 So I'll call it order the Green Mountain Care Board's hearing of June 21st, 2023. Today we have a couple agenda items. We have a palliative care assessment in Vermont that'll be provided to us by two physicians and then we'll have the Medicare only budget guidance and then the staff presentation on the one care Vermont budget guidance. And there's a potential vote notice for the Medicare only guidance. So I'll turn it to our Executive Director, Ms. Susan Barrett. Thank you Chair Foster and I have a few scheduling announcements and a couple of public comment announcements. So first this evening we will be, we will have our primary care advisory group also known as the PICAC that will be taking place from five to seven via teams. Also a physical location at our offices in Montpelier and also next Monday on June 26th is our general advisory committee meeting and that's taking place from two to three thirty also via teams with a physical location at GMCB offices. All of the information on these meetings can be found on our website. If you go under committees of the board tab you will find any of those and if you can't just reach out to me or Kristen and we can get those for you. A couple of public comment periods we will be, in fact we already opened up a public comment period for the one care Vermont FY24 budget and certification guidance which you'll hear more about today and Michelle will share more of those details on how you can public comment and we have the ongoing public comment period on a next potential all-payer model with our partners at the Center for Medicare and Medicaid Innovation. Any of those comments we share with the agency of human services as they are leading the negotiations and the implementation of the model and Chair Foster when Dr. Hepler and Dr. Wright start I can give a little bit of background of our work with them. I can do that now but I think you might need to go back to minutes so whichever you prefer. Yeah why don't I do the minutes really quickly. We have two sets of minutes because I missed them last week. The first minutes are from May 31st. If anyone's ever had a chance to review those and there's a motion we can take it up. I'll move to approve. I'll second. For any board discussion of the minutes from May 31st. All right all those in favor please say aye. Aye. Aye. The minutes are unanimously approved and then we also have the minutes from last week June 14th. Is there a motion to approve those minutes. They're moved. Second. And any board discussion. All those in favor please say aye. Aye. Aye. Aye. And the minutes from June 14th are unanimously approved. So Ms. Baird I'll turn it back to you to introduce our speakers and our first topic today. Great thank you Chair Foster. So as a bit of background and Drs. Hepler and Wright will get into the background on their program that they participate in which is called the Leadership in Preventive Medicine Residency at the Dartmouth Institute. The Green Mountain Care Board has been hosting these LPMR as we refer to them doctors for the last of gosh five or six years. Other state agencies have also hosted LPMR's for their government and public health experience requirement as part of their program and we at the board have always found the experience working with these professionals really helpful and learning experience on both sides of the coin here. So I will turn it over to them but I just wanted to thank them for their great work and I'm really eager to hear this presentation and also a shout out to Dr. Merman too who's helped us a bit to prepare help to the doctors prepare a bit for today's presentation. So thank you Chair Foster and I can turn it over to Drs. Wright and Hepler. You're a little bit quiet maybe turn it up a little bit. So thank you again and thanks everyone for your time today. Myself and my co-resident Dr. Amanda Hepler are going to tell you a little bit more about a project we've been working on with respect to palliative care in Vermont. We know that health care sustainability has been a focus for you all and we thought that taking a closer look at the state of palliative care would be a fruitful endeavor particularly given that palliative care was not included on the wait time study conducted a few years ago. So before we dive into a discussion surrounding palliative medicine we wanted to take a few minutes to introduce ourselves and provide you with additional background information about us. My name is Heather Wright and I'm about to complete a fourth year in training in Hemongue at Dartmouth Health. Before this I completed medical school in Maine and then matched in internal medicine at UVM. I completed my IM training in 2018 and I stayed on for a chief year after that. Like many other chief programs in internal medicine I had a joint appointment as a hospitalist and after completing this chief year in 2019 I started hematology oncology fellowship at Dartmouth where I opted into an extra year through the leadership preventative medicine program and with my training to date I have really developed a keen interest for early integrated and easily accessible palliative care for patients who are facing an advanced cancer diagnosis. And my name is Amanda Hepler. I went to medical school at Jefferson Medical College in Philadelphia and in my residency in family medicine in Lake Trope, Pennsylvania. I worked for 11 years in family medicine in Maine, New Hampshire and Vermont. Then I spent one year as an associate hospice medical director with Bayotta Hospice. I completed a fellowship in hospice and palliative medicine prior to joining LPMR and my goal is to help make palliative care more accessible to rural populations. So you've heard that myself and Amanda are co-residents in the leadership preventative medicine program or LPM as we like to call it. It's a program that exists in Dartmouth in conjunction with an established GME residency or fellowship program, meaning that it's not a freestanding residency. We're enrolled in LPM concurrently with our home program. For me it's HEMOC and for Amanda it's palliative care. It typically adds an extra year to our training and during this time we've received leadership training as well as an MPH through the Dartmouth Institute. We are required to work on a quality improvement project as well as a governmental health project. Hence our work with the support of the Green Mountain Care Board to assess access to palliative care within the state of Vermont. After we finish the program we are board eligible not only for our home specialty but also for preventative medicine. So while practicing family medicine in Vermont it had come to my attention that despite having an older population Vermont tends to have below average hospice utilization rates. The 2020 addition of the national hospice and palliative care organization facts and figures included the following information for 2018. It showed that 42.9 percent of Medicare decedents were enrolled in hospice at the time of death which can be compared to 47.5 percent in New Hampshire. The good news is that this was a 22 percent increase since 2014 but they were still well below the United States average of 50.7 percent. Vermont at that point had ranked 46th in hospice utilization and despite the fact that there are many patient benefits to earlier hospice utilization. So you may be asking yourselves why are we asking about access to palliative care? There is some literature to suggest that palliative care access can increase hospice utilization and while there has been good uptake of palliative care in academic centers and urban areas that is not the case in rural areas across the country. Furthermore it is the standard of care for patients with cancer and it can reduce costs at the end of life. Lastly the Green Mountain Care Board did a wait time study using data gathered from 2017 to 2019 that measured how long it takes patients to be seen by a specialist. But palliative care was not included in that study so this seemed like there was a gap that this project could fill. Really the purpose of this project was to understand palliative care availability and services with no intent to criticize systems already in place. Our goal was not only to gather information across the state about access to palliative care but also to share this information in ways that we can learn from each other. Ideally leading to more patient centered care and potentially cost savings. This appealed to the Green Mountain Care Board because you all are continually working on hospital sustainability throughout the state and we think that you all see better access to palliative care as potentially playing a role in that work. So for a little more background on palliative medicine it is still a relatively new specialty and is often misunderstood. In 2006 it was recognized by the American Board of Medical Specialties but it was not until 2014 that fellowship became required for board certification. The NIH describes it as specialized medical care for people living with a serious illness and that it is meant to enhance a person's current care by focusing on quality of life for them and their family. So we work to improve quality of life through both symptom management and providing support with coping and ideally would work as an interdisciplinary team to provide goal concordant care. And goal concordant care is defined as care that honors a patient's values and wishes and we use a structured goals of care conversation to better understand what that means to each individual and it is also important to realize that it is not the same thing as hospice. So there are not the same requirements for life expectancy or that the patient is no longer wanting to pursue curative treatments. So primary care providers, hospitalists and specialty providers are already doing a lot of palliative care through managing symptoms and having discussions with patients. But the reality is that they often do not have enough time to have the goals of care conversations which can sometimes take more than what they're already allotted for an appointment that is meant to discuss multiple things. Other times they may have the conversation but it doesn't go as expected and they're not entirely sure what to do next. So in specialty palliative care we are trained to help with refractory and complex symptoms such as pain, nausea, constipation or shortness of breath. Again that interdisciplinary team is really important in helping to manage some of the psychosocial and spiritual distress that patients have. So having chaplains and social workers and nurses involved we can approach it from multiple different angles. We also help a lot with complex decision making. So those patients who are stuck in that unfortunate position of not really having a good choice and all of the decisions that they have are maybe hard and aren't exactly what they hoped for. We again try to understand their goals to help them figure out what the best route is for them as an individual. And we also lead family meetings because we've probably all seen patients who have multiple family members who all have a very different idea as to how the patient's care should go. And we help kind of not only advocate for the patient but try to help get everyone on this same page because even after that patient has died some of those family members may need to live for a long time and how things happen during that really sensitive time period can affect them for a long period of time. So they can struggle with depression or anxiety or sometimes what we refer to as complicated bereavement. So some of the patient benefits from palliative care. One is there was a study in 2010 in patients with metastatic non-small cell lung cancer that showed that early access to palliative care allowed some patients to live longer. So the patients in the study lived on average 12 months as opposed to nine months for those who did not have the access to palliative care. Not only that but they had a better quality of life so they felt that their symptoms were well managed and their mood was better than the control group and they reported just a better overall experience. There are also studies that show that patients who receive palliative care are more likely to receive gold concordant care and that their families are more likely to perceive that their loved one had a higher quality of care. So early on in this project we were given an opportunity to join a regular meeting of the Vermont CMOs. We shared this information about palliative care with them along with an explanation of the project and how we intended to use the information. After this meeting we sent surveys to all 14 hospitals as well as to DHMC in Lebanon into the VA in White River Junction. The survey included aspects such as the number of full-time equivalent providers or FTEs, inpatient and outpatient options, weight and travel times for patients as well as telehealth options. We also inquired us to the barriers for patients and providers alike. The specific questions we posed are listed here on the slide. From the initial request we sent we received four responses. After we let some time lapse we resent the surveys again with just a few additional responses coming back. Eventually we ended up reaching out specifically to palliative care contacts within the hospitals that had not responded and we were happy that we took this approach as we found that the responses we received from palliative care providers specifically were quite robust particularly with respect to the open questions surrounding barriers and needs. This is an infographic we created to represent the hospitals by size who did and did not respond to our survey. As a reminder we sent the survey to the 14 Vermont hospitals in addition to sending it to the VA in White River as well as to DHMC. In total we received responses from nine of the 14 Vermont hospitals and from the VA in DH. The majority of the smaller hospitals are generally critical access hospitals which may have rehab beds in addition to the 25 inpatient beds. Two hospitals reported that they do not have palliative medicine as a subspecialty. Two hospitals reported that they have inpatient only. One hospital reported only outpatient home visits with respect to palliative care and four hospitals reported that they have both inpatient and outpatient services and of the five that did not respond. Four of these did not have any mention of palliative care on their websites. So the first item we looked at with respect to the responses is wait time. We split this into two categories inpatient and outpatient wait times. We found that inpatients as expected were seen quite quickly. The majority are seen within 24 to 48 hours. Outpatient visits were a bit more variable with three institutions reporting one