 Last for review of the health care wait time study that was convened by the agency of human services, the Department for Financial Regulations and the Green Mountain Care Board. Up front I want to acknowledge the study occurred during the pandemic and would like to start by thanking our health care providers, staff and Vermont hospitals for their work to fight COVID. Health care providers have worked tirelessly to care for the sick including those with COVID-19 to establish the statewide network of testing centers, provide mass vaccination and so much more over the last two years. They step forward and continue to step forward and as a result Vermont has one of the lowest COVID-19 death rates in the country. Let's thank them and keep that in context as we review the results from their wait time study. Looking back anecdotal reports of long wait times for health care services have been circulating for some time. Seven days chronicled the issue in September of 2021. Then secretary for the agency of human services Mike Smith convened a study that was intended to quantify the issue, identify key challenges and to address them. Working together to make sure Vermonters have timely access to appropriate care is the primary goal moving forward for these findings. With the study we recognize that while wait times preceded the pandemic the COVID-19 response fundamentally changed the landscape and contributed to the issue. Based on what we're seeing in the landscape with people showing up in much more acute need for care we recognize that one of the non-COVID related risks of the pandemic is the delay in preventive care and treatment. As such addressing wait time delays in care is essential for moving forward for recovery and revitalization. In order to be thorough within the timeframes allotted for this study there was a use of multiple methodologies and different time periods and it includes data which is intended to simulate the experience of Vermonters. The findings across each of these methods includes those before including those before and during the pandemic point to long wait times in Vermont particularly in certain specialty areas. These wait times occur regardless of a person's health insurance status. This is a first look at a complex problem at an unprecedented time in our history. The study was initiated in September of 2021. Portions of the data collection occurred during the downslope of the Delta Pant Wave and ended with the start of the Omicron variant in December of 2021. Thus two-thirds of the data in the study was collected during the pandemic and represents a system under pressure and at a time when the state and providers needed to prioritize resources which has contributed to the ability to provide non-urgent care. Further new safety protocols and workforce shortages have impacted services statewide even with a number of people needing care for COVID-19 decreases the system will be impacted by workforce shortages and potential new demands for deferred care. In other words this study is a snapshot of where we're at and represents a real real issue made worse by the pandemic and is going to take time to resolve. I'm confident that the study results and future transparency will be a useful guide to the progress through recovery and revitalization. Again this is a complex issue. In order to make progress we will need to work collaboratively with the health care system and patients to identify opportunities for improvement which are multifaceted ranging from processes in hospitals to communication among diverse providers to IT systems to payment methodology and Vermont's regulatory environment. Improvements and wait times will necessitate actions from the state and health care organizations which are reflected in the recommendations. I'm excited to see that the hospitals already acknowledge and are working on the issue for example the UVM health network published and is making progress on an access plan. While the pandemic has made a pre-existing access challenge even bigger it has also demonstrated that innovation and partnership are possible to solve complex issues. I have spoken with health care leaders and we agree to work together to make progress collectively. I am confident we can address this issue together so let's start by digging into the findings. For that I'm going to turn it over to the director of health care reform, Ina Bacchus. Thank you Secretary Samuelson and good morning. I want to reiterate Secretary Samuelson's remarks that this study was indeed conducted during a time of unprecedented disruption and strain on the health care system in the state of Vermont and that these findings are even more important as we move as a state collectively towards revitalization and recovery after the pandemic. This study was undertaken in collaboration between teams at the agency of human services, the Green Mountain Care Board and the Department of Financial Regulation and I am very thankful for the teammates contributions to this work. There's a large body of work and we provided four individual contributions from each of the teams and collectively brought the work together in this final report. I also want to thank the people who contributed to the multiple avenues of analysis that we took. We heard directly from Vermonters in this project. We heard from providers and we heard from those who are working in provider offices and hospitals who worked cooperatively with us as we undertook this study and review. I also want to thank the consultants that worked alongside our team from Oliver Wyman, Oliver Wyman Health and Oliver Wyman Life Sciences. I will start by summarizing the key findings and recommendations of this report so that we can work our way through the multiple areas of analysis that we undertook and you can see themes and learnings from each of those areas and you can see how they influence the recommendations that we have to make here today and we'll circle back to the recommendations again at the end of the report. So I also want to just take a moment to talk through how I'll work through the findings and the report on the whole. I'll summarize key findings and recommendations and talk about the study rationale and the structure for the work and then I'm going to turn it over to Commissioner Pichek to talk about how we quantified the problem and then we'll talk about possible causes. So first in terms of key findings, a summary of key findings, wait times do appear long in Vermont for certain specialties across multiple methods of analysis and time periods as Secretary Samuelson already stated. For approximately half of specialties, wait times are over two months. I want to emphasize that we don't have available data now to be able to understand whether or not clinically appropriate care was provided and how persons in need of clinically appropriate care may have been triaged, meaning we know that we can measure long wait times but we don't know yet how to measure who may have received care within two weeks versus who may have received care at the end of the wait time indicated. We also know and as Secretary Samuelson