 All right, good morning. This is a joint meeting with Senate Health and Welfare and House Health Care. It is March 31st and then we are today looking at the waiting list, waitlist report, not W-E-I-G-H-T but W-A-I-T report that has come to us and we have the folks who can share with us exactly what's in the report and because it's a joint meeting, I'm going to just introduce myself briefly, Senator Ginny Lyons, Chair of Health and Welfare and then Bill, did you want to say something? Just that I think it's good to be able to hear the report directly from the folks who are involved. All right, this is great. And so why don't you go right ahead with bringing us up to date with what's in the report, a brief overview and then I don't know how you have your testimony organized but we're ready to listen. We have an hour and we look forward to it. Thank you. For the record, Ina Bacchus, Director of Healthcare Reform Agency of Human Services. And if I may, I'd like to ask my colleagues to introduce themselves as well. Commissioner Pechak. Yeah, sure, I'll start. We have a few DFR representatives on here that I think are well known to the committee but I'm Mike Pechak, the Commissioner at the Department of Financial Regulation and I'll turn it over to Emily. Hi everyone, my name is Emily Brown, I'm the Director of Insurance Regulation at DFR. And Sebastian? My name is Sebastian Erdwango and I'm an Assistant General Counsel at DFR and I'll turn it over to Isaac. Hi, good morning. This is Isaac Dano, Special Assistant at DFR and I will turn it over to Susan. Good morning, I'm Susan Barrett, I'm the Executive Director of the Green Mountain Care Board. Thank you all for being here. We really do appreciate it and we look forward to hearing about the report. Thank you. And we're going to share some slides to walk through the report and we'll put those up on the screen now. Who needs to screen share? Can we do that? Well, I need to know who needs to screen share. Who needs to screen share? I will be screen sharing this slide. I did, okay, okay. And while that's in process, I'll get started. There have been reports of long wait times for healthcare services in Vermont for a number of years, both prior to the pandemic as well as during the pandemic. Late in the summer of 2021, reports again about long wait times were featured in the media. And our respective agencies, the Department of Financial Regulation, the Green Mountain Care Board and the Agency of Human Services had also been hearing anecdotally about long wait times for healthcare services in the state of Vermont. Former Secretary Smith asked that the Agency of Human Services conduct an assessment of these long wait times in the state of Vermont for healthcare services. And in order to do so, we invited the participation and collaboration of our colleagues at the Green Mountain Care Board and the Department of Financial Regulation because of their particular expertise and experience with this issue and the different angles of approach that they would bring to the project. Specifically, the Green Mountain Care Board has been asking hospitals to report information in their budget processes about wait times for healthcare services and the Department of Financial Regulation regulates the healthcare commercial insurance networks in the state. Again, these reports of long wait times for healthcare services are not new. They have been circulating for a number of years. And in order for us to assess this issue, we started by prioritizing and wanting to understand the issue through the lens of Vermonters who were waiting for these services specifically. And in doing so, we held a number of public forums and invited written testimony on the issue. And here you can see some of the information that we heard from Vermonters in undertaking this assessment. We know that there is evidence that long wait times for clinically appropriate care can lead to worse health outcomes, especially for those who are older and more vulnerable. There's also an emotional impact when persons are waiting for care or unable to receive care that they need in a timely manner. And this is a particular theme as you could see from the previous slide that surfaced as we were speaking with and trying to understand this issue through the eyes of Vermonters. And we certainly know that research and understand the research that patient satisfaction declines when there are longer wait times. There's also a financial impact from delayed care. When care is delayed, the individuals whose care has been delayed may get sicker. And eventually when they do receive care, that care is more complex to administer and more costly. And there is an equity impact. Barriers to care disproportionately affect those who may not have the time, resources or knowledge to navigate a complicated medical system. We set out in this assessment collectively to better understand and document the reports of wait times that we were hearing in the state of Vermont. There's limited data available about wait times for healthcare services nationally. And there's limited literature to consult in terms of wait times for care. Further, there's no agreed upon standard for tracking wait times, whether in the state of Vermont or nationally in the United States. There are a few organizations that offered some different metrics for tracking wait times. And we did consult with that information and it informed our assessment of the wait times for healthcare services in the state. Again, this is an issue that has not been systematically monitored in the state of Vermont. We don't have a single entity that is responsible for monitoring and tracking the wait times for healthcare services in the state. So this study was really a first step in trying to identify and take a more systematic and standardized approach to understand wait times for healthcare services in the state. And this study was also a broader study than looking at the wait times, for instance, for hospital services, which had the hospitals, as I mentioned, have been reporting information about wait times for services to the Green Mountain Care Board. But we had not, there was no information that was being gathered prior to this initial study about the wait times for services offered by independent practices and independent providers that are not employed by a hospital. So I'm gonna turn it over now to Commissioner Pichek who will walk the committee through the work that our group collaboratively undertook to better quantify and understand this problem in the state of Vermont. Yeah, thanks, Inan. And again, thank you both to the House and Senate committees who really appreciate the opportunity to speak with you and go through the report and interested in hearing your questions as well. So as Inan said, there were limitations and challenges to try to find data that already existed or even consistent or uniformly applied wait time metrics. So when we set out to try to quantify the problem, we really were starting from the reporting that we had heard in seven days. They were really