 While he's doing that, I'm going to call this meeting to order. Welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board until tomorrow. This will be my final meeting. I have some very exciting news for the public that the governor has named Dr. Jessica Holmes as Interim Chair, and she'll be serving as Chair of the Board until a permanent chair is appointed. Congratulations, Jess. I know that the Board and the public are in very capable hands. With that, I am going to turn it over to Susan Barrett for the Executive Director's Report. Thank you, Chair Mullen. I have some updates on public comments and then updates on our schedules. We are currently accepting public comments on the FY23 hospital budgets until August 30th. We'll be accepting those comments. We ask that you please put those comments to us, either through the portal or give us a call or you can email them to Cara by August 31st so that the Board can consider the comments and their decisions on the FY23 budgets. We also have an ongoing public comment period regarding a next potential model with the federal government, an all-payer model with CMMI, and please submit any comments regarding that next potential model to us. We are sharing those comments with HS and with the governor's office as they are leading those negotiations. Then scheduling, I want to let folks know that we will not have a regular board meeting next week. That's August 10th. However, we start in earnest the next week with hearings for the FY23 hospital budget. Please check our website for the hearing dates and the different hospitals coming before the board. Cara just put that schedule under What's New, which is on the landing page of the website. It's really handy for everyone to see the schedule for the hospitals and those start the week of August 15th. With that for the last time, I will turn it back to you, Mr. Chair, and just say thank you very much for all that you've done for the board for leading our staff over these last five years. You've done amazing things at the Green Mountain Care Board, and I just want to thank you so much and we'll miss you. Thank you, Susan. I'm going to miss everyone as well. The next item on the agenda are the minutes of July 27th. Is there a motion? So moved. Seconded. It's been moved by Member Pelham and seconded by Member Holmes to approve the minutes of Wednesday, July 27th, without any corrections, deletions. Is there any discussion? Hearing none, all those in favor of the motion, please signify by saying aye. Aye. Any opposed, signify by saying nay. Let the record show the minutes passionately. So with that, the main purpose of this afternoon's meeting is to look at different tools that are available to the public and to the board for looking at pricing, and I'm going to turn the meeting over to the leader of our health system finance team, Sarah Lindberg. Sarah, at least I thought I was going to turn it over to Sarah. Susan, do you know where Sarah is? Well, let me go around the corner because I believe she's in our office and I'll see what's going on. Hold one moment, please. Yeah. Apologies for having some technical difficulties here. So my computer is frozen. There you go. I thought you just skipped out on us, Sarah. Yeah. I'm going to have to reboot my computer though. It just froze up. So I'm on my phone. So just one moment, please. I'll be right back with you. Thanks. Okay. She was just so sad, Kevin, to see you going that she just couldn't face the audience for a while. Kevin, we are going to miss you, and we just so appreciate all your service over all of these years, not only in the legislature, but in the Green Mountain Care Board, and you're truly a dedicated public servant, and it's been a pleasure to serve with you. I really do appreciate your leadership and everything you've done for Ramoners. Thank you, Jess. Mike Taltrecco, I see you have your hand up. Maybe you could kill some time while we're waiting for Sarah. It's an important time to kill. Do you have a good joke, Mike? I don't have a camera today. I apologize for that. But I may not be able to stay to the end of this meeting, but I too wanted to express my gratitude for all the hard work and your contribution really to the board, but more so in your leadership at a long time Senate position. So Kevin, congratulations, and I hope you enjoy your retirement in a different way than some of the other people that I know that have recently retired. So enjoy your families important and go embrace that time that you have with them. Thank you. I would say, Mike, that those people failed at retirement, and that's my biggest fear. But I'm hoping to stay retired and to enjoy life with my family. So with that, I see that Sarah is back and Sarah. Yes, that probably feels staged, but I know how much you value punctuality, Tia Mullen, so I didn't plan that. So are you able to see my slide here? We are. Okay, great. This is more my old data hat than my current finance team hat and just a transitionary presentation, but as the budgets come before us, I thought it'd be a good time to look at some of these different tools that are available. The reason I put price transparency in quotes is because it's a term that a lot of people use, but can mean a lot of different things, and so we can explore that here today. So the agenda will review some terms. Language is really important whenever you're talking about any of these issues. Just review some of the established goals that people consider when they are interested in comparing variation and cost repayment. Then the tools we're going to review today are both the hospital and the plan price transparency requirements from CMS. The NASHP hospital cost tool, the RAND Corporation pricing studies that have been released in several iterations, and a couple of our own tools, one being the payment and cost variation work that Burns & Associates did for us as well as the reimbursement variation report. So probably the most triggering word in this area is cost, because it means totally different things to totally different people, and truth is very relative. So if you're a patient, likely you're thinking about cost as what's coming out