 that we already had a suggestion for the reimagined advisory group is we thought we should do them outside. Good idea. So Kevin and I are going to walk through some of the results that the board has attained in our regulatory work over the last several months. And then we'll open it up to some questions from all of you. But the focus of today, as we've heard from our emails and from some of the materials we've supplied to you, is we want to hear your feedback and thoughts on reimagining the advisory. And so we want to make sure we allow enough time for those breakout groups. We send out the questions to everyone. There's copies of the questions out back and there's copies of the presentation out back. And once we get to this presentation, we'll bring out the two groups and then convene and hear back from all of you. So we're just going to run through a few of these slides to talk about what we were up to the last several months. And this is not exhaustive and this is my plug for all the work that the Green Mountain Care Board and the staff do. We have an immense amount of work that goes into the regulatory functions that the board does. But there is a whole host of other work that we do. For example, we are the stewards of two large databases, the Cures and Buds, which is the all-day complaints database and the hospital discharge database. We have an entirely different advisory group, a technical advisory group that we run, the primary care advisory group. We have a data governance council that meets every other month. We're reimagining the health resource allocation plan. We're working on legislative reports and partaking in quite a few work groups that were set up through the legislature. I could go on and on, but I'll stop there and get into the details of our regulatory work. I just wanted to make sure that this is not an exhaustive list of what we've been doing. Coops and I guess our computer is not working. So, it's shutting down. Can people have copies in front of them on the slides? So, we're going to start with hospital budget results. The guidance was put out for the hospitals in spring of this year. We received all the budgets from the hospitals by July 1st of this year. The staff and the board analyzed the budgets. We had all of the hospitals come in for full presentations to the board. We worked with the healthcare advocates on the review of these budgets very closely. And then we released decisions by September 15th, and the budget orders went out forward to the 1st of this year. The results were that the hospitals initially requested a 2.9% increase in net patient revenue from the board-approved fiscal year 2018 base to the hospital-submitted fiscal year 2019 budgets. After the board approved the adjustments for several hospitals, and these for example adjustments will include adjustments for accounting changes, provider transfers and acquisitions, the submissions reflected a 2.2% increase, or approximately $56.5 million increase in PR. The board approved a 2.1% NPR increase for fiscal year 2019 over the approved and adjusted fiscal year 2018 base. And the hospital requested an estimated weighted average of 3.1% increase in commercial rates. So we'll look at the NPR, I should have said that at the beginning. We'll look at the NPR net patient revenue as well as the commercial rate for the hospitals. So the hospital requested a 3.1% increase in commercial rates from approved fiscal year 2018 to fiscal year 2019 budgets. The board approved a 2.7% estimated weighted average rate increase. You can see on the next page is the historical rates that were submitted and approved by the board. And I'll just, for the hospitals, I'll just note that over the last several years the rates for that have been approved have been the lowest in 18 years. Kevin, do you want to add anything to that? No, I think it's showing that the regulatory work is working and that we have gone through a period of three years of relatively low growth but there is a slight uptick in the trend line so we have to be wary of that moving forward. Great, and I'll also say that I'm going to run through these results and then we can open it up for some brief questions before I turn over to the advisory committee information. The next area of regulation that we took on this summer was health insurance rate review to the 2019 Individual and Small Group plans. The rates were submitted to us in May and were subject to a 90-day review and analysis period. We had hearings in July, two hearings, one for MPP, one for Blue Cross Blue Shield. We had an additional open public hearing, open public comment hearing that week to hear public comments and there were public comments within the hearings during the day and we accepted written public comments as well. Blue Cross Blue Shield of Vermont requested a 9.6% average annual rate increase with an effective average increase of 5.8%. If you look at the bottom, the asterisk, the effective rate increases. This is because of the actual rate increases that will be experienced by remoders in this submission. This takes into account the availability of additional federal subsidy dollars resulting from changes made to Vermont Roger in the 2018 legislative session. Many of you in the room are very familiar with the Silver Loading Plan. So it's important that you look at these two numbers and you look at the effective rate that the actual consumer will feel. And the real important thing here is that the rate felt by remoders is only going to be accurate if there is a successful outreach and getting people enrolled into the insurance plan that's best for them. So we're very hopeful that that message will get out and people will make the right decisions, but there's no guarantees. That's really important. The approved average annual rate could increase with 6.9% with an effective average increase of 3.2%. And that equates to an estimated dollar saved by remoders of $12.9 million. And so that's on the blue cross blue shield side. For MVP, MVP requested a 10.9% average annual rate increase. With an effective average