 Hey, welcome. Why don't we all introduce ourselves? Commissioner, you're starting. Because everyone knows Justin. Frank Green. Justin. Mental health, that is. Just in case you're running. Wondering. Yeah, go ahead. Selena Hickman, AHS. Craig Jones, Vermont Blueprint for Health. Monica Huddle, Inc. Michael Costa, Deputy Director of Health Care Reform. Inabakis, Green Mountain Care Board. Steve Constantino, Commissioner Antiva. Hal Cohen, Secretary AHS. Al Gore-Bay, Chair of the Green Mountain Care Board. Robin Lange, Director of Health Care Corps. Lawrence Miller. Pete Shumlin, Governor of the Great State of Vermont. And we're going to talk a little bit about what we are releasing today. And then you're going to hear from the Chair of the Green Mountain Health Care Board, Al Gore-Bay. And then you're going to hear briefly from Robin Lange, my health care person. And then we'll answer all kinds of questions. And that's where everybody else will help us, we hope. So first of all, welcome and thanks for joining us. And I want to start by thanking my team, by thanking Al Gore-Bay and the Green Mountain Healthcare Board and all that have worked so hard since really day one of my administration to get to the point where we can today, as promised in my budget address last week, show you what we are proposing to Washington to change the way we pay for health care to make it more affordable and to improve quality of care for Vermonters. It's important to know that none of this is set in stone, that it can all be changed, and that what we wish for is a transparent, thoughtful process where we invite everybody to help us make this even better. So I want to be clear, this is not a signed, sealed, and delivered document of, hey, this is the way it is. We now have the ability, by working with our federal partners, to share with you what we hope to build upon after this release. Basically, I promised last in my budget address that we would lay out what we asked for from Washington to transform the way we pay for health care. Why is this so important? We all know that the biggest challenge for Vermonters, and frankly, for America right now, is the fact that we've come out of a tough recession, the economy's growing, but many, many folks, particularly middle-class Vermonters, don't feel in their pocketbooks the prosperity from this recovery. And there's no question, as I said in my budget address, that public enemy number one, to affordability for Vermonters and for Vermont businesses is the ever-rising cost of health care that gobbles up the dollars that we make, faster than we can make them. So you have to ask, well, why is this so important? This is why. This is what's not only standing away for affordability, it's also standing away of quality health care. What do I mean by that? I can remember when I was a kid growing up in Vermont almost 50 years ago, when you'd go to a doctor and you'd spend a lot of time there, your doc would spend a lot of time with you. But as we've moved to a new managed care fee-for-service system, we find that in order to afford the reimbursements through fee-for-service that providers are given, that they've got to shorten up those visits and get you in and out more quickly. That doesn't lead to good health care. So very simply, what we're trying to do is move from a quantity-driven fee-for-service health care system that has been in place for over 50 years now that was originally designed when medical conditions pretty much required a single visit back in the old days of health care. Now, think about this, and this was not true 50 years ago, as medicine has evolved and technology has improved and we're living longer and we figured out how to live with terrible diseases much longer than we could in the past, 86 cents of every dollar in health care, think about this, 86 cents of every dollar in health care is spent on chronic disease, keeping folks who are sick, alive and healthy. So, or as healthy as we can. So the result is that Vermonters are receiving expensive, fragmented and disorganized care through the fee-for-service model. We are proposing to Washington that we be the first state that takes all of our payment systems, Medicare, Medicaid and private pay, so all three, and changes to what we're calling all-payer model where we pay our docs, our nurses and our healthcare providers for keeping us healthy, not for the fee-for-service system that we currently have. So instead of paying for every test, every procedure, doctors and hospitals would receive a set of payments for frankly keeping us alive and healthy and feeling good. Obviously that puts huge priority on preventative care, on eating right, on exercising, on getting off the smokes, on doing all the things that we know we should be doing, drinking Vermont grown beer instead of Budweiser, Vermont grown food instead of corporate food, but it means a team approach to our health. So what we're asking from Washington is a statewide spending target for all payers in a healthcare system of 3.5% with a maximum allowable spending growth of 4.3% for the next five years. So that's our first ask, that the healthcare system that we're saying we would live within a means of a 3.5% growth rate with a four point, that would be the goal, the cap or the ceiling would be 4.3% for the next five years. The financial cap is set approximately 1% higher than Vermont's economic growth as measured by a gross state product over the past 15 years. So those are the numbers that we've been using. Three healthcare quality targets increased access to primary care, reducing the prevalence and improving the management of chronic disease and addressing the substance abuse epidemic would all be part of that target. Under the all payer model, Vermonters will continue as important to know to see the doctor or health provider of their choice. So you continue to choose your provider just like you do today, we hope. Vermonters on Medicare, and I mean there's we hope you can today, we know you'll be able to under our new system. Vermonters on the Medicare and Medicaid would see no change to their benefits. That's really important. If you're on Medicare, no change to your benefits. We're often asked, oh, would this hurt Medicare beneficiaries? The answer is no. They say, well, what if you changed your mind? The answer is first of all, we won't. And secondly, we couldn't. Federal law does not allow states to reduce Medicare benefits, nor would we want to. So Medicare and Medicaid no change to their benefits. Vermont proposes to expand Medicare benefits to seniors under this plan. So it's actually an expansion of benefits, not a reduction of benefits. So listen, the goal is simple. If Vermont can be the first state that moves to an affordable, higher quality healthcare system where you get better care and bend the cost curve going forward that we become so used to in this country, we will put money in Vermonters' pockets, grow jobs, be