practices and hospital-based primary care practices by commercial payers is that something that we can see or understand good question are a series of reports that we can make sure you get dave that uh we're done at this point kind of a long time ago but the most recent one was done by board staff it does require um some special data analytics that aren't done in the routine course but yeah to susan i'll turn it over to susan but just let you know we have reports thanks i would just agree with you and we will get those to you dave dr merman sorry thanks thanks um one night i've got a lot of other things why don't i stop there and turn over to sam thanks so much um and i'll set a timer for myself for one minute because i know we're over 10 i just want to do a brief note of appreciation for everyone that presented today the perspectives are are deeply valuable i mean on a personal note my mom's a nurse i come from a line of positions and nurses and mps so it's encouraging to hear that just on a personal note but i just wanted to highlight a couple themes that really clearly emerged for me listening to this conversation it's encouraging to see how the base assumption oftentimes is that true health and ensuring it goes beyond the provision of medical care that includes housing and includes healthy food and transportation which is really challenging i mean it's going above and beyond what i think the initial call um the medicine i think a lot of people think of but it's really encouraging to see how baked into that model um it is um you know i think as all of us are considering what the future of health care in vermont is with respect to global budgets i think it's critical to think about what the concrete deliverables are for vermonters and i think support for primary care is is foundational um something hopefully we can all agree upon even if we disagree or have different ideas about how to how to go about it um so i'll leave it at that i don't know if that was one minute might have been a little over but back to you chair foster thanks thank you um the only we are short on time so i'll just ask that you know i think you all know how to contact me or at least contact susan anyway um my only big question is um and don't answer it now what provided to us when you can is where do you see the board um being able to take actions to alleviate these concerns what is your ask of the board to address these problems how can we uh facilitate resolution to some of these what tools do we have and i'm sure my fellow colleagues have a lot of ideas but i'd love to hear from you folks where you think we can help i think everyone's in agreement everyone says the words primary care matters primary care is the focus primary care is critical and yet all i hear is your losing workforce you can't hire people and you're not getting paid enough and you're potentially closing practices so if we're all in agreement why aren't we having any solutions for this community um so it's sort of a big ticket item and you know please reach out anything else uh we're here i want to hear from you um but i'll leave it that so i can turn to uh public comment um so at this time is there any public comment um and please use the hand function and i'll call on you as your hands are raised uh mr carpenter i see your hand is raised please please go ahead oh and please call me walter none of the mister stuff how are you nice to see you i was interested to see the uh the moille county people here because through a complicated turn of events i became a patient of theirs about 20 years ago and when i did that i was kind of near death and the reason i'm sitting here on this screen is because i got into la moille at precisely the right time and i've la moille county health has suffered me through at least almost 20 years as a patient dr valansky and i had a telehealth conference about a year or so ago and she probably remembers that or doesn't which but i just wanted to shout out them for putting up with me for all these years and one of the things that i hear a lot when i go into like little moille and i was in there three weeks ago they i got the freeze gun on my arm possible skin cancer was the idea of a single payer system and i talked to the line staff and they tell me i tell them i'm on the advisory committee i work with the care board and stuff like this and they look at me and they say please please do something get a single payer system so i wanted to toss that out there what do the doctors here in the primary practices think of that because the overall problems and what oh and so nicely summed up is that we treat healthcare as a business as a consumer product all these doctor's offices are like industrial practices used car places you know the patient is a consumer they're struggling to survive because of this and that ingredient that we all know the last thing i want to bring up before i shut up is that when we talk about payers payers are not insurance companies or public or private payers are us payers are the patients like me who come in and i enjoyed the stories that were talked about patient experiences here in the in the discussion because i've been through all those and then some as a patient the insurance companies are just dispersing agents that we don't need and i'll shut up now thank you for your comment walter as insightful as usual i appreciate your thoughts very very much so thank you for raising your hand and chiming in with those views you haven't thrown me out yet on well i promise i won't are there any other members of the public who have any comments they'd like to share great well i think this concludes the panel session i do want to thank you all very very much for your time and it's more important that we take action based on what we've learned rather than thank you for your work so that's the goal at this time do any board members have any old business to raise any new business and is there a motion to adjourn so moved is there a second second all those in favor say aye aye and we are adjourned thank you all everyone have a wonderful day