 Good afternoon, everyone, and welcome to the Green Mountain Care Board. My name is Kevin Mullen, Chair of the Board, and I'll call this meeting to order. The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you, Mr. Chair. First scheduling updates, I wanted to let folks know that we took off the Primary Care Advisory Group meeting that was scheduled for the 20th this evening, and we've put that to next month. We also added a morning meeting for next week's schedule. So that meeting starts at 9 a.m., and that is Blue Cross and Blue Shield, and MVP will be coming before the Board to share their updates on healthcare reform and other activities. And then we'll come back in the afternoon, and we'll hear from the University of Vermont Medical Health, University of Vermont Health Network, and an update on the inpatient psych unit. And then we also have after them our colleagues from the Department of Mental Health who will be giving us an update on their work. So I just wanted to make sure folks knew about those scheduling updates. And then two public comments. We have the ongoing public comment period for any comments folks have regarding the potential next agreement with all-payer model agreement with CMMI. We'd ask for you to share those comments with us. We share all of those comments, sorry, with our partners at AHS, as well as the governor's office. And then the other public comment is the Department of Financial Regulation and the Department of Vermont Health Access came before us earlier last month and talked to us and presented information on the new EHB benchmark plan. That is open for public comment. And if you go on our public comment portal on our website, we have a link to the Department of Financial Regulation website and you can public comment there. I want to alert folks that that public comment period ends 5 p.m. Eastern on Monday, May 2nd. So please get those comments in if you have them. And I have nothing else to report. I will turn it back to you, Mr. Chair. I apologize for the howling dog in the background. He likes to howl at the answering machine, so. Okay. Next on the agenda are the minutes of Wednesday, April 13th. Is there a motion? I'll move. Second. It's been moved and seconded to approve the minutes of Wednesday, April 13th, without any additions, deletions, or corrections. 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 that the minutes were approved unanimously. So next, I'm going to turn it back to Susan Barrett to introduce the leadership and preventive medicine residency doctors. So, Susan. Yeah, it's actually a really hard concept. They're residents, but they're also doctors. So they'll explain their program when they introduce themselves. But thank you, Mr. Chair. Today, we're welcoming doctors from Dartmouth's leadership in preventive medicine residency program. They are currently performing their government rotation with us at the Green Mountain Care Board. This is, I think, the fourth year we've hosted residents from this program, and it's been a really valuable experience for us at the Green Mountain Care Board, and I hope for the residents as well. Again, I know they'll get into a little more details about their program, but just as a summary, these physicians are currently in medical training in various fields at Dartmouth Hitchcock Medical Center, and they've also been accepted into this LPMR program for additional training, which at the end of that training culminates in the fact that they have a masters in public health on top of their specialty that they are doctors in. Just a little background on the work they've done with us this year. They've worked with our staff on Act 159 Hospital Sustainability Planning Report, and then they've also worked with our data team to look at ways to improve race and ethnicity data and collection and claims so that we can help inform health equity programs in the state. They're both still working with us, but I know they're going to be wrapping up soon, and they're going to be moving on both of them to exciting new programs, which I know they'll share with us in their presentation. So I want to turn it over to Doctors Alveil and Dr. Feng, and they're going to share their perspective on hospital sustainability and value-based care from a clinical perspective, and then also offer a high-level overview of health equity and how we may measure that in regulatory processes. So I will turn it over to the doctors. Thanks, Susan. This is going to be pretty interesting. Thank you, Anise. So we are, as Susan said, clinicians from various backgrounds. I myself, I am internal medicine-trained, board-certified, and Anise Ovalle, she will introduce herself, but she is also internal medicine-trained and also infectious disease-trained as well. And we're very happy to be here. We're very thankful to be given the platform to speak with you guys and to work with the Green Mountain Care Board on multiple issues, as Susan had mentioned, and having the opportunity to share this public comment, which was submitted to you guys and for you guys to read over has been quite rewarding. It really gave us new perspectives and the approach to healthcare policy, and certainly something experiential for us to reflect on. But anyways, this is going to be sort of a focused public, I guess you can call it public opinion or testimony, on reflecting on the public opinion piece that we submitted. And furthermore, we have no disclosures of any kind. Next slide. So as I was saying, our expertise is in biomedicine and clinical care. What that means is fairly concrete, despite what others may think. We went to medical school to study the human body, its biology, physiology, and its disease states. In other words, you know, you ask us about heart disease, and we can probably talk for hours of reciting causes, pathophysiology, medications, therapies, et cetera, and how to treat and manage such disease processes. However, if you ask us about how to get medications and therapies in the most efficient and best way possible to the patient or to the community, we can have a discussion. But ultimately, I myself would probably say, oh, I would probably ask my case manager or nurse care coordinators in the office because we're not experts in that field. For us, our further training has led us towards a new perspective in medicine in the LPM program, beyond the concrete science, and rather into healthcare delivery and implementation of efficient methods on promoting that type of delivery. And we're here today with you because we believe there ought to be a voice heard from healthcare workers. Obviously, you know, we're merely providing a facet of the many other individuals involved in direct patient care, but we hope that what we say may cling on and have some influence for the board today. Next slide. And so, you know, I'm terrible at giving or making power points, but a lot of people have said that I can, you know, talk to brick wall and I'll talk back. So I just put one name on here, and this is an example of a patient. His name is Fred. Fred is known to, obviously it's a pseudonym, but this is a clinical case that I myself and Anis have come across a few times. You know, those who read our public opinion piece that was submitted to the community already know who Fred is, but for those who did not, he was a patient that intersected with our healthcare clinics. You know, despite having excellent subspecialist care, he ultimately was admitted to the hospital due to an infection that was not well controlled in the community as an outpatient, rather. Unfortunately, the reason for Fred's admission was his hesitation to follow up due to the cost of care and reluctance to spend his hard earned money out of pocket to ensure that his illness was taken care of. Fred's story is, unfortunately, not that uncommon. And certainly during the pandemic, we've seen slightly more cases of it. We all have seen patients who could not afford even an annual visit due to the lack of coverage by insurance, lack of qualifying factors so that they can have Medicare or Medicaid, or simply didn't feel the need to see a physician until whatever chronic disease, state or illness was too late to reverse. You know, in our minds, Fred is a persona that motivates us to do better. Next slide. And so I don't think many individuals understand what physicians do on a daily basis, which is fine because it's mostly sort of details anyway. But more and more, we are hearing physicians leaving the workforce retiring early or