healthier, and go back to the old relationship where your healthcare provider could actually take the time to take care of you and keep you healthy, not have to move you in and out of the office in a fee-for-service system that under-reimburses them for the work that they do in too many of the cases. I'll turn it over now to Al Gobey. I want to thank Al for his great work and that Ford's great work. Take it away, you can fix what I just messed up. All right, you did great, Gov. So first thing I want to do is I want to do some thank yous, but to the reporters in the room that have asked me when would the term sheet be out, the answer would be Erin, today. Today it's out. It's off my back and I'm really happy about that. I've been asked probably about 4,000 times. But I want to thank some people. First, from the Green Mountain Care Board, is Ena Bacchus. Where are you? I know you don't want me to do this. Ena has worked incredibly hard to get this document and these documents out to work with the federal government so that we can understand how to put something like this together. She's been a great teammate of mine working with the administration. The next thing I want to do is I want to thank the administration. Lawrence, Robin, and Michael Costa have been simply extraordinary in this partnership of working together. And if I was the folks in the room, I'd ask why would an independent board work with the administration on something? If you're independent, should you be doing that? It's a really simple answer. Act 54 said we had to. Act 54 said that we had to explore jointly an all-payer model. And so these two teams have come together and produced the documents that you have today. The next point, why are we doing this? Many have heard me speak about my cartoon family of four and what it costs for healthcare today. Just real quickly, today, a platinum plan in the exchange is $11.52 an hour. When you think about minimum wage, when you think about a livable wage, that's an incredible number. That number was half in 2005 when I bought health insurance from my company. And by 2025, if we do nothing, that number could easily be double. That $11.52 can be as high as $19.68 an hour for Vermonters. That's something that we all have to work on making sure does not happen because pay does not rise at the same hyperinflationary rate as healthcare. That's important to remember that. So some key things that the governor mentioned. First, Medicare. Should Medicare beneficiaries be concerned that somehow the state is stepping in? There will be no comfort in me saying no if you don't believe me. But let me give you some facts. What the state is proposing to do is to use a program created by the federal government by CMS called NextGen. We will use NextGen, the same way we used Medicare shared savings to create a Medicaid NextGen-esque program. And to the folks from Medicaid that are here today, they've already worked incredibly hard in thinking and working on this. And on behalf of the Green Mountain Care Board, we look forward to working with you and we know how hard this is gonna be. It's no easy lift. We would then take that same NextGen platform and make a commercial program. Realize we've done this before with shared savings in our state. We currently have accountable care organizations that participate in Medicare programs, in Medicaid programs and in commercial programs that have no changes to the beneficiary. Same formulary, same appeal process, same everything. And so it's easy for me to say there'll be no change. But in fact, federal law allows there to be no change. And there's nothing in the documents you have that would point to anything but what we are saying. Okay, next, how are we gonna look at this new document, this term sheet? On Thursday, the Green Mountain Care Board will hold an all day meeting in public on camera to take the term sheet down to its core elements and examine them. As part of our analysis for the term sheet, we've hired an actuarial firm that has created a model, basically an Excel model, to take a look at the business plan that is at the core of this term sheet. That will be presented Thursday afternoon. It is through a transparent process from there that the Green Mountain Care Board will evaluate the term sheet, a potential contract, because remember, the term sheet is not a contract. What we're releasing is sort of in the middle of a negotiation, which is not typical. We're doing that because we wanna be transparent. Both the administration and the Green Mountain Care Board feel very strongly about that. Eventually we'll have to get to a term sheet that is 100% done and then build and write and sign a contract with the federal government. But that'll be done over public meetings at the Green Mountain Care Board, testimony in front of the legislature, countless meetings with stakeholders throughout Vermont. And so this thing will be thoroughly vetted and input is what we are seeking. And so the term sheet itself has, I've read it to my wife a few times and it has a great effect of making her fall asleep. It's detailed if you're not used to the words that Medicare uses for things for their waivers and for their payment structure. It can seem pretty technical. Robin is gonna go over that now and then we'll answer questions on what we've been up to. Robin? Thank you, Mr. Chair. Absolutely. Robin Lawner. I'm right next to you. Take it away. All right, thanks everyone. So as Al said, I think the most important thing to remember as we're starting to look at the specifics in the technical document called the term sheet is that this is a proposal. We're looking for feedback and we don't necessarily think we always have all the answers or the right answers. So we wanna make sure that people are providing good input through the Green Mountain Care Board process as we move forward. So that's number one. There are three documents that you have links to in the press release. The first is the technical document called the term sheet and I'm gonna walk you through that in a minute. The second is what we call a companion paper which tries to take the technical language in the term sheet and make it a little more readable and user friendly. So it's a more descriptive document. That's a little bit shorter and hopefully more accessible for folks. And then the third document that we'll be posting is really just a one page summary for people looking to get a broad overview. So add. Press. And others. Yeah. So the agreement is a five year agreement that would begin in January 2017. Now again, that's a target for the agreement. That is something that we need to get feedback on and make sure that operationally that's a feasible target. But at least at this point, the proposal is 2017 to 2021. And the term sheet walks through several technical components of the agreement or what will become the agreement I should say. The first is creating another step towards value and