to two week wait times and one institution reporting a two to three week wait time. The next item we looked at was telehealth utilization. We felt that this was an important measure given the reality of our state. Three institutions reported fairly high utilization at 40 to 70 percent with one institution reporting virtually no telehealth at less than 10 percent. With respect to travel time this was highly variable in range between 10 to 120 minutes with most falling in the 20 to 45 minute range. Lastly we looked at the number of full-time equivalents in palliative medicine which we'll discuss in more detail on the slides to come but essentially we found that the median was two FTEs with a reported range of one to nine and one hospital reported one per DM provider. So then this did raise the question as to how much access is actually enough. So the Center for Advancing Palliative Care is an organization which has educational resources to better understand palliative care and resources to help hospitals improve their access to palliative care. They review each state and they gave Vermont a perfect score so I was worried for a minute that we were on the wrong track but when we looked at it more closely they were only looking at hospitals with more than 50 beds and at that time six of these hospitals claimed to offer palliative care and there were only six total. But looking into it a little bit further the Center for Advancing Palliative Care is asking about any access to palliative care. So if they have a social worker or a nurse or a care manager who is either offering serious illness conversations or even providing any level of palliative care then the hospital is felt to meet the requirement of having some sort of palliative care access. So they weren't specifically asking about board-certified palliative care providers. So then found an article on understanding the current supply and projected demands of palliative care. The authors of the article looked at the number of palliative care providers per 100,000 people aged 65 and over working under the assumption that it's primarily older individuals who need access to palliative care. So the national average in 2018 when the study occurred was 13 providers per 100,000 persons over the age of 65 which they suggested was too low to meet demand at that time and was likely to become more of a problem as the baby boomers aged. Looking specifically at Vermont in 2022 the population aged 65 and over was roughly 133,000 people and based on the data that we collected Vermont had 22 palliative care providers which would put them at 16.5 providers per 100,000 persons over 65 which looks good at first but then we realized that in rural states like Vermont palliative care providers tend to work only part-time in palliative care. So the hospital that they work for may only be able to give them a part-time position in palliative and they're working the rest of the time either in family medicine or internal medicine or possibly some other specialty. So when we're really looking at the FTEs there are only 9.9 providers per 100,000 persons over the age of 65 in the state of Vermont and not only that there are some areas that do not have any specialty palliative care providers. So in the slide in the next we're going to take a closer look at the population density in the state of Vermont with respect to both provider time as measured by FTEs and the age of the population. So to start we looked at population related to excess. Here we have a map that roughly shows the population density in Vermont counties with darker colors representing a higher population density. Pictured on the right is a map with hospital service areas which we have shaded in green. This represents responses received that indicate this service area has access to palliative care. Area shaded in red we know does not have access to palliative care and those in yellow remain unknown as we did not receive survey responses. To note 26% of Vermonters live in Chinden County which has the best access to palliative care among the state's hospitals with 4.22 FTE worth of providers working in that county. The counties with over 60,000 people include Washington and Rutland counties. Washington County has the second highest number of palliative providers but only has access to inpatient palliative services while access to palliative care remains unknown for Rutland County as well as for Franklin, Wyndham and Windsor counties. On the slide we'll show you how age and access to palliative care matches up. Here's a map showing the percentage of people in each county that are over the age of 65. In the state of Vermont 20.6% of people are over age 65 and this is as compared to 16.8 in the US as a whole. Across the state those age 65 in each county is variable and it ranges from 16.2 in Chinden County to 27.1% in Essex County. So ideally the oldest counties would have the best access to palliative care but when we look again at the hospital service areas the only county with more than 23% of the population over 65 are confident that has good access to palliative care is Bennington County. The reality is that the best access i.e. the green hospital service areas on the right tends to coincide with the counties where less than 23% of the population is over 65. So our next step was to do sort of a qualitative analysis of some of the results that we were able to receive. So we included some open-ended questions in the survey to give respondents an opportunity to describe barriers to implementing or expanding palliative care at their hospital as well as resources that they would need to make that possible. We also conducted interviews with Dr. Diana Barnard who is a palliative care physician at Porter Hospital who was recently in the news as the physician for a patient from Connecticut who had sued the state over the residency requirement to be able to access medical aid and dying. We also interviewed Cindy Brzezi who is the director and ethicist for the Vermont Ethics Network which provides education about palliative care and oversees the state registry of advanced directives. Another interview was with Kerry Wolfman who's the CMO for One Care Vermont and we also met with the primary care advisory group who helps advise the Green Mountain Care Board on issues that are specific to primary care. We used a program called deduce to analyze this information and it was able to generate this word cloud which shows some of the key ideas that surface during these conversations. Some of the things you will see multiple times such as staff and funding because it was repeated in multiple formats. So as far as the perceived barriers to implementing or expanding palliative care the two biggest concerns that were raised were education and staff and I think staff is not surprising because staffing has been an issue sort of all over health care in recent years. As far as education we were able to break that down a little further into who the respondents were saying needed that education. So 40% said patients need more education stating that the biggest barrier is patient education and the patient not understanding the value of palliative care how it differs from hospice and prioritizing one more appointment. 40% said that providers actually need more education and it was Cindy Brzezi who said that provider awareness in general isn't great they often think it is the same thing as hospice and therefore are under utilizing palliative care and 20% of respondents said that both patients and providers need more education. Other issues that were raised were the distance that some patients need to travel to actually see a palliative care provider that it's difficult to have enough home support and socioeconomic support for patients and the stigma that's that comes along with palliative care in that people sort of automatically again link it to hospice but that possibly having palliative care earlier in a disease process and outside of an urgent situation would make the conversation less scary. When we asked what resources hospitals need it was not surprising that staff was the primary thing that they mentioned and Diana Barnard actually kind of gave a little bit more detail than most other respondents in saying that there is not enough outpatient palliative care and it's partly due to the lack of infrastructure for symptom management so if there's only one or a couple of providers in an area it is challenging to provide call coverage for a panel of patients and then there is the need for support staff. So when we met with the primary care advisory group one of the things that we were hoping to learn from them is what they see as barriers to having serious illness conversations so it kind of goes back to that slide that was shown earlier about the importance of primary palliative care being what most patients can access especially since specialty palliative care isn't available everywhere. So I was actually surprised to see that miscommunication was the thing that was mentioned the most and one specific example of this was someone who had a patient with ovarian cancer who understood where things were at but the provider felt like she could not get through to the patient's husband but after meeting with palliative care he finally got it. I expected more people to mention time because when you have only 15 or 20 minutes for an appointment it's hard to get through everything that you need to do let alone to have one of these conversations that can easily take 30 minutes or more and I actually during the the conversation did bring up my personal experience with difficulties with prognostication because when you have patients that you've known for a long time and have developed a relationship with it can become very difficult to admit to yourself or to the patient that they are getting closer to the end of their life. One of the other participants also did mention that when patients are seeing specialists that that specialist is focused on the next line of treatment and they don't come back to their medical home until there are no other options available or they're close to the very end of their life. So the question posed here is how palliative care can be helpful and as you can see most agree that palliative care is helpful with respect to support with complex issues. Some selected quotes to see are to the right of the slide on top. Dr. Merman is quoted as saying everyone leaves the conversation feeling good about what happened even if it was a difficult situation. Another quote we pulled from the peak hag meeting is on the bottom. Dr. Maloney was able to help my patients stay out of the ED when nothing else worked. In some of the individual interviews that we had we were able to harvest some improvement suggestions which we felt were very helpful and wanted to include for all of you today. One of the things that came up was that the need to expand into skilled nursing facilities and home health options. There is some frustration over the fact that home health services are usually only covered when a patient is homebound but a patient doesn't need to be homebound to be on hospice. So it doesn't really make sense that something that often precedes hospice care has a different requirement. They also notice that there needs to be improved communication among providers and that many providers would benefit from specific training to have serious illness conversations. Dr. Barnard also brought up that regardless of what you do crisis palliative care will always be needed but there is an important need to work upstream and the best way to do that is without patient palliative care services to begin having these conversations before things reach that crisis level. Cindy Bruzezi also made some great points about legislation and that Vermont has an aging population so this may need to be something that is addressed with legislation but may not be resolved only at the state level. And I thought Diana Barnard had this great quote in saying that systems see the value of palliative care but they don't have a good plan in place to set aside the money to make it possible. So I hope you all can see that our initial approach to this project including collecting survey responses and then this really evolved into a community assessment of stakeholders with respect to palliative care and it included interviews with both individuals and groups. Like many other issues access to palliative care is complicated and not everyone will agree on the best approach to expand access to such. We found that it is clearly helpful to hear opinions from various specialists and understand the breadth and depth of the issue to help formulate ideas for change that are most likely to produce beneficial results and unintended harms. Seen on this slide are two differing opinions on the subject and we think it really highlights the problem in finding a single solution. So before we conclude the presentation we wanted to take a few minutes to highlight what we learned that we feel strongly that educating the public and providers alike on the benefits of palliative medicine needs to be done thoughtfully so as to avoid creating a demand that outstrips what our healthcare system can provide. At some point despite staffing struggles the health system needs to take a leap of faith and invest in palliative care making it a priority and trust that this will lend itself to improved care and outcomes for patients. Furthermore we think that the same argument can be made to policymakers and legislators and we think that there are several opportunities for health systems to be created with respect to palliative medicine and home-based care but cost continues to be both a barrier and a challenge. Lastly we found that one of the biggest barriers to increasing comfort to involving special specialty palliative care is that many primary care providers want to be able to do this themselves. To some potential next steps that we see one would be to continue conversations with one care Vermont to encourage including palliative care measures in their next strategic plan to improve understanding of how palliative care services can enhance the quality of patient care in serious illness. To continue to work with members of the Vermont legislature to develop policies that will support expansion of palliative care in rural areas of Vermont and possibly policy to cover home health palliative visits for patients that are not homebound. We hope to create opportunities to provide education about specialty palliative care and ongoing opportunities to improve serious illness conversation skills to support primary palliative care and develop education for the public so that it is available when the time is appropriate. And to end I just added a brief comic from an article