sort of burning out, right? The phrase burnout is often heard. What you typically see if you at every visit with the provider is you see us running back and forth in the clinical space. We see about 10 to 20 patients on average a day spending about 20 to 40 minutes with each patient on a good day and having a wide range of discussions with our patients, whether it's about their illness or simply sharing life events. Some days the conversations can be very simple, like, you know, take a vitamin every day or no, you really should continue this medication to very difficult conversations about end of life care and hospice. Ultimately, what is not seen is what drains us most because a discussion about medicine and therapies or treatment is what we are trained to do. But behind the scenes we enter billion coding parameters for our patient encounters, making sure that we charge as high as possible for the patient visit we just completed. We learn about new updates in the electronic medical record and click around sometimes aimlessly to try and figure it out. We coordinate our workflows with our colleagues and medical assistants, secretaries, nurses, who without them we would be lost. We spend time on the phone with patients and other providers to share information, give instructions, something that cannot be built. We send faxes, emails, advocate for patients in public or government settings like we are now. And most of these tasks are completed outside of the face-to-face hours with our patient, usually between eight and five every day. And usually in the primary care setting, such conversations and work may be unequally compensated. So let's take a look at an example of a specific encounter from a clinic day for me. So Neosarathritis or Arthritis for short. So usually it involves a yearly checkup for lifestyle review, weight loss and exercise measures to strengthen the knee joint, screening for other diseases that potentially can be contributing to Arthritis. Physical therapy, medications, and time. So time is very important. And usually these visits to prevent further damage from Arthritis, it takes multiple encounters over months or years. Now let's consider the alternative. Let's say you know the knee osteoarthritis had gotten so bad because of improper follow-up or what have you that a knee replacement was needed. Well, this is a surgical intervention. So it needs a surgical evaluation. You need a surgical team. You need medical equipment. You need rehab after the surgery. The time required is certainly short. It's hours to days to weeks for rehab. But you know the cost is going to be several tens of thousands of dollars just in a conservative estimate. Another example, if that didn't drive home the point, let's take a look at coronary disease, coronary heart disease. Usually in the primary setting, it involves again, yearly checkup, cholesterol, blood sugar, blood pressure checks on a yearly basis, the correct medications, lifestyle modifications, follow-ups in the office, evaluation of cardiac risk. Usually it takes one outpatient care team, usually the primary care team, and perhaps a cardiologist. And the time required again is time, multiple encounters over months, the years. But once there is an acute coronary event or a heart attack more colloquially, the immediate interventions kick in to save the heart and the patient's life. And so the cost of an acute, to treat an acute heart attack is, again, several tens of thousands and upwards to estimates of hundreds of thousands by some estimates across the country. Next slide. So, you know, this brings up some questions and I'll present some of the rhetorical questions here, which we ought to think about, which you may or may not already have an answer in your mind. Which is better for the patient? Which is better for the bottom line for a healthcare system? And which one prevents the worst thing of the disease process, right? Is it the preventive measures and the yearly follow-up and making sure that the risk is lowest? Or is it actually going forward with the high-risk surgical interventions or procedural interventions that are certainly able to prevent further damage? But does it prevent future issues down the road? After all this, the question is how to balance this out, right? I'm an advocate for the need of any sort of medical intervention or acute intervention in medicine. Preventive medicine only does so much and we're aware of that. And without the capacity to do procedures as listed above, that would be a serious flaw in our healthcare system. Rather, what me and my colleagues are advocating for is changing the incentive and perspective that permeates the healthcare system today. That increased spending and billing for encounters and procedures is good because it earns us more money. We're advocating for a system where rather at least the change in culture where it is good to have that conversation about weight loss or to have that conversation about lifestyle changes and other preventive measures to stave off the need for a costly, risky, and sometimes very, very acute and immediate procedure. All right. So this approach should be data-driven, evidence-based, and certainly in the primary care setting. All this can and should be executed in a primary care setting. The emphasis on this is data-driven. There is a wealth of data available publicly and even more troves of data available within each healthcare system that is privately owned. There are methods to put that data to work and not have it just sit in some data warehouse, and all of this data, both clinical and administrative, can be used to target populations and deliver the care that is needed in a more precise and efficient manner. All the while anticipating gaps in care to an extent in the future. In addition, there needs to be a strategy to address health equity, which we believe can be solved with the proper utilization of the data you already have. And so how do we address this? Let's take a look at the example again with heart disease. Next slide. So here we have a map of northern New Hampshire with the shaded area on the left, so the left panel there. Shared area being the estimated driving time of one hour around a very prominent academic medical center in Burlington. So that's pinpointed by the car icon. So in essence, the shaded area is the patient catchment area around the academic medical center's cardiology clinics in Burlington, Vermont. We see that this catchment area overlaps quite nicely with areas of Vermont with the lowest prevalence of primary cardiovascular issues reported between 2013 and 2015. That's the right-hand side. Some individuals might say, well, telehealth can expand that coverage a bit. There's data for that as well. Next slide. So here is a survey which shows that the percentage of individuals per county that have at least 25 megabits per second of internet speed, some consider this as the minimum you need for a successful telehealth video conference or telehealth video interview. So in the Northeast Kingdom, we see the county of Essex highlighted. This is highlighted because it has less than 15% of individuals having this specific internet speed capable of a video telehealth appointment. In addition, the surrounding counties around Essex County have a range between 40 to 60% of individuals with this minimum required internet speed. Next slide. And so what's really important to us? You know, I gave the previous two slides and the data representation mainly to make the point that you have this data available to address certain inequities in your state and in the healthcare system. For me, as a clinician, we sort of gravitate not only towards our teaching, our education and our training, but we have certain tools in our toolbox that we can use. And clinicians have risk indices and risk scores. And what these risk scores and risk indices are are peer reviewed, published, evidence based scores that help us sort of determine a more holistic picture of a patient's illness and prognosis. It's mainly an input-output relationship. We put in what we find in our history and examine into a calculator and it gives us a score or percentage of likelihood of disease. It is sometimes very useful for definitive decision making, but more often than not, it serves as a guide for us when it comes to thinking about a medical management issue or case and trying to anticipate clinical course or outcomes in the future. In other words, risk scores, when created appropriately, statistically