said, wait times were long prior to the COVID-19 pandemic and we'll share with you and elaborate on how we determined these findings. Wait times vary significantly by and within specialties with dermatology, neurology, psychiatry, and endocrinology services having the longest wait times depending on analysis. We will go into depth with you about our methodologies for these analyses but I want to emphasize that we took a statewide look at this issue. We looked at services provided across the state of Vermont and we looked at services available for Vermonters that are being provided by providers in other states. We included in our look services provided by hospitals as well as services provided by private clinicians and private practice. Also in our key findings, metrics to assess wait times such as the first and third next available appointments, we found do not always reflect actual patient experience of accessing care and that's another key theme in the work that we undertook. This study was guided by the principle that we were trying to understand the weights for healthcare services through the eyes of patients in Vermont. Finally, as Secretary Samuelson also already shared, our findings showed that wait times are similar regardless of insurance coverage type and that wait times were not longer for patients with Medicaid insurance in general. However, for a few practitioners in private practice, specifically a few specialty types, they are accepting Medicaid insurance altogether at lower rates. Based on those key findings, I do want to review our recommendations and summarize our recommendations for new initiatives as well as ongoing work that we are engaging in collaboratively and in partnership with the healthcare system. The first new recommendation is to continue tracking and reporting wait times for health services in Vermont. The Department of Financial Regulation would be charged with monitoring and tracking wait times ongoing and making this information available to the public. As we'll continue to explore with you this morning, we learned a lot in terms of how to assess wait times from different angles and we know that there is more to learn about the best ways for us to monitor wait times ongoing and we want to do that in partnership with healthcare providers. The next recommendation is for hospitals either to establish a board-level committee or designate a board member to be responsible for participating in monitoring wait times at their facilities and in continuous improvement to promote patient access to care. We also recommend that hospitals and independent practices coordinate and collaborate to share information and successful strategies designed to improve wait time. Further recommendations for continued action include the Agency of Human Services, the Green Mountain Care Board, and the Department of Financial Regulation continuing to study this issue. We have learned a lot in the few months that we've been studying this issue and we've certainly learned that we have not uncovered all of the all stones. We know that we want to look at and understand access to primary care in the state of Vermont, that we need to do a comprehensive assessment of access to mental health and substance use treatment services in the state of Vermont, and we've also determined that further review and improvements to the regulatory framework may be necessary to promote patient access in Vermont. We also determined that because of the specific data that we saw relative to some practices that are not accepting Medicaid patients at the same rate that they are accepting commercially insured patients, that we need to investigate and understand the barriers for those private practice practitioners in particular in accepting Medicaid patients. We also recommend continued focus and prioritization of the recommendations in the comprehensive workforce development strategic plan. We heard from providers about issues, numerous issues related to the healthcare workforce and how these issues are a part of a multi-factor problem with respect to wait times, and we certainly know and can identify areas in the workforce development strategic plan that could help to address this issue. Specific examples are exploring whether a physician assistance program can be created in the state of Vermont to provide a stronger pipeline for physician assistance to be working in practice, as well as employing supply and demand modeling ongoing to determine whether we have adequate supply of providers to meet demand for services and expanding telehealth coverage and making tele-billing requirements clear, as well as working with the Office of Professional Regulation to ensure that there are speedy paths to licensure for practitioners in the state. We also see that there is room for continued quality improvement, specifically quality improvement in terms of how care is distributed between primary care and specialty providers and how these care providers integrate care in services in four Vermonters in the most appropriate way. And finally, we recommend that we need to continue our focus in shifting to a value-based payment model in Vermont, a payment model that rewards health outcomes, the most appropriate distribution of care, and that moves away from the fee for service incentives for reimbursement that we know can derive utilization of care that may not be necessary and that may impede supply for those in need of care. I'm going to frame up for you how we engaged in this study and how we arrayed this study and again how we looked to design a process that really was oriented towards seeing the system through the eyes of Vermonters experiencing access to care. As we heard already this morning, we certainly know and have heard about anecdotal reports, about long waits prior to the pandemic, and emerging reports were highlighted in the media in September that brought to light challenges and severe consequences for some Vermonters facing wait times. So through this study again, we wanted to hear directly from Vermonters both in public forums and written testimony to invite anyone to share information beyond what had already been reported in the media. And I want to read just a couple of the quotes here which do provide for some of what we heard. It is not okay for someone with a potential diagnosis of leukemia to wait four months just to get in the door. Some leukemias will be terminal in a shorter time than this. Others shared and expressed, I can't imagine how many other parents are struggling to find care for their children. And it was said, I'm a doctor and I told the scheduler on the phone it was likely cancerous. They gave me the earliest available appointment a five month wait. We know that there are impacts of delayed care when care is clinically appropriate. There's evidence that long wait times for clinically appropriate care can lead to worse health outcomes, especially among older and more vulnerable patients. And this is a key and important finding because as we experienced throughout our study and observed that there are multiple barriers and it's a complicated process