increase of 6.6%. The approved average annual rate increase was 6.4%. With an effective average increase of 1.9%. The estimated dollars saved by remoders for MVP after the board's work was $6.5 million. The total estimated savings between these blue cross blue shield and MVP was $19.4 million. And we got to have a little caution. I feel like I'm Debbie Dowler here. But we do have the most recent filing for the large group for MVP, which is a double digit ask. And we also are hearing from insurers that next year is going to be a pretty tough year as far as what the previous requests will be. This year we had some things going in our favor. There was the moratorium on the federal fees and there was also the tax change that benefited insurers. So we'll have to see where that all sugars up next year. But there's also a lot of pressure to try to increase the thresholds for reserves. And that really input comes from the Department of Financial Regulation. So where that will end up, we don't know yet. But it's just something to keep our eyes on. Absolutely. I'll shift now to the certificate of need work that the board has done to date this year. I won't go through each of these, but they are on our website all the materials related to these decisions on our website. I will just mention that there is also a quasi-judicial rigorous process that the board goes through with the staff on all of these applications and using our COI requirements and ATRAC standards and keeping in mind the triple aim that the application that comes to us is very different in terms of when it comes out on the other side after the board makes its decisions. So I just wanted to note that. And now, transitioning to the work on the ACO model, which I believe most folks in the room are very familiar with, I would just say the things we talked about to this point, rate review, cost of the budget, CONs, these are all levers that the board has to reduce costs for the monitors. But without going to the root cause of those costs and the increases in healthcare expenses, we're not going to be able to cut our way out of this. So this is where the all-care model agreement comes in, where we can actually get to the root cause of what's driving up healthcare costs. And this is, again, most of you are familiar with this, but I'll remind you that the all-care ACO model agreement is an agreement between the state of Vermont and CMS. And it allows Vermont to explore new ways of financing and delivering healthcare with Medicare's participation. And I think this is, on this slide, a nice depiction of where we are and where we're going. We're still very much in transition fee-for-service medicine. I think, you know, the providers in the audience who I think would agree. And where each medical service generates a fee, and this could encourage unnecessary services. And then those services that promote health, phone calls, emails, care coordination between providers may not be covered under the current system. What we're looking at is in a future state where we're looking to move from fee-for-service to value-based care under the all-care model. And the model allows Medicaid, Medicare, and participating commercial insurers to work together with providers to be accountable for the quality and cost of care for people they serve. So this model will encourage the kind of things that like care coordination, emailing, phone calls, doing the types of things that are not recognized from the current system as fee-for-service medicine. Kevin, do you want to add anything here? No. Okay, great. The next two slides I will not go into. They're again, background on the all-care ACO model. The all-care financial targets, which I will just review as a reminder, that we have an all-care growth target, which is a compounded ant, which is a compounded annualized growth target of less than 3.5 percent of the term of the agreement. And then we have a Medicare growth target of 0.12 percent in the national projections. We also have quality targets. The high-level population have goals of improving access to primary care, reducing deaths to suicide and drug overdose, and reducing the prevalence of morbidity of chronic disease. And we do that. We have the quality metrics that are filtered down through the ACO to the participants. So I won't go in depth here unless anyone has any questions. Anything we want to add on that, Kevin? No, just to remind everybody, because people fall on the trap of thinking that the targets are just for people that are enrolled in the accountable care organization. That's not the case. The 3.5 target is actually the population of Vermont, so we have to be concerned about the total cost of care everywhere in the state, whether someone is a member of an accountable care organization or not. And the reason for that number, the 3.5, was that that's the historical growth rate of the Vermont economy, and the theory was to keep it at the same rate of growth as the overall economy. Great. Thank you for adding that, Kevin. Very important. So some results on the work that we're doing around the all-care model implementation and ACO regulation, some of the activities that we've been undertaking in this summer and currently. We are continuing the ACO regulation from last year's budget and certification per Act 113 of 2016. The board has the statutory authority to both certify any participating ACO in the state of Vermont, as well as review and approve their budgets. We are moving currently, we're looking at the 2019 ACO budget. The guidance was issued for that in July of this summer, this year, and we did receive that submission earlier this month. We are in... The policy team is back at the office doing deep dives into that submissions. We'll be out with questions to the ACO, and then the ACO will be coming in to report on their budget October 24th here in this room. And then our target approval date, target, we're shooting for November 20th, and I wanted to mention that there is an open public comment period on that ACO budget until November, that target date of November 