of my pocket to take care of my medical care, and that's going to be things like co-insurance, co-pay deductible premium, but it also might include less tangible things like the time you have to take off work to get that care or the transportation costs to get there. So when you think about medical costs, it can be quite a elastic bucket of services and expenses for a consumer. When we think about providers, usually we're talking about hospitals, but not exclusive to hospitals at any means, but that's the expenses they're incurring to provide this medical care. So equipment, the staff, compensation, infrastructure like having to plow the driveway or the time it takes to shovel your front walk, and all the supplies that come with providing the care, licensure, medical malpractice insurance, these are all expenses that providers are incurring in order to provide that care. So they're probably thinking costs in a more kind of time in materials kind of way than a consumer might be. And for insurers or the health plans, they are thinking about the cost for that service as that allowed amount, which is the negotiated rate between them and the provider. And they also have administrative expenses to maintain those services, adjudicate benefits, monitor for fraud and abuse, things like that. But these are all different costs for kind of the same interaction in the system. So the truth is that it's very hard to determine the cost of any one interaction in the healthcare system. And so we'll try and focus on things that are easier to define and measure than things like costs. So I'm gonna use the word charges and I'm as guilty of anyone of slipping on language. I'm gonna do my best to stay disciplined, but the charges would be the full amount that's billed by the provider. A reimbursement would be the actual payment made to a provider by a patient or a health plan. And then there's the expected member share. So that's the cost sharing that happens usually for a medical encounter. And that's what the hospital is expecting to get. They may or may not are the provider I should say, but that is factors into that equation and some expenses providers take on is trying to chase those payments. And so that's kind of an important factor in this. And finally, a loud amount as we already talked would be that total reimbursement. So when you add up what the plan is paying plus what the members expected to pay, you get that allowed amount, which is a usually a negotiated rate between an insurance plan and a provider. Not always, there's exceptions to every rule. But I think for most people, what they're used to seeing is an explanation of benefits or an EOB. This one I thought was pretty nice that Blue Cross in Blue Shield of Texas had posted. And basically this is trying to say what the service was, when it happened, and then that build amount is the charge from the hospital. Then there's those discounts and reductions. That's where the negotiation comes in. And then that's how you get to that allowed amount in column I. And then the health plan pays a portion of that in this case. And then in this patient's case, they had both a deductible and some coinsurance, so a proportion of those services to pay out of their pocket. So probably as if I got this in the mail, I'd be looking at that 1701 and stressing out. But there's a lot that goes behind this. And I think it's really important to keep in mind that this is probably, it could be a dozen different claims that try to get narrowed down to this service. So there's lots of different ways that the invoicing and bills are going around behind the scenes. So it's hard to kind of get this look in a claims database, but this is kind of the way that we've tried to help make it meaningful at an episodic or monthly level for a patient. And so goals, these are kind of four that I think are probably not exhaustive, but pretty comprehensive. And that is one to inform consumers. So by providing consumers the information, they can get some helpful planning in place for any upcoming medical care that they know that they need. And then it can help reveal any price differences. So if different providers are getting different levels of payment or allowed amounts for services, that might change the consumer's behavior. So they might be looking for a place that offers a lower allowed amount for a service. And piggybacking on that is the theory is it might also encourage competition. So if providers see that they're charging relatively or their allowed amounts are relatively higher than other providers that it might influence them to try to price things differently. And then finally, and this is probably one of the more controversial goals, but there is some theory that it would help with care planning. So if a provider is able to understand that the options available to the patients and include the cost burden that those options have for that out-of-pocket expense, that that might help make treatment plans that are more reasonable and reflective of the experience of that patient. On the flip side, we've got some challenges. So as I've kind of previewed this information can be really difficult to understand. And even sometimes I have a hard time understanding my EOB that comes in and I know a lot of detail, unfortunately. Also there's pretty solid consensus that just the allowed amount alone is not super meaningful without some sort of dimension of quality. So if something's really inexpensive, but not done well, that is a problem. And particularly the idea that in absence of that quality higher allowed amounts are assumed to mean that it's higher quality when that might not be the case. So if you see a $200 mattress, a $500 mattress and a $1,000 mattress, like, well, that one must be the best, but that might not be true if you don't have kind of some reviews behind backing that decision. The other problem is no matter how good you are at doing your homework in advance that you show up, all I need is my screening colonoscopy, but bang, they find three polyps. And then all of a sudden you signed up for a lot more care than you realize. So it's totally clinically appropriate to address those, but