justified and clinically proven, act as guides for our clinical decision making. And one way of thinking about it is it compresses a lot of the individual data points that we see in our patient cases into an overall score that lets us understand a broader picture of the case. So my work at Dartmouth is risk stratifying individuals in a population level with regards to chance of admission to the hospital. Next slide. Yeah. Similar work has been done already, focusing on specific illnesses like community acquired pneumonia. And this is the graphic, a results graph that we'll go over in just a second. So for those of you who are not involved in health care community acquired pneumonia, or we call it as CAP for short, is an infection of the lungs either by virus or bacteria that usually requires an admission to the hospital. This diagnosis also pretends to an increased risk of re-emission. And so this article by this individual who I won't try and butcher their name on the public air, published in a very prominent journal, CHEST, in 2009, showing that certain risk factors pretend to a worse survival, or in this case, event-free survival, after discharge from the hospital. So in this article, he and the colleagues looked at the propensity for re-emission among patients initially admitted for pneumonia and distinguished certain risk factors such as laboratory tests, vital signs, length of their initial admission, et cetera, and came up with a method of risk stratifying these patients. Now looking at this, you can see that individuals with three risks or more had a worse survival outcome compared to those individuals with zero or one risk factor. As a clinician, I can then take these results in conclusion, apply them to the patient in front of me, whom I'm perhaps seeing for community acquired pneumonia, and it helps guide me to understand how to approach their transitions of care back from the hospital to the community and their homes in the most efficient and safe manner possible. For example, I can see that an individual with zero risk factors, I can not delegate as much resources and time and nursing care and nursing care visits as much as I would for an individual who I see with three or more risk factors. The principle can be applied to other chronic disease processes such as high blood pressure, diabetes, emphysema. On a population level, one can even focus down on these most highly prevalent, highly costly chronic diseases, all of these in the primary care setting. And we can highlight these individuals to help in our communities and be able to delegate the necessary resources in a much more efficient manner. This can also be applied to the general population with regards to morbidity and mortality risk beyond just the single disease process. And I'm certain that with the data that you have, you can do it too. This allows a healthcare provider to look at the patient, see a risk score, and be guided appropriately through a more holistic medical decision making process. And like I said, this is a good start for what we're advocating for, the use of the risk adjustments based on clinical conditions is a reasonable approach. And it's much better than trying to figure out ICD-10 coatings, billing coatings, and then ultimately trying to figure out the best approach to management and care delivery for our patients. Next slide. What else needs to be done? Well, this is just a start, like I said, to utilize risk scores and adjustments properly for Vermont's population, and also hopefully broadly speaking. But you need to sort of get into the data a little deeper. It's not just sort of looking at bar charts and line plots on sort of a one dimensional surface of that data representation, right? This involves talking to your patients, the Vermont citizens, and looking at how they behave in your healthcare systems through both public and hospital data. I do this type of stuff, this risk stratification at my own institution, and speaking to patients, I see what works and what doesn't. And I look at our patient population data and come up with ways to efficiently target and reach out to those most in need to prevent readmissions and adverse medical events. It isn't straightforward, it doesn't happen overnight, but if I can do it with my team of four pharmacists, secretary, and two nurses, then I'm fairly certain that all of your resources in your healthcare systems can do it as well on a much greater scale. And again, I emphasize the fact that each individual is different, and risk models are just tools and not the definitive means of providing healthcare. It still requires speaking to the patient as a provider and with the healthcare team through a shared decision making process through the most informed means possible. And I believe, you know, with having worked with risk indices and risk scores and risk stratification for this past two years, I think it can be done. And I think, you know, having this sort of change the culture of healthcare delivery and providing healthcare in the primary care setting can be of great value in delegating the appropriate high value and high efficiency care that's necessary on a population level. And with that, I'll turn it to Anise. Hi, sorry, every time I click something, anything, it goes off, the PowerPoint goes off. So when it comes to moving towards health equity, I think health equity is seen as an ambiguous topic. And so hopefully this is going to allow for some clarity in that and then kind of in line with what Henry was talking about, you know, give everyone kind of at least an initial starting point as to how to achieve this. So health equity in general is attaining the highest level of health possible for all people. And it really focuses on valuing everyone and ongoing social and societal efforts to address what are avoidable inequities and inequalities present. So equity needs to be intentionally pursued as a strategy. It's not going to happen as a byproduct of other development efforts. Addressing health inequities then means really addressing differences that aren't, are not just unnecessarily avoidable, but they're just, they're unjust and unfair. And so, you know, here, we mentioned a lot about health, healthy people 2020, well, now there's a healthy people 2030 and healthy people 2030, they have a visionary goal of achieving health equity in the upcoming decade. And they have five overarching goals that really relate towards that achievement. And it includes attaining healthy, thriving lives and well-being for four individuals that are free of preventable disease, disability injury and premature death, eliminating health disparities, achieving that health equity and achieving that health literacy to improve overall health and well-being for all, creating social, physical and economic environments that promote attaining full potential and well-being for all. And also just promoting healthy development, healthy behaviors across all life stages and engaging tea leadership, key constituents in the public across multiple sectors to design policies that then improve health and well-being for all. And I think that's where we come in in that last piece. And so, you know, understanding what the basic differences are between these definitions is going to be important. And, you know, there are important differences between inequality and inequity in health. And so, some health inequalities are inevitable because they're attributed to biological difference or free choice. However, health inequities are avoidable. Those health inequities or differences in health and well-being that are avoidable, unfair and just, they really are affected by social, economic and environmental conditions. So noticing that while health inequities can be really, really changed by us and the policies that we do, health inequalities may or may not be. And so, when we look at health disparities, health disparities are a difference between health status, behavior, disability, morbidity or mortality between social demographic groups, health care disparities. Our differences in quality of health care received that are not due to access related factors or clinical needs, preferences or appropriateness and intervention. And so just keep in mind that that, you know, people are going to throw out these words and you should know that there are distinct differences in all of these. And so, a person's overall quality of life and length of life are, you know, is determined by a multitude of factors that begin even before a