20th. Obviously, if that changes, then we will change the public comment period if we have to wait longer to approve their budget. But I would encourage folks to get on our website and look at this submitted one care budget. It's full of very, very important and meaningful information that I think all of the folks in this room would be interested in learning about. The All Pair ACO Model Program Development implementation, we're preparing to set the financial targets for ACOs that are participating in the 2019 Vermont Medicare ACO Initiative per the All Pair Model Agreement. We, at the state level, can design that program. We work very closely obviously with CMS and CNMI, but that is what we're doing right now in planning that program. We're also finalizing specifications for total cost of care and other measures described in the All Pair ACO Model Agreement in order to support reporting to our federal partners, CMS and CNMI. And we're working with federal partners on potential agreement changes, including consensus changes to quality measure sets, plans to tie Medicare financial targets to quality performance at several operational changes. I'd also encourage you in your slides you have a link to some implementation reports that provide a really good snapshot of where we are with the All Pair Model. We submit those quarterly to the legislature. And last slide, I promise. All Pair Model activities plan for October and December of 2018. We're continuing to monitor for the 2018 budget and ACO certification. We're doing, as I said, the review of the 2019 ACO budget. And we are, again, working on some of the developments and changes to the future All Pair Model Agreement here in the state of Vermont. And I will stop here for questions. I just want to give one other update, too, in that one of the goals that we've been working on this past year is to try to strengthen the data team. Thank you. And the goal is to bring back the house work that's being done by outside contractors so that the monitors are meaningfully deployed. But also to make sure that we have better data to make better decisions. And very soon, hopefully, within the next couple of weeks, we'll have a job offer for the last remaining position in the data group. And that should really move us forward. And I believe that we are bringing the costs down and bringing up the quality of the data. So that's a very positive thing to report out. Yeah, and our data team has expanded under Kevin's leadership. And we're actually looking, as he said, to bring more of that analysis in-house instead of using outside contractors. And I'd encourage you to look at our website. And I can follow up and send this to you proactively. But we're developing some standard reports and with our data team. And I think that that's all because we have the staff to do that. So I think that's all I have in terms of updates. Do you have anything else? That's it for updates. Do you want to phase into the webinar? I was thinking we could open it up to questions. Sure, let's open it up to questions. Or the board members have anything else to add? Sure, go ahead. This may be something that I just haven't seen. Do you have any early results on the population health outcomes that we've identified, the access to primary care reduction and suicide and travel, et cetera? We have information that the ACM has submitted in their budget. And I will follow up with our team and see what we can give you. As far as I know, we don't have any, on the large population health goals, but the ACO, I'm looking at Spencer, he's right in front of you, has in their budget submissions some work that they're doing on population health. But let me follow up on you with you on that to get specifics. O'Connor has some information. Yeah, as part of our processes we have a meeting as a data team and where we go through, we have the chief of the okay model team made and so we'll submit questions back to them. The HCA also submitted questions and so we sort of clarified these things and some of the metrics we got. So I expect in the coming weeks to hear back from them. And then as soon as it's accessible, I'll say how about presentations on that. At the board meeting. We've also seen some positive early results from the Medicaid program as well. Right. Yeah. But we'll get that information out to you. It's a great question. It is. Okay. Yeah, on the hospital rate increases, do we have information like how far above or below hospitals fell on this increase? Like if they ended up making a law we're losing the average rate. The target, yeah. Isn't that patient revenue? Yeah. So, yes. Do you have that? Okay. And I can set that to you. Great. Thank you. It was really a story of two worlds in that we had a number of institutions that came in according to guidance or below guidance. And then we had others that came in much higher and of course the ones that come in much higher in this particular case, you could lump them in the category of smaller hospitals and ones that we have concerns about moving forward to make sure that they're financially healthy and able to be sustainable in the long term. She was just curious, would the lower rate increases how that's effected over the past few years for all hospitals? Yeah. Yeah. And also, do you have a question? I think this is just a quick question. With respect to the all payer model comment, I guess that it seems to me that we're sort of institutionalizing the past history of excessive cost growth in healthcare. I mean, we're sort of using that as the starting point and then saying 3.5% a year on top of that objectives. And it concerns me because, at least from my perspective, kind of key driver of healthcare costs over the years has really been this volume driven business model that has started in the 80s, I guess, with our G-System. And I mean, there have been a lot of effects from that that we have built this, we've created this huge over investment that seems to me in healthcare and police and facilities and equipment. And now we're kind of taking that as a given and