that's not necessarily what you signed up for. So it's kind of hard to anticipate. You might go in for what you expect to be a vaginal birth, but end up needing a C-section. So these expenses change. And so no matter how well that we kind of plan, it's not really possible to do it perfectly. And then as far as helping providers understand the cost implications for options to a patient is that there could be an argument that that also might bias care. So you might give differential care based on knowing what the reimbursement might be like for you as a provider. So most provider, not most, I should say, anecdotally I've heard from providers that they just want to be blind to that. They just want to be able to treat all their patients equitably without that factoring into their clinical decision-making. And I think the other thing is that a lot of these tools are not necessarily aligned with incentives for either the consumer or the providers. So even if you offer that information, nothing's kind of backing it up for people to kind of use these tools or benefit from them. And when I say difficult to understand, even if you're an expert, it can just be really challenging to figure out even what procedure you need, whether it's inpatient or outpatient, how to navigate to the actual care you're gonna get. So I think that's a really another critical component of trying to untangle this. So the first tool, the tools we'll talk about are the CMS price transparency rules. So the hospitals have to produce these annually and they need to show the actual negotiated allowed amounts by the different plan types. And there's kind of two sets of files or tools that they need to offer. One is a comprehensive machine-readable file with their bulk of everything that they do. And then they also need to provide a subset in a consumer-friendly format. And that's called the shoppable services. For health plans, that's being rolled out in three phases. So phase one started just at the beginning of last month. And that is machine-readable files for all in network-covered items and services plus the allowed amounts for out-of-network provider services. Right there, that's a pretty heavy lift, especially the out-of-network part. So they had to comply with that. In phase two, which begins in the new year, they will also need to have a consumer cost sharing tool for 500 specified items and services. I should note, and I meant to look up the citation about when this happened, but in Vermont, the health plans do offer consumer tools by law. So that part kind of has been fulfilled by Vermont law. I don't know if it's the exact same services. So they might need to extend it or adjust it, but that's something that's already been kind of available in our state. And then finally, the following January 24th, they need to expand that to be all services. So that, and I guess one other, yeah, the current tools are only available for members. I'm not sure whether or not these will be public-facing or restricted to members. So I can make a note of that and look that up. Or someone who's on can correct me where I've just spoken. All right. So, you know, me again, claims analyst just said, okay, if I were gonna get a knee replacement without insurance, what kind of cost transparency can I look up? And so I just went to four random facilities and got a variety of different answers. Some of them I don't think could possibly be right. So I like obviously made a mistake along the way. And it took me probably, you know, 25 minutes to gather these. So I think like there's a big burden on the consumer to pull all this together in the current format. So, but yeah, so that is just one really important aspect of this. And, you know, you can see as an example in this spreadsheet version that they were able to break out both the physician component and what the hospital component of that service would be. So in some cases that's much less clear. But yeah, that's, that was a long time to get that all together for four screenshots, but it was good humbling. And so for plan transparency, much more technical prowess is needed. So basically right now I tracked down a JSON file. So that's a type of structured data that's in a text format. And I, you know, did some digging. And here I found four different negotiated rates for this payer with different providers for a knee replacement. So you can see, you know, you would have to be kind of a data wizard to get at that. So it's definitely not ready for consumers yet, but, you know, this information could be powerful if anyone can harness it from just my observations. It looks like there's a lot more structure to what the plans are providing than the hospitals. So that might be an easier thing to try to consolidate, especially by some, you know, larger data companies, but the hospital stuff is still pretty tough to kind of get to the same comparative level. And I should say that, you know, an incredible amount of work goes into creating these files. It's not trivial for the plans to pull these together. So overall I would say the strengths of this resource is that it does provide us very detailed information by payer and provider. We see that a loud amount, which previously we really only were seeing those billed amounts or charges. And it is, you know, something that where you can see for off hospitals and eventually we'll be able to see for health plans that CMS can boss around. But the limitations as I have labored as that it does take a lot of time and significant content knowledge to try to pull those together. And the other kind of challenge is that if you are paying for a service through a plan, this tool isn't gonna tell you what your expected share is from the hospitals. It just tells you what that overall amount is. And so your insurer is the one that can really help you with that level of detail. So it's really, and then there can be a variation in how services are bundled and kind of paid for across hospitals. So at times it's really hard to really get to an Apple's comparison for some of this stuff. So that's kind of the high level overview of those tools. So the next one we're gonna take a look at is the