to obtain appointments in the health care system. And we know that people who do not have the time or may not have knowledge of the health care system would then experience access to care issues at a disproportionate rate. The risk of patient mortality is increased when wait times were longer than 31 days for older and more vulnerable patients. There is an emotional impact. People experience frustration anxiety and suffering when they or a loved one is unable to access the care that we need. And this was a theme that was echoed as we heard directly from Vermonters and others. We know too that there is a financial impact when care is delayed and that delayed care can have a significant impact on hospitalization costs since some individuals will have gotten sicker when they do not receive timely care and that those sicker individuals require more interventions at greater expense. There's an equity impact as I already mentioned. Barriers to care disproportionately affect those who may not have time resources or knowledge to navigate a complicated medical system. So again our study goals were certainly to understand wait times through the eyes of Vermonters and also to try to quantify and corroborate the anecdotal reports about long wait times. We invited Vermonters to share their stories. We brought providers and experts together to speak directly with us about wait times in the system. We gathered data from multiple points of view to validate patient and provider reports and measure wait times statewide. We also considered reasons why medical wait times were so long in Vermont including the role of the COVID-19 pandemic as we've shared already today. We finally developed recommendations to help address medical wait times and improve patient experience. I'm going to turn it over now to Commissioner Pichek who's going to talk with you about the different approaches that we undertook to quantify this problem. Thank you very much, Ina and good morning everybody. Thank you for being here. I echo Ina's thanks to the Remount Care Board to AHS for their work in this evaluation. I want to thank the DFR team for their work as well. Many hours were put in, a lot of analysis, a lot of detail and happy to share the findings today. So I think when we're trying to quantify wait times one of the first things that we have to look at is what are the metrics that we're going to measure them by and when you look across the country, when you look across Vermont there are no uniform standards to measure and quantify wait times. So that is a challenge, no doubt. Also when we look across Vermont and across the country there's very little data collected, there's very little evidence that medical communities are trying to quantify this data themselves. So we really had to start from scratch in terms of what are the best approaches, what are the best ways to try to quantify this data. So for us that meant really trying to have multiple streams where we heard from Vermonters, we heard from provider communities, we looked at different data sets to try to answer this question of are medical wait times longer in Vermont and if so why is that? So the first place we started in trying to understand that is with Vermonters. As we said we wanted to hear from Vermonters, we wanted to have this evaluation seen through the eyes of Vermonters. So we held public listening sessions. We had over 20 or 70 participants in those listening sessions. We heard stories that were certainly challenging and heartbreaking. They corroborated the stories that were reported in the media primarily by seven days late in the summer and it told us that we needed to look further, that we had heard directly from Vermonters, we'd received about 70 additional written testimonies about challenges accessing care in Vermont and those stories combined really told us let's go to the next phase to the next level and try to get more information. We did that by speaking with providers, you know the community that obviously provides the care that sees hundreds of patients every year that can tell us their experience, what they're seeing and how we should consider evaluating this. We heard from over 90 providers both in focus groups and survey results that were very valuable. They talked about challenges relating to workforce, to retention of workforce, to recruitment of workforce. They talked about increase in administrative burdens and administrative tasks that they've been dealing with for years but also obviously throughout the pandemic as well. And they also talked about communications and technical challenges that they're experiencing that add to wait times and challenges referring primary care patients to specialists. There was also discussion about whether all referrals from primary care to specialists are appropriate and whether care that's being received at the specialist is also appropriate, whether that could be referred back to primary care. So all of those again were cooperating what we heard directly from Vermonters that the provider community found concerns about wait times, they had some suggestions about why that was occurring and it made us want to go further and try to quantify this data more holistically. So we tried to do that through three different primary methods and I think the importance here is to understand both what this data tells us and what the limitations are as well. I think what it tells us is that when taken together for certain specialties medical wait times are long in Vermont and where we do have benchmarks Vermont performs worse than peer states. So I think that's important but at the same time it's important to recognize the limitations and I'll go into that for each of these. On the claims data analysis this was done with V-Cure's data looking pre-pandemic so from 2017-2018-2019 that was done by Oliver Wyman an independent analysis and it looked at the wait time between the provider visit the primary care visit and the specialty visit. The secret shopper program was primarily conducted by the state of Vermont led by DFR where we called over 800 specialties acting as if we were a Vermont consumer again trying to get that perspective of a Vermonter seeking care. We had certain special certain reasons for seeking care among 21 specialties and then we recorded the wait times that were provided to us through that program. Again for that program as Secretary Samuelson said conducted during the pandemic conducted primarily in December of last year but into January as well and it is a snapshot it's that snapshot of time so it's not indicative necessarily of wait times overall or over the entire year period or over multiple year periods so I want to make sure that's evident as well and then we did a review of a primary care chart so we looked at about 2300 primary care charts again looking at that referrals from primary care to specialties seeing how long those referrals took and we're able to get that from about 2300 patients for the year 2021 so again that conducted during the pandemic. Looking a little bit more specifically at these three analyses starting with the claims data analysis