 Well, it looks like we have everyone so I'll call to order the Green Mountain Care Boards hearing of November. Sorry, January 17th, 2024. We have two agenda items. We have a monthly update. On the ahead model and global payment development. Michelle degree will lead that discussion. She's our health policy project director. We'll be hearing from Pat Jones, the interim director of health care forum at AHS. And she laid garbage are consultant from Mathematica policy research. And then later on this afternoon, we'll have an update on Act 167. And around one community engagement for hospital transformation. Which will be led by Marissa Melamed, our associate director of health systems policy, and we'll hear from our consultant on that work from Oliver Wyman, Dr. Bruce. So I'll turn to director Barrett for her executive director's report. Thank you, chair foster. I want to let everyone know that yesterday the board submitted, submitted it's 2023 annual report to the legislature. That report is located on our what's new page. It's also located on our website under legislative reports. It's lengthy, but it's actually, I just, you know, I'm always so impressed at our team and what we accomplished every year. And I just want to shout out to the entire staff and thank you for all your work and also the contributions to the annual report. I also wanted to let you know that there's two ongoing public comments, which are very relevant to today's board meeting. The first one is an ongoing public comment on a next potential all-payer model with CMMI. As I've mentioned in the past, AHS and the administration are leading the negotiations on this model. So when you send us public comments, we send those over to our colleagues at AHS and share them with them. We also have an ongoing public comment period on the community engagement work in Act 167 of 2022. At the last check, we had 94 comments. So keep them coming. We love to have public input from all of you. And then scheduling this evening, we have a primary care advisory meeting. We'll be hearing from Pat Jones again, Interim Director of Healthcare Reform, and she'll be joining the PCAG and discussing the AHAD model and the NOFO, similar to what she's sharing with all of you today. So with that, I will turn it back to you, Mr. Chair. Okay, and we have some meeting minutes to address. They're from December 20th, 2023. Is there a motion to approve the minutes? So moved. Second. All those in favor of approval? Say aye. Aye. Aye. I didn't hear Dr. Merman. Did you vote? I'll take that as an aye. Okay, the minutes are approved. And we'll turn to Michelle Degree to walk us through the AHAD model. Before I do that, though, I wanted to flag that I'm going to take public comment after each section of our presentations today. It's possible that we have an executive session and Ms. Degree will talk about that, but I'll try and take public comment after the public portion of the presentation so people don't have to wait if there is an executive session. And we'll try to make sure we get as much as we can done before that. So, Mr. Degree, I'll turn to you. Thank you, Chair Foster. I just want to. Can you all see my screen? Yes. And obviously you can hear me because you're nodding your head. So, today we are doing a pretty robust update covering two topics, primarily the AHAD model and global payment development. And during these, you have a staff update from me on the board's kind of staff processes with the global budget tag workgroup. Since we haven't had one of those and we don't have another scheduled until February, my portion of this will be very short today. Chair Foster noted there is the potential to enter into executive session in the event that any of the questions or comments would relate to possible or potential negotiations with CMMI or CMS on a future AHAD model agreement. I think we're all aware that at this point the state has decided to apply for the model. That does not mean that we will be selected or enter into negotiations necessarily, but in the event that happens, we want to make sure that we can have these conversations. And so I've called, well, thanks to our general counsel, got some information here on the screen for you in the event that we do decide to go into executive session. Just a couple of notes. It will need to be, there will need to be a motion to enter into executive session, so I will defer back to you all should we choose to do that. But at this point, I think in the event of not having tons of time today and a huge, huge, robust agenda, I'm going to turn it over to Pat Jones and Pat and Shule, I have the slide so just let me know when you'd like me to advance and I will run from here. Great. Thank you so much, Michelle, Chair Foster, members of the board for letting me come again today to to provide an update on where we are with the AHAD model so you can go to the next slide, Michelle. The first few slides I'm going to go through quite quickly, especially given the time constraints, but I am, you know, I feel like it's important every time we talk about this complex potential model that really sort of levels at why we're here, why we're talking about this. So this is actually a Green Mountain Care Board slide and it, you know, delineates the work for Act 167. The work that we're talking about today is a subsequent all payer model agreement with the federal government should that come to fruition. Next slide. So why, why consider a new federal model and why now, you know, and its most basic sense as you all know, when we engage in discussions about healthcare reform, we're really trying to use the public policy process to address challenges in our healthcare system and you all know as well as anybody based on the work that you do that we're facing lots of challenges in healthcare. And so I've listed some here with their related goals, but you know, ensuring affordability, improving access not only to care but also to insurance coverage, optimizing quality and experience of care for for volunteers who seek care, improving the health of the entire population, improving equity, reducing disparities and health health care health outcomes, identifying and addressing those social determinants of health that really impact health status. Workforce is a huge issue that we've all been working on together. There's a lot of complexity to in health care and that can arise in part if there's misalignment between public and private payers, and then trying to create a sustainable health system for the future. So we spent a lot of time talking about payment reform, but really that's just one component of health care reform. We should think about as a means to an end. The goal really is for payment changes to encourage and support the care delivery transformation that leads to better outcomes in relation to health. So just wanted to really level set why are we even considering this. Next slide. So you've seen this slide before, but one of the reasons why we're considering it now is that our current all payer model agreement is set to expire at the end. We've signed an agreement through 2024, but we are in conversation with CMMI about continuing that model through 2025, but it will not, it will not extend after that. What the all payer model agreement really does for us is it brings Medicare to the table in Vermont's health care reform efforts. So it allows Medicare to pay differently for health care and establish some statewide facilities. And so, you know, we have currently the all payer ACO model. The original performance period was through 2022. As I said, we have extended through 2024 and are looking to go into 2025 is with an extension. But beyond that CMMI has made it quite clear that single state models like the one that Vermont has or Maryland or Pennsylvania that they want to move to models that more than one state can participate in. You've seen this slide as well. So I won't spend too much time on it, but it really outlines some of the benefits of including to include Medicare in Vermont's health care reform efforts. It builds on prior reforms. It gives us, you know, some ability to influence how Medicare reimburses for providers. It's provides support for the blueprint for health advanced primary care program. And for our SAS program, it gives us some waivers of Medicare regulations that can improve how care is delivered. It's alignment between public and private payers. And that really sends a good signal to our health care providers and other health system partners. Next slide. So ahead announced ahead is the next iteration of a federal model that stands for states advancing all payer health equity approaches and development. It was announced on September 5. By the Center for Medicare and Medicaid Innovation, November 16, they released a notice of funding opportunity, which invites states to apply for the model. And I just want to emphasize here that really the focus in that what we call no foe is that they really want to see do states and states have to be the applicants. Do states have the capacity to implement a model like this? And how would states use up to $12 million that CMMI is offering in cooperative agreement funding to support the model. So a lot of the focus on the applications, which for cohorts one and two are due on March 18 is in those areas. What is the state capacity and how would we use that funding? There's a link to the website there. I do want to note that again, the application really is the first step. It keeps us in discussion and at the table. States have to be accepted into the model. And then states and CMS have to reach agreement in order to move forward. So think of this application very much as staying at the table on a first step. Next slide. You have also seen this and it's the ahead model at a glance, but just for folks who may not be as familiar with us who are listening in. It really lays out what the ahead model entails. First of all, there are accountability targets that states will be responsible