person is born. Now, while we have clinical care that impacts preventing, diagnosing and managing, treating diseases, it's only about 20% of a person's overall health that is attributed to or determined by clinical care. Social determinants of health, however, you know, they have a much bigger influence on our health than clinical ones. 60% of a person's health could be driven by social, behavioral, environmental factors like their education, income, race and ethnicity. And these are conditions that are actually, again, I've colloquially spoken about it as, you know, the conditions in which people are born, grow, live, work and age in. And so, you know, here's just another representation. We call this a social ecological model. The social determinants of health, oh, sorry about that. The social determinants of health are shaped by distributions of money, power and resources at a global national and at community levels. And again, like these are mostly responsible for health inequities here. You know, we have social and environmental factors that drive health disparities, including equitable access to education, employment, healthy environments and healthcare driven by structural systems of oppression, honestly, that include gender discrimination and racism. And then even like unmet social needs in general, like these are all formed by what we create as a society. And I think it's important to make the connection then, you know, people who have these unmet social needs, you know, who have health inequities are actually associated with higher utilization and cost to a healthcare system. People who report food insecurity or lack of transportation are more likely to have multiple ED visits as compared to those who don't and also multiple inpatient stays. And so here's just yet another way of categorizing this. And I think it's really important to look at the different ways that people can see this overall. Why? Because like no single individual organization or community, you know, or sector has so ownership, accountability or the capacity to sustain the health and well being of an entire population. We know this, you know, there needs to be really just like some kind of synergy between education, housing, healthcare, justice and other sectors to play a role in creating this equitable space for folks and for people to be healthy in order to then reduce these health disparities and advance health equity for all and reach that healthy people 2030 goal. We really need to be able to design a system where we can interconnect all these different aspects of public health. You know, what we need to do then is look at these efforts and try to find a way to change the distribution of power, engage agency to disadvantage communities and also just empower them to then also saying, okay, this is what we need and us to have to build something that's able to identify and meet those needs, hopefully. Sorry, one second. And so, you know, in thinking about all of this, I'm hoping everyone's able to keep up with me. And if not, let me know, please email me. So we have this goal to achieve health equity. And one way to do this is through addressing the social determinants of health, which we all reviewed, you know, but how do you measure this? And so addressing the social determinants of health in clinical care is a rapidly evolving field. Best practices and national standards are honestly still in development. The diversity of early social determinants of health ecosystems really presents a lot of opportunity and a lot of again, yeah, just a lot of a lot of space where we can have integration of health and social services. But we also have the potential to be to be signed a little bit by those lack of standards and inconsistent communication. And so what we need to do is we need to increase social cohesion and social cohesion. It could be defined as like a group or a population that works towards the well being of all of its members. We fight exclusion and marginalization really promotes a sense of belonging and trust. And, you know, we have to have that in order for us to promote our nation's health. And, you know, we're looking for that ultimately, I think in this. And so we have to be able to develop strong expectations for then, you know, social determinants of health screening, because we have to be able to identify all of these determinants of health in some way, shape or fashion. And then we have to be able to have the data available to us in a way that we're all able to have a foundation that and how to tackle that to create a more equitable space. Now, there are some approaches that have been outlined by, oh, sorry about that, that have been outlined by individuals or attempted to, you know, this is a list, I apologize again, of health equity measurements that explore various populations and distinct, you know, measurement approaches that they have. And I think I'm here over all the three main ones, ones that's focused on determining existing quality measures. And that's that's the first box here, you know, and here it focuses on measurement identification, where, where they're trying to do more of a health equity comparison between the same groups and then looking at delivery of health care. The second one is engagement of particular kinds of comparisons, and it's a measure by measure comparison. And it's between groups of patients with greater or lesser social risk burden again. And so if we look at the population here, you know, it looks at the social risk, and then it does it in a distinct fashion in that way. And then the last approach kind of looks at a summary index. And again, all of these, what I'm trying to highlight here is that there are different ways of looking at things and health equity in that sense. But these are larger scale measurements. And you really miss the granularity in your population by doing this. Notice again, how large these populations are not necessarily, you know, applicable to to a county, or to a certain, you know, section of a county. And we have to be able to collect data then that actually focuses in on that. Because if you're, you know, if you're looking at the forest, you again might miss the tree. And I think that that's, that's one thing that that health equity actually makes a transition to. And so this red health care actually, you know, mentioned the set of guidelines for health equity measurements. And so when we think about that, you know, these measures should be based on disparities that are already known and exist for certain populations that address this health disparity and culturally appropriate care, you know, reflect available evidence in relationship between the social risk factor and health or health care outcome as we defined earlier. And it should be defined to incentivize achievement or improvement for at risk beneficiaries, while including having a valid or appropriate benchmark. And, you know, we should then be able to reference those benchmarks. We should include design that guard against unintended consequences of forcing quality or access or disincentivizing resources for any beneficiary. Again, including the at risk ones that are focused with the with this measurement and establish measureability requirements and ensure the ability to rely make reliable distinctions between health care providers and their performance in the domain of health equity capture information about all small subgroups when possible, while limiting the influence of imprecise estimates for provider performance. And then all of this needs to be summarized in a way that is psychometrically sound. And we should really allow for disaggregation of information to permit them easily identifiable spaces where we can do quality improvement. And I know that's a lot. You know, and and then I kind of went down a rabbit hole looking into, OK, well, does this exist? And no, it doesn't. But the Lone Institute actually tried to create a hospital index. And I think he did did one rather well that looked at socially responsible hospitals. You know, but then, you know, now we just spoke about what health equity is, you know, and their definition of of not necessarily definition of what they consider health equity is like, which ones of the hospitals are most inclusive in America, invest most in their community and pay their hospitals fairly. And so here, you know, their equity measurement is is somewhat limited compared to what we just saw. And so I don't necessarily think that this, particularly this, this is