that was on one of the earlier slides about how palliative care is the umbrella not the rain and how early palliative care gives people the resources to have on hand for when they need it instead of waiting until again they've reached that crisis situation. So we just want to thank you all for your time and we are happy to answer any questions that you may have. Thank you both very much. I have a couple quick ones and I'll turn to the other board members. You said that palliative care in Vermont has increased I think is 22 percent since 2014. Do you have any sense of you know to what that could be attributed to? That was actually hospice that increased the hospice utilization increased 22 percent. Do you know if palliative care in Vermont has increased in the last several years? That I am not sure. Sorry. In terms of Vermont being below national averages do you attribute that to morality access awareness or anything else? As far as hospice utilization, morality probably does play a role in people that are in rural areas it's harder for them to get hospice visits at times. I feel like having worked in Vermont that Vermont is somewhat stoic and not necessarily wanting to access all help that's available and that there is some stigma that goes along with hospice care in my personal practice I've actually had patients say that they did not want to be placed on hospice because they were just going to give them medications and kill them and so I feel like more education needs to occur about the fact that hospice isn't there to kill you it's there to support you through the end of your life whenever that may be. And I think earlier conversations again can kind of help to change the way people are looking at hospice care so that they don't have that fear that everyone's just sort of giving up on them at that point and also helping improve communication skills among primary care providers so that it's easier for them to kind of clarify some of those concerns for patients. You just described my family which is why I was asking the question because I know they don't access this kind of care because they're stoic and don't want to get care so I was wondering if that yeah that's sort of cultural issue is part of it as well. Okay I don't have anything else if any other board members have questions go ahead. Hey this is Dave I just want to turn my video off because I've got a funny connection today but I just really want to say I really enjoyed working with both Heather and Amanda on this project with Susan's many rich, rich conversations I learned a lot from both of them and learned a lot about Vermont and what we have for resources so thank you so much for the hard work and for the for all the conversations around it. I just want to say thank you to you too Dr. Marvin because it was nice to hear a physician in another specialty who has had good experiences with palliative care. I know I can be somewhat biased toward it or I would not have gone into palliative care so it's good to have that balance and thank you. Good afternoon Amanda and Heather this is Tom. Thanks for presenting to us it was not only did you present well the slides were beautiful and I think that helps with impact and the information that you shared was very meaningful. I just have two thoughts I believe there was a study maybe more than a decade ago now but I believe that folks who opt for hospice care actually live longer on average than similarly diagnosed patients and I thought when that came out that was a big surprise to those of us in any type of medical field and I thought I always thought that that should be pushed more that more people should know about that that because of the coordination of care that often goes along with palliative care and hospice there seem to be some real benefits it's not giving up all right and so I think that that's a really important message. The other the other thing that I just wanted to comment on the on a few slides you had a quote about it could be a potential disservice to educate patients because we may not have the supply and I just I've had some experience with that type of thing in the late 1990s we started I was taking care of patients with chronic back pain and we started trying to find out how much what proportion of those patients were suffering from co-morbid adjustment disorders anxiety depression and how we could better utilize the psychologists we had on staff and in our initial assessment of that we found that it was way more prevalent than we thought but it was underused over 20% of our patients had it but less than less than 10% of those 20 were actually seeing the psychologist we started trying to design ways to improve the use of effective care the psychologist but when we did the math it looked like the psychologist would just be overrun there'd be so many patients who would who would need this that it would just it would burden the whole system and there was a lot of fretting about that and it never happened right then the numbers look ginormous but it didn't occur right and subsequently over the year since the late 1990s I've done that type of work at dozens of places and the numbers always look scary and they never materialized to their fullest extent and so the idea that we would not educate patients or that we would not start to make changes because it might blow up the system I just I don't buy it anymore and I'd encourage you to listen and nod but don't stop doing what you're trying to do out of that fear it just doesn't happen that's great to hear thank you because I know that there is a lot of fear with the low number of palliative care providers that are out there that they will become overwhelmed but yeah I actually do agree that more education if nothing else if it does start to put a little bit of a stress on the system it it encourages more people to hire more palliative care providers and expand services which is really what we actually need but thank you that's good to hear I think that the first study you're referring to might be the one in metastatic lung cancer patients that had early access to palliative care and you're right the study showed that they lived about two and a half months longer which is significant in someone that's facing a metastatic lung cancer diagnosis and I think if we take a step back and we ask ourselves if this was a pill would it be approved and would be recommended and I think the answer to that is unequivocally yes and to my knowledge there's no studies that show any harm to palliative care so I think it's a really important point that you make that and this is how I explain it to patients too they're unlikely to do you any harm they really can only stand to do good by you and so I think that's a very valid point and something take away that we can take from this right and the umbrella cartoon at the end was just so good so like that was so so good nice job thank you so much I'll just hop in here with a quick question really appreciate all your hard work and doing this work with the board and then presenting it to us it's really helpful I'm just wondering if there are any states and you know did you encounter in your research any states that are doing really innovative impactful work on the legislative front or in other vehicles to expand access to palliative care are there any states that we should model ourselves after or think about to explore what they're doing and how we might you know import that here that isn't something that has been thoroughly explored by us yet there are some examples of states I know that Kansas has recently passed some legislation to help support palliative care but I'm not sure of the details of that and yeah I think more states are starting to realize that it is something that needs some way of supporting it because palliative care sort of is one of those things that on the surface looks like it's losing money so it's kind of like primary care in that it's difficult for us to actually bill enough to pay not only for ourselves but those support services of chaplaincy chaplaincy and social workers and nurses that really make the team the the good functioning team that it needs to be for patients but when you take a step back and you look at reduced readmissions shorter ICU stays fewer ER visits those sort of things that it typically is saving money for the hospital system but it's really hard to measure those things that don't happen so it it's difficult case to make sometimes thank you I just wanted to chime in and say thank you for your work it was a very interesting presentation and I'm glad we could have you at a board meeting to talk about the information and maybe do a tiny bit of education ourselves here thanks thank you any questions or comments from the healthcare advocate afternoon thank you doctor right doctor hepler hope I'm not seeing your last names correctly I just wanted to thank you for the presentation and it's a personal comment before I ask a brief question palliative care has been had an enormous impact in my own not my own personal life but my family's lives so I appreciate you doing this work because I think it's an under understudied and misunderstood area of medicine particularly just having older family members who've been a little bit reticent to receive the type of care for the misconceptions that you laid out so I want to thank you for for elevating that and the question I have is there was a piece in the New York Times about a week ago about the use of AI particularly chat GPT and how helping physicians have difficult conversations with patients which I mean I had a conflicted reaction to personally but I'm curious if in your research and in your interviews with providers and the PCAG this came up at all or if people are using it just curious if you could talk a little bit more about that I would say it's a brand new topic to us we I think correct me if I'm wrong but I think chat GPT was only created in March of this year is that right I think that's true we just had a lecture on it as part of our LPM studies and we talked about AI and how it's likely to change the face of healthcare and how we deliver care but how do we mindfully how do we mindfully do that I would say it's it's a little too new to understand how that will play a role but I will be curious to see how that plays out thank you I would also be very curious to see how that plays out is yeah I mean I I like to think that there are just these nuances and things that you really need a human being to pick up on but um chat GPT I think can probably do some kind of scarily amazing things sometimes but I will need to look at that article because that sounds fascinating thank you back to you chair foster we can take a public comment I see there's a hand raised Mr. Ham Davis how are you doing please go ahead Mr. Davis is your hand up right Sharon got one how are you you can go thanks I thought that that was an excellent presentation very informative and clear and I can see how it's confusing to understand the difference between hospice and palliative care because there's some overlap but I was thinking as I was listening to the presentation how kind of putting them together in the presentation added to the confusion and they the palliative care is not as I feel like helped in the confusion and I can see how palliative care would be great with the one care organization in better access more affordable coordinated care and definitely would like to to see you get in into one care thanks thank you and thanks for bringing up that point about that it did make it more confusing um and yeah and I actually have kind of clarifies the differences between hospice and palliative medicine so wish that we had included that so I apologize for the confusion doctor I think I was confused a little bit but it's mostly because I didn't get a whole lot of sleep the last couple nights so it wasn't you know it was entirely me and I apologize because I mixed it up in my head just not paying attention closely enough so I'm sorry for that um mr. Davis I see your hand is up are you do you have a question or a comment yes thank you mr. chairman I think the the whole issue of palliative care is a really sort of a canary in the mine here for the what I think is the real issue which is not simply overall whether you need whether you need this kind of care or not have you got it how much of this and that the question really is it seems to me is how are you gonna how are you gonna build it into your overall system you've got for who's gonna pay who pays these people if they're hospitals okay what you've got is 14 hospitals but eight of them primary care hospitals which may not have anywhere near enough people to justify enough patients to justify paying a full-time person to be a to do that palliative care so that seems to me the real issue the the question seems to be um you what where do you want the who do you want to buy who does the system who do the people that are sort of managing the overall vermont system who do they want to pay these people is that hospitals if it is hospitals then at what level can a hospital afford a palliative care I mean if you get in can you afford a palliative care specialist for just new port or you know or just springfield or something like that even needs something bigger so to simply say well we need it and we've got so many overall and we the question my question is if you really want to do this somebody has to suggest how are you going to manage it on a system basis and I don't think I don't haven't seen any any of that thank you mr chairman yeah you're welcome and thanks for raising your hand just just chair um just chair is I think my title but thank you um if you guys want to address that or respond or you please go ahead but you don't you don't have to up to you if you have any thoughts sure well I just the thoughts that I would have on that is that is actually a pretty common problem in vermont in that having full time palliative care providers isn't always an option which is why at some host some of the smaller hospitals that do have palliative care only a portion of their time is dedicated to palliative care so they may work three days in family medicine and two in palliative care or work in the er a few shifts in some time in palliative care so that helps ensure that not that much um time is being allotted if it's not something that could be properly filled um and also palliative care physicians actually do make less um than primary care providers uh so it's one of those you special times where you do fellowship and specialty training to make less money so it's not hopefully overly expensive for most um systems to hire palliative care providers but it does come back to that how are you going to make sure you make good use of their time and I think splitting