for, and that includes total cost of care growth, and that would be for both Medicare, traditional Medicare, what they call Medicare food for service, and also across all payers. There are targets and this is novel. This is something we haven't seen before models, but they're looking for there to be increases in primary care investment. And so again, there are targets for the Medicare fee for service population, and also for the all payer population. And then equity and population health outcomes as well that will be determined if states are selected and they execute a state agreement with CMS. And then the components of the model are that cooperative agreement funding that I mentioned before, hospital, global budgets are a really critical element. You're going to hear a lot more from Shulay on that topic later. And then a primary care program called primary care ahead. And then CMMI has outlined a number of strategies that you can see that they anticipate will support achievement of the goals of the model. Next slide. I did want to sort of call out those statewide targets and show you how they bucket them. So they really look at the primary care investment targets and the quality and equity targets as addressing overarching goals of improving population health and advancing health equity and the fee for service total cost of care and all payer total cost of care growth targets really focus on that area of curbing health care cost growth. Next slide. And then the next one. You've seen this slide as well. This is the application implementation timeline. So for the states that want to be in either cohort one or two, they need to apply by that March 18th date. The difference there is how long of a pre implementation period they get cohort one states would have a first performance year of 2026 cohort to 2027 and then the cohort three states just get a few more months about five more months to prepare their applications. So their applications are due in August and they get a 24 month pre implementation period. So like the cohort two states would start in 2027 with their performance year. I should have noted this is limited to eight states or sub state regions. CMS only has funding and will only approve up to eight applications. And there does seem to be quite a lot of interest from states not sure which cohorts are when but there's definitely a lot of interest in this model. And it's a longer time frame nine performance years for cohort one, eight for cohorts two and three. That's longer than previous models that we've seen and seems that there's been some learning that taking additional time to implement these complex models. Next slide. This really outlines the broad timeline for cohort one state. So, in red, our deadline is March 18 for applications to be provided by states. CMS has indicated that they anticipate that the award to states by sometime in May of 2024. And then that implementation period would start in July and go through 2025 for cohort one states with that first performance year of January and 2026. So, you know, just want to put this out here because some of the work, you know, we're really focused right now on that March 18 deadline. There are some flexibilities for states that I'll get into in a moment that really, you know, we have longer time periods to address. Next slide. This is a very busy slide. I'm not going to spend a whole lot of time on this because I can come back to it at a future meeting but the base slide here is CMS's and they've laid out what they see is the operational milestones. And this will be once a state has been accepted and decided to move forward with CMS on this model. And so we've put in some, you know, we've added the dates that we understand to be the deadlines for those cohort one states. So just wanted you to have a chance to see that that again, you know, some of the decisions are well after the application period and would require acceptance into the model and subsequent negotiations. Next slide. And the next. So I am going to, you know, highlight sort of a format that I'm using here. The way that I've tried to share this information is that I wanted the board to have a sense of, you know, what is actually required in that application that is to March 18. And as I had mentioned earlier, they're really looking to see what's the state's capacity to implement the model and then in addition, how does the state think about using that cooperative agreement funding of up to $12 million. So I'll go through this slide, just to give you a sense of how they're thinking about this. And then on the subsequent slides, I'll skip over the details, but I just wanted you to see what's expected of us for the application. And I want to spend a little time on what we believe are flexibilities in the model should we get accepted. So this, this section of the draft narrative that we'll need to put together for an application really speaks to that statewide accountability. So again, looking at total cost of care measurement and growth, primary care investment, and then, you know, the, some of the levers that we might use for being able to address the statewide accountability requirements. So you can see here that the application is asking us to describe our strategy for measuring statewide total cost of care and measuring primary care investment across payers over time. So they want to see what's our ability to do that on a multi payer or all payer basis. And they want to know, you know, what, what's our baseline, how are we doing currently on those measures. They want us to talk about how we will include targets for total costs of care and primary care investment, and they suggest three possible mechanisms for doing that. And, you know, here they're really talking about codifying a process for establishing those targets. So state executive order is one mechanism statute would be another and regulation would be another way to codify those all payer total costs of care, primary care investment targets. They want to know how would reinforce it as well. They want to, they want to know how can we obtain the information that we need each year to measure results in those two areas from commercial payers and from Medicaid. Give a nod to the board that the all payer claims database is a nice mechanism to have, even though it has, you know, some limitations, it's a great asset to us when we're responding to this. And then what are some of the policy levers that we might use to increase primary care spending by commercial payers and by Medicaid. And then similarly, what regulatory and policy levers could we use to achieve or enforce total costs of care growth targets across payers. And then finally, what are some of the gaps, if we have them and how we report on total costs of care and primary care spending so this is an example. This is one section of the NOFO. That's the kind of information that they're looking for. So next slide. This is where we think there's some flexibility in, you know, for discussion or negotiation with CMS in these statewide accountability areas and you'll note the deadlines on the right. Again, they go well beyond the application submission. So while we're not focused on this in the application, it's top of mind for if we get accepted into the model. So a couple areas. One is that for Medicare fee for service. So again, remember, they're measuring total costs of care, primary care investment, quality and equity targets. They're measuring those both for Medicare fee for service and across all payers for states that are successful in the model. And so a couple of areas where we've gotten indications that there will be some flexibility is that when we calculate total costs of care for the Medicare fee for service population. The selection of baseline years and the waiting of baseline years, because the baseline year is really that start that the baseline value is that starting point. And they've said they want to see three years in there, which three years and how that's weighted there does appear that there might be a little bit of flexibility. And then they also will build in a savings component. They want to see some savings or at least not, you know, they've said at least, you know, budget what they call budget neutrality. And we think there's some flexibility there as well, particularly for low cost states like Vermont and also states like Vermont that have engaged in prior healthcare reform with CMS for Medicare and have shown savings. We believe there's some flexibility there. And then calculation of primary care investment. The board, you know, a couple of years ago did your report on primary care investment worked with some other New England states on, you know, methodology there. There's a lot of non claims payments that are currently occurring in Vermont to primary care. And so one area of flexibility might be how those non claims payments are handled because CMS is indicated they want to see them included. And then quality and equity targets. It looks like there'll be some flexibility there to include in the in a state agreement if if we were to move forward with this model. And the state agreement really is that agreement between the state that has been selected and CMS. Other areas where we think there might be a little bit of flexibility. You know, I mentioned sort of the executive order statute or regulatory change to set those all payer total cost of care and primary care investment targets, you know, how we set that up and and articulate that we believe there's some flexibility there. And the deadline for that is September 30 of 2025. And then the methodologies and targets, actually setting the targets for those measures. And so we believe that there will be some flexibility, and that does not have to occur until September 30 of the 2026 so actually into the first performance here. We could still be setting targets there. Next slide. I pretty much laid things out in a similar fashion for the other areas of the application. I'm not going to