we're going to grow it further from there. And I just wonder if we're going to really accomplish what we hope to do. Clearly, there's some things on the individual health side where there's lots of opportunities that are better done on the cost side. I wonder if we're not starting from a place that we're guaranteed to not kind of succeed. So, I understand your question and I agree with you about the past system being broken, but I think it would be unrealistic to think that we're going to reduce overall costs in the system. But if we can bend that curve all the time, it'll have a similar effect. And if we can get people out of the habit of the mentality that we had a good year because revenues were up, then we're really making some strong progress in that direction. When you brought that up, I was thinking of Joe over there because I always remember hearing the stories... Okay, lead possession. The stories about how the federal government locked in their reimbursements for home health based on the past. Louisiana was about four or five times the lot as far as what the costs were. I don't think it's not a fear system to begin with, but I don't quite think it's not a fear system here. Maybe some of the other corners just... I'll add a little bit of something. I think that the other piece that's changing is you're right. We're using the baked-in base that has excess utilization in it and we're saying let's bend the cost curve on the gross side. But the other thing that's happening because the incentives are changing is the hospitals are changing how they allocate that pie So we've already seen through the hospital budget process we're seeing hospitals, for example, investing in social workers in their EVs. We're seeing hospitals place practitioners in school-based clinics. We're seeing hospitals invest in housing in their communities. These are changes that we have not seen before. So I think the size of the pie that we're starting with may be the same, but how those slices are allocated is changing and we're also bending the cost curve. So that's at least the way I look at it. I'm seeing really strong progress in how those investments are made. Many years to actually see the results is that everyone knows about population health measures and it takes a while, but I'd agree that we're doing things here in Vermont that many states are not even touching. Just remind everybody to speak louder. Sure. I just might add to that healthcare is 20% of the Vermont economy and it's just not something that you can move the dial real quickly, especially when you're dealing with something so important to our society, which is healthcare. But I think if we were to take this chart that's presented in your packet and draw the line about healthcare costs nationwide as another benchmark, not just Vermont versus Vermont, but Vermont versus other states, you'd see that we're coming in on the right side of that line and so I think over time, incrementally, without being overly disrupted to the system, we will be in a better place four or five years down the road. I just want to be mindful of the time. I know there's one more hand. Can we take one more question? Go ahead. To echo the concern about the institutionalization and sort of following on what has been and created and hearing the board talk about all the effort and time invested in these major institutions. I don't hear, and I was hoping to hear from the board any attention given to the other healthcare pieces that are more community-based, that aren't hospital-connected or the big institutions in tracking them in any way. Like, what are they doing? What are their results? How much reimbursement? I haven't gotten any information about the statistics on healthcare businesses that support healthcare within the communities that are not hospital-based. In one other point, I don't see why we need to have hospitals even do more. I mean, to me, they were designed to take care of sick care. Why would we want them to get into housing or schools? What's the point if we can do it more effectively, efficiently within communities, empowering the people with passion in healthcare within the communities? The whole theory of healthcare versus fee-for-service is to have that collaborative effort so that you're keeping people healthier so that you're trying to coordinate the care so that the person isn't readmitted to the most expensive setting, which is the hospital. So, in theory, that's what we're all working for, whether or not that's actually happening in practice is still to be determined. Is the board aware, though, that physical therapy hasn't received any more money and has been on the same needs as a larger hospital at needing expenses but has not gotten any more from insurance companies? Is the board even aware of that? I'm not going to get into other things, but the point is I don't think the board is aware of these other parts that are smaller pieces. Could I jump in? Sure. Would you mind? So I think what we try to do, because our regulatory authority is over hospitals and it's not over the community providers, we have no statutory role in terms of those providers. But what we try to do is stay aware through looking at the data, through our public comment process and also, for example, we periodically have panels on different topics and that's, I think, one of the ways that we try to stay on top of the issues in other sectors because obviously we care about those and it's important to understand health care as a whole, including what's going on with community providers, but for the most part, other state agencies have the role of overseeing or understanding in depth those sectors. Not so much physical therapy, but for example, designated mental health agencies that AHS has a role there. And so I think what we try to do is balance our statutory responsibilities with also other mechanisms to get information about the burning issues that are out there that we don't have authority to do anything about, but we have an interest in. And I was sad with the ACO. One of the things about that