you can see here that the first thing we needed to do was try to identify some peer groups within the region that we could compare Vermont to. So you see there the primarily New England and the Northeast states where Vermont matches well in terms of providing care at a managed or well managed level from there all of a Wyman looked to find the right demographic mix the right mix of chronic conditions to try to get as much of an apples to apples comparison as they could. Again they looked at wait times between when a patient saw their primary care physician for a specialty diagnosis and then when they saw the specialist for that same diagnosis. If we look at the results on the next page you'll see that wait times as I said when we compare ourselves to pure states do not measure as favorably as we would like. When you look at how many of those visits were able to be seen within 14 days in Vermont that was 22 percent in pure states that was 27 percent. When you look at the 28 day time period 34 percent for Vermont 43 percent for pure states and then on the outside scope of this on the 60 days that somebody was able to see their specialist 50 percent in Vermont 63 percent among pure states and we'll mention also that overall wait times from this analysis showed that from the primary care visit to the specialist average about 100 days for 2017 2018 and 2019. Now again one of the limitations on this data is that this is a subset of patients these are patients with chronic conditions things like heart disease diabetes asthma so it is a subset of Vermont patient care but they are likely individuals that are in the system seeing primary care doctors and seeing specialists on a somewhat routine basis. Looking at the next analysis which is the secret shopper program we mentioned that we made over a thousand calls we called over 400 unique specialty practices these specialty practices represent over 90 percent of the physicians in Vermont that provide these specialty services. The map there on the right you can see the geographic distribution of these phone calls the larger the circle the more calls that were made into that particular community basically representing the size and population of those communities. You see that we also included contiguous counties and care that might be provided in New Hampshire both at Dartmouth in northern New Hampshire as well as western Massachusetts and parts of New York as well. So for each of these unique specialty clinics the state of Vermont called as a blue cross blue shield insured and we also called as a Medicaid insured to try to assess whether there are differences in the types of insurance that individuals have. We called the 21 different specialties and again we tried to replicate as closely as possible the experience of a Vermonter trying to access care here in our state. Looking at the next slide you'll see that there really was not a significant difference between those that were calling with commercial insurance versus those that were calling with Medicaid. In fact those with Medicaid had slightly shorter wait times on average compared to those with commercial insurance and generally they were both equally long when you compare them in terms of the wait time. So in some ways a favorable result that Medicaid was not being seen in a slower time period and this is data that was also confirmed by the Oliver Wyman analysis as well. Looking at the next slide we looked across specialties so this is across specialties both commercial and Medicaid and you'll see here that there is a wide disparity between these specialties. This is the median wait time for the calls that we placed and the appointments that we were able to provide. You can see some are quite relatively short on the left hand side of the slide while others comparatively are relatively long. But we do want to say that you know of course not the acuity the reason for the call may differ between these different specialists. So we tried to have non-urgent reasons to seek care but that being said there are still reasons why one type of care might be perceived by the provider as more urgent than a different specialty. So that needs to be considered. But generally what this tells us is that there is this disparity between specialists in terms of wait times and something that needs further exploration. Looking at the next slide you'll also see that within the specialties themselves there was also quite a discrepancy in terms of appointments. So those green dots represent the first available appointment by specialty. Those orange dots represent the average wait time and then the red dot represents the longest wait time that we received in terms of one of the secret chopper calls. So for example with dermatology on the one hand you certain providers said they could see an individual within 11 days. Different providers said that that would be 410 days. So again I think this speaks to the reason why it's important to provide transparency to the consumer that if somebody happens to call that clinic that can't see them until over a year that they understand and realize that there might be a care that is more easily accessible to them. Maybe in a different geographic region maybe not but a critical element of transparency that we think needs to be provided to Vermonters at large. And that of course would help smooth out some of the supply and demand issues that we might be experiencing in our state geographically as well. The next slide looks at the same data that we just referenced the secret chopper data. It's looking specifically at the Burlington Metro area. The reason we are looking at the Burlington Metro area is because the only national survey that tries to replicate wait times through a secret chopper program does so for medium metro areas. So we are able to compare as much apples to apples here in terms of at least the size and type of location in city. Now again an important caveat. The Merritt Hawkins survey was conducted in 2017 prior to COVID-19. Ours obviously as we mentioned was conducted in December of 2021 leading into January of 2022. But when you look at the results you'll see that on average Vermont is experiencing longer wait times for these four specialists that we're able to compare against. The Merritt Hawkins analysis only reviews these four specialties that's why we have them up here. We did use the same exact reason for seeking medical care as they did in their survey to try to replicate it as closely as possible. So again I think this is a another instance where it tells us that this is an issue that needs further examination. And then finally on the secret chopper data we also looked by hospital. So we put all the specialties that we called by hospital together and looked at what the average and median wait times were across the spectrum and then how they performed for each of the entities themselves. So again here an important caveat that there are certain specialties as we all just saw that have longer wait times than others. Some of these hospitals have more of those specialties than others so that's again something important to