concerning stories in the seven days article published back late last summer. We wanted to basically open up the platform, invite Vermonters to tell us their stories and see from those public comments, what we heard, how pervasive the issue was. We then did the same thing with the provider community and then did some analysis around data on claims. We did a secret shopper program that replicated the experience of a Vermonter calling and trying to schedule a specialty. And then we also looked at the blueprint data to try to understand again, what some of the wait times were that the individuals were experiencing between a primary care referral and the specialty visit. So those are the ways we quantified it. I'll go through each of them in detail, but I do think the way we approached it was trying to sort of understand, we have some stories, how much broader is the issue by trying to listen to the public, then went to the provider community, which sees dozens and hundreds of individuals on a regular basis and what was the perspective from there then broadening it out further to trying to collect data and analyze it and do the best we could at trying to make some determinations around wait times in Vermont. So as it relates to the public comment section, you can see there that we had two different public listening sessions. We had 70 participants collectively in those two different listening sessions. We also heard from Vermonters, 68 patients and caregivers that responded with their stories around wait times. And as Ina already alluded to and showed some examples of, we really heard from these over a hundred people about the material impact to their health and well-being that came from delayed medical care. They described physical, psychological pain, at least a third of the individuals we heard from said that they were experiencing pain while waiting for the care that was delayed and were fearing declining health as a result. They described bureaucratic hurdles that they experienced in trying to make referrals for specialists in particular, complex referral process, different forms for different departments, imaging and testing requirements before an appointment could be scheduled. So for example, someone that does have a primary care physician that does get a referral if there is some lab work or imaging work that needed to be conducted, that needed to be scheduled first and once that was completed, then they were able to schedule the specialty and that just added some delay into getting that final specialty appointment. They complained about communication between the hospital and their primary care physician that was making the referral or themselves in particular and as WCAX has recently shed more light on, we heard directly from Vermonters about the difficulty in accessing psychiatric and eating disorder services and both of those particularly for children being a concern. So if we go to the next slide, we'll just show a little bit again what the provider, what we heard from the provider community. So we did the same sort of approach. We had some listening sessions that broke out over three different days. You can see there are 20 primary care physicians, 12 specialists, five mental health providers and eight referral coordinators were part of these provider listening sessions. We also had some provider emails that came to us and there was a survey of providers as well asking them specific questions around wait times and their experiences within the system. So the themes that we heard here probably not all that surprising to the two committees but they described workforce challenges, shortages of workforce, whether that's both administrative workforce but also provider shortages, a high turnover among both of those providers and administrative staff. Recruitment challenges as well were some of the items described by the providers. So we also heard issues relating to the consolidation of specialty services at certain hospitals. They believed that it was reducing the ability for some Vermonters to be seen at regional hospitals which was putting more pressure on UVM in particular by putting more pressure on certain hospitals compared to others. There's also a theme that we heard from specialists primarily that there was maybe instances where primary care doctors were referring to specialists that may be unnecessary from their opinion which was adding to more workload and making it more challenging for specialists to see the appropriate specialists for an issue that needed urgent or quick attention. We also heard the inverse from primary care physicians that they were concerned specialists were holding on to patients for too long and not sending them back to primary care which was putting burden on specialists to see new patients and to get those scheduled in a relatively quick amount of time. So we heard that sort of from both perspectives. We heard concerns around administrative duties in offices, entering information into the system, work around prior authorizations. Basically, we heard individuals from these offices saying that they were doing more administrative work now than they had a decade ago and seeing fewer patients. So they were saying that was a challenge both from a revenue standpoint, they had to hire more people to do more work but they were seeing fewer patients other than also of course creating some pressure on the availability of time slots for specialty care in particular. So if we go to the next slide, I'll sort of talk a little bit more about the claims data analysis. So those were the two analyses that we did that were more anecdotal in nature. Obviously we were hearing from Vermonters who came up and had something that they wanted to share with us. We were hearing from providers similarly, we tried to do a survey to get a broader array of providers. We were limited to these universes of individuals although numbering over 100, 200 people, it wasn't sort of the hard data that we were really trying to get to better quantify the problem. So the way that we tried to approach this issue is that we had three separate analyses that we conducted and three separate teams conducted each of the analyses. We had first the claims analyses that Oliver Wyman outside actual firm that we hired to help us with this study conducted looking at a subset of patient records from Vital or from V-Cures rather. And I can get into that a little bit more in a moment. We did a secret chopper program again trying to replicate the experience of Vermonters looking to schedule appointments and then looked at the blueprint for health, a chart survey audit and trying to understand again were there certain specialties or wait times were longer, were those wait times appropriate if we could measure that? And the three different analyses I would say each had their strengths and limitations. They also each in some ways reconciled with each other in terms of wait times being long generally for certain specialties in Vermont. So I think that part of it was a strength but I'll get into each of sort of the