away from our expensive and fragmented system through a proposal that would have all payers approach payment in a common way that rewards the healthcare system for providing that value and positions healthcare providers to lead in partnership with the state and the federal government. In other words, what we're really looking to do as Al said is to align people through that next generation model that Medicare has released to move from fee for service to value-based population-based payments. So that payers will be paying healthcare providers with quality incentives, a set amount, risk adjusted of course to keep their patients more healthy. This will ensure that from a provider's perspective they're getting similar incentives across Medicare, Medicaid and commercial payers so that they can really shift how they do business and they're not getting mixed messages from different payers. As both Alan, the governor, have indicated for Medicare beneficiaries they will keep the same benefits, care, covered services, choice of providers, appeal rights, all of the core components and beneficiary protections in Medicare. And also as has been alluded to, we are asking the federal government to actually expand benefits to Medicare beneficiaries. So let me run you through a couple of examples. You're all, I think, familiar with our Blueprint for Health program, which is a medical home and community health team model that's shown great success. That program is set to expire at the end of 2016. So a core component is to ensure that that program is maintained with Medicare participation. Medicaid and commercial payers also participate in that program and that piece won't expire and would continue. But what we want to make sure is that Medicare stays participant as well. Second, we'd like to expand the hub and spoke addiction services treatment program to Medicare beneficiaries. Currently, those on Medicare have no coverage for those types of services and so this will ensure that if they need them, they will be there. And then third, you may have heard of the services and supports at home program, SASH. They started with Cathedral Square in Burlington. That program has proven to be very successful in helping seniors stay out of the hospital and prevent more expensive care. We'd like to expand that statewide with Medicare participation. As the governor indicated, the financial targets which are for a set of services, not for example, all services, prescription drugs are outside of this, but there's financial targets that would set a spending target 3.5% or 4.3% as a cap and then also a goal of decreasing costs to Medicare below the national average of 0.2%. As I just indicated, the financial targets are based on a set of services and those services are Medicare AMB, which is hospital and physician services and for Medicaid and commercial, the same services that are included in our shared savings program, there's an appendix that goes into that in a lot of detail that's part of the documents that are on the links that you've provided. And lastly, we really have three ambitious population health goals and these are a pretty big deal because no other state has really sought on an all-payer basis to target these three high-level population health goals in this way. The first is increasing access to primary care. If you move to Vermont today about half of our primary care provider practices are closed, meaning you can't, it's really hard to find a doctor. We wanna see that get better. So that's one of our high-level population health goals. Second, reducing the prevalence of chronic diseases. So not just improving quality but actually making people healthier. And the third is addressing our substance abuse crisis as we've spoken about earlier. And then I think I'll just close and let you get to your questions by saying again, the process for this is to walk you through the process. So we've released the draft term sheet. As Al said, the board will be taking a look at it on Thursday, that's the beginning of a public input process. We are hoping for lots of public input from folks so that we can really have a good vetting of what we've proposed. Then after that, that process will take a couple months still with the federal government. So the feds need to have their internal vetting of the document as well. And then if we are able to get to an agreeable place with the term sheet with the federal government, then we would turn to drafting essentially a contract between the parties. So that process will be ongoing throughout several months as well. Now simultaneously, our partners at AHS who are here today are already working on thinking about the operation so that they'll be ready to go when we reach an agreement. So that's, I think. Thank you, Robin. The details. Alan and I and all of us would be happy to answer questions if you have them. Is the term sheet available? Yes, you have a link to a website and it should be up there. Is it not up there? In the release, it should be in the... In your email? Yeah. And it should be on the Green Mountain Care Board website by now as well. It's been sent out to... Yes, sir. Why would a hospital enter into this agreement? Well, I think that you have to understand, you know, sort of how they view the world right now. I mean, I think you can see in the piece that was in Vermont Digger this morning what Dr. Bromsted's thinking. And I won't speak on his behalf, but you know, I think hospitals are very, very aware that healthcare costs too much and that the way that we currently pay for it and how much we pay for it is not sustainable and that we need a new model. And so they've participated willingly in the shared savings model, which is I've described in public as training wheels as we move toward more value-based payments. But they realize better than anyone how they need to work with their community partners to actually bend the cost curve by keeping people healthy. You know, Vermont is a very intelligent state. We have some, you know, great thinkers and I think that people can understand where we're at is just not where we want to be. Aren't they assuming a lot of risk? Well, let me take a shot at that one. Anyone in a fee-for-service system in Vermont right now is at risk in the current system. And I think the reason that Vermont is making progress on this faster than other states is that we have a lot of enlightened healthcare providers who recognize that in a system where fee-for-service rewards quantity of care without really emphasizing quality and where they can't pay their bills because of the crazy fee-for-service payments that we have, they're going, hey, wait a minute, how can we all get around a table and figure out a smarter way? This has been 50 years, lots have changed, our system hasn't, we've got to change with it. And you know, we're blessed to be in a state where our hospitals, our docs, our nurses, our chiropractors, so many people are coming