go through it, but you know this lays out what does the application require for hospital global payments. I will highlight the full fit throw there. We do need an order for a state to apply. There needs to be at least one non binding letter of intent from hospitals. CMS is trying from a hospital CMS is trying to understand, you know, it how is the state engaging with hospitals and health systems about this potential model and I think as you know, we've, we've been engaging quite a bit with hospitals and others on this model and in particular on hospital global payments. So just note that the application will require a detailed hospital recruitment plan as well they want to see as many providers as possible in this model, and they have a particular interest in safety net providers such as critical access hospitals, federally qualified health centers and rural health clinics. So they're really focused on how to support care for people that receive their care from safety net providers. Next slide. And then here's some, you know, again some flexibilities that that we appear to have with this model. The first and the most, you know, critical is that states that are like Vermont that have, you know, budget authority have prior experience with value based care. They can design as their own state Medicare fee for service methodology for hospital global payments. Now they've outlined some principles and they need to, you know, there needs to be an alignment and by the way CMS will have to approve any state design methodology, but they are, they are willing to provide that you know to allow that flexibility and tailoring for states that have that type of experience. For cohort one states that real that methodology really would need to be submitted by July 1 of this year. The reason is that it generally takes CMS about 18 months to to review and set up their systems to prepare for paying for services differently. So that's why the 18 month, you know, deadline there 18 months ahead of performance year one. A couple other areas where we think there's some flexibility. You know, what's the process for reviewing individual hospital requests for adjustments in their global budgets. So for those hospitals that choose to participate, it would particularly pertain to whether there are changes in service lines either providing additional services or not providing services any longer. And the deadline there is May 1 of 2025 so that it can be included in the agreement between the states and CMS. A detailed Medicaid hospital global payment methodology, the requirement here and part of what makes us multi payers and CMS isn't just looking for Medicare global payment model. They're also looking for Medicaid and eventually commercial as well. And so Medicaid would have to implement a global payment methodology sometime during 2026. And they would have to submit that detailed methodology to CMS by June 30 of 2025. So fair amount of flexibility there. Next slide. So that's the primary care ahead. So they ask in the application for a vision for primary care transformation and a plan for how primary care practices will be recruited to participate in primary care ahead. A couple of pluses for Vermont is that a lot of what they're looking for in terms of primary care transformation and payment methods and so forth is we have that in the blueprint for health that really aligns quite nicely with the blueprint for health. So the thing with primary care is that for primary care practices to take advantage of the opportunity that the Medicare is offering in the ahead model, they have to be participating in an advanced primary care model for Medicaid. Some states might not have a Medicaid advanced primary care model. Others like Vermont do. And so when most of our primary care practices as you know participate in the blueprint for health. And so we're in pretty good shape. It appears on this particular aspect of the application. Next slide. And so in terms of flexibilities in primary care ahead, I have outlined a couple that appear to be in the model. And I couldn't quite tease out the deadlines here. So I assume that it means that this will be worked into the state agreement, which they want to see negotiated by May 1 of 2025 for cohort one states and then executed by July 1. They have said that they'll require five measures for primary care practices that want to participate in the ahead model, and they've outlined specific measures. However, they have said that if a state wants to propose an alternative measure to align, you know, maybe we're using it in our Medicaid advanced primary care model, that they will consider that. But it has to, they outlined some domains and I'll share those with you. But they want to make sure that the measures are comparable to the measures that they've suggested and that they support the model's goals. So that's one area of potential, albeit limited flexibility. And then another is that there might be an opportunity that under the primary care ahead model CMS is prepared to offer practices enhanced primary care payments. They're saying that will average $17 per member per month, no less than $15, no more than 21, but in that range. And they're going to risk adjust based on the population in the practice. And so there seems to be some indication that there might be some flexibility around what tool they use to risk adjust a practices population. They want to pay more for practices that are serving vulnerable populations. So those are a couple of areas of flexibility in the primary care model. Next slide. So model governance and health equity, the model, you know, we have to outline, do we have existing structures that we could use to help build a model governance structure, you know, how we identify folks so forth. There's quite a focus in this model on health equity. So they want to know what is the state currently doing in the area of health equity and we've got quite a lot going on, including at the health department, and how we can leverage those activities to improve performance. They want to see some activity focused on identifying health related social needs addressing them reducing health disparities. So they want to see it's kind of a currency. What are what are we doing now and these are in this next slide. So, you know, we're really quite a bit of flexibility. There's requirements, but they want to, you know, know how we're going to set up a model governance structure within their guidelines and the deadline there appears to be around November 1 of this year for cohort one states. And then one of the key tasks of the model governance group is to establish a statewide health equity plan and that needs to be done by December 31 of 2025. So, just before the first performance year for the cohort one states. Next slide. Commercial payer alignment. You may recall that in the model by the second performance year there needs to be at least one commercial plan under hospital global budgets. And so this outlines in the application, again, sort of what's current state commercial payer participation in care delivery reform and value based payment programs and, you know, other sort of readiness activities and then is there for authority to support or facilitate commercial payer participation in the global budgets and, you know, some other requirements there. Next slide. So, for flexibility again the timing of commercial payer participation, any time for model inception, but must be done by January 1 of 2027. There would need to be hospital global budget methodology for commercial payers. And, you know, there's no firm deadline outline but just logically thinking about how long it takes to make the changes again the systems so forth. I put in a date of Q4 2025 at the latest to have a methodology outlined for commercial payers. Next slide. This speaks to health information technology infrastructure and again they're really looking to see what's our capacity in terms of data and HIT to support the model and its implementation. Next slide. I didn't really, I didn't notice any flexibilities around the HIT they're really just looking to see how we're doing. So, this slide speaks to the cooperative agreement funding remember that set up to $12 million that they are prepared to give states that are selected. So, you know, they've they've outlined intended uses. So, recruiting primary care providers and hospitals to participate. You know the technical work of setting those total cost of care growth and primary care investment targets. They specifically call out building mental health and substance use disorder infrastructure and capacity and supporting Medicaid and commercial payer alignment across the model. You know, very broad implementation supports and within the NOFO, they have asked for a very detailed budget and narrative to accompany that budget and one of you know one of the requirements seems obvious but that the requested funding must be reasonable. And then in addition, they want to see a sustainability plan because really this cooperative agreement funding is intended more for one time or short term activities. So, I want to make sure that the work that's underway can be sustained after that funding goes away the $12 million would be available for the first five and a half to six years of the model, depending on which cohort a state is in so it's not ongoing throughout the duration of the model. Next slide. I'm going to go into a little more detail about examples of how the funds could be used so could be state agency staff could be do technology integration of community services referrals. Those are the focus on health equity, supporting demographic data collection is going to be important to the model, you know, bolstering HIE clinical data collection and creating dashboards for providers, supporting population health activities that's very broad, implementing health related social needs screening referrals and development of both those, you know, the Medicaid hospital global budget but also