strengths and the weaknesses of each of these analyses as we go through them. So we go to the first one. The first one was the claims data analysis that I mentioned. So Oliver Wyman was looking at data from 2016 to 2020. They excluded the 20 data in terms of doing this analysis. So it really was focused on pre-pandemic and they were looking at vCURES claims data for certain individuals with chronic conditions. So some of those examples are asthma, anxiety, heart disease. They're looking for people that would regularly need to see a primary care physician and who would be regularly seeing a specialist as well to try to identify the amount of time between when a patient saw a primary care physician for a specific specialty diagnosis and then when they were able to see a specialist for that same diagnosis. So that was the approach that they took in terms of trying to identify a subset of patients that were recently diagnosed with a specific issue and needed to see a specialist for additional treatment. So they only included situations where there was a clear linkage between the primary care and the specialty appointments. They excluded anything that didn't have the same diagnosis code. And then they used some of their proprietary matching modeling that looked at what would be a peer state among these 12 or 13 states that we have here in New England. So they looked at states that had similar demographics as Vermont, they included a subset within those states that had a demographic that looked even more like the Vermont demographic. They looked for chronic condition prevalence and the mix of all of those things together. So essentially if they were able to find a 44 year old man that had just been diagnosed with diabetes, they went out and found within these other states a 44 year old man that had been recently diagnosed with diabetes that was needing to go see specialty care. So of the subset of patients that they were able to identify in Vermont, believe it was around three or 4,000, they then created a population from these peer states that mimicked Vermont and tried to make it as apples and apples in that way. So basically what we were left with was this Vermont population looking at the subset that had chronic conditions. And then we had a population that was created out of all of these peer states to look like Vermont and then measured how quickly were individuals going from their primary care doctor to a specialist in Vermont and how quickly was that happening in a peer state as well. So we go to the next slide, we'll see generally the appointment time in Vermont. This is not comparing us to other states so this is just looking at Vermont. And what Oliver Wyman found is that pre-pandemic, the average days between that primary care visit and the follow-up specialist visit was about 100 days and that was pretty consistent for the three years leading into the pandemic 100 days. And then if we go to the next slide looking at how we compared to those peer states that we mentioned which is really sort of a peer population that they created from those peer states. Vermont is here in purple, the peer states are in that gray color. And the question here is how many of these individuals were able to schedule a follow-up visit within 14 days, 28 days and 60 days. So for 14 days, 22% of this population was able to schedule a visit in Vermont, 27% so a greater percentage in the peer states. 28 days, 34% of those in the Vermont population were able to schedule a follow-up visit that would have them be seen within 28 days. That was 43 days or 33% rather for the peer states. And then 60 days, 50% of Vermonters were able to get seen within 60 days but in the peer states it was 63% of that population. So basically, again, what this is telling us and showing us is that of those specialties that were being referred to in Vermont, a fewer people were able to get appointments quicker relative to the peer states that we're able to see. We're able to see their specialists at a greater percentage more quickly. So this is pre-COVID it's a little, it's from 2019 is the most recent year. So that was something for us to keep in mind in terms of a limitation. It's also the subset of a population not sort of the broad Vermont population. But I do think in Oliver Weiman believed it was a strong representative sample of the Vermont population and particularly those that would need care as well. So looking also, putting to the side on this chart 2020 data, because that certainly was disrupted due to COVID and the inability for many people to see their doctor early on in the pandemic and go to the hospital. But if you just look at the other years leading up to COVID, we do see that the utilization among specialists in primary care positions appeared pretty stable in Vermont. It did decrease even in the primary care or sorry, in specialty care situation really stable in the primary care. So that utilization actually decreased on the specialty side and primary care remained steady. So those were the way times were being seen basically even absent a dramatic increase in utilization from the Vermont population is sort of the point to be made there. So if we go to the next slide I think this will overview our seeker chopper program. And if we go to the next one, Isaac, this is again a representation on the right about where the calls were made both in Vermont and in the surrounding communities where individuals from Vermont will seek care. So Western Massachusetts parts of New York and then a lot of the care being seen across the Connecticut River along the Vermont and New Hampshire border as well. So a thousand phone calls were made to specialty clinics in Vermont. There were 400 unique specialty practices that were called representing about 90% of Vermont specialty providers for those specialties that we focused on. Each of the providers was called twice once the caller was calling as a Medicaid insurance individual. The other call they were being called as a Blue Cross Blue Shield of Vermont commercial insurance individual. And we call 21 different specialties that was the scope in terms of the difference in specialties as well. So again, this was the goal here was to try to replicate as closely as possible the experience of a Vermonter seeking to make a new patient appointment with a specialist for non-emergent medical issue. So for each of those 21 specialists obviously the reason for seeing the specialist was different when you went from one type of specialist to another but the reason that they were seeing the specialist within each of those specialties was the same. We had the same non-urgent medical issue that we were calling each of those specific specialties for. And we tried to again design that the wait time study is close to this national survey that's been conducted by a firm Merritt Hawkins that tries to assess wait times across the country for metro areas. They do this on a regular basis every three or four years. They're in the process of getting the candidate right before the initial speed. So that was the focus