a good starting point. However, this doesn't necessarily meet our need. And so how do we how do we then measure that granularity? Because that's that's what we're missing here in my mind. You know, and I think it's it's really first starting with the basics, you know, we want to be able to have a strategy that the or health health equity strategy that that that has, you know, all of these metrics, at least down, you know, I think it first starts with data collection and stratification to identify inequities. And then from there, you set your priorities. And then it drives improvement activities, you know, so the strategy applies to more, you know, multiple numerical performance data and clinical processes, like people talk about patient experience and also public health. And we can get dashboards set up and score cards for different levels at a different health care system, at different health care systems. And again, like obtaining that real data we look at, which is, which is attributes of race, health, I mean, ethnicity and language that are tied to individual patient records that can be used to stratify clinical patient and public health measures, SOGI data, sexual orientation and gender identity data is awful helpful. And then again, having that social determinants of health screening. This, you know, for and this goes for any of the data, honestly, when we look at it, we want to make sure it's accurate, it's complete, it's unique, it's timely, and it's consistent throughout all. And if we don't have that, then it's kind of like we're comparing apples and oranges. And so ideally, again, we want to we want to collect all of this data from individuals. And in that, you know, have it in some some space where we're able to go back to it, you know, and then from there also have the determinants of health screening. And so when we have social determinants of health screening tools, like there are multiple tools out there, the National Association of Community Health Centers have a protocol for responding and assessing patient assets, risks, and experience, they call it the PREPARE tool. It has 15 core questions and 15 supplement, I mean, sorry, and five supplemental questions, so a total of 20 questions. And that can that they've tried to have it uploaded to different EMRs. The American Academy of Family Physicians has their own social determinants of health screening tool. It's part of their everyone project. And then the CMS has a 10 question tool that's health related social needs screening. And honestly, you know, any of these can be helpful. I think it's determining what would be most helpful for the state or for the region and making sure that there's interoperability in all of this. And then, you know, rather than expecting the physicists to add just one more thing to their daily practice, you know, this screening should be a team based effort into the into the practice flow. And it should be inpatient and outpatient, you know, because there's multiple settings where this this tool could be could be implemented. And so again, like, just to kind of finalize it. But I think it would be, my ask, at least, is to kind of create an outpatient hospital level of social determinants of health screening with with collection of real data. And one socially cohesive state registry. So then you can, you know, first benchmark your study deliverables, and then, you know, provide a current state of what's going on. And then, you know, you can use comparative analytics versus your cohorts to find and then really just identify those actionable opportunities in the state of Vermont, in different pockets of Vermont, to then deliver the, the, you know, the resources required there. North Carolina is an example of a state that actually has tried to do this. And in that, you know, they, they may have, I think they, I don't necessarily know if they've achieved it yet, you know, but I think that they're, they're actively working in having and having something similar in place. So just wanted to, to you, to use this time to share this with you. And thank you again for allowing me to speak. Thanks for being here and doing that. Kevin, you're on mute. Chair Mellon, you're on mute. Well, that doesn't help, does it? The bigger question is what can we do to keep you here in all your fellow classmates? What is the biggest drivers in your decision making when you determine where you want to work? Wow. What a question. I guess like for me, it's being able to connect with my community and being able to, to assist my community in need. And that's at least like for me, like my, my, my, my, my, I think my mission and passion is, is be working in a, in a health equity space. Right. And, and so having, having an infrastructure that can support that is important. And that's, you know, secretly when I'm a driver, like, if this is in place, this would make it much easier to come back. I think for the flip side of that is you might be able to be on the ground floor of helping to build that type of system. That's very true. Henry was going to say something. Sorry. Oh yeah. I was just saying, like, yeah, I completely agree with you on these sort of identifying and working with the community that you're going to be working in is a big driver. And, you know, I, maybe this is naive of me or whatever, but I think this is really exciting for primary care being going into internal medicine and outpatient medicine as for practice. I think this type of change in healthcare delivery is what makes primary care exciting. And I think it's the next chapter, sort of looking at not just each individual coming through the office as an individual, but going on to sort of a separate level, a more sort of elevated level and seeing, okay, I have so many patients on my clinic panel. And, you know, that I'm taking care of in the community. What is sort of a common driver that I can sort of change among hundreds, if not thousands of them with a change in the process or changing a way of approaching care in my clinic through sort of this data-driven approach. And I think that's really exciting for primary care. We have the technology. We have the methods on analyzing it and utilizing that data. We just got to be really creative and efficient with it to generate this type of change. So that at least for me is, you know, exciting and what drives me forward. Well, it's a fascinating presentation. Board members, why don't we go in alphabetical order? Dr. Holmes, Jessica. Sure. Well, thank you so much for the presentation and for working with us for the last few months. It's really appreciated. I guess I'm wondering, you know, from your perspective, how do you think training in medical schools has to really change to think, you know, to so that our providers and nursing schools and other, you know, training areas to better address, you know, social determinants of health and health equities so that providers, when they leave school, are better equipped to manage, address, collect data, ask the right questions beyond some of these survey tools. But once they have the data at their disposal to be able to better address some of those, you know, really valid concerns that you've raised. And I ask that with, you know, having spoken to some providers who feel like I'm trained in medicine, I'm not trained in the larger social determinants of health and having to manage, you know, navigating that space. So just wondering what you think about training in medical schools, nursing schools, other areas. Do you want me to answer that? Do you want me to answer that, Henry? We can tag team. Okay. So overall, like, I think there needs to be an overhaul in the medical education system. And I think it's happening slowly, where multiple institutions that are integrating health equity, health equity curriculums, where really what they're doing is they're going through their curriculum and adding in that lens, that perspective and really, you know, seeing, okay, what is the root cause of all of these things. And I know that's happening from a medical school standpoint. I'm not sure if it's happening from a nursing school standpoint. And in that as well, different medical schools should be providing what's available to the community. You know, what community, what does the community have? You know, what resources are available and what can you provide to the patient that's in front of you? You know, and I feel like it's a medical school's responsibility to a degree to have that list, quote unquote, whatever