the FTEs is a good way this or the the full-time equivalence is a good way to do that hopefully and if anyone has other thoughts please feel free that was helpful thank you um Sharon please go ahead I was just thinking though that I heard that there's cost savings in palliative care so while it costs there is greater savings on the back end so I was thinking if it got more involved in one care there would be cost savings and I just heard yes shifting away from more expensive hospital based care and ER visits and um a lot more I mean coordinated care will always save money so this is not an added expense this is a reduction in expense thanks thanks Sharon and that is actually a very excellent point too that I should have included um and most studies actually do show that um palliative care does save the hospital system money and in worst-case scenarios it does tend to be cost neutral so evens itself out okay it looks like um there's no other public comment this time so Dr. Hepler and Dr. Wright thank you guys very much for your work with our with our team and for the presentation thank you thank you thank you for having us and for supporting this it was a great experience so I really want to thank again Susan and Dave it was fantastic to work with you great have a good day um we'll turn to our next topic which is the Medicare only budget guidance and I'll turn to um health policy advisor Julia Bowles and our staff attorney Russ McCracken thank you chair foster um I'm just going to get my green chair set up um yeah do folks see the slides okay okay so we are back to talk about the Medicare only ACO guidance which we reviewed last Wednesday um and as uh was mentioned at the top of the meeting we do have a potential vote scheduled um at the end of this presentation so in terms of the agenda for this presentation today Russ and I are going to review some updates that have been made to the guidance since last week um and then we will hand it back to uh you chair foster to facilitate discussion um public comment and then the potential vote um and I guess I should also say I didn't link to it on the slides this week but the documents are linked on our website under the 2024 ACO materials um great so just diving right in um the first change that we wanted to highlight was the addition of two questions in section two um these were mentioned this content was mentioned in passing at the meeting last week and um I realized in reflecting on it that we didn't explicitly ask these questions but that the this information was something the ACOs had historically given us in their presentation so we just wanted to add the explicit questions um to make sure we more consistently collected so specifically the questions were how many other states will the ACO operate in for 2024 and what percentage of the ACO's attributed lives for 2024 will be in Vermont and again this is information we historically had um but not asked as directly so that is the first change um and then I'm going to hand it over to Russ to walk us through the second change um thank you Julia so this is following up on a discussion um from last week and uh what we've done here is we've separated well we've preserved question uh seven that we talked about a little bit last week and then added a new question eight so that um I think it's more clear what is being asked in these two questions um the first one question seven which we discussed a little bit last week what it is really targeted at asking an ACO if they do a performance benchmarking against another data set or another peer group and what that other peer group would be um and it asks for a few more details about how that's done and how the ACO uses it um it's a question that we've had in the guidance uh before and so we're carrying that through um the new question which is question eight is um calling out particular metrics I'm not going to use the word benchmarks here but particular metrics um that the Green Mountain Care Board anticipates may be included as reporting requirements in um an ACO's budget approval and um I wanted to say just a couple of things about this the the first is that the board has authority under its rule 5.501 to specify data and analysis regarding an ACO or ACO activities that an ACO must report to the Green Mountain Care Board. Second thing is to really make this requirement binding on the ACO it will need to go into the budget orders as part of the budget approval the guidance tells the ACO's how to shape their submissions um but to carry through conditions into uh reporting and and um you know modifying a budget and any other condition that we have on the ACO board's FY24 performance here it has to go into the budget uh it has to go into the budget order so the language that we have here for question eight is that the GMCB expects to require FY24 reporting of Vermont performance data for the uh from the ACO as part of the FY24 budget approval the reporting requirements will be finalized in the ACO's budget approval the ACO should review the metrics listed on Appendix Tab D performance data and justify any proposed deletions or additions to these metrics uh so Julie if you could flip to the next slide this is the list of metrics that's included in the guidance in Tab D I won't read through them all but they're part of the guidance and we can refer to them um Julie if you could flip to the next slide sorry I went back once right so the idea behind the question is that as I said the final metrics need to be reviewed and approved either way um by the board is part of setting the budget approval by phrasing the question this way we're trying to identify any concerns or areas of concern that um we may not that may be particular to an ACO or that we may not have um or that the board should rather consider in setting the final reporting requirements so you know we're soliciting comments from the ACO it's also an opportunity for other um stakeholders or public or other agencies to review and comment on on these metrics um the metrics you know they're not the all-payer model agreement metrics they're another set um that I think my understanding is are metrics that an ACO should be familiar with um you know potential concerns I would let an ACO raise those but we want to ensure that this isn't passing on any additional reporting burdens to providers we want to make sure that it's something that an ACO could calculate just from the claims file that CMS provides to the ACO um at the end of the performance year um any concerns that want to be raised around kind of alignment with the all-payer model metrics and also allows the board to kind of consider any particulars of an ACO um a Medicare only ACO that may result in for example any of these metrics having a sample size that's just too uh too small for them to really report or track um and I think we lead by putting the question in the guidance this way we're trying to solicit that kind of feedback to make sure it's um issues are or concerns have been raised before these metrics are set in the budget orders um this fall um so the next slide is uh just some suggested motion language um for the board to consider um following your um review and and discussion and so with that I'll turn it back to uh to you chair Foster thank you both um we'll open it up to board member questions or comments and jump in um thank you Julia and Russ um on the performance data I'm wondering if we have any sense of how these metrics compare to the metrics required by the Medicare ACO programs understanding that there are several so that may not be a question that you're able to answer um I we have not I haven't done a cross walk to that exactly there are um as you noted we would I would expect ACOs in Vermont who are coming in under this budget review would be um Medicare shared savings program ACOs but I that's not certainly true um so I um I don't have a specific answer totally understandable I just thought I I just wanted to ask to to make sure we had an understanding of that um you know I'm I'm of two minds I like uh the idea of performance metric on one hand um on the other hand these are Medicare only ACOs where Medicare is the primary uh designer and uh and quite frankly regulator in some ways of these programs and so it makes me a little uncomfortable to layer additional metrics without knowing how those compare I do think you know the way the staff have framed the questions does give me more comfort because there's an opportunity in in each budget decision to understand that um the and also to understand uh how other stakeholders and particularly the agency of human services would consider these metrics in Lua it when thinking about the current all-parent model metrics and uh sort of design but also um any future movement and future performance and quality framework um I think it's important that when we add reporting in metrics that we understand how those fit into the larger statewide efforts so that we aren't unintentionally working at cross purposes um with them or you know if we want to do that we are intentionally working at cross purposes I just want to understand it in relationship to those items um so I'm still you know I'd be interested what other people think um I'm sort of on the fence with this one although I will say that the way the staff have framed the question um allows for that information to come out in the budget process so that makes me more comfortable oh the only thing I'll chime in is the other alternative for me to get more comfortable would be to put the metrics out for public comment so that there was an option now which I think would need to be more than just at the meeting since people will be seeing them for the first time today to get that understanding so those are all the thoughts swirling in my head any other board member questions or comments well this is Tom I have some I'm also interested to hear um other board members questions and comments um but if you could Russ or Julia could you bring the measures back up please so I think this list is terrific and I I'd like to explain why if we think about what an ACO is supposed to be able to do it's to analyze data and provide insights from that data to help participating providers manage the care of patients in such a way that it reduces the costs of care for those patients that's what generates the savings that the providers would then get a share of that's why it's called shared savings the way that an ACO would go about doing that is to look for patients who have an illness that could become very very expensive and to manage that illness in a way that keeps it from getting very very expensive those conditions are called ambulatory care sensitive conditions if they're managed well you should be able to walk into your doctor's office and walk out if they're not managed well you end up going to the emergency department because of a sudden need unanticipated or you end up admitted as a patient so these measures look at admissions emergency department um admissions in hospital admissions um and the ambulatory care sensitive conditions specifically that managing those better should help reduce the total cost of care ed visits should go down primary care visits should go up there's nothing new or unusual about this set of data they were designed to assess how well an aco is doing i think robin has a great point we should compare it to what medicare wants to measure i think we'll find almost a completely perfect overlap these aren't new it's not something different they're the measures that should change when an aco is working well measuring other things like well baby visits or preference sensitive care those an aco cannot change asking acos to measure those things and report on those is a waste of their time and resources this is a parsimonious list of the measures that should be changed by an aco it also includes i i believe there's a measure about mental health we're interested in that in vermont because we have such a crisis with our mental health system but all the rest is just straightforward things that our aco consultant has suggested high performing acos monitor so i'm not sure why there's such resistance to asking any aco that comes into our state to monitor these measures they'll help us improve the care of people in our state um maybe you can answer for me so for example medicare and if you can't no worries of course but medicare has an aco program for those with es rd specifically so i would certainly imagine that a subset of these measures might be relevant in that type of an aco program but probably not all of them yeah and so what's beautiful about the way that the the team wrote the question end stage renal disease we'd really care about total care we'd care about admissions those patients should not be admitted right unexpectedly they shouldn't be going to the ed unexpectedly they should be going to dialysis routinely we shouldn't ask that aco to tell us about diabetes long-term complications and they should be able to tell us straight up this does not pertain to our particular population that's the way the staff has arranged the question but the vast majority of these questions are perfectly relevant for end stage renal disease sure and all i'm suggesting is that we should be having that conversation before we include the list with the public and other members other folks who are interested before we put in the guidance not after that's all i'm suggesting that makes great sense procedurally i think that's great no problems for me i observed some hands clapping kind of thing while you're speaking i don't know where those came from um that's weird someone's more tech savvy um than i am but anyway um jesser dave do you have any comments or questions i'm happy to you know to chime in here i support the proposed guidance i think we always have to strive to ensure that our regulatory review and the staff resources are somewhat proportional to the number of people impacted and the our potential ability to take action in particular in this case when it's a federal program overseen by cms but i think the guidance here achieves that proportionality and i support it so i'm a yes vote on this guidance if i could jump back in for a second please you reminded me and i just um sorry dave i'll be done in just a second the small number concern um i think we should not be leery of small numbers the goal with preventable ed visits for example is not to have a statistically significant difference between one organization or another it's to get it to zero right so the small number problem isn't a concern each organization is trying to improve its number over time wherever that number begins and so we're not we don't need a large enough end to get to statistical significance with the type of quality improvement work