in the goal of the secret shopper program. So we go to the next slide, Isaac. We'll see some of the initial results. So one thing that we saw that was favorable news was that the vast majority of specialists were accepting new patients, 85% of those that we called were accepting new patients, 15% were not. So in terms of just getting your foot in the door by establishing yourself with a new specialty, that generally seemed to be something that was able to be done by Vermonters, if you were to call today. On the next slide, Isaac, we'll see another thing that was favorable that the difference between those with commercial insurance and those with Medicaid were really not that much of a significant difference. And in fact, the Medicaid wait times were shorter than the commercial wait times. So again, I think another thing that was favorable here, these were not necessarily the results that were conducted by that national firm when they looked at the difference between commercial and Medicaid and Medicare insurance that they were concerned that those with Medicaid had longer wait times. We did not find that at least in the secret shopper program in terms of the types of insurance. And there was some analysis done by Oliver Wyman as well that is reinforcing of this finding also. So I think this is a favorable finding as it relates to not finding that considerable difference between the types of insurance that a Vermonter has. So looking by specialty, as I mentioned, this includes the average wait time for all specialists, both those in Vermont and out of Vermont in the contiguous counties. You can see that the average across all of them was 54 days. But by specialty, there were differences. So you can see dermatology, that is one that's often cited as having longer wait times 109 days, a general surgery on the other end, 27 days. Now, one thing that we need to certainly point out both between specialists and even within them is that 109 days might be totally appropriate for dermatology if everyone that needs to be seen within a week or two weeks is being seen within a week or two weeks and everyone that does not need to be seen until six months is not being seen within six months that sort of that speed in which somebody is being seen and triaged is critical. And that was not being measured in the secret shopper program. However, when we did conduct our provider surveys and the provider listening sessions and tried to get other data sources we didn't necessarily have confidence that in all situations that was able to be done at triaging where you can ensure that those that need care quickly are being seen and those that can be seen later are being put off for later appointment. Obviously it's happening in certain specialties and certain offices, but we didn't have we had a sense that it was not happening uniformly across the system, which was something else for us to take note of. So we go to the next slide, Isaac, just looking at I guess this is the, I guess the first one was the I guess this one is just for Vermont rather sorry. So the first one included all the contiguous counties. This one here includes just Vermont. So it excludes New York, Massachusetts and New Hampshire. And you can see when we do that the wait times do go up. So generally, the wait times were shorter and New Hampshire and the other medical providers based in Massachusetts and New York when looked collectively. So instead of 109 days, it was 140 days for dermatology and so on and so forth. And the average went from 54 up to 61. So again, when we look within each of those specialties you can see quite a range between what was the shortest wait time, what was the average wait time and then what was the longest wait time. So looking at dermatology again just as the most dramatic example the average was 109 days in across all of the specialties but there were some instances where somebody could get in in 11 days. There were others where it would take 410 days again calling for the same reason. So I think this was another thing that made us take note. You can see on the left where the green is there were appointments available for individuals if they called the right place. And I guess the other considerations if they were able to travel if it was outside of their community. But there were appointments that were available in all of these relatively quickly but the average was much longer and those outliers were much longer. So you can imagine an individual calling a provider and getting for neurology and getting a 305 day wait time and being discouraged not realizing if they called another provider it would have been only an 11 day wait to see them for that same reason they were calling. So again, I think this showed to us another reason why tracking wait times and trying to provide this information to patients for them to be able to make more informed decisions about where they can seek care more quickly. I think it's an important thing for a fitter as policy makers it would also help distribute the demand on these services and hopefully reduce those outlier wait times and wait times across the board as well. So if we go to the next slide Isaac I think this is just looking at I'm not sure if the slide switched or not but if we go to the next slide this is looking at the hospitals in particular and looking at the fact that there were also differences between the hospitals within Vermont these are all of the specialties that were provided to each of the hospitals bumbled up and just average per location. So some of these hospitals obviously provide a different type of specialty mix than others some provide all of the specialties that we looked at. So for example, Dartmouth Hitchcock provided all of the specialties that we looked at Springfield Hospital only provided a subset of them. So you can see again, differences here UVM off to the right, Springfield, Gifford, Brattaburl, off to the left. And again, this does not mean definitively that one is doing a better job than the other there are these specialty provider mix issues but it was a way of trying to quantify the experience of a Vermonter calling and trying to make these specialty appointments and what they were seeing and what they were experiencing. And also, at least in the case of UVM would verify the anecdotal information to some degree that we were hearing that maybe there was a significant pressure on specialty care at UVM relative to some of the other hospitals. So that is what the data showed at least one when looking at the wait times, secret shopper data. So we go to the next slide, we'll look at how at least for these three, these four different specialties that we're able to identify and how they matched up both with the secret shopper data that was conducted for medium-sized or mid-sized metros by Merritt Hawkins in 2017 and also by the Veteran Affairs Administration and the wait times that are being experienced in Vermont and surrounding clinics. So again, the limitation here is that the Merritt Hawkins data coming for Albany, Manchester, New