Nash piece hospital cost tool. And I had this all set up before my computer crashed, but oh, it is still set up great. So here, I'm just gonna walk you through this set again, very high level, but essentially what they have provided is information they've harvested from something called HCRS. So cost reports are submitted and updated and put into this public use file that does get updated. So one important thing about cost reports is just to make sure that we know which things are more likely to be updated down the line versus others. But the first tab allows comparisons among hospitals. So if I selected Vermont as my state, and so here we see adjusted patient discharges by hospitals. So no surprise that the University of Vermont has the lion's share of those discharges. One important note is that this is something that's estimated. We know what the inpatient numbers are, but outpatient is just estimated based on the charge proportions. So if that number's off, it's gonna trickle down through all of this. However, the same method is used across everything. So unless we have reason to suspect a systematic difference, that might be okay, but it's just an important caveat. And then if you look at how they're measuring the net patient revenue per that adjusted discharge, you can see kind of statewide comparisons. So Vermont is showing up as 11,923 for the median. So that is in the second tier of their encoding here with Alaska being one of the more expensive at 33,459 with 22 hospitals. But I think one thing I like about this is I think it does have kind of, if you actually encode the variation that we see, it does help clean it up. I'm sorry, we're in the third tier, not the second, but yeah. And you can see that this thing is also gonna be sensitive to utilization. So if people aren't utilizing care, the expense goes down, the revenue goes down. Is that right? Yeah, yeah. Okay, sorry. And then here we see it just in a graph form for the Vermont hospitals. So one thing to keep in mind here is that low denominators are gonna make for some wonky things, which is probably part of what's going on here with Grace Cottage's result. And also the types of care they're providing. So if they're providing more intensive care, like I say rehab or something, probably that value is gonna be greater. And then they have the operating cost per adjusted patient in discharge. This is as defined in the cost reporting. So again, nobody knows what cost is. This is just one definition that is not the true expenses necessarily faced by the provider, but Medicare tries to get it in a consistent format. So we're trying to get apples to apples there. Here are the operating costs by discharge for the Vermont hospitals. And then the operating profit and loss. So this is from calendar year 2019. These numbers are likely not gonna tie to what we get in the hospital budgets just because we have a much more comprehensive set of financial indicators than the cost report offers. So this is gonna be high level policy idea of comparison. So I think it's important to remember that we're gonna have more detailed data. They also show charity costs, uninsured and bad debt as a proportion of their net patient revenue and the cost to charge ratios. So basically of what Medicare is assigning these things to how does that compare to your bill that you're getting sending out? So that is the first, oh wait, I'm sorry. The last thing that they include is what they call the commercial break-even point. So that would be what proportion of Medicare commercial payers would need to pay to get to 100% of the Medicare rate knowing that they're taking losses. So Medicare doesn't pay 100% of the Medicare rate per se. So this is also gonna be something that we wanna watch carefully in the next round because those kind of ratios are based on the RAND study that we'll talk about later. And this is in RAND version 3.0 which didn't have a lot of Vermont data. So this needed to be computed for Vermont hospitals. So I probably why I almost skipped it is like I'm not ready to look at that. I'd love to see it next year once I have our data in there. Yeah. So then you can also look at a single hospital on some of the same metrics. So I just picked Maine Medical Center. So you can see their operating costs and revenue over time, net profitability indicator. So how much are they, what's their operating loss or gain, the net profit margin, that uninsured and bad debt over time. And then they have a payer mix including that charity care and other fund sources. They have it by payer type what those operating margins are and the profit margin. And then here are the cost to charge ratios over time and that commercial break even over time. So lots of material here. And then if you wanna look at the whole state so you can compare Vermont to national it's pretty much the same measures. And then you can also, one thing I think is kind of neat is you can look at it by health system. So here if we compare the UVM health network to the Dartmouth Hitchcock Health Network you can kind of see how they are operating at that more network level versus at individual hospital level. So I think it's an interesting tool. I think it's a helpful tool but I also think it's a high level tool and that it can be the start of some questions but I wouldn't end there by any means. And talking with the people who developed it said kind of something similar. This is met high level top line comparative to help inform policy. So they were not recommending it as a direct regulatory tool by any means. It's also somewhat lagged. I'm already getting into this but yeah. As I said, standardized high level information we can see those comparisons that we walk through. They do use very transparent methodology which is nice and they have a public use data set which is helpful. But it is pretty lagged, 2019 is the most recent. I already mentioned that Rian 3.0 pricing might be a little suspect for Vermont in particular and those utilization estimates like I was saying. So since they're backing into the outpatient utilization if there's anything wonky with that that varies by hospital that could be kind of a problem. All