commercial hospital global budget methodologies, and then any, you know, here's the all other, but any other aspects that align with a population health agenda. These are examples, but you can see sort of their you know what they're seeing as priorities. Next slide. I think I've only got two more slides so you know that I wanted to just, I know there's some interest in the quality strategy and while we don't, you know, have to have things locked down for the application I want you to get a sense of what CMS is thinking. So in the no fo they talk about you know the quality strategy needs to have three sets of quality measures and they all have to have a health equity focus so there's a statewide measures that's part of that statewide accountability. Primary care as I mentioned there need to be five primary care measures for those practices that participate in the model, and then hospital quality programs as well. CMS has outlined four domains, areas of interest for them, prevention and wellness, population health, mental health and substance use disorder, and healthcare quality and utilization, and there's goals and in a way they can be seen as examples of the types of measures that they'll be looking for in each of those four domains. So we, you know, in our discussions and our technical groups and so forth we've, you know, sort of taken it a little further. We, there are the federal and state accountability targets there's a hospital level there's some primary care, but we also believe that as part of this model it'll be imperative that there's broader monitoring and evaluation. Just to make sure that there aren't unintended consequences that we're measuring in areas that are of high interest, for example, you know, access to care, care delivery, you know, trends and utilization and so forth. So, you know, we've sort of started that discussion but that's going to be really important to the model. And then as always is the case with, with quality and performance measurement, you know, to the extent that we can have alignment across these areas, across payers, it can really help align incentives for the people who are actually providing the care and doing the work and it can limit administrative burden. So I think that might be my last slide. Yeah. Thank you for listening. I mean, I feel like that was a lot of material. I might have no voice left tonight for the PK meeting, but we'll see. All right. Good afternoon. Do we pose for questions for Pat or should I continue? Why don't we keep on, keep on moving on Shule and we can just do questions all together unless Pat, do you need to leave or do you mind sticking around? What's your preference, Pat? No, I'll be happy to stick around. Thank you. Okay. All right. We'll hold them. Good afternoon and you can hear me well, I assume. So, thank you for this opportunity and I also want to thank the staff GMCB staff and the tag members who really worked with us continuously in the last 12 months or so to get to a place where we are today. So, what I will be doing in this presentation is to recap some of the great information Pat shared focusing on hospital global budget. Next slide, please. And then kind of start building the way that we've been discussing global payment program in Vermont with our stakeholders and thinking through what the head requirements are. And where the state may want to take the global budget payment mechanisms for the head application and beyond. As Pat mentioned, a head has multiple levers and multiple components. There's a lot there and she did a great job summarizing all of it. And my easy job is really focus on one box here, which is the hospital global budgets, which from the head perspective includes only hospital facility payments. So these are part A and part B in the Medicare beneficiary structure and it only includes payments made to the hospitals. It doesn't include any professional services associated with those utilization. Next slide, please. The way that the head is setting up the global budget is they are visioning to have separate global payments for each payer type. So CMS is providing an option for the Medicare fee for service site to create a state designated methodology. That means state is going to have flexibilities, but they need to meet certain alignment criteria set forward in the head application. Or CMS is going to design and implement a kind of a standard methodology under the Medicare fee for service budget. For Medicaid budget states, Medicaid agencies responsible creating the methodology. And again, there are some alignment criteria that CMS is expecting states to meet. And on the commercial payer, including Medicare Advantage, as Pat mentioned, at least one commercial payer must participate. But the requirements for commercial and Medicare Advantage methodology is much higher level. And the states are again in charge of developing the commercial methodology as well. So from this overview, Vermont has two options on the Medicare fee for service site. Vermont could design their own version of global payment or they could sign up to the standard CMS methodology for Medicare fee for service. Not every state has this option. Reflecting on Pat's presentation, you know, the list of problems that we are dealing with is kind of similar across the board in the nation. Vermont has very unique challenges, but Vermont also has very unique capabilities that could address and create solutions. And in this case, with the rate setting authority for provider prices, as well as the Green Mountain Care Board and AHS infrastructure, Vermont may qualify for creating its own methodology and because of the experience the state has as well as the infrastructure that they have. Another thing to point out is that the head is kind of designed with lessons learned from prior state learning. So Vermont, Maryland and Pennsylvania are mentioned in the NOFO as the example states and models that the CMS kind of draw lessons from. So we do think that the Vermont has a very strong positioning here. The Medicare requirements, as Pat mentioned, I just want to reiterate, not all hospitals have to be under global payment mechanism to meet the ahead requirements. It will only include 10% of the overall Medicare fee for service spending in first year and then you would need to increase it up to 30% by year four. So it's a voluntary program for all payers with the targets that needs to be met by the recruitment efforts from the state side. Next slide, please. So this is another way of looking at the times and deadlines that Pat mentioned. I did notice that Pat is thinking June 30th and I'm thinking July 1st. So if you are detailed oriented, there might be a month difference, but it's only a couple of day difference in the way the timeline set up. The important thing is if Vermont chooses to go with its own methodology, we need to submit the preliminary budget methods by July 2024. It also includes the Medicaid proposals as well, but obviously Medicaid has a longer timeline to get the regulatory approvals. But by January 2025, we need to have the final methodology established and hospitals would need to sign up to the new payment program by October 2025. And all the programs are scheduled according to the cohort one timeline to start in January 2026. Next slide, please. So we do have some time we don't need to mention much in the no forward related to methodology details, but after the move no boy if we were to be picked, then there's really a short period of time to submit that initial proposal for global budgets. So before I get to details, I want to kind of take one step back and think about the global payment model and why why states are interested in moving in that direction why hospitals and and payers are interested in this. The ideas behind global payment model is really to move the system from fee for service payment model to a fixed revenue model, where in the current model. In Vermont, we do have a CEO of fixed payments already that are impacting the care delivery, Medicaid has the fixed payments, but commercials are mostly on the fee for service side. And the incentives underlying incentives are still remaining to be higher payment rates, higher utilizations from the business model perspective. And the focus in service delivery that is, if you want to keep the doors open, you have to focus on high margin services. And there might be some contradictory incentives there with the community needs versus what is the high margin services that hospitals have to offer to keep the the doors open and you all are very similar with this dynamic given your budget review process. And the global payment model. So you could consider that as a tool and the way you apply it will determine the results. So it could bolster the incentives to change delivery. It could bolster sustainability of the hospital finances, but the ideas is that the revenues are set prospectively ahead of time so the payment amounts are determined prospectively and those payments are paid to a monthly or some other schedule so that it is a guaranteed revenue for the hospitals with the policies determined ahead of time. And over time, this revenue is updated with again using several adjustments that reflects inflation and membership change, and maybe other changes like online changes that we're going to get into more detail. So it doesn't mean that it is a constant number over time. It is prospectively calculated, but also it is a guaranteed revenue from the hospital perspective. So they are getting that revenue as a payment amount. Next slide please. I'm glad. I also picked up from Pat's presentation. What is the goal? We should start there and then figure out how to get there. So this is why it's backwards. The first left part is that where we want to go, what are we trying to do in this? Payment system is again a vehicle, right? So by itself it's not the goal to change the payment. What we are trying to do is to improve delivery and really support the transformation in the