that you're trying to do with an aco over time other types of analyses we do need to worry about sample size safety reliability quality improvement not so much you know that's great time i wasn't mentioning that with respect to statistical significance in data analytics i'm more talking about i think you know we have to recognize that a medicare aco medicare only aco is largely a federal program and i'm just more thinking about the administrative resources associated with the board's oversight and our regulatory oversight in proportionality you know to the to the number served and so like i said i think this guidance achieves that balance and is appropriate and i support it so but i'm i was not talking about statistical significance of data analytics in that case i was talking about you know our staff resources and their ability you know to oversee all of these processes with multiple aco's right now we don't have many aco's operating in the state but that could expand so that was more my point that's not that makes sense to you those things i'll try to go in with my camera on here um yeah i actually feel like i'm in agreement with all the comments because i don't feel that they're very counterfactual at all uh i i think this seems just like a very reasonable list of metrics to um have for evaluation i agree with jess's comments that i think we should be mindful of the regulatory our regulatory requirements proportional to sort of the magnitude of an effect that we can have through regulation and and the impact that that has and that that uh entity would have on vermonters um i i like the idea that robin mentioned since this is a a list that's coming out today um that there ideally would be time for some public comment and to cross-reference this carefully with the medicare list to see if there's some um obviously either additions or or maybe a deletion but i i sort of want to agree with tom that i think this is a pretty reasonable list so i guess that would put me in the camp of uh preferring there be a period of public comment on this list of metrics prior to approving but all things that i intend to approve the other way we potentially could proceed would be to um approve the guidance uh and come back and you know put the list out for public comment and then come back so approve the guidance with the idea that there's a placeholder or you know some language saying that appendix d would get developed after public comment that would give us the mechanism to put it out for public comment without there being a big rush it would mean there'd be have to be some language tweets to the guidance to reference that there would be so similar to in the hospital budget guidance we have language that says we will come forward with some data that we would expect folks to react to so we're approving a prospective inclusion of some additional information so we could potentially do it that way in order to vote today but still have time to do public comment on this for later inclusion understanding that um you know there's a little bit of time before the ACO submissions i don't know Russ and Julia if you would be comfortable with that well if it's okay i i can weigh in um with a couple of thoughts um when the ACO submits its budget it's not going to submit metrics in response to this list these metrics and are for the completed performance here so they're um and so there is um kind of our thought process in setting up the question and having it in the guidance here was that there is this period of time between the guidance and the budget approvals where the board could get from ACOs, HHS, any other stakeholder and even you know do a little bit more of our own work on sort of internally doing a check against the Medicare reporting requirements to the extent that's helpful before a final list gets approved by the board in connection with the actual ACO budget approvals and orders so that was kind of the way we were thinking about one process um it um board member lunch here absolutely right that we do a little bit differently um for some of the hospital budget metrics where we um approve a guidance with a data set to come um so that i think is a approach the board could take here as well um either way either way the board would have to revisit and put this into the budget um factual budget approvals for the ACOs because the guidance won't carry through past those who have to go into the budget orders i think we should just open it up for public comment for a week and take it all up exactly as it is depending on the outcome of the public comment and if it changes any board members mind um so why don't we do that if that's okay with you russ and julie i think we're okay on time for that and we have a hearing next week is that right yeah it looks like there's a head down okay so i'm fine with that unless julie or russ you have a objection to doing so okay um i'll turn to the health care advocate chair foster that suggestion makes sense we support it thanks great great and then um turn to public comment um but i will ask you know that i get emojis that you're going um please refrain from using them it's kind of funny i guess in a way but it's also rather distracting and um i don't think we need real time sort of uh responses as we speak so we can wait till public comment for those um and with that i'll turn it uh mr davis please go ahead thank you mr chair um i i think we got two comments here i think that one of the one of the things that's true here in this whole issue is that you already have a ton of this information if you look at the uh reports by uh a h uh by berkeley research group math matica um uh four or five others that darmouth research group on october 27th of 2021 they tell you things like how much of your inpatient how much of your how much of your inpatient your uh utilization is coming out of your er is is wasted is not justified those numbers run from anywhere from 21 to over 33 percent um they have stuff like the leapfrog group uh uh unnecessary surgeries um and and so forth the real question is uh the real question is is is what what you then do about it you've got this you've got a ton of this information it's already that you have never never used or even talked about the second thing i would say is i think it's an air of unreality here because if you look at this this laundry list of huge lists of well do this and do that and do this and do that i would i don't know how much your familiarity is with small hospitals in vermont but they don't have the they don't even come can't even come close to getting that kind of stuff the only uh new uh medical organizations that can handle that kind of complexity uh uvm and darman uvm can can be ordered to do that and they should do that um darman can do it also but darman is outside of your reach but but those are the two organizations that uh that really understand exactly how i those are the only places in our system we have real deep understanding of how to run a full service hospital and if you like it someplace like your organization or um or one care one care has got one primary care doctor and the idea that one one care doctor can just start start figuring out how to drive how to drive these uh movements that would really substantially increase quality okay is really really hard i just don't believe it thank you mr chair yeah no thank you for the comment very much appreciated um okay so we'll have a special comment period for this and um why don't we take um just a 10 minute break and then we can turn to the last agenda item the staff presentation on the one care by budget guidance so we'll come back at 230 thank you um okay uh it's 230 and we can resume and um miss soyer and mr mccracken will present the one care uh budget guidance thank you very much chair foster we are here today to talk about the fiscal year 2024 certified aco budget guidance and the certification form review um i would like to take a minute to thank the broader aco team and the hca for their efforts in preparing the materials uh for the basis of today's presentation it really did take a village to get it to where it is today so the agenda first we'll cover background and the statutory authority of the board we will go into the certification eligibility form we will walk through the budget guidance we'll talk through next steps and of course have time for public comment and questions and there is a timeline here um the staff spent may and june um working with stakeholders such as the aco and the hca um getting um the guidance and the certification form feedback and then today we are presenting on this next week june 28 there will be a potential vote on the budget guidance and then we plan on publishing both the certification form and the budget guidance on june 30th um there is a public comment period um susan mentioned it opened yesterday um we welcome all public comments you may do so by visiting gmcboard.vermont.gov and you'll see a button right in the middle of the screen um that will lead you through the so um the aco budget review um all acos operating in vermont are subject to a budget review there is a threshold of 10 000 lives which defines the scope of that review um and we create a guidance so an annual it's like an annual budget review manual that we give to the acos to help that guide the way that they submit their budget to the board we heard from julia earlier about the medicare only aco uh guidance and today we're really talking about the certified aco budget guidance the board also goes through the aco certification process so acos that want to accept payments from medicaid or commercial insurance must also be certified um acos that plan to accept payments from medicare only are not required to be certified they just go through the budget process um and for certification the staff create an annual eligibility verification form we call it colloquially the certification form that particular document does not need a board vote but we will review it today and then the board's authority is outlined in those two um the statute they're linked as well as rule five this may be familiar um we have presented on this before this is just a visual outline um that shows really that the guidance process overview depending on the type of aco that we are considering so today um if you follow the boxes that are highlighted in yellow that's what we're talking about today whereas on the right was um the medicare only acos that julia and ross walked us through earlier so the standards and requirements by which we review the aco submissions are set forth in 18 vsa chapter 220 um and gmcb rule five and in the all payer aco model agreement um and i will also notice uh note that the aco does have the burden of justifying its budget to the board so here's our approach for the fiscal year 24 oversight um process so the process started really with input for multiple internal and external parties um i'll just note that one care as of this meeting had not provided feedback on the guidance this year other than some minor technical um edits so the priorities really the budget targets as we will discuss um this section of the guidance has been fleshed out considerably this year um we also prioritize the use of the benchmarking report and expect to see the aco tying their budget to trends we see in this report um the staff aims to complete a data-driven analysis to allow the board to make data-driven decisions and of course we um look to standardize reports and templates with consistent metrics and definitions the outcomes of these processes are the reporting manual which was published at the end of march and the f y 24 budget guidance for medicare only and the certified acos as well as the certification eligibility verification form um as a reminder the reporting manual exists to outline the standard reports collected from one care during the performance year year over year um it includes things like the network development strategy clinical focus areas population health and quality improvement reporting quarterly financial reporting um and then specific reporting on such things like the cpr program and how they're addressing adverse childhood events um there's also a section for ad hoc or one-time reports uh as might be requested by a budget order um we aim to also make the budget submission to be about the forthcoming budget year rather than reflecting on the current performance year um because that is really the rule of the um the reporting manual so here are some staff goals a lot of the goals from 2023 were carried over into 2024 so i just wanted to outline the ones that we we carried over um we started off the process by crosswalking the guidance to rule five to ensure that we were covering all of our bases that all of the requirements the board must take into consideration were covered by um prompts um or data collected within the guidance um we do try to emphasize data whenever uh over narrative explanations whenever possible and where appropriate um we do consider the timing of information requests such as like sometimes it's really possible for a piece of information to be included with the budget cycle but depending on um you know the way that the aco updates certain reports or does planning sometimes it's more appropriate to collect it at a different time during the year we're taking into consideration that actually both 23 and 24 extension years of the apm agreement we always aim to remove areas identified as duplicative duplicative um and streamline questions and we uh incorporated last year for the first time um performance benchmarks and prescriptive guidance as allowed um and as i mentioned we really fleshed that out this year so for certification this year we updated questions based on potential aco changes um i know that there were there was a special interest in data analytics so we fleshed out some of the questions around that um in the budget we increased focus on performance benchmarks and that prescriptive guidance um we're utilizing the benchmarking report as a source of data for budget analysis um and also included in the budget guide is an executive compensation analysis that is is really new to the budget process so let's look first at the certification eligibility form so this is an overview of the certification process for acos um as mentioned before all acos the accept payments for Medicaid or commercial insurance must be certified once initially and then once they are certified an aco must annually submit a form to the board to verify that they are continuing to meet the certification requirements to describe any material changes to any matters addressed in the certification sections of rule five which are listed out here so the 2024 certification materials have undergone changes with the intention of improving