right, I'm gonna take a drink. Rian, so we just said that these studies are actually feeding into the previous tool but essentially this is a series of reports that was initially envisioned to help employer groups learning about their payment variation between providers. So employer purchasing groups are the ones who are figuring out who the best administer benefits for their employees. Is it some administrative plan where they're self-fund? Is it a fully insured plan where they can be underwritten because they have a good risk profile? But the idea is that if they had more transparency into what's being paid they could help incentivize their employees to potentially seek different care options and or negotiate different allowed amounts with the providers. So this most recent iteration is the fourth take and it uses data from those employer groups. All payer claims databases like we sent in and then some health plans have also submitted data voluntarily and they're calculating two different things. One is a standardized price which is saying I'm gonna try to tie everything to the same unit of service and I'm gonna try to use that, get to that with using Medicare's relative weights and then figure out what is being paid on average. And then I'm also gonna see what that relative price is compared to Medicare. So if here's what the payment was for commercial, here's what it would have been for Medicare, what's the difference there? So what's that delta? What's the commercial payment relative to what Medicare would have paid? And I have the link here if you wanna look at all the gory details, but I tried to summarize it and I think that both those measures are important to keep in mind. So if you look at the right hand graph that shows our PPS hospitals, you'll see that the University of Vermont and Dartmouth actually have a very similar standardized price for their inpatient care. So the price per discharge is really close on the X axis but the relative price is really far apart. So that tells me that Medicare is likely reimbursing Dartmouth differently than UVM. That probably has to do with the regional adjustments. I think that Dartmouth might qualify for the Boston kind of bump. So I think that you can't look at the relative price alone is kind of the major thing here. But if you look at the median reimbursement per discharge in the whole study was about $20,500. So we have a few that are above that and a few that are below that for the PPS and the median reimbursement for the critical access hospitals tended to be higher than the median, but also overall there was less variability in that dataset than the PPS hospitals. And so for outpatient, we see, so price per outpatient service is gonna be a lot more services less expensive each. So we see that most of our hospitals are above the line but not too far off the 282 per outpatient service on PPS a little bit more spread for the cause but their price per service is a little bit higher as well. So the 331 for the relative price but we see more of that disparity in the relative price in between Dartmouth and UVM and the outpatient side. So yeah, so those are those studies. So it's just commercial insurance but it is give us more of a national perspective on facility differences. And I like that it does both of those calculations. So we can kind of consider those more holistically. However, whatever we see in her may be distorted by the plans we choose to participate in particular if we've over-weighted self-funded plans they tend to have a higher average allowed amount. So that might be bringing things up in this study. And we're only seeing that commercial stuff and the comparisons are at a facility level. So sometimes that's a little tricky because a facility that's doing relatively more acute care is gonna look more expensive and that's not about anything but like this type of stuff they're doing. So even if you standardize it by the relative units they're doing more acute relative units. All right, two more to go. Everybody doing okay, here we go. So our payment and cost variation work was done by Burns and Associates. And so part of what actually inspired it is getting some feedback about challenges with the RAN methodology. And one thing that immediately cropped up is like there's no assessment of costs there. We talked about how that's a very difficult thing to factor in, but we kind of blended both the hospital cost tool and this RAN thing to come up with this methodology. And so what we said is, let's look at what the cost to charge ratios are in the Medicare cost reports. Apply those at a claim line level to kind of get those relative weights and we're gonna see how things compare for what the Medicare cost should be. So those ancillary services, bill and charges to the cost is gonna give us that Medicare allowable cost. So it's saying, according to Medicare this is what that service should cost to provide. And then they look at, we also looked at what the payment variation look like and how much those payments are covering those Medicare derived costs. And so kind of the lessons we saw there is not surprisingly, this is looking just at the outpatient services that are adjusted for acuity. So the average payment for the commercial plans was quite a bit higher than the governmental payers. However, we saw much less spread in the costs. So even though costs were pretty comparable across the payer types, the reimbursements are higher for commercial. So this doesn't tell us why that is. That doesn't tell us if it should be. That just tells us kind of something we already know, but that the payment rates differ based on payer type. And we also, I think what was neat is that we also looked at how the costs, I'm sorry, how the Medicare allowable costs payments and payment to cost ratios differ based on service line. So we not only saw comparisons across facilities, but even within facilities by service line. And we can see here that imaging tended to have a higher relative payment. If we Medicare fee for services 100%, closer to 300% for that, those imaging buckets for commercial payers. And we can see that it also was interesting that for some