Hampshire, Hartford, Connecticut that was all collected in 2017. The data that we collected was in December, primarily in December of 2021. So it was pre-Omicron surge, but it was during the pandemic. So that was the most recent data for Merritt Hawkins. So they're coming out with another survey in the next number of months, interested to see what the results are there. But you can see for some of the specialties from Vermont and the Burnley to Metro area perform pretty consistently with the VA and with other mid-sized metros and then others like cardiology and dermatology, we appear to be an outlier when it comes to those specialties. So this was trying to get as much of an apples apples comparison as we could. You know, it's Burlington Metro compared to some of these other northeast metro areas. But again, the time difference couldn't be accounted for. This was pre-COVID for the other areas during COVID for the Vermont data. So looking at the last series of analyses that we did, this primary care chart audit from the Blueprint for Health program. You know, some of the Blueprint for Health employees and staff were able to go in and look at a chart and do a chart audit for a number of charts. I think it was about 3,000 or so, trying to understand, again, the length of time between when a referral was made from a primary care specialist to when those specialty services and appointments were able to take place. So that was the approach similar to Oliver Wyman. But this was looking at a different subset of patients than the Oliver Wyman approach, looking at a chart audit rather than aggregated claims data. So if we go to the next slide, here Isaac, it just shows the results of the Blueprint for Health audit. Looked like the average wait time, 61.5 days, pretty similar to what the secret chopper program found in Vermont, it was 64 days. If you remember for the entire area, it was a 55 days. And then some of the specialties match up in terms of the length of the wait time. Others seem to do better on this analysis than others. But again, if you look off to the right, some long wait times for certain of those specialties. And we would like to really have confidence that those that need to be seen within a very short period are being seen and those that can wait longer are able to do so, but weren't able to quantify that through the three different analyses that we did, unfortunately, something that I think needs greater examination and consideration. And then Isaac, if we go to the last slide here, just looking at the percent of practices accepting new patients and Medicaid patients by specialty. We mentioned earlier that there were 85% of the specialties that were accepting new patients period. This was just looking at if there are any differences between patients that had commercial insurance and those with Medicaid. And generally across the board, there were not material differences that is pretty strong. Number of practices accepting new patients and new patients both for commercial insurance and those accepting Medicaid. So again, another I think favorable finding of the report that there were not any material differences in terms of wait times or in terms of accessing care based on your insurance type. However, there were issues around accessing care in a timely way based on these three different analyses for all remodders regardless of insurance type for certain specialties when they were looking to access care. So Isaac, I think we go to the last slide. I think sort of some of the key findings here we've went through most of those already at this point. The first analysis of all rewind approximately half of specialties the wait times were over two months. Wait times were long prior to the COVID-19 pandemic based on that all of the women analysis showing each of the years between 17 and 19 having a hundred plus day wait time at least under those chronically ill patients that they looked at. Certainly wait times vary significantly by specialty and within specialty. Some of the specialty is neurology, psychiatry, endocrinology, dermatology with some of the longest waits depending on the analysis. And then I think also we found that certain ways of measuring wait times did not necessarily reflect the actual patient experience of care. So using approaches such as the first and third next available appointments might not actually capture the amount of time that an individual does have to wait for that specialty care visit. And again, no appreciable differences between Medicaid and commercial insurance. So I will turn it back over to Ina now to go through the recommendations. Excuse me, thank you Commissioner Pichak. As we move through the recommendations I think you may wanna elaborate on some of the first key recommendations we have but before doing that relative to the analysis and the analyses that we undertook in this project I do want to thank those providers that participated in this work alongside this team in studying this issue. And I also want to thank the blueprint team which did provide the study design for the chart review in determining what the length of time was between when a referral was made and when a specialty appointment was set. And the blueprint team worked with quality improvement facilitators and program managers in the blueprint practices to design this study, to collect this information. And as I talk about the recommendations have since been working to understand the outcomes of these analyses and to consider approaches for quality improvement relative to primary and specialty care access. If we could go to the first slide of recommendations however, I do note that mental in this study and as we indicated based on the information that we were hearing from those who are contributing feedback in provider forums as well as public forums and public comment. We did focus this assessment on specialty care as you've heard. We have recommendations for further work in the arena of mental health specifically as well as primary care. But first, the mental health recommendations are for completing a mental health and substance use disorder services access assessment, implementing healthcare workforce development strategic plan recommendations that are specific to mental health and substance use disorder services. And these include evaluating the opportunities that we have in the state of Vermont to address the barriers to licensure for clinicians as well as we have already signaled to our partners in the center for Medicare and Medicaid innovation that we would like to see Medicare reimbursed at parity with Medicaid licensed alcoholic drug abuse counselors, licensed clinical mental health counselors, licensed psychologists, licensed psychiatric nurses and licensed marriage and family counselors so that we can improve the access that Medicare beneficiaries specifically have to services by these license types as well as improve access on the whole by being able to better serve Vermonters with the most appropriate mental health care. And finally, we also recommend that the Department of Mental