clarity and breadth of questions while also reducing burden for both the aco and staff the materials are a set of narrative questions and a small excel workbook that collects data regarding acos policies and procedures um so the material changes and i'll just make a note throughout this presentation all of the text in bolded blue um indicate changes from last year's guidance so the first change was the removal of questions regarding the structure of executive compensation and the logic behind that was that we were going to move this over to the budget process because there's a lot more flexibility um in the in the statute in the way it's written out so it is not that we are not exploring this area it is that we simply moved it from certification to the budget guidance that being said there are still certain requirements in the certification rule around executive compensation and we will continue to ensure that one care is fulfilling those requirements through the certifying process we updated software related questions to better align with the current state of the data analytics structure and to provide more detail in how the requirements of 5.210 are being met um and we modified a question to ensure compliance with 5.206c regarding one cares process for monitoring the effectiveness of its population health management policies um so when once published the materials will be posted to the GMC website under the 2024 aco budget and certification page um and they will be issued to one care by july 1st um and one care must return the materials um to the board uh on or before september 1st and just another reminder the board does not need to vote on the certification form updates all right let's get into the budget guidance so i will just breeze through this slide we've covered most of this um just noting one care vermont is currently the only certified aco in vermont so this guidance really is has been created with one care in mind all right so themes for updates this year each section was reviewed for clarity word count key narrative um highlight of the updates the submission instructions um we edited those to require formulas to be included within excel files that were submitted there were times where we would get information in or like financial information through an excel document and not always know where those numbers were tying within other workbooks so hopefully that will make analyses a little bit more straightforward for our staff we did remove some of the COVID-19 related language and some of the narrative questions um we targeted questions based on internal review and stakeholder feedback um we focused on benchmarking report results hospital primary care um part payments and executive compensation um we improved upon the data collection templates and we placed more emphasis on budget targets so we moved um the order of the guidance around so that the budget targets are the very first part um of the actual document after the instructions these targets are our um front and center um the objective of these these targets is really to provide the aco with with the opportunity to develop their budget based upon um the budget targets so these are priorities that the board has made clear that they would like to see in this budget um there's also in the section the all-pay model all-payer model growth and financial targets are included and then we have a set of data and sources that we use when looking at the submission for this um for this section we reference the medicare united states per capita fee for service projections we're looking at the march 23rd uh sorry 2023 medicare benchmarking report we're looking at medicare advantage uh united states per capita fee for service projections and we reference the hcp land report as well um as far as any implications for not meeting a budget target or missing a budget target um there is no hard and set um um consequence of that i would say that if the aco is unable to meet a proposed budget target that that would result in just a very thorough staff analysis the aco would have to justify why they were not able to meet this budget target and it would just undergo a thorough rigorous analysis um at the staff level and and we would of course bring that to the board um and if a budget target is to be met then that would result in um a you know a still review but lesser scrutiny um on that particular measure so here is one uh budget target that was carried over for from fiscal year 23 with no or minor updates so the first one is that the f y 24 commercial benchmark um trend rates must be consistent with the aco attributed population and the greenland care board approved rate filings so new proposed budgets targets for fiscal year 24 are the remaining eight uh the first is that the aco shall use best efforts to meet or exceed the goals for reconciled and unreconciled fpp as adopted by the green mountain care board as seen below and identify and report specific obstacles to achieving the goals and action steps required by one care or others to overcome these obstacles and the goals for um that the reconciled and unreconciled fpp for medicare is 53 percent medicaid 55 percent and commercial 24 percent the third budget target is the aco shall hold 100 percent of the medicare uh advanced shared savings dollars at risk at the entity level and not pass this risk along to the provider network this budget target is a carryover from one of the budget orders from the fiscal year 23 budget where the aco the aco was um ordered to hold a portion of those shared savings dollars uh as risk at the entity level and this is um that that acted as like a glide path to holding the entirety of this um of these dollars the fourth aco budget target is to increase risk corridors for all payer programs above fiscal year 23 levels um uh an increased corridor without we didn't want to dictate the amount of that increase um because that would we want to allow for the network um to increase the dollar number of dollars at risk and allow for flexibility and negotiation with payers and with the risk or bearing entities um number five the ratio of operating expenses to population health management or payment reform payments which includes fpp shall not exceed the five-year average of 3.25 percent um and then budget target number six uh reflects a continuation of the trajectory that was set during the vote on june 14th last week regarding executive compensation the aco shall cap the total compensation in fiscal year 24 for the aco's executives vice president and above at the 50th percentile of the benchmark used by the aco to establish its executives compensation number seven um the aco shall structure the variable proportion of executive compensation so that that at least 40 percent is tied to one carers fiscal year 24 achievement of specific and measurable goals related to performance and cost in quality metrics quality metrics should align with any payer program quality priorities or aco clinical focus areas as long as those priorities or focus areas are consistent with the all-payer model quality framework um this has been an area of interest for the board uh the general consensus being that the goals that have been set by one care historically have been at the aco operational level rather than at the aco performance level and that the board wishes to see at least a portion of variable compensation tied to goals that are more closely tied to the outcomes that affect for monitors and we also want to see these goals align with the clinical priorities that the aco already has in place so as to support the streamlining of efforts number eight the ratio of population health management funding to the number of attributed lives must be at a minimum of the fiscal year 23 revised budget amount specific line items may vary based upon any internal evaluation of the effectiveness of individual population health management programs um one care has reported evaluations of some of their internal population health uh programs and while we want to see um population health investments continue to be a priority for the aco we do want to allow for the flexibility should the outcomes of evaluation show that a shift in investments is warranted and the final aco budget target um this is regarding the march uh 2023 medicare benchmarking report where one care ranks below the 10th percentile among the national aco cohort or for metrics where the trend has shown a decrease in performance between the years of 2019 and 2021 choose three metrics that the aco will address through the quality evaluation and improvement plan the aco should use metrics on which the aco has the most influence on the outcomes and should justify their choice of said metrics and then we'll go into part two again this was previously part one um there there have hasn't been a change in the structure of this um section other than just moving where it is in the guidance so section one is an aco budget executive summary um the objective of section one is to provide brief narratives to summarize the components of the budget submission and describe the aco's vision for the coming budget year including a strategic plan update the provider network payer programs attribution estimates finances network programs and population health and evaluation there's no specific data or documents for this section because it is an executive summary so the main change is that the section was revised to capture the shift from the last strategic plan to the new strategic plan um that one care is putting in place for 24 so question one a b and c um they were added to capture changes made during the strategic plan that have been in development for 24 and reflections on the previous plan g and h were added we added language asking for summary of plans to integrate findings from evaluations and the benchmarking report into their budget and practice section two covers aco provider contracts the objective of this section is to describe aco network development strategies and any changes changes to provider agreements and addenda for the budget year we use appendices 2.1 and 2 which are the network provider lists um and we also reference the provider agreements and addenda uh that are submitted for 2024 um the main change here is that we asked for a description of any changes made to contracts the provider contracts but in question one we simply removed a table as we found that it was duplicative of another piece of information that we asked one care to provide um question number two um we asked uh the aco to explain changes from the previous year and how each contract aligns uh provider incentives with the aco's mission question three um we went a little deeper asking to um the aco to explain rationale for any changes made to their network development strategy um and then question four we updated the table associated with this question to include provider type and ask how the aco addressed any provider concerns this question um for context is around any changes to the provider network if there were um provider practices that left the network um just collecting the reasons why they might have left what kind of provider they were any response that sort of thing section three uh looks at aco pair contracts the objective here is to describe the aco's uh expected or assumed pair arrangements used to construct the budget assess pair arrangements uh for qualifying as scale target initiatives we use appendix three which is the scale target initiatives and program alignment forms and um we do reference the payer program agreements once they're executed for 2024 the main change here was that the section was updated with questions regarding changes in public payers and progress with commercial payers so question two uh we removed a summary table and we added questions regarding the effect of the Medicaid redeterminations the impact of Medicare Advantage enrollment and changes in the result combined pardon me question five the question was added to inquire about the aco's efforts to excuse me execute risk bearing commercial payer contracts question six is a question requesting an update on the fbp pilot with diva one care described this pilot in as part of their fy 23 revised budget and we're just asking for an update so section four covers total cost of care the objective being uh describe the assumptions used to set trend rates and total cost of care targets by payer program and the driver's affecting settlement results of the prior year we look at appendix 4.1 which is the total cost of care performance by payer and we look at appendix 4.2 which is projected and budgeted trend rates by payer program um so the main change here is that we did remove um COVID language from a couple of questions question one we updated appendix 4.1 to include both a starting and after um and average attribution by payer program um so we could get a look into what they're expecting for change over the year and attribution question two uh we updated to include an explanation of growth rate by year compared to national growth rate by payer and question four the question was updated to assess how the aco is aligning incentives to meet their growth targets section five covers aco network program and risk arrangement policies the objective is to describe aco program policies for provider payments and risk arrangements uh describe the aco risk model by payer and by risk bearing entity any aco held risk and third party risk protection the data sources used in this section are appendix 5.1 which outlines the risk held by payer and by risk bearing entity um as well as appendix 2 5.2 which covers the shared savings and loss by payer at the HSA level risk bearing entity the main update is um we are exploring provider payment strategies that may differ between hospital and non-hospital primary and specialty care practices um we hadn't in previous iterations of this guidance gotten down to that level but for question one we wanted to see if there were differences um in strategies between hospital and non-hospital practices as far as how providers are being paid um question two the question was expanded to capture the aco's goals strategies opportunities and limitations on monitoring and providing incentives for reducing potentially avoidable utilization question six we just reordered this question and we also inquired about how efforts will improve uh in fiscal year 24 for identifying high and low value care section six is the budget section so the um section objective to submit the aco financial plan prepared according to the full accountability or the non-gap and the entity level or gap financial sheets these are submitted through the adaptive database um we also ask for them to submit additional financial data as specified such as sources and uses population health