procedures that we saw that Medicaid was actually offering the best payments for mental health and substance use services. So the strengths of this is that it did incorporate some assessment of costs in an apples to apples way and give us some insight into that variation within service category as well as across hospitals. But it only was the facility claims. So that's the thing that's easiest to be like, yes, that I know this is tied to this facility. It's only the people we have in our APCDs of Vermont residents with claims in there. And as we've really driven home today is the actual expenses to the hospitals, not the same as the cost as defined in the Medicare cost report. So even though it's like a way to get at comparative costs, it's not actually what that service costs or all the expenses behind delivering those services. And then last but not least, per statute, we built out this reimbursement variation report. And this one's quite a bit different look than the others have been. So this is saying more from say a consumer's point of view, if I have an upcoming service, what is the total cost of that episode? So I know I'm gonna have imaging, I'm gonna have maybe some aftercare. So we are pretty tight. We don't like do any like follow-up periods or anything like that, but we do include everything that happens on the day of a surgery for outpatient surgery types. And I think what this, I just wanna remind people that, there's a median reimbursement, that's the allowed amount for that service, but there's variation within that. So there's both variation between the hospitals and within the hospitals. And so it's very hard to show both those things at the same time. So just a reminder that any points you see here have these confidence intervals around them. That there's definitely a lot of variation even within the same service at the same facility. And so here, this is showing MRI of the spine. So you can see this is for all payers, what the difference in that allowed amount per episode is. And you can select for different procedures and you can also select for different time periods. So that's just a very high level and you're also able to look at it by payer type. So this shows commercial Medicare and Medicaid. So good content validity when you see Medicaid all lined up. That's what you'd wanna see if you're doing it correctly, but you can kind of see how much variation there really is between providers for this. And then if you wanna look at a specific provider, so if we wanna look at Dartmouth, we can see that point estimate as long in the variability from the fifth to the 95th percentile, as well as their payer mix. And if you wanna only look at it for certain services, you can also drill down to that. And then that full data set is here as well as some technical documentation. It will also show you the, if you want, you could just look at the member share. If you wanna be interested in the expected member share variation, you can see smaller numbers, a lot more variation. Stu, that is the last tool. It's, I think it's helpful to be able to show the full episode of care and showing that all that variation within and across facilities. We're not incorporating a specific person's benefits. So it's not very helpful for shopping purposes again, because we don't know what your specific benefits are. It's also lagged, you know, we're up to the calendar year 2020 and it's only limited to a few services at this point. And probably the most important point for regulatory purposes is just because a facility is associated with the service, doesn't mean they got all the cash for it. So like anesthesiology is kind of a classic example. They're often contracted out. So even though that's included in the cost of the episode, that doesn't mean that facility got that money. And so it's gonna be less kind of one-to-one with what the hospital or other provider revenue might look like. So to wrap it all up, all the resources are backward looking. When we're thinking about budgets, we're looking forward. So that's always an important caveat to keep in mind. And I think that all of these tools aren't gonna be a tidy fit for a hospital's financial picture. And that's okay. Like we can buttress analysis around that, but I think there's not any silver bullet here. And I just want us to be careful with some of these tools. So for instance, looking at things at that negotiated level, unit level, could distort things just because of those billing practices and other things. So it's also unwieldy to try to get it in a comprehensive uniform format as I showed you. So that's just gonna be, it can give us a sense of how things are going if we have a specific type of service question. I think it would be a good tool, but when evaluating next year's budget, not the easiest thing to translate into that. The ran payment variation, I think at a very high level can look at both that standardized price as well as the relative prices and look at some, they do have, I think two or three years of data in there so we can look at some trends. But that's all back to 2020. It's very hard to apply some of those lessons to the current environment. For our payment and cost variation. So we pulled out a lot of things because they don't really have a Medicare allowed costs or payment associated with them. So labs are kind of a notorious example. There's not an OPPS reimbursement tied to that. So we don't have that in the study and that tends to be a revenue loser sometimes for hospitals. So the other thing is that we're not seeing a lot of other important dollars such as dish, graduate medical education in some cases. And the tricky part is that we're using the would have been paid for Medicaid and not those fixed perspective payments. So as we move away from fee for service, this kind of comparison gets a little funny like when you're looking at what would have been paid. So that's one of the trade-offs I think to reform efforts. And I already kind of highlighted the challenge with the reimbursement variation report. So I don't mean to say that they're like not valuable tools. I just think that when you are trying to apply them for a hospital