does, not that we directly deal with the therapist or other community providers, but per Act 13 they are directed to work with those community providers. So thank you for that. So we're going to switch to the second segment of the morning, which is to look at the advisory committee structure. In your slides you have some summaries of what we've heard in the past from you and we heard that this group, from your perspective, class disruption that perhaps for some of you you think that the members feel that their time and expertise aren't optimally utilized and that you feel that your concerns aren't heard by the board. And we really take this seriously and I thank you for those comments. And one of the reasons we're here today to work on this is because we've heard you and we want to make this a more meaningful experience for all of you and from my perspective to get that information back to the board and to others, whether there's information that we do not have regulatory authority or we'll make sure that the folks who do have the regulatory authority get the information from you. So this is really timely too yesterday had to appear before a joint legislative committee that's going through and taking a look at every single board and commission and advisory group in the state and some of the questions they were asking is how do you manage 51 people on an advisory group and things like that and you can see from today that we probably have less than half of the advisory group here. So what we'll do and we do break up is I'm going to walk around and just give each person a number and we'll break up into three groups and the ones will start down here at this corner. The twos will start over here at the second level. I said three. I want to ask you a handful of discussion. We can do three. And then we'll do the third one in the back. We're going to do five groups but I'm going to ask a couple of the board members to team up because each one was prepared to have their own group but I think given the numbers that are here to have that meaningful discussion in the group I'd like to get at least six people in every group that are not from the group on the board. So again we'll have we'll keep Jess. You're going to leave one group and I'll have Kevin, Mike, Joe with that. Robin, you'll have Jess, you'll be group number one. So you'll be down here. Robin is group number two. And you'll be right next to where you are, Robin. Okay. And now I have to choose between board members. Just say it's Tom and Raine together. In the back corner over here. And then we'll have all of you just count out one, two, three. There's no self-selection here. I'll take yours. One, two, three, four, five. One, two, three. One, two, three. One, two, three. One, two, three. One, two, three. One, two, three. And one. So before you disperse, please follow the questions. You're going to have copies of those for your group. And the staff member and the board members will facilitate this. We're going to meet back here at 11.30 and we'll report out the information that you shared with us. Have fun. Thank you. 31 or 224. Let's see, we have 20 minutes and three groups. And we'll try to figure it out. So we'll start. Yeah. All right. We have a great group. And our group spent a lot of time talking about how to improve, I would say, the focus of the advisory group and adding some clarity in terms of the advisory group's purpose for the board so that people felt like they were coming to provide meaningful input and that they also felt like they had some follow-through afterwards. So for example, ensuring that we were doing maybe a little better job of articulating how we were using the feedback and information so that it didn't feel like people were coming and providing information into a vacuum and didn't really understand how that was, whether it was not being used. We talked a lot about group size and how to structure it because of course there's a tension between having a manageable working group size if the purpose is to tackle a specific topic or issue versus having a fully representative group which necessarily has to be much larger. So a couple of ideas around our group were could we have a larger group where the purpose was really informational so the board providing information about our work and what we were doing and the results of our work and then having more of a work-group structure which I think for us it presents a staffing challenge if it were too many work-groups but there are ways that we potentially could tackle that either by having a work-group self-staff or keeping it to a limited number where maybe as a board we pick a topic or two that we're going to have a work-group on that's more targeted and then those targeted work-groups we need to be more like 10 to 12 focus on a specific issue and involve people with expertise or interest in that specific issue. In terms of topics of interest we talked about transparency evolution of the ACO regulatory interconnectedness between our different regulatory functions employers and employer engagement population health and also kind of views of consumers we had a great idea of maybe trying to incorporate this in a webinar slash Skype format so for folks who really are coming from a long distance they could participate in that medium instead of having to drive what that means. I think you're getting most of them and also just kind of operational stuff you know making sure Robin mentioned making sure that whatever is discussed here at the advisory gets back out to the advisory and if appropriate share with other entities like legislators etc. and also I think with this view that members here if there are representatives of different advocacy groups if they can actually take the responsibility to filter back into their group the information that we discussed here at the advisory we talked about the space and this is not a great space for breakout groups I think that we know we hear you and so we're folks to share with us some ideas on different free spaces and times also just different times to