management expense breakout hospital specific information um FTEs by functional area within within the aco as well as leadership management salaries we ask the aco to describe major variances in the financial plan from the prior year we ask them to describe outsourced services and fixed operational expenses and describe the basis for the variable executive compensation so the main change um questions were added to assess specifically outsourced services um fixed operational expenses and the executive compensation bonuses so our sources of data here are the full accountability budget the entity level budget the variance analysis report the FTE reports aco management and compensation as well as the form 990 which is generally available um in the fall of each year doesn't always exactly line up with fee um with the budget submission and as well as their financial audit so here are some other templates used in this section the um as far as the adaptive templates we did do some updates to um the line items in collaboration with one care to ensure that appropriate items are captured um we uh added some columns in the source and uses template uh to capture the uvm health network self-funded payer program uh and any hospital fixed payment offsets we for the hospital participation worksheet we added a row for the um uvm health network self-funded payer program as well um as far as collecting information in uh 6.7 for aco management compensation we asked for both the current year projected as well as what they were budgeting for the budget year and as far as 6.8 population health management expense breakout we added a row to capture the mental health screening and follow-up initiative in the case that is something that is being budgeted for in 2024 um and then also in the adapted database I apologize these may have oh this is the questions the narrative questions we included the staffing sheet um which was not previously collected through adaptive um sources and uses um just for clarity we requested definitions for each one of the funding sources um and then question 6 we added this question to explore aco operational expenses that may be fixed versus variable um we wanted to really get at um what operational costs might be affected by increases and decreases in attribution or participation of payers um versus fixed cost necessary to do business uh business um as far as question 8 goes it's a data analytics transition question um looking to assess the expected outcomes of the data analytics transition we wanted to get at what is going to change at the network at the provider and at the patient level um as a result of this transition and then we also for question 12 wanted to expand this question to capture discussion and use of any prior surpluses or losses section 7 captures population health information the objective is to collect data and information on the aco's approach to population health management and care delivery um we receive the data in the form of four different appendices the aco clinical focus areas simply compares the status of these areas um from previous previous years um to the current year uh the population health and payment reform um appendices it or appendix is a convenient way to capture basic information about all of the population health programs delivered by the aco in one place um appendix 7.3 provides information about care coordination efforts over the past few program years and the final appendix provides us with data regarding the amounts paid out to different provider types for each program year with care coordination or or more recently the phm program the main update here was to reflect the new care coordination model there has been a multi-year shift um into what we currently know as the phm the population health management model which incorporates other disparate programs um including the previous care coordination program so the care coordination program doesn't really exist anymore it's part of the phm program um so we have some updates we needed to make um question one we did remove a duplicative question um that we covered in section five under risk methodology um question three we uh asked for insight into um how they use specific strategies to address root causes and improve results question four um the question is to as regarding the acos methods for prioritizing their investments um and we also updated appendix 7.2 to include columns for major objectives and outcome measures and kpis this was the um worksheet that collected kind of uh all of the um different population health programs all in one place so we're looking to collect any kpis uh measures objectives that are being collected at the programmatic level um question five is around care coordination we updated the language to capture uh assessment of implementation of the phm program in 2023 any observed clinical outcomes and any anticipated changes for 2024 uh we updated appendix 7.3 to capture the percent of care coordinated population by payer uh and care managed target for 2024 question seven is a new question um we asked for description of how the aco ensures that primary care earned incentive dollars are flowing to these providers and uh or are being invested into primary transformation efforts this may sound very familiar um to our discussion that we had last week um and then question eight was a new question exploring the consequences um or expected consequences to care delivery resulting um in the end of the public health emergency there may be waivers that are being rolled back and how does the aco anticipate that changing healthcare in vermont section eight um is around evaluation and performance benchmarking the objective is to discuss evaluation of provider satisfaction with aco participation and network programs um and evaluation of the aco quality improvement program discuss the use of key performance indicators and the implementation of the aco performance benchmarking system there is a new data source appendix eight eight point one and we also use we reference the medicare benchmarking report as submitted in march so the main change for this section is um is is a continuation of efforts from last year this section was new last year and it was a really good starting point but this year we've really expanded the breadth of questions about how the aco is evaluating itself and the actions that it is taking as a result of these findings um so question one is a new question and appendix eight point one is part of that so we're looking um to collect information about surveys conducted by the aco and the response taken and the outcome of those responses and that looks back you know over the life of the aco um and then question two gets at what questions um the aco intends to ask its network uh in the future um and any improvement in their surveying practices um question four is around evaluation of their population health management programs there are some new sub questions to this um part we asked about the evaluation outcomes of the cpr and the 2022 care coordination model as one care has shared that they have been doing evaluations on both of those programs um question six is a new question around the roi analysis that was described during one care's fiscal year 23 revised budget hearing question eight um is a question that's tying back to budget target um number five which is the benchmarking um the benchmarking metrics so it's the choosing three that the aco will work on for the performance year um and so we're just tying we want some narrative to accompany um the the metrics they're choosing to justify and and tying the metrics that they've chosen to the funding streams where they are basically putting money into those efforts question nine is around some causality around some of the the metrics that were shown um so there were um identified there were a few different metrics identified by one care during their hearing of their revised budget where they said we have not yet um determine the causality of you know why specialty care visits are low um and why there's high spend in utilization why length of stay is high um and so I just wanted to follow up with them we wanted to follow up with them and see if they been able to dig into causality of those those outcomes so question 10 um is is you we would like the aco to identify specific metrics where they feel they have the most influence on the outcomes um and for those where external factors play a role how the aco envisions progress being made in these areas we're all well aware that um healthcare reform is a very complex beast and it is not um it is very multifactorial and so being able to parse out where um different parties are able to really play a role and be effective in moving the needle on things is something we're trying to get at with this question at least from the aco's perspective and find the final section section nine um covers other vermont all payer aco model questions the objective here um is to describe strategies for assisting the state to achieve the goals in the vermont all payer model agreement um describe the aco's roles in achieving those goals and to identify opportunities for stakeholder collaboration to achieve these goals there is um appendix related to this just collecting information on the quality measures from the all payer model um and the main change here it was very minor we just removed some COVID-19 language all right so the last couple of sections part three is really the revised budget this just outlines the expectation that the aco will have to present a revised budget in the spring of 2024 and the only change was to you know just a technical update to update it to um align with the current revised budget process and then likewise with the monitoring this just um outlines the you know the expectation that there will be a reporting um manual and that there is a current reporting manual that's been published found at this link um so just technical updates there as well just as a reminder here's the outline of the timeline um just for reference encourage any um public comment through next Tuesday uh prior to the potential vote which is scheduled for Wednesday and I will turn it back to you chair foster for any discussion very much um I'll open up to the my fellow board members for any questions or comments that we have I was trying not to go first again so if somebody else would like to go that's great otherwise I do have a couple you're you're welcome to go Robin go ahead okay thanks um so I had a couple of of questions um the first that is relating to the budget targets um so Michelle you did an excellent job explaining what happens if targets are met or not met but I went back and looked and I did and I could have totally missed it but I don't think that's actually spelled out in the guidance and I think it might be helpful to spell out what happens if the targets are met or not met in the document itself which is something that we did do in the hospital budget guidance so that's just a suggestion for for you to think about um no no need to respond to that now because I'm just bringing it on you so I did have a question about the fpp medicare goal um in the all peer model agreement it is the state's responsibility to negotiate changes to the medicare program which quite frankly the state has attempted to do in the past unsuccessfully and so I'm a little curious why we would put a goal around medicare when it's our respond our collective not our necessarily green mountain care board but the state's responsibility to do that negotiation and make those changes to increase the availability of fpp so that might be a rhetorical question if you don't want to answer that's fine I just I think it's a little weird for us to put a target to improve that when we're the ones on the hook for it we collectively the state I can give um I can give a brief explanation of where that target was pulled from and that was a previous target set by the aco itself and so we are just in an attempt to hold some accountability to a target set where we're just encouraging you know the aco to um achieve a target they set and if not possible to explain any obstacles or barriers that might come between the aco and their ability to achieve that so that would give the aco an opportunity to explain why they might not be hitting that target and if very well maybe the situation that you are explaining robin yeah I think I mean my recollection is that that the point of that the board requested the aco to set those targets at one point and in that submission that they made it was essentially like we would like to achieve this in Medicare but state it's your responsibility to do it so I don't need to be told that again personally I mean if others would like to do that then I'm not going to die on my sword I just I think we know the reason why the target has not been met um and it just seems unnecessary to me to include it so I'll just throw that out there um thank you for um including a question around the impacts of the waivers being rolled back from the sunset of the phe I think that'll be interesting and helpful information to understand how some of those waivers will you know which made it much easier to coordinate care and do things even outside of the aco um how that will how that's impacting care delivery if at all and maybe you know there's been other ways to implement the care delivery changes without those waivers now with from Medicare but um I think that'll be interesting to learn about and understand a little better um so hold on let me just check my list so um the other questions I have are around and I apologize I didn't ask these last week but I was not expecting the conversation last week so how is how is the 50th percentile benchmark of the executive comp chosen so currently um um uh the aco through its its parent company if you will um uvm health network um they set their executive compensation based on um in an internal policy and then in that policy it is described that the base salary is um approximated at the 50th percentile there is some nuance there um they set a a range and the median of that range for that particular position is set at the 50th percentile they reference um you know national kind of comparative comparative groups that they that they look at um but they also make adjustments in salary depending on the region and then they kind of give themselves some flexibility there so the 50th percentile is a little bit of a um a simplification of this of the current model um the way that the aco's executive compensation is currently set only that their base salary is at that 50th percentile and then with the um inclusion of variable pay uh it is benchmarked again approximately at the 65th percentile so just very much simplify it you're essentially eliminating