be it, you know, that resource available, because they're in the community, they're the ones that are, they're constantly versus like medical students go in and out. So I would think that that to me, that that is like a staple of what should be provided. And I think with regards to the general overhaul, that's certainly, you know, very large 30,000 foot view perspective. And that takes time, that takes years to change. I think what I'm just drawing from, you know, my own training, I'm from a school in the greater New York City area. And so each individual medical school has their own approach to socioeconomic inequalities, healthcare inequalities as well. And I think the curriculum ought to be adjusted to what is local to the school, but taught in a way that, you know, in a framework so that that framework can be applied wherever that individual medical student goes. And finding out that framework is difficult. And I think the next step would be to actually perhaps, you know, I'm speaking about associations, but association of American medical colleges, double AMC, they're taking the next few steps to sort of figure that out and to have recommendations created for medical schools in the United States and Canada to try and, you know, brainstorm on how can we approach this sort of education in a framework perspective, but have that framework be applicable and experiential for the student itself. And obviously, I can only speak to medical school training. Thank you. Back to you, Kevin. Thanks, Jess. Next, we'll move to board member lunch, Robin. Thank you. I found both the parts of the presentation very interesting. So thank you so much for your work and for sharing your work with us today. I'm really intrigued by the health equity lens and thinking about how we can start to incorporate that in, you know, from our perspective as regulators, we, you know, have certain regulatory tests that we perform on behalf of the state. And this isn't really a question. It's just more kind of me thinking out loud from a lot of what you presented and in the thoughts. So I need more time to digest, but I think it's really intriguing to think about how do we start to build that framework in a way that's thoughtful. And also one thing we hear a lot from providers is, oh, my God, you know, we have enough measurement, don't measure us more. But how do we like balance all the interests and make sure we're measuring the right thing in the right way without adding administrative burden and that kind of thing. So just a comment, but I really appreciate the discussion. Thank you, Robin. Next, we'll turn to board member Pelham. Tom. Well, thank you, Mr. Chair. And thank you for this presentation. It's one of these presentations that can overwhelm you as you're trying to integrate all the moving parts. And so I'm probably trying to think about a way to simplify some of it. And one of the things that I notice is that in Vermont, health care is 20% of the economy. I mean, it's a big deal. And there's a lot of resource out there. But I don't think in the public debate, and this is an election year, in the public debate, health care is one of the issues that is front and center, you know, at the granular level. If you're at the local level, you know, former Speaker of the House, Tip Unil would say that all politics is local. And so I'm thinking, how might this process get its arms around having some influence in the political process? And I would think that, hey, there's only 30 senator seats in the state of Vermont, you know, maybe folks who are of your orientation can bring focus to some of the issues that you're concerned about by just focusing on 30 elections, maybe holding a candidate's night, or maybe holding a forum on the internet, or maybe getting Vermont Digger to sponsor some forum so that these issues can be raised front and center. So unless I'll give you a hypothetical, say some rich person were to come along and say, you know, here's $20,000, we've got an election year coming up. You know, what would you do? How would you invest that $20,000 in the promotion of your interests in kind of data-driven social determinants of health, preventive health care? What would you do with it? Besides pay off your credit loans? I'm assuming that's off the table. That's an interesting question. So what would I do with $20,000 that would be helpful in the space of health equity or social determinants of health? And this is just because it's my part of the presentation. I know Henry talks about risk calculators, so he probably invested in data infrastructure. Well, I think like, you know, I'd probably give it to the community health workers and have a community health workers kind of have various health fairs. And then from that, have screening questionnaires available to those individuals who participated in it and collect the data from the health fairs to kind of have at least a screen, a snapshot as to what's going on in the community with regards to determinants of health and where then my next bolus of money would be put to. So that's just one idea. But yeah, I mean, my part of my background in the earlier years was don't agonize, organize. And I was involved in a group of people who stopped highway construction through low income neighborhoods in Somerville and Cambridge and the Boston area and literally stopped them. They were on the drawing boards, bids were out and changed public policy in Boston to want to protransit, extend the transit system out to Alewife, out to Oak Grove in Melrose, south to Braintree. And it was, you know, a four or five year effort. And it was a hammer-and-tongue. And so the media was important, you know, getting some of the media folks to understand it. And I'm kind of looking at that experience, which was health or skelter and looking at where we are here on healthcare in Vermont. And it doesn't seem to have reached a critical mass of awareness out there. It's still a kind of a side issue relative to some of the other issues that are front and center in Vermont. And so that's kind of where my mind went as you're presenting, where would I go to bring this issue that consumes 20% of the Vermont economy that is, you know, it's not front and center in the legislature this year. Health cares, it's important and it's a big issue, but it's not an issue that is driving elections. And my guess is you're not going to hear a lot about it on the campaign trail. But it's just something to think about that that data can be used in a political context to affect how people vote. And I'll just add, you know, I completely agree with Anise going down to the Camille level. And I think one of my emphases is to speak with the citizen, to speak with, you know, the patient, your constituents. And I think putting that money into the local health fair drives and raising that awareness is probably the most efficient way to go about it. I think Anise and I are on the same page on that topic. I'm not a politician, nor do I think I will ever will be. It's not my realm of expertise. And certainly, you know, there I would just caution on sort of the phrase using data in a political manner, mainly because, you know, from our perspective, we are scientists. We like to use data objectively and for a good scientific purpose and the benefit of everyone. And so putting that into sort of a political purpose doesn't really sit right with me. I like things to be peer reviewed, open to the public. And if you have criticisms, great. Let's discuss them. But, you know, serve that perspective on creating it towards a political lens through political lenses. It doesn't sit well. Well, that's just kind of the authenticity, I think that attracts people, though. I mean, if you're going to use data and use it in a public, even political setting, you know, you can have people that present it that aren't very authentic and often authentic and people can see that. Whereas others, like how you're coming across now, speaking truth to power, just saying, this is the data and we want to solve these problems. And we want the political system to be addressing them. Just offhand conversation. But I I'm not I'm not suggesting that you politicize your data, but that you use good, good solidly well-crafted data to tell a story that people can rip you wrap their arms around. I think I think actually that's a good suggestion. You know, it like to tell the story the way the story is, you know, and then in doing that, that's how that's how you're able to to get support for, you