to the table. Not everyone's in agreement, but so many people are coming to the table and saying, yeah, we want to figure out a better way. Well, this encourage providers to take on patients who are already relatively healthy. I mean, if they're getting rewarded for their outcomes, then you would be looking for folks who are already going to be producing good outcome, right? No, not necessarily. So if you think about it, if you, so it's all works off of attributed lives. So if you're a primary care doctor and you want to join this, so we have to make it attractive for primary care docs and nurse practitioners to want to join. But if they join, their attributed lives come with them. And so all of the health, healthy folks and the infirmed are already in that population. And so that's already in the math. And so if you want to actually perform well, you have to take care of your entire population. So in other words, that would be true if there was no measure of the outcomes related to your work. But as long as you're actually measuring whether or not you're making progress with a patient, the question becomes, are you doing well to keep them well and not so much the current system where how many people can you get through the door to make a billable hour or billable moment in the medical field? So the primary care doctors receive a set amount per patient based on the demographics of that patient? So that would be one strategy to build a transformative model and that's something we've been working on. So basically that is known in some places as a primary care capitated payment or a panel management agreement where you agree to get a certain amount of money for a panel of patients. And then it's not the total amount of money, then there's always some fee for service in there. But yeah, there's a different way to pay for primary care that there's a couple of different ideas of how to pay for primary care that would make it much more enjoyable to be a primary care doctor. But let's be clear, we're inventing this as we go, right? I don't even get to that. So that's why we're saying we want this to be a transparent process for everybody in, but we do need the providers to help us design the effective payment system. Yeah, and let's be clear here. This has to be provider led and provider driven. You don't want me doing that. We can set the table to make the payment no longer the problem. But they have to be willing partners in this to move to a better world. And they have been, and they have been for a long time. What makes Vermont's proposal different from what Maryland is doing? So Maryland currently, Maryland's really the only state that has done this, had it for years and it only applies, as I understand it, to their hospital budgets. So it's not their entire healthcare system and it's Medicaid of their hospital budgets, right? Well, it's actually, so in Maryland, they signed an agreement on what is thought of as Medicare Part A. And so that's pretty much what we think of as hospitalization. Part B is what we think of as doctors or physicians. And so over time, they're supposed to move to a total cost of care over the five years of their agreement, but they started with Part A. We're talking about starting with Part A and Part B from Medicare. And then doing that across payers, meaning Medicaid and commercial. And that makes sense. So they've done a small sliver of what we're talking about trying to do for the whole system. They're also setting rates for hospitals, as I understand. Do you plan to set rates? That's where I'm going. So we can under this agreement, but no, that's not our plan. What we want to do is we want to actually do something that is a little bit more informed toward the value-based payment world, which is work with an accountable care organization so that they take risk for the health of a population. Whereas in Maryland, it's basically global budgets for hospitals. And it allows hospitals to think differently. This would allow FQHCs, independent physicians, designated agencies, home health, the whole care continuum to be engaged. We think it's a much better approach. Who decides what all these different payment models are going to be and determine the X amount for somebody's knee replacement and keeping people healthy? How does that get done? So starting with the NextGen platform in Medicare, they basically have put forward a plan to make a population-based payment to a group of providers called an ACO, Accountable Care Organization. That accountable care organization over time will have to decide those rates. So the providers. ACO sets rates. Red, the providers would set rates for providers. Do you have a minimum percentage of providers that are going to need to buy into this all-payer model for it to be feasible? I mean, it's going to be voluntary, right? So how many folks are going to need to get in before it's going to be sustainable? OK, so let me be clear here. Yes, absolutely voluntary. We don't want to make the outside world worse, the fee-for-service world worse, and force people into a new model. We want to make the new model actually attractive. We want it to be transformative. Like I said, so primary care docs want to be in. But there is no threshold. We haven't said we've got to be here by this date. I think it's going to be something that we start at one level and we keep evolving because we have to build a commercial plan, a Medicaid plan. It will take time. But if we have basically the momentum that we've been able to maintain, I think we're going to be fine. So we're going to phase into this. When Alan and I talk about this, we're talking about the end goal. Obviously, we're going to phase into that. Can you just remind me again what the five-year agreement that you're seeking? Five-year. That's the longest they'll go. So that's what we're seeking. And by the end of by 2022? Well, we hope to have the agreement in place. 