budget that there might be little slivers here and there we can kind of apply but we're not gonna have like a magic way to like figure out what is appropriate in this domain. I think, yeah, I think it would be a great goal for us as an organization to think about why do we care about price variation and kind of start there. And then once we know what the goals are around monitoring it, we can kind of hone in on more specific ways to measure what we're interested in. So that felt like an intense lecture. I'm sorry. I think you're on mute, Chair Mullen. Good board members have any questions or comments for Sarah? Robin, your lips are moving, but I can't hear you. She'll have to sign off and back on. I can be very brief while she signs back on. I just wanna say thank you, Sarah. It's a topic where terminology matters a lot. And people will both use the same term and think they're talking about the same thing when they're not. And it happens over and over again. We see this just talking about margins. If you have a financial officer and a surgeon in a room and ask if they understand margins, they'll both say yes but they're not thinking the same thing. And so it takes work to make sure that there's shared information, shared understanding and shared language when you do this type of work. And so thank you very much for talking us through this. I appreciate it. And Robin, are you back? I am. Can you hear me now? We can. Oh, good. Yes, my usual teams challenge. So I wanna say thank you, Sarah. I think this is helpful context to your point. Not one-to-one translatable into the budget process but I think having the different lenses provides more context, which at least for me is always helpful so that I'm seeing things in a broader and in the bigger picture as well as the minutiae of each specific hospital budget. I didn't have any specific questions, but thanks. Okay, other board questions or comments? Yeah, I have one probably idiotic question but given the complexity of all this data, I mean, it is overwhelming. Every time I've tried to kind of poke around it, it's so easy to get lost. You've had some of the independent providers say that they're not being treated fairly by the commercial payers and you can kind of go on and look at some of the procedures in our variation report. And at least I think I see that. I think I see information that would confirm what they're telling me but I don't know, I'm just not sure. And I mean, when I first came on the board, there was a cardiologist, an independent cardiologist that came up to me at a meeting and said that they were getting paid peanuts for an echocardiogram, for example. And you look at your report variation report and that cardiologist is being paid 322 bucks for their echocardiogram versus the UVM medical center getting paid at the higher end of $2,166. But I've learned that you can't jump on that data and write it anywhere very far, very fast. As much as you want to help these folks. But one thought I had is, given the CMS data for the hospitals, they all have to produce a report once a year on January. And so I've spent some time poking around those websites and a few other people I know have as well. And they found that it was very difficult to use that because different technical platforms, it's just a whole bunch of variation out there. And I just wonder that for something that has to be produced once a year and there's only 14 of them in Vermont hospitals, why can't we at least assist in creating a common format for the reporting of that data that all hospitals, and we would have to work us out of the CMS, but given our relationship with them, I can't see them resisting this. So that at least once a year, that data, those 300 shoppable procedures are in a format that allow not, maybe not so much patient facing use, but public policy use. Yeah, it's just overwhelming. And if there's somebody out there that can create a simple path through that and how they used it, it would be helpful. So that was just one thought I had is once a year, there's 14 of them, why can't the Green Mountain Care Board save the hospitals? Here's the format you're used because obviously all Vermont hospitals have submitted two or three of those reports by now because this law is two or three years old. They've all submitted them and none of them have been rejected or fined or anything. So it seems that what they're submitting, even though it's a variation, CMS isn't complaining. So if we could get them on the same platform, that might be helpful. But there again, I'm sure there's a hundred reasons why it wouldn't be helpful, but that's my simple thought about that one. So thank you for this. I mean, it's, I've learned to embrace your ambivalence about making any conclusion about what you think you see because what you think you see might not be what you really see or so. So thank you. Thanks, Tom. Other board member comments or questions? If not, I'm gonna go to public comment. Does any member of the public wish to offer comment on the price transparency presentation? You can either raise your hand or if you're on the phone, just speak up. And the first person I'm gonna call on is Eric Schulteis. Eric. Great. That was a wonderful presentation. Thank you so much, Sarah. I think when I'm looking at how much the board's capacity to look at data has improved and I'm thinking about what the next step is, it really is in thinking about continuous improvement. It really is moving beyond data and information to knowledge and trying to understand what is the cause of what we're seeing. So data informed policy shouldn't just be about looking at numbers, but actually using the data to draw hypotheses about why things happen the way we do. And I mean, I think something Sarah said, it just shows us what is. If I'm thinking about some work I did for the Cambridge Housing Authority that I think that illustrates this point is we did mapping over a decade and a half of section eight voucher flows, usage flows. And in the end of the day, all that I told us was that there's this movement happening outside of Cambridge. And I think the knock on part of that was to try to understand why that was