meet because sometimes for for instance a primary care provider 10 to 12 in the middle of the day is not great but then you get into if you do it earlier or later if you have people traveling that might be an issue but that's the idea of having maybe a Skype alternative would be helpful. I guess the last thing I would mention we did have some suggestions around could meetings be more in this sort of goes with the work group concept I think, be more problem solving focused and or thinking about kind of a healthcare system and moving forward and as a bigger topic while then also understanding that some of those topics don't necessarily tie back to our let's ask for a charge or focus so we had a budget thank you our group was great now we're eager to hear I don't know what number it was what was the group up there Sarah? come on up here Susan there was too much laughter in your group you did kind of block out our ability to hear a focus but I did notice we said that I just want to point out that you did save the best group for last I just want you guys to go next I wanted to know about that that our group was also really fun and even our problems here so I picked out some kind of key high level themes and I'll ask Morina to chime in on this as well we're going to talk about topics and what this group focuses on and about processing group management so in terms of topics our group I think that there was consensus that we should be soliciting topics from members through surveys or at our meetings for the next quarter topics should be more member led and not just limited to areas of the board regulatory authority and these meetings should be a way for the board to inform the group about what we're doing and the results of our regulatory process even our other work but it should also be a way for the board to think outside of that the quotes that I wrote down the state of the brain is out of the box so we can really be exploring a wider variety of issues in addition to a combination of kind of updates on Morina's work and digging into new topics we should also be looking at national and international best practices so where other states or other countries are doing things that are really cool that Vermont could learn from or partner with or pack on to those are things that we should be discussing in this group and then there were a couple of topics that specifically came up repeatedly those were things like work boards of hiring and training technology and health information exchange and geographic disparities and access and resources in terms of group process and management our group consistently was urging us to become a little bit of a smaller group so limiting the group size to allow for deeper discussions and then inviting experts or subject matter experts to folks in the community with particular interests when we're discussing a particular issue that might not be at the center of most of our discussions specifically when we're discussing the oral health we need to make sure that we're engaging folks from the dental and oral health community but we may those folks may not need to come to every meeting we also had a number of folks who are just to read this to our charter and really assess the shared expectations for participation in this group and the key quote on the section was that meeting management, good staffing and number of accountability are key Maureen, do you have anything else you want to add? I would add two things I think along with the charter really just making sure that we've set forward one specific goals and objectives are that we were trying to get out of this process and possibly looking at some leadership from the advisory group too to be able to come back and summarize two, three, four, five topics that the advisory group agrees on and the reason we're kind of talking a little bit about that is because we're pretty siloed in the representation across the advisory group and it was kind of getting your brains out of your own silo and saying what can we collectively impact and what can we look at and picking three or four topics because I think for us to be throwing that out to you guys some of the feedback is maybe it's not touching on all of your areas however if the group were to come back and consolidate things I think you'd probably find similar themes that we would be looking at and you would debate that amongst yourselves I think that was really a big part of it as well I can't say it any better than that I mean the aspect that caught my attention was a push for somewhat more self-governance within the advisory board to be able to for them to come together figure out what the priorities are figure out what their charter is and what their vision is and then you'd be able to move forward in that regard and to be able to advise the board at how we might be able to use our levers to get to an end I mean we're not an all-powerful board we've got a legislature, we've got hospitals we've got all these moving parts that we have to be concerned about but you know if the advisory committee can become helpful to us in terms of saying we can do this, this would work it will cooperate with you here the whole governance issue that seemed to be an important product of our discussion and I'll just add that we also had a discussion about a charter I think going back and forth on whether we should have a charter or not I am convinced that we should have something like that that came up as something in our group as well overall the best for the last best for the last we had members and Kristina and I were at staff members we had sort of we're going to probably repeat a lot of things the other group said and I think the things that we heard were really representative of a wide range of opinions and what makes it so difficult to make these decisions moving forward with the future but a couple of things we heard were there's a bunch of different advisory groups across state governments and how do we know what the different advisory groups are doing and is there ways that we can coordinate so that our