Health in collaboration with the Vermont Association of Hospitals and Health Systems, VAAS, should study the potential to establish and offer a statewide tele-sacrificatory program in Vermont emergency departments specifically to address mental health need. To address mental health need. And so those recommendations again are ones that are already existing in the workforce development strategic plan and through this work, we would emphasize the importance of carrying through these recommendations. So on these recommendations, I'll just read these quickly. These are some new initiatives, tracking and reporting hospital review of wait times and then coordination. So on the tracking and reporting, we mentioned seven days earlier as sort of something that I cause some action here in terms of formulating the team between BFR, AHS and pre-monitor court. But there was really strong reporting from the Burlington Free Press back in 2017 that looked at this issue of wait times. And the stories were really actually remarkably similar talking about individuals that faced months to get care who were in pain and were suffering and that there was an issue and that needed to be addressed. So that was a five-year period of difference. And the most recent reporting this study does find that it still appears to be an issue in Vermont. So our point with that is just that if we're not tracking it, if we're not reporting on it regularly and by we, I just mean every stakeholder in Vermont whether it's government or hospitals, then it's really hard for us to know whether it is a problem, whether it's a problem that's increasing, whether it's a problem that's decreasing and getting better. And that really was one of the primary recommendations here about developing and tracking wait times. So we have here a request to the Vermont legislature but the tech that we wanna take at the department is to examine our own regulatory authority that exists now within the department. Once the legislative session ends, we wanna work with the stakeholders. This process that we conducted, obviously stakeholders had engagement and provided us information but it was initially couched as an investigation and we sort of moved that to a study. But the posture of it didn't allow really for the full engagement that we would like to see in developing standardized metrics and appropriate ways of measuring wait times. So that's what we would like to engage in with the provider community and other stakeholders to try to identify ways that we can track and report over time. And if it does turn out that more statutory authority is needed, then that will be something that we plan to come back with next year and make the case for why we believe that's necessary. The other thing that we mentioned here is hospital review of wait times. So we recommended that hospitals established a board level designee or committee, basically somebody at a very high level that was responsible for monitoring wait times in their facilities and trying to implement continuous improvement plans around patient access. And we understand that this has been work that for many of the hospitals was already underway but across the board, this is something in particular with the hospitals that they're taking very seriously and implementing and working on at this point. So we were pleased to hear that and that they're going about implementing that as we speak. And then also just talked about coordination, the need for hospitals and independent providers to regularly collaborate and for hospitals to regularly collaborate to share information, share their successful strategies that they've designed to improve wait times and measure wait times. There was a lot of coordination that occurred during the pandemic that was excellent and I think really just building on that momentum. And I just would be remiss if I didn't mention that as we talk to so many monitors during this process and as I personally talked to them our team talked to them uniformly, they talked about their great care that they received when they were able to see a medical provider in Vermont. So that was another highlight of the report was the quality of care, the experience that they were seeing that they were experiencing once they were a provider. We did not hear, I don't remember hearing any complaints about that at all, that they were really appreciative of their providers and how they were treated once they were able to be seen. And obviously the provider community were just going through two really challenging years and were the heroes of the COVID-19 pandemic. So we all saw that firsthand over the last two years in ways that were incredible. But just would be remiss if I didn't mention that before turning it back over to Ina for the last part of the recommendations. Thank you. As we are advancing healthcare reform in the state of Vermont, we know that services are not always delivered in the most appropriate and the least cost setting. And our health reform initiatives are driven to try to promote a system of care where Vermonters can receive the most appropriate care in the best possible setting to meet that need. And as we look at the wait times for specialty services, it is very important that we consider that information in light of our healthcare reform objectives and in thinking through how to best provide for the right care in the least cost and most appropriate setting. And that means managing care between primary care and specialty settings is an area that we want to support. And we want to support that in a variety of ways that we recommend here for continued action, certainly assessing access for Vermonters to primary care to understand whether Vermonters are able to access primary care in a timely way, whether Vermonters have access to primary care providers, access to mental health and substance use treatment and reviewing improvements further for the regulatory framework for the healthcare system and determining the barriers for private practices in accepting Medicaid. As Commissioner Pichek pointed out, we do see broadly that access, the picture of access for Medicaid covered individuals looks very similar to the picture of access for the commercially insured. And this is a very favorable piece of information and it may be reflective of the years of work that Vermont has done for its reforms and its healthcare delivery system design to truly be payer agnostic. However, for those practices, there are some particular practices that do appear to not be accepting Medicaid at the same rate as they are accepting commercial coverage. And we would like to understand better the barriers for those practices which are private practices. Further, we want to support workforce development and prioritize the implementation of the Workforce Development Strategic Plan. And as you're certainly familiar, ensuring that that plan is implemented so that we as a state have the full and most appropriate complement of provider types to offer the care and services that Vermonters need. And again, I'm thanking the