system. And the transformation here is about lowering the avoidable utilization. So we have the capacity to do better services, right here, right time at the right place. So that entails shifting the balance in our resources away from kind of creating incentives to reduce avoidable utilization and invest those resources into more population health essential services. So changing that balance in our system from sick care to prevention and wellness care. In the global budget payment mechanism, we bring the financial incentives. So the business model would need to change, but also to accomplish these goals, there needs to be additional support on the transformation side and ahead has some of those components with operational flexibility that we could get from CMS on the Medicare side, data systems, infrastructure investments, as well as alignment around performance measures to be clear what we are measuring and how those measures are impacting provider payments. Next slide, please. All right. So I mentioned the tag already. So the charge of the advisor group was to help us to think through the key components of the global payment methodology and we met since January. So it's been more than a year and we are going to have one more meeting to at least one more meeting to kind of do the comparison with ahead and what we've been working towards. Again, I would like to thank everyone who participated in the tag as well as hospitals, payers and the Office of Healthcare Advocate who had additional meetings with us to really unpack some of these complicated questions with us. So what I'm going to present in the next couple slides is incorporating their feedback and but as you're going to see there are still a lot of decisions and questions to be asked and decided. Next slide, please. So there is an alignment in the way that we reach to kind of have to construct the global payments. We will be looking at separate global payments by payer. So here the tag focused on the Medicare side and this is going to be my focus as well. And Medicaid is working their own global budget payment methodology and we're working on aligning certain aspect to it. And then for the commercial payers, the vision for the global payment is to create this payment at the payer company level and have adjustments for different markets for their ASO fully paid and Medicare Advantage plans. They're all going to come together to create a one single payment from each commercial payer who will be subject to or who will be participating in this model. The considerations here are even though the ahead requirements are smaller for a system-wide change, obviously you have to have a larger portion of the hospital revenue under a similar methodology. So there's a balance between increasing the participation with incentives and creating that overall transformation that we are seeking under this model. As you can imagine, commercial market is quite dynamic and complicated. So that's another reason why we focused on the CMS first, but we are actually thinking about how we can take some of those methodologies and adapt it to commercial payers as well. Next slide, please. With hospital revenue streams perspective, we started with the facility payments and this is aligning with the head minimum requirements, the facility payments for hospital inpatient, hospital swing beds, and outpatient departments. In terms of the phase two, as you see here, there is a big interest in including professional services, professionals billing under hospital 10, so owned by hospitals that goes into the hospital revenue stream. So we bucketed as phase two mainly because of the data limitations and additional considerations that we need to make on the professional services side. On the exclusion side, you do see that the patient portion, so the coinsurance co-pays will be excluded from the global payment. This is kind of if you think about the mechanics, the global payment is going to be paid by CMS and the patients will continue to pay their own share based on their own utilizations. On the other operating revenue, we are not going to be changing the way the other revenues come to the hospital. So these examples are dish payments, GME payments, and any retail pharmacy that the hospital owns that is outside of the hospital benefits that the individual sells. You do see a quick table here just to understand the percent of the revenue excluded and you do see that it is about 13% in 2022 and it's actually declining. It seems to me that the more included revenue is going to be, if the trend continues, we don't have an issue about excluded revenues kind of growing disproportionately compared to the included revenues. Next slide please. From the board's perspective, you have an established process to do budget reviews for each hospital every year and in this table, we try to explain where the budget review happens and where the global payment is going to come. So the budget review focuses on NPR, net patient revenues and fixed prospective payments. So that's the overall revenue of the hospital from the patients. As we continue to build our global payment revenues in this table, the maximum amount that we have is around 70%. So this includes 26% of Medicare fee for service revenue that through ahead we could include in the global payment. It does include Medicaid, assuming that Medicaid is going to include all their revenues under global payment. And on the commercial, as you see, it's a potential. We do not expect all commercial payers to participate. You know, at minimum, some of these commercial payers are quite small, right? So there will be challenges for them to create a global payment and change their practices. So we are still working on what is the potential for commercial payers to participate in a global payment program. So at maximum, you know, the 70% of the net patient revenue may potentially be under global payment model. Next slide. All right. So we covered what is included, what is kind of potentially from the hospital side, what percent revenue. And now we're going to go through how do you construct the global payment over time. The step one is determining baseline revenues. Here, we are going to start with historical payments and then we'll go through additional adjustments in a minute. Once you have that baseline revenue, we need to think about on an annual basis, what are the factors that we need to take into account to update those baseline revenues. And once they are done, the decisions are how do you pay it during the year. Step four is what happens if there is something happening in mid-year, even though we did the prospective calculations, what are the scenarios where there might be a potential update or adjustment to those payments amounts. You know, COVID, we are still kind of aftermath of the COVID impact. You can think about a scenario where utilization really went up. There is a crisis or some sort. Obviously, the fixed payments may not be sufficient temporarily to cover the cost of those additional services, or there would be dips that you may want to think about as well from the payer perspective. And finally, as you finish the first year of implementation, what will be the trans factors that we would like to use for the subsequent years here is an example is year two. So those are the key steps and key decisions that we need to make as we create the global payment model. Next slide, please. All right. So first step is the based on payments. So again, focusing on Medicare fee for service only for Medicare budgets. This aligns with the head as well that we are including the amounts from the claims. So this will include party payments, which is the retail pharmacy. It will exclude beneficiary co-pays and then it will exclude any payments that were made outside of the claims. So these will be the baselines and we are looking at a three-year time period. If we start in 2026, you see the baseline years as fiscal years 2022, 2023, and 2024. As Pat mentioned, there is some flexibility in determining the baselines and the weights, but we thought that we would start with the head as it seemed like an alignment to begin with from the historical revenue perspective. Next slide. In terms of the step two, as we update the payments, these what we call standard payments are general kind of adjustments across the board for all hospitals participating in the model. There is the inflationary adjustment, beneficiary changes, policy changes and performance updates. And I'm going to go through them in more detail in a minute. And then we do describe additional adjustments. So if a hospital, so these are more, I would say one-on-one adjustments, so not all hospitals may get this. It depends on whether they are making changes to their service lines, whether there are market shifts happening in the market. And then we also kind of discussed hospital specific payments for tertiary care, for example, the TAG and the leads we worked on creating additional adjustment for tertiary care. And we are working on creating special considerations for safety net hospitals. So you see a lot of acronyms here, but critical access hospitals, safety net hospitals, sole community hospitals and Medicare dependent hospitals. So depending on their nature of the provider type, there will be specific adjustments to account for different factors that these hospitals face. Next slide please. So once we do those adjustments, CMS is going to be paying on 26 payments. So they are going to stop paying claims and they are going to start writing checks. Hospitals will still submit the claims, so we could do calculations. But at the end of the day, payment is going to be a regular salary for hospitals, if you will, rather than depending on the ups and downs of the claim payments. Next slide. And on the mid-year updates, we propose to have these ad hoc and reserved for very unique circumstances so that we keep the premise of prospective, sustainable and predictable revenue. So as you can imagine, mid-year updates