the variable pay um however there is nothing in this um budget budget guidance that says that there cannot be variable pay they would just have to keep that variable pay within the 50th percentile that you would not be able to go above that if that is helpful yes thank you and certainly I could see how like variable pay may vary year to year uh with the 50th percentile benchmark is that a policy that's used at hiring like when someone is hired so the um there is a range I would imagine it would depend um on the individual and experience and all of that um but the so the the the pay range of a certain position varies from its median which is the 50th percentile there is 50 percent below and then 50 percent above at the high range so I can't speak to how any individual being onboarded um as as executive um for the ACO where they would fall in that range. Sure what I'm trying to figure out is is it similar to the state where you're hired into a step in that range encompasses all of the steps that potentially you might accomplish or whether it is um like basically the way that it's used to hire somebody into a specific salary and then increases over time would perhaps be set using a different benchmark or a different budgeted amount I just don't know so I was just trying to understand that sort of the basics of how this works. Sure I did not see that described in the policy we were provided but it could be that that's included in another more generalized um policy that we did not collect um yeah so it could be the case but I did not see it described as such um I would imagine that as um national trends changed the benchmark would then change so the 50th percentile would change year to year um so salaries would move. Okay um and do we know how this impacts current employees um the the budget target? Yes um well it is up to the board of managers at OneCare to establish their budget um and it is up to them how they want to either um I don't want to use the word comply because they are not they are not required to comply with any of these budget targets um but they they can decide how they they want to try to fit that into their budget or not um so I don't have a definitive answer I'll also I'll just want to open it up to Russ too I see who popped on screen and he might be able to help with some of these technical questions too. Thank you Russ. Sure I don't have an answer to that exact question offhand but um it's something we can uh definitely circle back with uh next week with a clearer response. Okay great um I think that is it for me for now um but I'll double I'll go up uh I'll mute myself and look through my notes to make sure I didn't miss anything so if someone else has questions they could go. Any other board member questions or comments? I guess I'll um I'll pop in here then since we're on the the topic of executive comp um first a huge thank you to the village as you described Michelle for all the hard work on this um ACO guidance that you know having watched it over the years it continues to evolve and improve every year I think there's some great questions that have been added this year and improved data templates and uh really really thorough so I'm really appreciative of all the hard work that you and Russ and the rest of the team and village did to get us where we are today. I don't have any questions I just have a request um actually for our legal and our ACO oversight teams um the proposed language capping executive total comp at the 50th percentile it's a it's a fairly new regulatory approach that the board is taking and I think if we decide to continue in that direction we should do so with full information about the potential intended and unintended consequences of that sort of regulatory approach I've always appreciated the board's focus on evidence-based decision-making so I think it would be really helpful if the staff could report back um you know if we're talking about this next week or what we before we vote I guess I would say uh if the staff could report back on the pros and cons of imposing total compensation caps for a subset of employees in this ACO guidance but potentially in future regulatory processes as well so I guess specifically I'm looking for a staff analysis of the pros and cons of using executive compensation as a regulatory tool and also a staff recommendation based on that analysis on whether you think this regulatory approach should be pursued in this ACO guidance um and I think just as a board I think we should make sure that the benefits that we hope to see by imposing compensation caps outweigh any potential costs or downside implications um I also and I think Michelle to the degree you did answer this to some degree but it'll be really helpful since you're digging into this before next week anyway I think I'd like to better understand the specific benchmark chosen by the ACO um is the compensation compared to all healthcare executives in the U.S. is it executives at similarly sized ACOs you know who are the pure organizations that a national benchmark is you mentioned it might be regionally adjusted that would be helpful to know I think if we're going to impose uh caps on salaries or tying it to a particular benchmark I think we should understand what that benchmark actually is so those are just my requests before we head into a vote on this I think just a deeper understanding of intended and unintended consequences of going into a new lane here so to speak for regulatory action any other board member question or comment um I had one uh Michelle um I might talk to you about it offline because I want to do some drafting um so I'll wait and get back to you and maybe raise it next week any uh healthcare advocate comment or question thanks chair foster um thanks to Michelle Russ and Jen and others for the great work on this I think there are a lot of really important updates and edits to the guidance um we just had we largely support it just a couple of recommendations for the board to consider and no we're not voting today um the first one we would encourage the board to consider revising section six to include directors in addition to VPs and above as the category there are a number of executives that have that title rather than just VP and above and I think the intent of this approach if the board decides to adopt it would be better served if we include those categories as well and similar to member Holmes's comment I think it would be good for the board to consider what peer group to use the benchmark with I don't similarly I don't really know what the benchmark is currently used it seems like there's a couple different ones and I think that the board would be better served to identify one themselves um and on section seven we would recommend setting the target to be 100 percent of variable compensation connected to performance measures that are specific and measurable we think this aligns with the intent of the rule much better and we have concerns that the board would be unintentionally lowering that standard by having a percentage that's lower than 100 so those are our comments thanks a lot and appreciate the discussion thank you and sorry miss sir we don't actually have the benchmarking data that's being discussed and we don't actually have where the numbers lied in relation to the benchmark data we don't currently possess that is that right correct we are not in possession of a um an analysis of really position by position and where each position is is benchmarked currently um in the percentile um we may have some additional information about the peer group I have to do a little digging on that and I will get back to you on that okay yeah it seems like a fair question I mean we might as well understand it I think it's a good point so if we can put in and ask for that I think it's logical um I'll turn it to public comment mr. Davis please go ahead thank you mr. chair I've just got a couple things to say I think that this I've watched government for 62 years as a professional from one end of the country and including the national level what you're looking at what you've just described there is I've never seen never that's just a bureaucratic nightmare there's just it take you if you if they actually if the all these hospitals had to actually do that work it would cost you at least 20 million dollars and you wouldn't have any idea what to do with it uh this is in a government has been working on this for for all that time not not in in Vermont I mean but looking at well what well how does government function how should it how should it actually work and an interesting test that I would recommend to you that I know you won't touch is that you should not they should you should not accept any of the the uh tests suggested unless the board unless the bureaucrats can show what they would do if they actually had that information they if and to just to get it but you can't you can uvm will be able to do it but the the other hospitals won't even begin to come close to this okay I mean it just it's just can't be done maybe 10 but if they would actually do it at the cost at least 20 million extra dollars you'd add to cost I'd like to just make a comment that I on your indulgence mr mr chair the do you mind do you mind if I interrupt for one minute I started to interrupt but I wasn't clear what um topic you were talking about with your first comment about the challenge of being able to get something and what the hospitals would do with it what what topic were you discussing the the the the entire the entire laundry list what I'm talking about is the entire laundry list of question after question after question after question after question it's not that each question can't be justified but when you add them all together there's simply this there's just simply not enough time to do that then and the only hospital that has a chance to do it is uvm that will it's never going to happen in places like springfield and rottler I mean really is not that's what I meant I do have an extra comment on your indulgence mr chair one of the things I've been critical here of this of the board a lot but I want to say this that I I'm impressed by I think uh that you're that one of the things that this board is now really doing is I think they're attacking the issue I think that they're really starting to get at what it's going to really take to make this make a system that is sustainable for most cost and quality I don't think I'm close to it yet but really trying you know I just want to comment that I think that the single most disturbing thing is that the people that really that run 60 percent of this whole system 60 percent of it I'm not part of this conversation and that's their choice that's uvm that's uvm's senior management choice and they are not you cannot play in the game unless you're willing to go on the field and whatever else the board is this board is done they're on the field okay and whatever else is going on uvm is not on the not on the field thank you all right thank you very much um uh Sharon uh please go ahead I see your hands raised yeah I do believe that management of any system um in accountability must have compensation relative to the outcomes and that's where variable pay comes in I don't know that that has been the past that variable pay has been on um actual improvements because I I guess the improvements are are not there questionable so it is a bit confusing I would think in the guidelines that I understand the base salary would be 50 percent of the benchmark and what I heard was the benchmark is what the aco presents so it's not like the board needs to determine what is 50 percent that comes from the the aco management or whatever and and then I would hope that the variable pay um but I don't know how it can be legislated would actually be variable you know and and I don't I did not hear in the guidelines if the variable pay plus the base would be at 50 percent or a variable pay would be again based on this peer benchmark um and of course if if everybody is basically getting paid regardless then um it defeats the purpose of variable pay and then you might as well just go to base salary being 50 percent so that's the only the guidelines there should be some direction of variable pay um being paid on outcome thanks thank you very much um and walter how are you hey oh i'm uh hanging in there heads robbing from all the detail here um I do agree with ham a little bit about the executive compensation though I think it should definitely be regulated I also agree with the HCA on it and then I can't executive compensation is already outlandish and most of the remonters that are paying this in the one care make 15 20 25 bucks an hour and don't have benefits don't have healthcare don't have retirement pensions or anything like that because they are no longer provided so the day to day remonters who are paying these salaries should see some account for what they're going to pay for what they're paying for if so that's a that's a great thing and michelle made a comment at the end of her presentation about healthcare reform being complicated it doesn't have to be complicated it should be inordinately simple every other democratic nation has figured this out one care to me it's just another layer of complications that's it thank you very much any other question or comment mr burman how are you please go ahead hi this is a burman on the interim ceo of one care vermont I just wanted to um clarify that we did submit a letter on june 9th and we followed that up with a second letter today we were not able to comment earlier than that because our board did not meet until yesterday with this regularly scheduled meeting and further in reviewing the budget guidance and you know I'm a little bit new in the role having only been here about three weeks now just you know noteworthy that this is a significant body of work that the aco has to go through each year to provide this information um and unfortunately that takes away from our ability to work on some of the strategic initiatives that I think the board agrees are really important so um I uh I appreciate all the work that's gone into it and we certainly will comply to the best of our ability but I just wanted to be clear that it is a significant body of work and it's it is bigger than it is in previous years this year thank you thank you very much any other question or comment okay great um miss Sawyer and mr mcracken thank you very much for your teams diligence and work on this I think one of you has a day off tomorrow so enjoy it um I think that's all we have on the agenda today um so is there any uh old business to come before the board a new business and is there a motion to adjourn all those in favor please say aye aye aye and we are adjourned have a good afternoon