know, your next notion or your next movement towards towards whatever it may be. But you know, I don't necessarily think it needs to be aligned to any kind of political party or anything like that. But it could be told by by other folks who are at reach with the people in a political sense. Back to you, Mr. Chair. Thank you, Tom. Very authentic question. Next, we'll turn to board member Walsh, Tom. Thank you. Thank you, Kevin. And thanks for being with us, Henry, and on ice. I enjoyed your presentation a lot. It was informative and inspiring. You know, I got my start a long time ago now as a clinician. I got interested in outcome research and really trying to do what I could to understand everything that I was reading, the data that I was reading and the evidence. And I learned that being evidence based is difficult because it can change. And that requires you as the clinician to be able to adapt and change. Right. And that's hard when if there's something that you've been doing and there's you find out that the evidence isn't there for it to then go learn to do something different is really hard. And that evidence based approach and creating a learning system and agility and adaptability in a system. You guys are in a leadership program. You're going to be in roles where you're trying to build systems like that. And you'll be maybe taking roles in your community where maybe there will be some political aspect or some regulatory aspect. And and you've just reminded me and inspired me to even in my new regulatory role to think about what is the evidence for the decisions that we're making? And am I can I help create a learning system and create agility and adaptability in that system so that we're using evidence to drive the decisions that we're facing and we can be transparent in that. Right. And I can I can see why the two of you are here. You know Henry your your desire to understand risk stratification and the benefits of that the insights that it comes. Well addressing inequities means that we identify the risks the population the parts of the population that are the most at risk and then making sure that they're receiving the resources they need to achieve equal outcomes. Which is Anais's part right. And so it's really can can we as regulators help bring about changes where there are health care systems have the data to stratify the way that Henry can to find out what the needs of the population and the individuals are. And then can we design a learning system that can adapt once we know where the subpopulation is the hot spot where the patients with rising risk that we can move resources to address those things. Right. And you're learning how to do that as clinicians. It's exciting. It's great. It's what woke me up in the morning. And to think of how do we build how do we bring that type of thinking into our policymaking and our regulatory work. So so you've inspired me. And I hope that as you keep going as you get into your different roles you reflect and think you know if I'm going to be if I'm going to be teaching others how to do these things or advocating for them. Also remember to look internally with within yourself. Can people see the principles and practices. Can they see what you care about and the principles and practices of the organizations you're in the culture that you help create. And the budgets right when we when we look at we want to say inequities important we should be able to see evidence of changes in inequities through the principles and practices of our organizations the culture of those organizations and the budgets. So I just hope you keep those things in mind as you go forward. And once again thanks for being here. It was informative inspiring. And the example of Fred was illustrative. So thanks. So as a final question from the board before we open it up for public comment. I just want to ask you if you could share how you came to your decision. You're both specializing in internal medicine which some people would say is a specialty. Others would argue it's primary care. Others would argue it's both. But was there some point in your educational or personal career that helped you focus and decide that internal medicine was the medicine that you wanted to pursue. I could go first this time. That's a great question. I am the first person in my family to ever become a physician. And so in my mind I guess you can say that the image of a physician was a medicine physician in my mind. It was medicine or surgeon. And for me medicine dealt with a lot more thinking. And certainly there's acuity and procedures involved. But for medicine it was a lot of very scientifically heavy. It was more stimulating, cerebrally. And for the training aspect I think thinking about the physiology and thinking about pathophysiology, the correct medication and therapies was more of a mental stimulant than anything else. I had thoughts of becoming a pediatrician but I found out that it was too touching. My emotions I couldn't handle seeing a sick child. So that diverted me away from it. And I definitely at times thought about general surgery. But it was great. I worked with my hands in the OR, managed patients on the floors as a medical student and during my clerkships. But ultimately I found myself being drawn more towards the floor patient management of patients medically than I was sort of more interested in the procedural aspect. So that's what drove me to deciding on going into medicine, internal medicine. That was really nice, Henry. So I'm in infectious disease. So I'll kind of focus more on why I went into infectious disease. And so medicine drew me more for the cerebral aspect and I found myself asking a lot of why. How did this happen? Why? And then my family is from the Dominican Republic and I actually spent my formative years in the Dominican Republic. And so for me global health is really important. And seeing the interconnectivity of just even at end of microbial resistance. That to me in the Dominican Republic during my training, I saw a wide array of different bacterial resistances. I saw tropical neglected diseases. And I saw a lack of infrastructure to support treatment of such conditions. And with that I've just had multiple encounters and I've met with enough people that I was like, okay, infectious disease interests me. And then from an advocacy standpoint, most of the infectious disease dots that I encountered during my training were the biggest health advocates that I knew. And so with that, it kind of felt like I just naturally slipped into wanting to do infectious disease. And it actually, I've never felt more fulfilled in a specialty because infectious disease, again, is a lot of intersections. We have a pandemic now, which I did not sign up for, but it's here. The intersection of public health in that really just strikes home. So that's kind of what drove me into where I'm at. Great. Too often we hear the stories that your peers chose their professions because of the dollar aspects. And clearly we're not hearing that today. And neither one of you even mentioned that, which was great in my book. So with that, I'm going to open it up to public comment. Does any member of the public wish to comment? You know, I'm going to start with Dale Hackett. Dale. Hi, just two quick questions. One, I think has already been visited, but I just wanted to revisit it again. For example, I was in Maine and I was as rural as you could get out there versus what role is here. And yet the people I was with, I mean, one of them is an OR nurse and she's totally happy living that role and working at the hospital. You know, they're five miles from the nearest store. And yet the hospital that she works at is closer than UVM Medical Center. It was intriguing. And the other person, you know, has to travel an hour and 45 minutes just to get to where they work. And again, they're happy, but they're, you know, you just walk up the street and you can see Mount Washington. They're in a beautiful area. So the question would simply be Vermont's rural too, yet we don't seem to have that same effect on people in terms of them wanting to come to Vermont. So I'm sort of re-asking the question about what's the one thing that you would really need to see to be in Vermont versus other New England states. The other question is, I'm very curious in terms of the training you've received in your medical school, how do you see that being applied if you were to go to any state in the country? Do you feel prepared or do you feel prepared