could create unpredictability. So we are creating this very limited scenarios and reserving this for major disruptions in financial flows or services or exogenous factors. Next slide. So at the end of the year, it's time to update and calculate the next year's budget payment. Here, learning from the prior experience where the settlements and reconsolations back to fee-for-service creates major barriers in implementation and kind of reduces some of the incentives that we would like to have, we propose no retrospective settlement under global payment. So all the adjustments will be calculated for the next year's global payment, so there won't be any settlement process related to year one, but the year two budget will be updated. Am I going too fast? Should I slow down? Okay. The same sort of adjustments again. So now you're going to look at the future year adjustments for standards as well as the additional adjustments. So everything is updated for one year. There will be different numbers, but the methodologies will be the same year over year for updating the global budget payment. Next slide, please. All right. So that's kind of the step. So again, I'm going to take you one more level detail, and I have a few slides left to kind of not taking a step back and thinking through what are the considerations for each step. So for the historical revenue, you know, validation of the payment amounts and clarifying what is in, what is not in is going to be a key focus for the state. No matter which option the state chooses, whether it's the CMS standard or Vermont. The uniqueness in Vermont is that we need to think about how CMS will continue to pay for blueprint, CHT and SASH. So that's going to be an ongoing conversation and potentially something to clarify during the pre-implementation phase. There will be additional adjustments. So if you think about the three-year baseline, a lot of things may have changed. And if a hospital closes service or opened the service, we want to make sure that we align the historical revenues. So the starting point for a hospital is kind of reflecting their current service line offerings. Next slide, please. The baseline incentives in the CMS methodology, CMS is offering an upward adjustment of a 1% to fund transformation activities. This incentive is available only in performance year one and performance year two. The goal here is in addition to provide additional services, you can think about this as an additional incentive to join the program early. If a hospital joins in performance year three, they are going to be missing out of this additional 1% in the CMS methodology. As we discussed the potential incentives or baseline adjustments with the TAG members, we came up with a few additional considerations for Vermont to think about, given the focus on improving access and also investing in health equity. So we listed them here. There is a consideration to provide additional revenue in the baseline for hospitals serving the most disadvantaged populations. There might be upfront investments needed for targeted areas for access related. And after me, I understand you will hear a little bit more about that work to understand the needs. There was also a discussion about, as we build this from the historical revenues, and if the hospital continuously have a negative margin, how is the hospital going to change the financial picture of the institution under global budget payment. So there was some consideration about whether we should make additional adjustments as one time to get them to a acceptable level from the start. And there could be exception based factors on a case by case basis and CMS methodology actually has that as well. That also opens up maybe unique circumstances that we may need to make adjustments to the baselines as well. Obviously, we could come up with many more and the important thing here is, do we have how much funding we have to invest in the baseline and that will be driven by the requirements at the statewide on Medicare savings or for Medicare trends. So these are all options at the end. The final decisions I suspect would depend on where the state ends with the CMS ahead savings requirements to go back and figure out what it is that we could invest at the beginning of this model. Next slide, please. In addition to the size, so I think the variation between hospitals and other consideration is, you know, how unique this funding is going to be based on the circumstances of each hospital. The 1% transformation incentive is our understanding at least currently is going to be 1% to all hospitals participating regardless of their situation, I would say. But you may consider, you know, variations between hospitals, giving more funding for hospitals serving most disadvantaged population is a good example, as opposed to giving a 1% across the board to all hospitals. Another consideration here is, you know, cost efficiency, financial stability. There might be some balances there if the eventual model has the sustainability adjustment taking into account some of the margins that I mentioned in the earlier options. On the time period side, as I mentioned, CMS's vision is to use this as incentives to join the program early. If the state creates its own model, is it going to be for 2 years, 3 years, and whether there will be payback if the hospital leaves the program in mid-year. So there is an option that any hospital could leave the program since this is a voluntary program and CMS does have some clauses if the hospital lives early that they would have to pay back the transformation payments. And finally, on the accountability side, there is a language in the head that hospitals would need to submit transformation plans, how much you want to tie the baseline incentives to some of those plans, or actual changes on the ground is again another consideration that we need to work out as we build the methodology together. Next slide please. One of the requirements of the head is to make adjustments based on health equity. Global payments will be adjusted based on the social risk of the patients. And we do not know what CMS is planning to do in this area, but I'm teeing this up and it will link with our health equity measure sets as well that we will be looking at this a little bit more closely in the coming months. And the prior comments from the tag is that there is a general support in this concept, but the measures and the tools might be very complicated and we may start with a progression plan. If we have a desired goal, we may not get there in the year one and it may build up eventually starting with the measure itself, collecting additional information, supporting data collection, and move to a payment adjustment in year three and four as well. Next slide please. All right. So those are all baseline, how much we could do in the baseline revenue calculations. Now I'm going to briefly touch about the adjustments. I did list the standard adjustments here. I'm not going to go through them in detail, but the idea is that to provide the sufficient updates every year accounting for changes happening outside of the hospital as well as paying for performance, right, paying for outcomes as the last point. Next slide please. The proposal for inflation adjustment is to use CMS hospital market basket. That is a number that CMS uses for their own hospitals. We do not know what they're going to use for a head model yet, but our starting point is to use the update factor that they use every year and it will be kind of projected by the actuaries and we could use that number as in our inflation adjustment. Here you see the graphic. We all know the increase in inflation in the prior years, 2023 and 2022. You do see that eventually the trend picks up, but there is a risk here that with forecast, we may not pick up everything that may happen during that year. Critical access hospitals and Medicare dependent hospitals may need additional considerations as their cost structures are different and the average number that is calculated across all the PPS hospitals may not be sufficient for that. Next slide. On the beneficiary adjustments, so we addressed the cost and now we are thinking about people served. On people served, we do need to make adjustments based on their risk profile. So as you know, as we get older, we spent more on healthcare. So age, gender and ESRD status for Medicare beneficiaries will be taken into account and that we will distribute the beneficiary growth to each hospital based on their revenue from HSA. So we are proposing to do this at the hospital or health service area and calculating the membership change and allocating that membership change after adjustments based on the hospital's revenue from HSA. Next slide please. On the policy and performance adjustments, we propose to use CMS policy adjustments. So this should align with ahead as well. And ahead is also requiring a quality adjustment. We could ask for a waiver not to use the CMS programs, but the proposed initial proposal is to start with CMS and move towards creating an all-payer quality program during the implementation period. There are additional performance adjustments that would be happening under global payment and those are total costs of care, accountability, improvements in health disparities and efficiency, which I'm going to get in a minute. Next slide please. If Pat gave you a lot of information, I'm giving you even more and more detail. So I'm happy to kind of take questions at the end if you want to get into more detail. But, you know, we talked about the transformation incentives being only two years. There is also the opposite that some of these adjustments are going to start in year four or year five. So I want you guys to focus more on the health equity improvement bonus on CMS methodology. It's starting in year four. As a payment adjustment and the TCOC performance adjustment is also starting in year four and effectiveness adjustment is starting in year two. So CMS made decisions