consider. But when you see that difference especially when you're trying to look at hospitals that are relatively similar to each other. Again it's another reason that we believe further exploration is required here to truly understand whether these differences are meaningful or whether they are simply the byproduct of the populations that these entities are serving. On the last slide this is the blueprint analysis that we mentioned. So we looked at 2300 blueprint charts. We again tried to assess the time between primary care visit and the follow-up specialty visit. Similar to the secret chopper program you can see that there's a wide disparity here between special list in terms of wait times. Some of them corroborate the secret chopper program data like rheumatology. Some of them diverge such as a dermatology. But again it speaks to the fact that for us there's more information that needs to be gathered about whether these differences in specialties are again clinically appropriate. Whether people within these specialties even if it's 87 days are seeing care as quickly as they need to see care or whether that is not happening that's leading to worse health outcomes. We just don't have that data. It's not being tracked by the state of Vermont. It's not being tracked uniformly by the health care system. So something that we believe is important. One point of note again for the secret chopper program and also for this blueprint program as well. We're looking at the specialty right so the time from the primary care visit to the specialist. If you don't have a primary care doctor there's also a wait time that will be associated with that to try to get established with a new primary care doctor. If you have a primary care doctor there may be a period of time that it takes for you to get an appointment with that primary care doctor. So that is not represented in the wait time analysis for secret chopper or for blueprint. Also for secret chopper if you need any imaging or lab work that might be required before you can make your appointment with the specialist that could be something that adds to the wait time as well. So I think in conclusion when you put this all together each of these different methodologies you know they have their strengths they have their weaknesses but it is what we were able to do with the authority that we have and again I think that speaks to why we believe one of the recommendations should be expanded ability to develop metrics collaboratively with the healthcare system so that we can track these metrics on an ongoing basis so that we can measure whether we're improving and so whether Vermonters have more transparency into this as well. And I think that will be very critical for us because the analysis also showed that Vermonters are getting older I think that's no surprise to any of us and that our primary care doctors and our specialists are getting older as well. So over the next five years for some of these specialties that already have long wait times we do anticipate that the demand for those services will go up and that the provider community may actually go down due to retirements and people working less as they get older. So all the more reason for us to come together and try to solve this problem now. So with that I'll now turn it back over to Ina to again summarize why some of this might be happening and to reiterate our conclusions. Vermont is unique among states in taking a look at the issue of access to healthcare across the entire state and across multiple types of providers as I mentioned both hospital employed as well as private practice providers. This is certainly new ground and new territory that we are treading with this analysis and with that we can see that this issue is a multi factor issue and we can also recognize that we have more to learn about the contributors to the problem. And we want to do that again in collaboration and in partnership with the healthcare providers and people who are working in Vermont's health system. Even though we are looking at this problem and seeing it newly with the with the quantifying information that Commissioner Pichek has just shared we do we do posit that there are some potential factors that are influencing wait times for care in Vermont. These factors include the workforce availability and composition. Demand may exceed supply for certain specialties. Demand may exceed supply of hours worked may exceed supply in certain areas of physicians. Hours worked by physicians are stable but the workforce is aging and we do know that as the workforce ages clinical time does decrease. We also know that there are certainly teams of specialty providers that work together to deliver care and to move people through practices and advanced practitioners have a key role in these teams. Our analysis did not look at the supply of advanced practice practitioners in the state. We know that there are critical components of care teams along with nurses along with front office staff along with a host of people working in the health care system and we acknowledge the workforce the workforce shortages that have certainly been created by COVID-19 or exacerbated by COVID-19. The distribution of care may also be a contributing factor to wait times for certain services for Vermonters care that could be delivered in primary care care that should be housed in primary care is delivered at times in specialty offices when in fact it could be well managed in a primary care setting. We heard from specialists and primary care providers both on these issues related to the distribution of care and we also heard that for some patients they are being managed long term in specialty care settings when in fact their conditions are stable and they could be well managed by primary care providers instead of specialty providers. Again COVID-19 is likely exacerbating the issue of long wait times these long wait times as you saw demonstrated with the claims data analysis in particular we do see evidence and that long waits appear to be true prior to the pandemic but the workforce and staffing shortages caused by the pandemic are certainly factors that we've considered that are influencing this problem today. There's a complicated referral process and Commissioner Pichek just talked about some of that complicated process there's numerous steps and requirements and in receiving numerous steps once you've received a referral to then obtain that specialty appointment visit and often lab work and other documentation is required by providers prior to the appointment actually being scheduled and there's a lot of communication between provider offices that needs to occur in order to efficiently schedule these types of services and so that presents multiple points of potential failure that can slow that process down because it is a complicated exchange of information between multiple actors the patient the primary care provider the primary care provider and the specialist the patient and the specialist and back looping around again technology is also something that we've posited could be a factor in influencing wait times