for some states but not for others? I'm asking a really macro question there, but those are my questions. Please Henry, either one if you want to tackle those questions. Thank you Mr. Hackett for the questions. With regards to the first question, which is what aspect of Vermont, if I may rephrase the question, what aspect of Vermont will be enticing for healthcare providers to come to Vermont and practice here? Is that a fair rewarding? Yes, it is. Okay, great. Well, Vermont is great. Being in the Upper Valley area, it's certainly a rewarding place, beautiful all four seasons. And I'll just say personally, for myself, I'm not speaking for others, Vermont offers a great rural lifestyle, but it's not something that I personally would consider be fitting for me. And certainly that's not true for everyone else. That's just a personal preference of family preference. And the second one, and I'll just lay it out here, mainly because Susan and we have all discussed it, the amount of paperwork and the steps on actually acquiring a Vermont medical license is quite significant. And I have to say, I personally gave up after three to four months of trying, and you guys still have my check. I haven't asked for it back because I haven't found the time. So that's another, and I think that's a little more concrete and actionable. You know, I've worked with the state of New Hampshire, and it took I think six to eight weeks. And they were very communicative. And straightforward, I got a lot of help. And I didn't necessarily have to pay anyone to complete it for me. Whereas for Vermont, it was, you know, it was a little rougher. And, you know, at this moment, I don't have a need to seek it and see it through. But that could be something to consider moving forward. Thank you. Okay. Next, we'll turn to Walter Carpenter. Walter. Thanks, Kevin. Dale got my first question, so I won't repeat it. But the second question concerns health equity. I've always been curious about this phrase, because it doesn't say anything to me. And I say this as a patient who's been that Fred that Henry talked about. You know, I've been there, can't afford health care, can't do this, um, losing insurance in the middle of treatments and stuff like that. Because our health care system is actually built on inequity. If you say that equity means equality. Its whole purpose is inequality, you know, by low cell high. So I think I was more curious on how you wanted to address that. I mean, as new doctors coming into a system like this, and how, you know, it's health equity, inequity by cost is what it is, you know, deliberately. How would a new student or a new person coming into the medical field want to address that? If possible. So I think you bring up a good point in the sense that, you know, health care delivery in general, like in the health care industry is definitely like very cost, very money driven, you know, and that's separate from health equity because in my mind, like health equity, I think as we mentioned before, is that notion of people attaining their highest level of possible health that they are able to do, you know, and there's, you know, and attaining that healthy life that's free of preventable illness, disability, injury, premature death. That to me is what health equity is. And so social economic drivers can lead to either, you know, more equitable space or inequitable space, right? And so not having the means to go to your visits, you know, not having the means to get treatments like that is an equity, as you mentioned. And so, you know, as a provider, what I would do in the clinic is I would actually talk to a social worker and see if the social worker knows of any programs that's available from at least the state first to see if it can help overcome the barrier that you have to achieve your health equity. If not, then I would actually go to the particular insurance company or the medication company or whoever to ask them directly, hey, this is what's going on with my individual patient. How can we work this out so they can get the care that they need? You know, and that going to that level, you know, ideally we won't have to do that if we set up a system that allows for people to actually have the care that they need when they need it. And to add on to Ani's point, everything that she had mentioned is pretty much what I deal with every day as well in the primary care setting. And thankfully I have, you know, secretaries, nurses, and pharmacists to help me with that. But that is a key factor in burnout. Okay, sort of healthcare provider burnout, it's sort of 10% face-to-face direct patient care and speaking with our patients and 90% administrative, you know, all of the other things that are involved. And, you know, I think, Walter, thanks for your question, how do we actually address it in incoming individuals new to sort of the healthcare sphere from students and trainees? We, I feel like the problem is we revolve too much around the dollar sign. I think, you know, using some sort of currency is a great way to communicate equity or inequality in sort of, so everyone is on the same page, right? It's a currency. But unfortunately, that becomes so ingrained that, you know, you made the analogy of, was it by low, sell high, right? Unfortunately, that analogy comes from sort of sticking around some form of currency. And that's where, you know, I, myself and Ani, you know, in the presentation, I emphasize the fact that we have to sort of shift away from this culture of trying to build the maximal amount of, for billing that patient encounter is possible, figuring out the correct billing code. We have to, you know, divert ourselves away from that and actually look at it from a value-based perspective, which is what are some of the key aspects, the low-hanging fruit in individuals, social risk, healthcare risk, that we can approach and tackle and have not only healthcare savings moving forward, but also perhaps figure out something and prevent a budget catastrophe down the road as well. And I think that that's, that definitely will take time to shift that in culture. I agree about the culture. I agree pretty much what she said. I'm not a big fan of value based because I still don't understand it yet. Even though I've been dealing with it for five, six, seven years, and I've been, I've studied healthcare systems around the world and stuff. One of the problems we have is access. This is the one issue we haven't been able to solve. We don't have the, we could solve it. We don't have the political will to do it. Access, we have enough data where I think if you laid the data out to the moon, I could walk up to the moon and back on all the data we've taken about the healthcare system. And I sit, I've sat in probably in hundreds of committee meetings where all I've listened to is data and we seem to want more. So that's not, that's not the issue. It's the, I agree with you, it's the whole culture that I agree. It's based around the dollar sign. That's the unequal access. I don't see value based as doing that because value based, you're still insurance, you're still deductibles, you're still co-pays. The whole thing is designed to prevent you from getting healthcare so that you don't cut in the bottom line. And when you're a patient, you're especially one with an illness that's longer than a, a little while, you're a medical loss. And the question, again, I was just trying to address how would a medical student coming into the field who wants to go into primary care. And I've worked with many as a student in my various primary care visits. How would you go about addressing that or trying to change that and make it into a different culture? But that's just the, I think, Walter, you hit the nail on the head. It takes a lot of thought and consideration and certainly beyond our discussion today. So I thank you for that question. And certainly, we all will have a lot to reflect on and think about. Appreciate it. Thank you. Walter, is there other public comment? Thanks, Walter. Is there other public comment? Hearing none, I want to thank you both. Great conversation. And you're a positive image for the hope for the future. So thank you. With that, I'm going to you're welcome. With that, I'm going to go to old businesses. 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? I moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion, please signify by saying aye. Aye. Any opposed? Signified by saying nay. Thank you, everyone, and have a great rest of the day.