Blueprint for Health team for the work that they did in collaborating with quality improvement facilitators and program managers in this initial phase of assessing wait times. And further thanking those teams for the work that they have ahead of them in terms of the quality improvement activities that can promote referral best practices and care distribution between primary and specialty care. And again, I'm emphasizing the importance of moving in our system towards one that promotes prevention, care coordination and management in primary care when appropriate and that has strong systems and supports to provide for the best distribution of care between primary and specialty care. And finally, continuing our shift from fee-for-service reimbursement to fixed prospective payments in Vermont that do provide for predictability and more flexibility for providers to appropriately coordinate and to provide for care in the most appropriate settings. Good timing. Why don't we take this right now and then thank you. This is terrific. I know that the House committee is on a very tight schedule so Bill, I will open it up for you to ask any specific questions and then we'll ask a couple of specific questions but I think our time is pretty precious right now and we're going to have to end very soon. So go ahead, Representative Locke. Yes, I think we can take a few more, some more time, perhaps a little bit after the hour. I know there's a number of questions. So let me represent Goldman, you had a question. Representative Black, Representative Fordis, thank you. Let's do be aware of our time because we do have other commitments this morning as well. So good morning and thank you so much. I was looking through your report and particularly interested in slides 52 to 54 which really put the processes and referral processes and really pinch points. And I was wondering where that lands. So now that you know this information, who in the system is responsible for the understanding at all these levels throughout the system it sounds very big. So I'm wondering who takes that out? When you respond, can you repeat the essence of the question because we're having a difficult time hearing folks? Yeah, I'm sorry, I was, that's the slide. No, I'll let whoever responds sort of give us the umbrella question and then the response. I think it would help for us to repeat the question too to make sure that we heard it clearly. I think that the question was asking if we could evaporate on those pinch points in the referral process that can create a longer wait between when a need is identified and when an appointment is scheduled. Yeah, and who is responsible sort of to address that statewide? So as you can see from the information that Isaac is sharing here on the screen that we do have a mapping of these processes. These processes are particular to those providers and practices that are offering these services. And again, if we go back to our recommendations, I think that that is why we are certainly recommending that providers are working in collaboration with between of course specialty and primary care but also hospital providers as well collaborating with independent providers to be sure that they are working together to identify these pinch points and collaborating to try to improve on the length of time. So let me just insert a little question in here. One of the things that I've been thinking about as we're going through this of course is the comment on prior authorization and you don't have the insurance process included in as a pinch point. So my question is how significant was that as you went through the analysis? Yup. Thanks. I don't see a lot in here about insurance, private insurance triage. Yeah, I don't know if Ina, you want me to jump in? I see Sebastian had his hand up too. We actually looked into that to see if the insurance prior authorization process would essentially prohibit a specialist provider from scheduling an appointment. And we actually found that it wasn't actually a limitation in the health insurance practices but sometimes providers would actually have implemented some internal processes where they had decided they would not schedule someone until they received the prior authorization. But in general, we didn't find that the insurance process of prior authorization was holding up the scheduling of the appointment or the receiving of treatment. So that's an interesting area to explore if the wait time is expanded because the specialist wants to be reassured that the specialist is accessible to the patient. Right, yeah. And we do have, and DFR has a regulation that addresses prior authorizations and maybe Sebastian can speak to it a little bit but it puts time restraints on health insurance companies in which they must respond to a prior authorization request especially if it's an emergent situation. Sebastian, do you wanna speak to that a little bit? Yeah, in general, health insurers have to render a decision on prior authorizations within a week. And if the prior is denied then there are internal and external appeal processes but in an emergency situation those processes can take place in a matter of days. Thank you. Go ahead, Bill, it's still on your side of the fence. Sure, so I think represent black and then represent quarters. And then I just need to say I think we're gonna need to stop like what case represent black and then represent burrows. Then we're gonna need to stop at quarter after. I think my question's very simple. I was just wondering if you had compared wait times for specialists between same specialty but hospital based specialists with independent practices. So I can let Nina elaborate on this but we were able to do that primarily I believe through the secret shopper program but we weren't necessarily enough data points that gave us comfort that we wanted to include those specific comparisons in the report. But it did show, correct me, if I'm wrong that wait times, they were long sort of across the board. I'll just put it that way whether it was independent provider or associated with the hospital. That's correct. We observed if going, in my mind, I have the chart that commissioner Pitchek walked you all through with the wait times being short all the way up through the more than 400 days of wait time. So we saw that wide range and that wide range was consistent between hospitals and independent providers but we did not undertake an analysis specifically to compare hospital to independent providers for the reasons commissioner Pitchek named the data for independent providers was not as significant to be able to make that comparison. Thank you. Representative Burroughs. Thank you, I'll be quick. I'm... You just need to speak up. Okay. I'm puzzled as to why there's no data included regarding pediatric specialties. I see on slide 84 that Oliver Weiman said that Vermont's experiencing a decline in availability of clinical FTEs and family and pediatric specialties or was pediatric care. And then I also see further down on slide number 95 it's included among specialties that were looked