there has been slow rate of adoption of telemedicine in some areas e-consults and office hours and poor each EHR in electronic health record interoperability across different sites of care and as I just mentioned providers in different settings need to be coordinating and working together to engage in the the complicated scheduling process and so if their systems for communication don't work well together that can be a hindrance as well so I'll repeat again the recommendations for new initiatives that we have that we have identified during this study tracking and reporting of this information ongoing with work certainly to best articulate and enshrine the way to measure wait time for appointments in the future hospitals designating particular committees or board members that would be responsible for participating in monitoring wait times and to promote continuous improvement in patient access to care and services and coordination among hospitals and independent providers should be also pursued specifically related to those areas of potential failure in the scheduling process and in the information that I just shared and we've recommended further study by the agency of human services the green mountain care board and the department of financial regulation to look at access and timeliness of appointment of appointments in primary care this certainly could be another factor that is contributing to wait times for specialty care appointments access to mental health and substance use treatment doing a holistic assessment of vermont system and service availability and reviewing improvements to the regulatory framework such as the green mountain care board has already initiated a review of whether the thresholds for certificate of need are appropriate the certificate of need process is is a key process in the availability and access of facilities that provide for access to patient care in the state of vermont and further the green mountain care board looking at its regulatory processes and how its regulation of hospitals in particular is a component of the landscape in which hospitals are working in the state of vermont we want to also as I I said before and as you learned from the data we shared regarding Medicaid access to specialty care and appointments we want to look at and understand the barriers for those those practices that are private and that are not accepting Medicaid patients at the same rate that hospital practices accept Medicaid patients for certain specialty services again we want to emphasize that there are many recommendations that are already in play in the health care workforce development strategic plan and that these recommendations speak to numerous areas that we heard about from providers as we undertook this review and this study the physician assistant program is one if if we posit that advanced practice professionals are key components of the specialty care team then it would be important for vermont to explore whether we have a healthy pipeline for physician assistants advanced practice professionals working in the state we also in this work we employed supply and demand modeling of a sort and we did look at whether supply and demand for specialty care were impacting the availability of appointments in the state and we think that this sort of analysis should be employed ongoing we also recommended in the workforce development strategic plan specific strategies to increase telehealth coverage which would improve the availability of services for some Vermonters and certainly making tele billing requirements as clear as possible to promote the utilization of those types of services we also recommended that the blueprint for health which is a program that supports primary care practices patient-centered medical homes community health teams and the care continuum working together that the blueprint for health program looks specifically at quality improvement activities to promote referral best practices and care distribution between primary and specialty care so that we can promote the best utilization of the resources in our state for the most appropriate type of care in each setting and finally we do we do recommend and certainly want to continue our focus as a state of vermont to shift away from a fee for service reimbursement to a system that focuses on population health and outcomes and that focuses on the most appropriate care being delivered at the most appropriate setting and when patients need that care questions routines um list from yes um yeah i guess um it seems like there may be some sort of investment that's needed on the front end especially with the data sharing involved hospitals and kind of collecting this information go I don't know who this question is for but how how much do you see uh some of these investment costing and how that discussion could play out in the legislature and among the most possible so I think as we've mentioned during the study this is really preliminary data um we are in the process of you know we've analyzed the findings we see what we found but we need time to work with our health care system to identify really what the solutions are it's hard to quantify what those investments would be needed until we have an opportunity to really do that collaboration with our health care partners and so on that we'll have to get back to you but again we are committed to working with our health care system to really did it get in now to the root causes of what the data has shown and I guess my my other question is you know access to primary care and there's a problem for Ina is is it's access to primary care is a cornerstone of um shifting away from fee for service to global payments all pay or whatever it may be I guess to what degree does we do these hospital wait times and access or delayed access to care to what degree does that hamper against our war methods and how would we I guess overcome that so first of all as we indicated we didn't look at access to primary care and the reason we didn't look or start looking at access to primary care right off the bat was because again we did orient our study around the experiences that we heard from Vermonters in those first in those first public forums that we arranged and we did hear a a quite a number I would say an outsized number of issues with specialty care access which is why we focused our analysis there you are correct that primary care is certainly a cornerstone for healthcare reform we know that here in the state of Vermont that we've been able to build on the successful foundation of the blueprint for health which does invest in primary care and make resources available to practices that otherwise you know may not exist in other states and that practices are supported in collaborating and integrating care across the continuum so I think we need to look and understand what access looks like for primary care and we that's one of our key recommendations for the future we know that the primary care system certainly does need to be strong and we want to understand we do want to understand the primary care system in light of these findings about