on when and how these adjustments would start. If Vermont chooses to do their own options, then these are all going to be discussed and decided on the methodology as well. Next slide please. So on the total cost of care accountability, this is a requirement if the state does their own methodology. And the requirement is that we need to create a methodology if the state does not meet the Medicare fee for service state accountability. So if we don't have enough savings, basically we need to create a methodology where we can link that performance back to the hospital global payment. That's the requirement for the total cost accountability. CMS also indicated that the initial transformation incentives and additional payments for primary care will be excluded from this. Again, in the standard methodology, there is some variation in terms of the timing, but Vermont could also think about which payments will be excluded from the total cost of accountability as we design this methodology in more detail. In addition to the CMS requirements, if we can create an accountability this way, the physicians working with the hospitals could qualify for additional incentives and payments from CMS. And also it is aligning the work with the total cost of care. So not only just putting a levers around hospital payments, but linking the payment to a total cost, even though there is a limited impact from the hospitals perspective to non-hospital providers from the beginning. Next slide, please. Creating a total cost accountability on hospital is also complicated. One thing to keep in mind here is that CMS is requiring a geographic attribution, so we are not going to attribute patients to hospitals. We have to figure out how we can do and assign certain geographies to each hospital. And there are multiple options here and we'll be working and looking at CMS methodology to understand what their requirement is to see if we can adapt this to the Vermont methodology. Next slide, please. So finally on the additional adjustments, you know, the service line is a big one. How do we handle if hospital is changing services and the hospital specific adjustments are to a certain extent related but has their own separate considerations. So I'm going to go quickly on those two. Next slide, please. The service line, you know, we are thinking about four scenarios. One is how do we fund new and expanded services? Because they are no longer going to be paid on a fee-for-service, so we have to prospectively adjust the global payment. What do we do when they close or reduce services? The idea here is that as we are removing the margin question out and incentivizing them to shift services, do we need to take all the payments out from the historical revenue if a hospital is doing the right thing and closing a service that the community doesn't need anymore? The third option is temporary changes. If they hire, you know, if they need to hire a new physician for a retired physician, we know that it's a temporary dip, but we may need to think about how long we want to keep that as budget neutral before we go and make adjustments to global payments. And then finally, to create the incentives and maintain high quality of care, we do want to think about whether we do want to make adjustments if the patients shift from one hospital to the other. And here is the way we are thinking about market shifts is that if a hospital, you know, gains or provides more services on the inpatient side, we do want to see declines in another hospital for us to be able to assess and adjust the global payments. So we maintain that overall budget neutrality in the global budget payment program. We did do some development work on the tertiary care services. The goal here is to adjust the global payment based on the changes in high cost services. And this is a unique to Vermont. This didn't come up in the head. They do have different concepts. They are trying to do outlier adjustments and exception based. So this could be something we can consider as well. But the way that we have developed this in the strong model is to come up with a list of services where we create a reconciliation process. So to speak to adjust the global payments up and down downward or upward based on the utilization in tertiary care. And this will only apply to UVM and one or two more hospitals depending on how we define tertiary care. Next slide please. And finally, we are kind of on the hospital side. We are watching what CMS is going to do for critical access hospitals and Medicare dependent hospitals. They are they clarify that they do not plan to reconcile critical access hospitals back to the cost report, which is a major change for critical access hospitals and a big issue in Vermont. Given the hospitals that you have, we want to understand what CMS is envisioning. They do have some adjustments already to help critical access hospitals on the quality adjustment program as well as the performance measures. As I said, they sometimes start late or they have only upward adjustment. And they do mention there might be a concept of floor that, you know, the payments will cover certain fixed costs for these hospitals and that there might be some sufficiency. So those are all undefined terms in the head for expediency and the timing perspective. We are waiting for their definitions to see if we can adapt those and modify them if needed for the Vermont methodology. All right. I have two more and then we are done. So those are all the things that we discussed and worked through in the last 12 months. We did see a few things that didn't come up in our discussions, but worth mentioning here for your consideration. Next slide is the health equity improvement bonus. We did discuss to say a little bit what we didn't really formalize it in the straw model, but CMS is going to provide a bonus upward adjustment if the hospital perform on certain quality measures that are related to health disparities. So that's the first one. Next one is an effectiveness adjustment. This is a downward adjustment and CMS is going to be looking at potentially avoidable utilization and reducing the global payments based on the progress made on these measures. Again, it's starting in performance year two and the cause are going to start in performance year three. The measures that they are using is in the next slide in terms of avoidable utilization. They do not define them yet. They mentioned them as examples, readmissions, ambulatory care sensitive inpatient admissions, emergency department visits are what they consider as avoidable utilization. They also mentioned overuse or low value care measures and I put some examples here. So all of these measures are driven from claims analysis and there are specific algorithms developed or vetted by national organizations. And I did provide some detail if you are interested in the appendix for each of these measures. All right, we are ending in the same slide as Pat. You know, at the end, as we develop the methodology from my perspective, we have a clear link between all three, but more importantly, which measures we want to make payment adjustments, which measures we want to put in the monitoring plan is an important factor to consider. So there might be broader sets for monitoring and those measures may eventually get to a payment model, but there will be a link and assessment in both of those from the alignment perspective to ensure that we have the incentives balance in the global payment. So and more to come on those measure sets and the way that we are going to be linking that with this statewide selection of the measures as well. So with that, I think I and I ended here. Great. Why don't we take a six minute break and come back at 2.40 and then we'll have board members questions and comments, HCA and public comments. So we'll see it 2.40. Thank you. Okay, looks like we have everyone here so we can resume our hearing. I'll open up to the board members for any questions or comments that they may have for Shuley or Pat. I can jump in if you want to foster. Sure. Great. Okay. Well, first of all, thank you so much. There's so much to digest here and I know there's a lot of hard work and stakeholder engagement and modeling efforts that have gone on behind the scenes for a year plus to get us to this point and I really appreciate that. And I want to say I think this is an intriguing model that I'm really glad is under a serious consideration. I think there's a lot to like about it. I think most of my questions may be more directed to you Pat and are probably closer to the top of the decision tree. In terms of I think of the decision tree ahead or no ahead and then if ahead what is what is the global budget look like under there that was the model look like under there that's going to be best for Vermont or so. I think today a little bit as I'm just trying to get a sense of the analysis that we need to do to make sure that ahead is best for Vermont compared to the next best alternative. So really trying to understand what what happens if we don't do ahead? What does that look like? What fee for service version are we in? And then how do we compare the two worlds on a couple of different dimensions? And I just want to preface by saying I know that the NOFO app is just a preliminary kind of non binding step which I totally agree we should submit and you know I'm grateful that we are submitting it because it allows us to have this conversation with the federal government. I'm just more thinking about what are the types of analysis that I think would be helpful to see before the state signs any final agreement or perhaps as we go into negotiations around what that agreement looks like. So most of my questions like I said are a little bit more 40,000 foot today than you know 5,000 feet about the intricacies of the global budget model which I think I will have questions and I like a lot of what I see there. So one of the I think I'm going to back up a bit and when I think about the challenges