happening. And that involved talking with clients, it involved talking with realtors, it involved talking with the universities. And what we ended up finding was that the universities were selling or leasing property to large companies and it was displacing that. And the universities weren't like kind of building affordable housing for residents of Cambridge. And so I think for us, it meant that if we had just tried to increase the fair market rents that HUD allowed, so allow clients to lease off, that really wouldn't have solved the underlying issue, which was what the universities were doing and how they saw their commitment to the community. And they weren't thinking about this, they weren't aware of this outflow of Cambridge residents. So I think that in the end, data informed policy is trying to move just beyond charts and data and draw inferences from that data about why things are. And the hope for that is that then when you have policy interventions, it's your best guess about what that interface, based on your idea of causation, what that intervention will do. And I think that in the end of the day is what's most important to having effective policy. Thank you. Thanks, Eric. Next I'm gonna turn to Walter Carpenter. Thanks, Kevin. I guess this is your last meeting, huh? Wow, I came in the last row. Your last row, God, I wore out, I wore out three board chairs. In any case, my comment is, I'll back up everybody who said, praise Sarah for her presentation. And I just back up Eric and what he said. I also wanna say that this presentation argue is a great argument for simplicity. As a patient, to try to get to the bottom of this would be virtually impossible as Tom said and Tom's experience with this, as he says that, can you imagine what it was like for someone who was uninitiated and as to suddenly look at these facts, figures, statistics, et cetera, and try to compare them? And it's just, it's nuts. So I was wondering if there is a way to simplify the whole thing and put it down into, here's what's this charge, et cetera, et cetera. That's all. Thank you, Walter. Next, I'm gonna turn to Ham Davis. Thank you, Kim. I may basically have questions if you could ask, I could ask through you. One of the questions I have and I'd like to ask Sarah is my sense is we're not rigorous at all, but that is that as we went through all the work by the consultants and the blizzard of stuff that's come in on all of these issues over the last couple of years, there's been some of the data has been hospital only and not doctors in other words. And so what I'd like, my first question to Sarah is, can you just tell us to what extent is the data that you're providing when you're using the word provider? Is any of it affected by being, including only hospitals and not doctors? Can you just tell me whether that's a problem or not? It depends. Some of these resources would include the professional claims. Most of them don't. So, but okay, so in your judgment, Sarah, do you really know what the costs are if you don't know what the doctors are getting? Really? Yeah, it's a huge issue. And when you say what doctors are getting, like do we mean that can look a lot different if it's like an independent provider or a salaried provider at a hospital, right? Like what's the most meaningful metric there? I don't know. Thank you. I just think we need to start figuring out a way to get the, when we get the cost of some, you go to, if you get a medical procedure, you have to pay the doctor, but you also have to pay the hospital. If you only know, and the real driver is not the hospital, the driver is the doctor, the real decision baker is the doctor. No hospital out there, no hospital administrator is deciding whether to operate on the left knee or operate on the right knee. It's all the doctors. The second question I'd just like to ask, Sarah, and I know this is maybe just a fantasy, but is there any way in your judgment, Sarah, to start building in volume into these, volume into these judgments. If you get a service, some service, a knee replacement, you guys gonna cost X at one hospital or Y at the next hospital and so forth, and you're gonna see the difference in cost of the provider. The whole purpose of the Greenmont of the Dartmouth Health Atlas, and which is considered, I think, a highly reliable piece of analytical Bible, in fact, is that if you could have a hospital with very low cost for discharge, okay, but if it was doing twice as many discharges, then the cost for the low price place would be the much higher cost place. Can you tell me what you think about this? Is there a way to start moving towards the volume-based thing, which in point of fact is the whole goal of healthcare reform? Yeah, the reimbursement variation tool does include the number of procedures. So that is there. It's not directly visualized, but yeah, I think the long game here is once we come to some goals in the hospital budget process, we can do a better job of building the monitoring tools to support them. And the hospital discharge data set was built to support the hospital budget process that's drifted over time. So I'd love to see that kind of come back into fashion and yeah, figure out what these key metrics are and do a better job of kind of simplifying them to an earlier comment. Kevin, that's all. Thank you, sir. Thanks, Ham. Is there any other public comment? Hearing none. Thank you, Sarah. It was both enlightening and frustrating at the same time. So thank you. My biography title. So with that, is there any old business to come before the board? Hearing none. Is there any new business to come before the board? Hearing none. Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion, please signify by saying aye. Aye. Aye. Any opposed, please signify by saying nay. Nay. Nay. Oh. If we don't adjourn, you can't leave, Kevin. I still have another day, Robin. So I guess I can wait you out for a day. Let's try that again. All those in favor of the motion, please signify by saying aye. Aye. Any opposed, please signify by saying nay. Nay. Thank you everyone, have a great rest of the day. Thank you, Kevin, for all you do. Thanks. Thank you, Kevin. Bye.