access to specialty care that's a great question and I'm I'm going to field it to commissioner P check because I know that he's got something to say here well the or just on the question of what do Vermonters do now right we have that one chart that showed that disparity between providers in terms of the specialty appointment times so I think it's important for individuals that might call and hear that there's a long wait time to not stop there to call other providers in that specialty maybe outside your geographic area as well if it's outside of the network if you have commercial insurance if you can't be seen in a certain period of time there are regulations that provide for the same type of cost reimbursement if you have to go out of network so I think the answer to that for now is that you shouldn't you know don't take the don't take a call with a long wait time as a roadblock shop around and try to find other appointments that might be more you know available in terms of your question and I think also sort of you know what do we do here what or what how do we you know try to dig into this more you know I think the recommendations the first two recommendations work well together we need to measure this better we need to measure this across the spectrum not just specialty but primary care mental health access as well we need to have hospitals and independent doctors we need to have all of that together to try to better understand and quantify the wait times but also quantify the question of if there's a hundred day wait time but everyone that needs to be seen in two weeks is being seen in two weeks and everyone that can wait six months is waiting the six months and maybe that one hundred day wait time is appropriate nobody is receiving you know care that is that is not at the right time but we don't know the answer to that question and that's why we need to find a further that's why we need ability to get further metrics and that's why we're also asking the hospitals to engage in that process themselves to evaluate and collaborate with independent physicians to try to get at those root root to those root questions really a lot of questions uh that was there are no some consumers like you know all people spend time exactly and feel the internet connection and that's not something that everyone has and so that's how it's going to be like just consumers are going to have to wait and make their phone calls while we rank them for the year yeah no doubt and that is that is you know a big challenge that we heard during this whole investigation when we talk to consumers when you have inequitable systems or you have systems that are hard to access those inequities are going to fall and burden those that are most are least able to navigate them right so that is no doubt not a not a position you want to be in it's just the position that we're in at the moment as we work to try to improve this complicated structure so we certainly recognize it's not where you want to be but all we can do is evaluate where we are at this time it's a good time to evaluate due to coming out of the pandemic due to all of the challenges that we face prior to the pandemic in terms of our health care system to try to plot that path forward so in a year or two years you won't have to ask me that question even six months we'll we'll do it as quick as we get but yeah exactly right um yeah i just have two questions one was you said that uh wait times if you've been exacerbated by the pandemic do you have a wait time metric uh that was established prior to the pandemic against which you're able to compare the results of this so the Oliver Wyman analysis was looking at vcures data for 2017 2018 2019 2020 so it did cover one year of the pandemic there was also the data was in a raw form so for both of those reasons they excluded the 2020 data so we did have 17 to 19 for this vcures uh you know subset so that subset like i said included people with chronic conditions so diabetes asthma heart conditions and it measured how long does it take those individuals to get from their primary care to the follow-up specialty appointment for the reason that the primary care made the referral and for each of those years the average rate wait time was about 100 days so you know the secret shopper as we said wouldn't include if you needed to do imaging or labs or things of that nature so that might account for why secret shopper was more like 40 or 60 days if you look at the average or the or the median and why that was 100 days but but that is the that is the benchmark that's the data that we have pre-pandemic is that Oliver Wyman vcures data um and then my other question is probably to the secretary you know um the commissioner talked about this inverse uh relationship between uh the trend line for need need for health care and the health care professionals they're going to be available to administer that care um is it possible that our expectations for when we're going to get care that we need from the health care system are just no longer realistic and that we need to confront um this new reality in which we're not we're just not going to be able to get the care we want so I think that's a very astute question um and this morning we were discussing that internally one of the things for us to consider is is that over the last five years um the consumer demand for many products not just health care services has led us to the point where people expect things to happen instantaneously again to reflect what commissioner p check mentioned the study doesn't actually demonstrate whether people got appropriate care within the appropriate timeframes that were necessary based on their acuity and I think that that those two things are potentially colliding here in terms of our overall expectations that have that are urgent and now kind of expectations with the actual needs for people further in order to maintain and improve their health so it's a very astute question we don't have the full answer but I do think that what we are seeing is a generational shift in a consumer demand shift for immediacy while while having um an expectation in the health care system to serve people as they as they actually need care so you've laid out all the things you're asking the health care system to do do you want to ask the consumers as well I think right now my ask to consumers particularly as we come out of the pandemic is to be kind and compassionate to to be understanding but also to work with their primary care providers if they feel like they have an urgent need um and the and they feel like that needs not being met that their primary care provider can help them navigate the system um to to so that they can get again the appropriate care in the appropriate amount of time okay next person we're going to go to is Colin Flanders uh Colin I'm going to unmute you okay um so so I'm curious whether the best team has had any conversations internally about sort of how we can get to this point um as I'm thinking specifically in terms of oversight like I see Dan here I know Dan has written about way times before um way times