at. And I wondered why it's left out of the presentation that you just gave us. Yeah, I mean, I will just say that, we didn't know that particularly when it came to psychiatric and eating disorder specialties for pediatrics, there were reports of significant wait times. And again, I'll turn over to Hina, but we just, when we did these analyses we would like to look at everything. We'd like to have looked at emergency department wait times. We'd like to look at mental health. We'd like to look at general primary care but we just had to make some initial determinations around what to focus on first. So that does not mean that it was a greater priority or lesser priority, it just was the first area and we do have other areas that we want to explore in more detail as well. Okay, thank you. Can I, because of the time, I might just comment that some of the recommendations that you've made particularly around workforce development I think have been trying to address in initiatives taken in the house healthcare and the house generally. And so I'm hoping that they'll be favorably received as the Senate reviews the work of healthcare workforce initiatives. And that, I guess one of the last questions I have is whether the Department of Financial Regulation I would like to better understand what authority you believe you need in order to continue the monitoring and investigation or analysis and to understand that if whether I'm hoping that you're able to continue this analysis even absent specific statutory authority in the immediate time given where we are in the legislative session. And that I think you alluded to the possibility of coming back with some particular with some additional suggestion. But yeah. Yeah, sure. That's exactly right. I mean, that's our hope. And we think we can make progress independent of specific statutory authority right now from the legislature, but I do want to turn it over to Emily and Sebastian to elaborate on that. Yeah, I can jump in and then I'll turn over Sebastian. So currently under regulation 0903, which governs requirements over managed care organizations or health insurers in Vermont and their practices. We require health insurers, for instance, to provide an updated directory of all their providers as well as informed consumers of whether providers are taking new patients. And as well as the state law, there's actually new requirements and no surprises act, which Sebastian can probably elaborate on, which require a quarterly update of the provider directories to make sure there's accurate information. So we think we already have some authority, even though it's through the health insurers to require reporting on provider networks. So I think that would be a good first step to look into that authority that we have to see whether it wouldn't just be, the health insurers letting consumers know who the providers are and if they're taking new patients, but also expand into other metrics, which could address wait times. And so I think as Commissioner Pitchek mentioned earlier, we wanna work with stakeholders providers and the health insurers to make sure that the metrics that we'd be asking for would make sense and be applicable to all different provider types. And then once we have an idea of what those metrics should be, because there aren't really any uniform ones that exist today on wait times, hopefully be able to, through our regulation of health insurers, as well as if there is extra legislation that's needed to clarify that authority, work with the health insurers and providers on reporting that wait time information through the health insurers. So at least if you had commercial health insurance, as well as we could probably work with Medicaid, that you, if you were a subscriber, you could go to your health insurer and understand, okay, if I can see this provider, it would be approximately two months and I can go to another provider and maybe wait a shorter time. So I think that will be our starting point and then we'll see where we have to go from there. So I'm gonna, I'd like to interject at this point because our committee is going to have to leave in about 30 seconds, but I just a comment here and I'm finding this very thought-provoking what you're talking about because it does raise issues around contract relationships between ERISA plans and others that may preclude any opportunity for changes in wait time. So there's some issues there that we bump into going along. The other area is around the clinical judgment that's used around the acuity of a patient. So the determination of who is gonna wait longer and why, sometimes patients don't understand that. You know, certainly. But so there's a lot mixed in here that is going to stir up a lot of different issues and concerns that I think have been expressed over time. I think that the work that you have done is raising some really important questions. But I guess my hope is that the professional judgment isn't going to be put on the back burner in this process. Certainly we can't have that. So we don't want it to end up being a contract that says wait time will be no longer than X, Y, or Z when we don't fully understand the patient needs. So I'm making all these comments because I have a hundred questions for you but I appreciate everything, the work that you've done and raised these issues. Yeah, and Chair Lyons is just very quickly like the consumer experience over almost every product that we consume or service that we consume now is wanting it to be on demand and wanting it to be faster and quicker. So we do recognize that there is that general sentiment that you have to navigate against because not everyone needs to be seen today or tomorrow. It might be very appropriate for them to be seen in six months, although they want to be seen very quickly. So that's, is a challenge built into this problem that we have to certainly account for. Yeah, thank you. Thank you so much. I appreciate the depth of work that you have done and bringing us to report and the response that you have made to the public outcry. I mean, obviously the news article was jarring to a number of people. So thank you for your work. Yes, thank you as well. Thank you as well. And maybe one final note that I think while we go past it to look at other issues, I think it is significant that there was not a significant difference between access for Medicaid, many of our monitors on Medicaid than on commercial insurance, which is historically something that is been challenged and talked about. And I think that's actually a significant finding in the midst of all of these other questions that are raised as well. And I think we need to highlight that and to appreciate the work that's been done to establish that as the norm. That's no small achievement. So thank you all. And thank you, Senator Lyons. Sorry, we took more of your time than we had anticipated. No, I think this is the beginning. And we'll have to go through the report independently and then we'll certainly listen to requests that come to us from folks. So thank you for your time.