advisory committee is working sort of in tandem on different issues and maybe sort of a divide and conquer approach to be more efficient the large and diverse nature of the group it may be difficult to come to any consensus there are some skepticism about advisory groups not meant to be vehicle for advocacy what are the options for the group moving forward there was a concern so when we talked about possibly making it a smaller group there's a concern that some people they're part of their day to day jobs are to attend meetings like this while other groups do not have someone that can represent them on these meetings coming down of of the advisory committee we run the risk of not hearing from the smaller groups or those that might not be able to make it here and decisions could be made that would have impact these groups or we might not be able to hear from them and they might have important things to add to the conversation we heard that people like the panel structure could give a great opportunity to hear from a wide variety of voices and continue in education I think we heard on both sides the advisory group felt that they need more education on certain topics but also the general public on issues such as the all fair model even the green mountain care board there's sort of a lack of knowledge in the public sphere of what the board actually does we don't regulate from our health connect or Medicaid rates from our Medicaid it's called green mountain care it's confused all the time and so sort of being more vocal about what our role actually is conversation around can the committee push information forward and push outward to their different organizations to help communicate some of the things the board is doing then we talked about advisory structure as mentioned that other groups have specific seats for different organizations also groups have at large members of the term limits the idea that we need to think outside of the normal group of people that we use specifically senior citizens were mentioned because of their hint because of the way they may be impacted by the all fair model and they not only need to know these changes but what those changes might look like some things are mentioned about hearing more about the ECO and the all fair model of its larger effect on the health care structure and consumers certificate of need there was an idea that the committee could not be so formal but instead it's a loose group of people that have different specialties and the board could choose to depending on the topic ask them for their assistance and they could maybe function with a clear direction knowing that that was the issue they were working on I will say that my favorite quote that we had is the advisory committee is currently like a cocktail party with nothing to drink I'm not sure what Christina has if I missed anything I think you had everything I can't remember who touched on outreach the idea was perhaps the advisory committee could help facilitate the outreach on the ECO and all fair model and just in their everyday lives but also special needs which is probably a great idea do you guys have anything to add board members? what my thought is that there was one suggestion that in between the quarterly meetings and once the advisory committee developed a little bit of leadership and governance that tools like the survey monkey could be used to kind of sift through issues and refine issues so that a lot of time at the meetings could be more productively used and kind of refreshing yourself every time you need just anything? yeah I understand comments that have made which was a good feedback was having the advisory board comes if the topics are out there in advance that people have prepped for it whether they did homework in between or whatever but they're ready to participate when they get here and it's not just a feedback so that it can be productive in the meetings that we have that's great so we have a few more minutes I want to talk about next steps we are going to come tie along this information and send it back out to you some of the key themes I would I don't have the exact date when the new configuration of the advisory will go out I do know that we will have an application process which will essentially be your CV I do know that we want to get representation throughout the state and we want it geographically and we want to have representation not only from different healthcare entities but I really know what you heard today like senior citizens I heard in our group reaching out to more employers so we'll go over all of the information and pull out key themes and send that out to you and then have an application process I'm thinking towards the end of November I think that would be enough time and then we will as part of this review process decide how many meetings and what those meetings will look like and we'll get those on once we have the reimagined advisory we'll get those meetings on the schedules is there anything else you want to add Kevin or any other board members I don't think I have anything to add I'd also encourage you if things things percolate up and you said oh I forgot about this this is a great idea please send that to us you can send it right to me and we'll make sure that we incorporate all of your great ideas I want to thank you all very much for your attendance today I felt like it was very informative and it helps me as I look at the new reimagined advisory committee for the remount so we'll be back here at one o'clock for our regular scheduled board meeting we're hearing a very interesting topic on and I'd invite anyone who wants to come back and listen to this presentation some of our board members recently from the organization Kevin is it's the business round table it's the talent pipeline and while you're talking about that I just want to really give a shout out to Deb for what I think was a very successful conference down at Castleton created seeds for some movement moving forward to try to address some of the workforce issues in the state so thank you very much Deb