our problem that people have known about three years and yeah it's taken us this long to do something like this I'm just curious as what regulatory gaps have we found in and crew's job was this attract this um or was was sort of just nobody tasked to pay attention to yeah Colin it's a great question I think what you said about regulatory gaps is it's just is astute here because there there was a regulatory gap you know we have we do split our healthcare regulatory framework among the Green Mountain Care Board among AHS among DFR none of us tasked with this issue of wait times particularly when you're talking about system wide wait times so we do think we can rectify that with a recommendation that DFR uh has oversight around the metrics around measuring it around providing transparency not around you know what that means in terms of substantive changes for the healthcare system but if you're not measuring it you really just have no sense of whether things are getting better or getting worse or you have no sense of whether they're bad in the first place like like we talked about needing to go down and understand whether people are seeing you know the right the right doctor at the right time for the right treatment we just don't know the answer to that so I think it's a critical step forward that what we're proposing here today and look forward to working collaboratively with all of the stakeholders to make progress on that but aren't getting in versus how many people can afford to wait I understand that some more data we need but I'm curious through the work that you did through the focus groups through the surveys with patients themselves I guess can you stay with certainty that there are people out there who are being forced to wait for things that should be taken care of quicker yeah so I would say Colin it's definitely a serious concern of ours you know I'm not a doctor I can't make that clinical judgment but what I'll say is you know two things one in the public comments when we had the public forums you know we heard from individuals who said I am in pain both physical and emotional as I wait for my medical appointment I think about one third of respondents said that to us so that is certainly impactful to us whether they're seeing whether they're being seen within a clinically appropriate time I can't make that judgment but they are certainly telling us that they're experiencing pain and deteriorating health conditions so that's a concern and we also heard through the provider feedback that they're not always able to do the necessary prioritization or triage when they get referrals in some instances we heard that primary care doctors might be overly using an urgent designation because they just want to try to get their patient into the specialist and that makes it challenging for the specialist to truly understand what is urgent and what's not urgent so it's not just that we are concerned that we don't have that data we're concerned that in many in some instances that analysis is not being done at all which means that people can be falling through the cracks so it is definitely a concern so you know like like we said we don't have the ability at the moment to understand who and who is not getting clinically appropriate treatment relative to the wait times so that was not part of this analysis but obviously that would be a concern you know you saw the data that suggests if people are not getting care within clinically appropriate time periods there's a study by the VA that said you know that's established at about 31 days and particularly important for those maybe more chronically ill or those that are elderly so that's a again a real concern but we can't point to the data and say that there is a strong correlation that suggests that one's related to the other it'd be great if we get to that point in terms of one of the metrics that you try to track and measure but that's not a part of what we were concluding here in this study and that's how they know like if you need a knee replacement you should it should only take this amount of time but if it's taking longer then we go there's a problem do you envision this taking to a place where we're going to be setting some clinically appropriate metrics or is that you're already not taking that from you so it's some it's a discussion that needs to be had there are examples that we heard where when you set certain thresholds you know there's an incentive to maybe do things that make it seem like you're hitting those thresholds when maybe you're not so there you know whether you know that's one of the limit you know you would you want to do it as simple and easy as possible but you don't want to create any perverse incentives on anybody's behalf and you want to make sure that you're actually you're accurately capturing the information so I don't want to prejudge if that is going to be something that's important or not I think it's going to have to be part of the conversation so we'll wait to have that conversation and make that determination and I would like to add thank you our our study was pointed on the time that individuals wait for an appointment our study did not take very other important things about the health care system into consideration and key considerations that we will be looking at in the future as well are outcomes for the population health outcomes for Vermont as a population I think we need to look at these wait times relative to our health outcomes for our population and similarly as we look forward to monitoring and providing the public information about wait times for services it's also important that we're providing information about the quality of those services and I think that's something else we would look to in the future as being an important pairing of information for people about what is a multi-factor issue so we've got this slate of recommendations I mean what's the next step here right I mean it goes to the hospital sounds like the legislature and regulators are involved I guess kind of what what do you see as the next steps and kind of as a timeline I didn't mention to your six months what do you see going forward again a great question I think it depends on each of the recommendations separately for the quality improvement related recommendations were we're beginning conversations with our health care partners that's something we're going to need to do in collaboration with them as mentioned before some of them already have identified this as a priority for example the UVM health network who has published and is working on an access study I think others will depend on the legislative timeline so for example the the work that we have with DFR and ensuring that they can collect and have the authority to collect the data so we'll be taking each of these our next step is to take each of these lay out a concrete plan for addressing them and again each of them will likely be on a different timeline based on both the priority of the recommendation and just the reality of the implement of the implementation with things like the legislative cycle appreciate your time today