21. By the end of 2021, we would then have to between now and then come up with where we go from here. So where did 3.5% growth come from? Because I don't think wages are going up that much. We all wish they were. It came from a look at the 15-year growth state product growth number. And that's very close to it. It also came from where we have been holding hospital growth to in the range. So we've tried to say, what is reasonable for health care? Understanding that health care is a capital-intense, technologically-driven industry. How fast can they grow and still have the quality that we all expect? That's what's, it's a balancing act there. It seems like a key part of this savings is your assertion that there's a lot of unnecessary medical care taking place today. Is that true? No. No. I think that there's all sorts of ways to talk about this that kind of point the finger. And that's not it. What I firmly believe is that we have so many people with multiple physicians and multiple prescriptions that incenting doctors to coordinate that care is a way to bend the cost curve without pointing the finger at anybody and keep people healthy. I think that's where, and if you think about it, that's what the blueprint is about. This is just taking the blueprint to the next level of financial incentives. Well, if the fee-for-service system is causing people to get more tests, more x-rays, more is this or that, and people are just doing this up the chain, that would seem to indicate that some of these procedures were not necessary for the health of the patient? I think that almost anyone in a health care system would agree that the fee-for-service system promotes inefficiency and promotes duplication and promotes a lack of coordination and care. And that's the problem we have with our system, one of them. So are you reporting to ration care employment? No, we're not. So the word ration is used to kill money, progress, and health care. We are promoting a much better integrated system where providers no longer have to do quantity to make a living. They can do quality and make a living, be rewarded for keeping you healthy. And what I would say is that when we started doing hospital budgets, hospitals were growing somewhere around $110 to $120 million a year. In our first year, I've said publicly I didn't give us high marks, hospitals grew at $141 million in new revenue. Since that time, they've been as low as $57 million. Yet you haven't seen any picketing or any rationing. It's about getting things on a trend in a way that we can believe is sustainable. And our hospitals and our doctors and the leadership of those institutions have been committed to that. And so when you think about Blue Cross, we basically have 63,000 people through Vermont Health Connect that use Blue Cross. We do a rate review case and say, this is what it's going to cost per person. And we trend it forward. And they don't ration care. These are things that are done in health care today. The only answer is not, oh, we must somehow ration. So, Stuart, you had a question. Sure, it's the one. The next step in the process, have you guys sent this proposal to Washington? What do you see and what's been the feedback? So this has been an ongoing negotiation with CMS. It's been going on really for how long now? A year. A little more. And we continue to make good progress. Our challenge has been that we really have wanted, from honors, to know what we're asking for or what we're up to. And really, what today is about is to be able to march out what we've been talking about with the hope of having a more inclusive conversation going forward as we try to come to an agreement. But we did send everything this morning to CMS that you have copies of. Right. So can we go to English from Gubliak, which is what we talk about when we do health care? I think I tried to lay out in my budget address my own personal experiences of plain English, what's wrong with our health care system. But as someone who has lost one older Vermont parent and has another one still alive, I can't believe that my circumstance is unusual. I found that when my parents got over 80, one still alive and well, the other passed away close to 90. So he got 10 years of service. They spent a good deal of every week in doctors' offices and hospitals. That's what they do. You start to get lots of ailments at that age. And if I look at the money that we spend through the lack of coordination or health care system just on my parents, it's pretty astounding. It's a lot of money. And their quality of life, I would argue, is not measurably better because they are going to lots of different providers and no one's integrating their care. So I think we have to sometimes remember, if you design this system from scratch, and you said, let's build a health care system where we have lots of really qualified providers, but folks aren't talking to each other. You get to call up anyone you ever wish any time and go see them. They'll do all kinds of things, tests, and everything, but not necessarily talk to the next provider that you choose to go to. And there's no integration of that care. And we're all going to pay for it based upon the number of minutes that each person spends in that office, number of tests they get, number of procedures that happen. We'd all say, well, boy, that system isn't going to make people very healthy, and it's not going to be financially sustainable. That's the system we have. So here, if this is a major announcement, I'm surprised. Our health care system fee for service system is broken in Vermont. It's broken in America. If Vermont can be the first to figure out a more efficient system financially that gives better quality outcomes to patients, we all win. And we've got some mighty small shoes to fill. Let's not forget that. One thing in terms of the payments, will we still see a discrepancy between Medicaid, Medicare, private insurers for each doctor? Or is there going to be a common payment system for everybody? So no, there will not be a common payment. I wouldn't use it as a discrepancy. There's two points in there. One is the cost shift will still exist. And the second thing is that the way that you interact with the system if you're a Medicare beneficiary, the way that you handle your co-pays and deductibles and like that won't change. And so that doesn't change within the structure. So you still have a situation where health care providers will not be enthusiastic about taking on new Medicaid patients? So the ACO could change that in the way that they pay providers, but that doesn't change the rate that Medicaid pays. So we get the same general number of money from the federal government, but how every health care entity distributes those dollars could well change, right? Right. So there's a chart that I showed last year when we were talking about the payroll tax. And it showed that Medicaid on average paid $75 for a 15-minute office visit of one kind and paid $125 for commercial. That's how we pay now. The way a new way to pay would be if Medicaid paid an ACO $6,102 per person. And if commercial paid $5,110 per person, and then the ACO could say, how do I want to pay for primary care? Because then everything has changed at that point. And by the way, we have a whole model we're going to show Thursday afternoon that is going to get into, through spreadsheets, exactly what we're talking about. So we might have been a little hasty and sane no to your question, I think. The hope is that the system will get redesigned by the providers so that there will not be an incentive to take care of one patient rather than another because of money. You want to say? Yes. How much do you expect this year's administration of the ACO? That's a great question. We're going to have to work on that. That's a really good question. We brought that up in our board meeting last week. And how are we going to look at that and what type of oversight is proper for that? Again, this is the beginning of a conversation. All the work has not been done. And I said earlier, Medicaid has a huge job to do in this. Well, so does the ACO. So does commercial. We've met with Don George. We're going to meet with MVP and we'll meet with others to try to figure out how we build these programs with them. We did it before. We shared savings. So it's not, it's certainly within our wheelhouse, but it's a lot of work. And that's part of it. Under this model, could you see if you can reduce some inefficiency, aren't you reducing somebody's job? Will there be administrative positions that will not be needed under this model today? Yeah, so a really wise guy just answered the question behind me, Steven. Jobs are going to change. I mean, I think that when you think about the way that primary care is delivered on a 15 minute turnstile, we're trying to change that. And then so what does their office look like? Let's let the providers decide that. Let's let them figure out what that means. I would ask when John Romstead's digger commentary, I would ask him to get into the heart of what he meant by that. But I think there's work that has to be done in involving what people do with their every day at work, so to speak. I think it's fair to say, just to be clear about our creative answers, we don't know all the answers yet. What we do know is that the fee for service system is busted, that there's no way that it's serving patients as well as it should because of its old design for a new technology, new mission, frankly, keeping people alive a lot longer than we used to. And it's fair to say that we don't know all the answers yet. But what I do believe is that Vermont has the motivation, because under the fee for service system, too many of our providers are getting killed in the system we've got. Patients have the motivation because they find more and more that they don't get the time with their provider that they used to get. And the state has the motivation because this is the one thing that's really holding up prosperity, sucking up income faster than we are. Why would a visit to the primary care physician suddenly be extended? How are they going to have more time? So right now, on a fee for service system, whether you stay there for 10 minutes or an hour, they get the same money at the end of that visit. Under this system, they make money by keeping you healthy. Medicaid has different rates for a 15-minute office visit versus a 30-minute office visit. So how are they making that same amount of money 10 minutes versus an hour? So you have to submit that claim. You have to submit that code and say what you did. The point is, right now, we pay them. Everyone here is familiar with time and materials, right? Plumber comes to your house. You pay them for the materials that they used and their time. That's fee for service medicine. What we're talking about is, if you were going to buy a new home, you would do it on a bid. You wouldn't do it. Time and materials of the house would never be finished being built, and it would cost millions of dollars. No, it's just the way it would work. And so the way we're talking about paying primary care doctors differently, and by the way, Craig Jones right now is dying to probably explain all this. If you pay them differently, they then don't do 15-minute office visits. They decide based on what you need. If you walk into your primary care nurse practitioners or doctor's office today and say, I'm here for my annual physical, they say, great. And if you say, I've been feeling blue, and I'm not as happy as I used to be and I've been drinking too much, what do they say to you? Seriously, do they say, hey, let's hang out for the next hour and really talk about this? Let's figure it out. They can't do that. They have somebody else coming at the end of that 15 minutes. They're set up on 15-minute office visits. Is there somebody there? And there's been great work done in Vermont to get so that there's a mental health professional that you may be able to access. But we can do way better with that. You take a look at the, we've talked often about the waiting list for, at our Methodone clinic in Burlington, actually South Burlington. The system isn't set up for UVMMC and the Howard Senator to work together on a project like that. It's uniquely set up for them not to work together. Craig, come on up, because I don't want you jumping out of your jacket. So, these questions get right at the heart of it. And the opportunity really is to change what you're paying for, as you've heard described. Instead of having to work every 10, 15 minutes running patients through and generating revenue for your practice to keep your practice doors open and running, you have a panel, as was mentioned earlier, a population that you are responsible for taking care of. And if your payment's structured, and we don't know how it's gonna be structured yet, but if it's structured so that you know upfront you have a certain amount of money every month for the population you're supposed to care for, and you have quality measures you're supposed to meet, then you can change how your practice operates. It no longer has to just cycle people through to make sure the revenue's in at the end of the month. The revenue comes in on a capitated basis early. You can plant, you can change your staffing, more counselors, social workers, to be available to answer those questions about how somebody's feeling. So you can change the payment system to engineer a more effective, preventive, upstream approach to delivering care to people. And why would a hospital get into it? A hospital would only get into it if they thought the future was going in this direction and that their old capabilities to bring in revenue were somehow going to change. And CMS has already started that change nationally. So they see a future where they have to change the way they deliver care. They have to understand to re-engineer and instead of more inpatient beds and generating revenue there, they may have to have more outpatient and preventive facilities. So instead of thinking of it as why would a hospital enter in or how is it gonna hurt a hospital? The hospitals in Vermont have been progressive about this. They're looking at how can we shift our operations to bring better preventive care to people and these new payment models will let that happen. That's really what this is about. I think it's worth mentioning when I speak with my other governors around the country, Democrats and Republicans, while they're not where we are of actually negotiating an agreement with CMS that I know of, there's no question that there's bipartisan agreement among governors that this is the way to move forward in terms of reforming our healthcare system. Will one care be the ACO that handles all this for the state? So right now we have three ACOs in our state, accountable care organizations. They are three very, very different entities with very, very different size, scope and resources. It would appear to me that one care could apply to these programs and actually do them. In fact, one care applied to Medicare and received a next gen waiver for Medicare and has it now and has deferred till next year. I don't know if the other two ACOs have the size and scope to be able to participate, but I'm not gonna choose for them. That's a decision they'd have to make. And it's a competitive process. And I will tell you that they have been working to figure out if they wanna come together from three become one. I don't know what will happen with that. Is it will three become two or will three remain three? But those are all things that are yet to be determined. For some reason, this doesn't work out the way that you planned and the costs are not reduced the way that you hoped. Who's at risk? Who financially is at risk? Is it the healthcare providers? So the first thing is, and it's an important point in the contract is there's either party can get out of this pretty quickly. So it's not like we have to do this for five years if we decide it's a bad thing. So let me just say that. Second, it depends on how the risk contracts are put together. I mean, it depends on how the ACO wants to pay people. The ACO could make capacity payments to hospitals to cover the cost of their emergency rooms. And then they don't necessarily have to chase other lines of revenue that are profitable. And so, is that gonna cause risk on the ACO, risk on the hospital? That all have to be worked out. But I think that there's more than enough time to design this and there's more than enough opportunity to turn back if it's something we decide isn't good. But I wanna say one thing about risk. Every time somebody asks me about rationing and risk, I just keep thinking, you do know that it's in the current system. I mean, you know that the Howard Center can't serve everyone they wanna serve. We heard their budget. They have 500 people on their waiting list for services, not just opioid. They have 104 vacancies for people they can't hire. Okay, if you don't think that's not serving their mission, you'll see in a report that we're gonna put out Friday that it's not serving their mission. So it exists today. Blue Cross has risk. That's why they have reserves. In fact, our hospitals have risk. That's why they have balance sheets. All businesses have risk. I own my own business, I have risk. Your business has risk. So there's risk, but then there's risk that's just too big. And I don't see this creating that. I think we have to be smart about how we do it. Why is this taking so long? I thought you were hoping for something like involved, and yet you're just turning over some of the documents now? Is it just that it took longer for the state, all of you to develop the proposal to send or CMS taking a long time to figure out what it's asking you? So what I would say is that I can't believe we got it done for today. This is really, really hard. And everyone keeps saying to me, why is this taking so long? I'm like, wow, why did this take so short? I mean, this is a big deal. Let's not forget we've been in a fee-for-service broken system with the rest of the country for a long time. And finding a way where everyone can agree to move forward from it isn't easy. This is not easy work. But it sounds like there's an awful lot to go. There is. We're talking about the single biggest driver in our economy, in other words, you don't just flip on a dime. Well, and I would also say that, I don't know how long ago we joined at this podium when I first got on the Green Mountain Care Board, I think it's four and a half years ago or something. You were cleaning our grease scraps at the time. Everyone said, what are you doing with that guy? Right, what are you hanging out with, show me for, right? What's he know about healthcare? So I said, well, he knows. Well, I remember he feeds a lot of the stuff they shouldn't be eating. Exactly, I'm the problem. So, but when I think about this, we've literally been working on this for four years at the Green Mountain Care Board. We've been talking about this. Craig and the folks at the Blueprint, that is a value-based payment program that pays for performance. Medicaid has been working very, very hard. And just because healthcare is expensive, they get beat up every day. I mean, they work hard there to try to figure out how to move away from fee-for-service. And so, this is the culmination of years of people's work. And it's literally just the first step in this giant thing that'll go on for a long time. What if you're going to say that you basically have the outline of the plan here, but there are just top framework, right? Framework. Like you have tons of details. Tons. I mean, so it's... And this will go on for many years. In other words, we really are inventing a new way to pay for healthcare that improves quality, makes people healthier, and bends the cost curve. I don't want to say reduced cost, but bends reduces the amount of money we otherwise would have spent it if we stayed on the unsustainable trajectory that we're on right now with spending. That's the goal. We're about to see a new presidential administration. Do you have that in mind at all? Could that impact this plan? Yes, we would like to have this signed up while we have a secretary and a president that really want to see this done. And I can tell you, the president personally wants us to get this done. One more of the year ago, you announced that we could not proceed with single-payer assistance because of the tax increases that should be required. How does this compare to you, this all-payer model, in terms of its desirability, in terms of its significance to this reform? Would you be satisfied with this? If we can get... Listen, I mean, I said right at the beginning, even though sometimes we only remember the salacious parts, we could... There were three things we had to do in our healthcare system from day one. Universal access, everybody should have insurance. Two, move to a smarter way, pay for it from premiums to tax-based system. We're not gonna get that. And three, we've gotta find ways to have better outcomes for less money because I said at the time, there is no system, whether it's publicly financed or premium-driven supported that can support the trajectory of spending we're on now. Cost containment is clearly the most important part of the puzzle because without cost containment, nothing goes well for us. Businesses struggle, Vermonters struggle, we all lose. So anyone that thinks that the current pace of healthcare spending the last 10, 20 years in America and in Vermont is sustainable, just isn't paying attention. The rest of the world will eat our lunch since they spend a lot less with better outcomes. Going to keep back to the example of your parents and explain how their experience would be different when you're a model like this. Under this model, a primary care physician would be able to take the time to really work with them on what their healthcare challenges are and then obviously send them wherever they need to go. Under the current system, you literally, there is no incentive by providers to have coordination of someone's healthcare plan in a fee-for-service system. There's really no incentive financially to make you healthier. In fact, I would argue in a fee-for-service system, providers do better, can maybe stay in business, if you come in a lot and you're really, really not doing well because they can do lots of fee-for-service. You know, it's kind of like, think about this. The mechanic hates you driving a used car, a new car. Because what does it mean for the mechanic? It means an oil change every 10,000 miles. In and out. Get lucky if they change your, if you change over to snow tires, you know, back in the spring to summers. In the current healthcare system, if you can't do quantity, lots of fee-for-service, you really can't pay your bills. And that's the challenge we're all facing together. It doesn't matter who you are, what you are, where you are, you're in a system that rewards quantity of care, not quality of care. That's what fee-for-service is designed to do. And it was made sense back then when there wasn't, we didn't have the advanced in healthcare we have now. You really, they were providing, the job of a healthcare provider was to, you know, get to your penicillin when you needed it, or whatever it was. But you died a lot younger and you didn't have the kind of ongoing health challenges that we are now able to manage and manage well. So, you know, it's really fee-for-service that has been left behind by medical technology, medical advancement, and a whole new world where you get this down this earth a lot longer. Are there any examples you can think of from your, like your father's experience, or even somewhere you know, where the lack of coordination costs the insurance company, or whoever paid for it more money? Well, I'm gonna be a little careful there because, you know, whenever I bring up in a real example, everyone says, well, if you hadn't done this, you hadn't done it. So, you know, I'm not a doc. All I can tell you is, the healthcare providers wouldn't be coming around the table in Vermont to join this effort if they thought fee-for-service was working. They just wouldn't be coming. They would say, hey, we've got a great system, leave it the way it is. I can't find a healthcare provider in Vermont who says we've got a great system that's really serving our patients, some of them that's serving us well, can you please leave it the way it is? They're just, maybe there's one out there. I don't know, but I haven't met them yet, or yet. You said the president personally wants to see this. For the record, I didn't say that. All right, yeah. He doesn't talk to me much, I'm not sure why. No, the president really wants, you know, as you know, he has encouraged Secretary Burwell and CMS to move states towards this kind of payment model, because he recognizes that we're gonna, there's no way that we can sustain our economy or Americans can sustain the healthcare spend we're on right now. And he's aware of what we're doing, he's excited about what we're doing, and he told CMS to get moving on this about nine months ago, I wanna say. Nine months ago. Would this plan help independent physicians stay in business? I don't wanna suggest CMS wasn't moving, but he expressed his enthusiasm for them, sorry. Go ahead. Independent physicians, would this help them stay in business? Yes, absolutely. Because really, if you think about it, the people that are one of the big losers in our current system is primary care providers. It's the reason that, you know, we talk about rationing. Listen, I'm sorry, but we've got rationing right now. If you call up someone who just got on Medicaid, you go ask them how it's going, finding a primary care physician that can afford to take care of them. That's called rationing. You call 30 providers, and none of them can take any more Medicaid patients. If that's not rationing, I don't know what is. So my point is, I'm probably not 30, but they're calling four or five or six, and they have to drive farther and farther away from their homes in many cases to find someone who can actually take them. So the point is, we've got a broken system. We are, we have a real opportunity here to fix it together. Can you see the relationship between NISC and the business for physicians? Well, I mean, I'm not pretending that my provider tax fixes our healthcare system. It is a band-aid on a broken fee for service reimbursement system. So you know that I proposed a plan last year that I thought was a lot more comprehensive. As I made clear, I hope in my budget speech, I've now come up with a second idea that's not as expansive as the last, but certainly will help get us through this budget year anyway. But our system's broken, it needs fixing, and my proposal and my budget is directed at this year getting us through, or maybe the next couple of years getting us through, but it doesn't solve. It's a band-aid, not a fix. And until this new system, until we all pay our waiver? Correct, assuming that the negotiations for the All Pay Our Waiver go well for Vermont. And let's be clear about this. These negotiations are really, really important. We're gonna make sure that we don't take a situation with federal reimbursement and make it worse. So we're trying to take a situation with federal reimbursement and make it better. Isn't the issue for primary care providers that they don't get nearly as much money from the same payer, such as an insurer or Medicare, as hospitals which have more bargaining power do? Isn't that one of the issues, rather than the capitation-style payment? I think there's a whole host of issues. Most of the primary care doctors in our state get paid the same as hospital primary care doctors do for the same codes. There's a report that we have to do for the legislature and some work, and that'll come out. I think the reports are due to us July and then we're supposed to work with them. You'll get to, you know, we'll dive into all that. But let's be clear about what really hurts independent physicians. What hurts independent physicians is the fee-for-service system that we currently have that pays them, basically, on a 15-minute office visit format that Dr. Jones was talking about when he came up here and doesn't allow them to practice medicine in a way that they would choose to if they designed it themselves. And so the reason that the independents have said, that, you know, some of this makes sense to them, I'm not speaking on their behalf, is because this is an opportunity to fix some of the things that have disadvantaged independent physicians. And, you know, we've been meeting with them weekly to try to figure out how to make this work. Great, thank you everybody. Thanks, Dean.