that our health system faces right now. And I think about you know obviously affordability of health care I think about it for the uninsured the underinsured the employers the school districts everybody is trying to pay premiums right now. I think of really long wait times for specialty care I think of insufficient access to primary care I think of patients boarding in the ED because there's no mental health beds or in patients ready for discharge but there's nowhere for them to go because there's not enough sniff beds. These are the things that I think are acute challenges that we face and so when I start to think about the ahead model I imagine how will this model impact those very very specific issues relative to that next best alternative of probably some fee for a second. So one of the questions I guess I have for you Pat is I this this model is certainly designed to curb health care costs specifically for Medicare and Medicaid. And it looks you know has promised to do that. I'm interested in thinking about you know the balloon analogy that sometimes I give right if you squeeze on one end of the pop out the other end. And so I'm wondering are there plans to try and model what's likely to happen to commercial insurance premiums under ahead versus under that next best alternative. But I guess that's my first question and I've got a couple others related to that but. Thank you Dr. Holmes. There's a lot. There's actually several questions embedded in there I think. And so I'll try and you know address each of them. You know the first is you know what happens if we don't do ahead. And I really do. You know we get asked that question a lot. That's why I started out the presentation with the why. Why are we thinking about this and why now. As you know our current model will not exist beyond 2025 CMS has made that very clear to all states that they're not going to do these single state models anymore. And so it's not like we can stay in the status quo. If we don't do ahead. We're really looking at fee for service for Medicare at least. And you know I think a lot of folks with you know was for the incentives that are baked into a fee for service model. You know I think folks would see that as a step backwards. We've done a lot of work to really position ourselves to continue to advance alternative payment models. Maybe we you know could do Medicare fee for service but that leads to that type of fragmentation across payers and I think we've all worked hard to try and avoid as well. And if we don't participate. Yeah. I think you know you all know I've been at this for a long time. And we thank you for that. We know how much work you've done. And you know I mean I I feel like you said I see some opportunity here that I have not seen in prior models that have been offered by the federal government. It's not perfect. You know there's some things that are missing but I want to start with the investment in primary care. This is you know for looking at ways to address costs and now I'm you know I think really going to get to your question about what does this mean for costs overall what does this mean for commercial payer costs. There is I just spent a couple days Michelle and I did talking to other states in Washington about primary care investment and sort of the evidence around that and why it's so important to continue to focus on improving investment in primary care. It's better for patients. It's better for for it's better for the system. And so to see a model that actually says the state is going to be accountable for not only Medicare fee for service primary care investment but also all payer primary care investment to see a model that you know actually makes a strong effort to increase payments through those advanced primary care payments for primary care practices that participate to see a model. The focus is the way that this one does on safety net providers critical access hospitals federally qualified health centers rural health clinics and that focuses on health equity and how can we reduce disparities and health. How can we make sure everyone everyone is getting the care that they need and deserve that. Those are some pretty encouraging aspects of this model that do potentially have impacts on outcomes and costs. And so sort of the more comprehensive nature here that we're seeing is encouraging. I think you've all probably heard me say that you know one area where they where CMS is expressing interest. But they are not you know there's nothing overt in the model but they're definitely saying they want to see that balance from from you know hospital care. Let's invest more in community care in post acute care the very things that you're concerned about our bottlenecks in the system. You know there's definitely a desire to do that. And and so you know that that we I think we have some opportunity even if it's not really over there. There is a fair amount to lose if we are unable for any of a variety of reasons to move forward with with a head. You know it includes that you know Medicare obviously wouldn't be in our health in our in our health care reform so that you know we would not have Medicare at the table. As you know almost 10 million dollars comes from Medicare to support the blueprint and sash programs and if there's not continuity in the models that's going to go away. The 12 million dollars in cooperative agreement funding it's not a ton of money. It might not be enough but it's something to help Vermont continue to advance toward better health care for Vermonters. The per member per month those enhanced payments for primary care would not be available. And you know there's again that opportunity to really focus on equity all of those things together. This is not a one solution. Yeah. I know that I'm just trying to it's helpful to think through and quantify what it's going to look like in a world where we don't do this right so the but for world what does that look like and I I think about you know you've raised some other important dollars coming into the state. I think it would be helpful to model the difference that we expect in federal dollars coming in under each scenario for the duration of the model right. So there's federal dollars that are coming in and ahead. There would be federal dollars coming in if we were in fee for service as well. I mean you know there's dollars coming into the state and there's expectations on total cost of care reductions you know that are going to impact those federal dollars coming into the state. There's dollars coming in for for blueprint and other you know really important programs. But there's also costs associated with being in the program in terms of the regulatory costs and the compliance costs and the quality reporting costs. So I guess and I'm only asking this because I think it's really important to to understand what what are we what does it look like in the world where we're going to go forward with this and what does it look like if we didn't and what are the what is the delta on the federal dollars that we can expect over the duration of the model and quantifying that and really trying to isolate the dollars that are coming in for health care services under each payment model netting out dollars coming in that are tied to be doing the model right. I'm trying to understand that and I think that's a really. I think that would be helpful for us to see for example if we go ahead with it you know one of the rationales is potentially there's all this different targeted dollars to help us achieve our equity goals and our other types of goals but I haven't seen that number yet and I'm trying to figure out how do we get our hands on that. Yeah. We don't have the CMS methodology yet for hospital global budgets. So and you know frankly you know because there's some actually a lot of flexibility and state design methodology that'll be part of our if we were to be selected and I want to keep emphasizing that there are other states. I just heard of another one today that's applying I mean there are plenty of other states that are interested in this but you know it's a competitive process if we're selected part of the negotiation will be around you know how do we you know make adjustments in the hospital global budget methodology and then we'll have a better sense of that number and we should look at that and model that as to what it means for the state. You know it's a little hard to tell with fee for service because it really depends on volume of services. You can project what would happen if we were to revert back to a fee for service model. We could do some projections so there you know I'm not going to over promise there would be some some estimates and some assumptions that would have to be made in doing that type of analysis. So we're anxiously awaiting the methodology then we would look at that and try to do some modeling based on what we're seeing but the real modeling is around what we negotiate if we are selected in terms of the Vermont specific methodology if that stops and we decide to Right and that makes all the sense in the world. You know I can appreciate a lot of the stuff has to be done after we understand the CMS methodology and after we you know design these strong models and tested them and take the tires around a little bit on what the adjustments can be and what latitudes we have to draw down more federal dollars in those adjustments and I think that that will all I recognize that will all take place in the negotiation process. I just think that if we have a strong understanding of all of this going in we might be able to bargain for more. I recognize to that there may be other states that are competing with us and we may not have as much bargaining power but you know let's try and leverage all that we can to try and shore up some of the challenges in our in our state as we see them now some of these really acute challenges what are the ways that we can address those through this model and through drawing down some federal dollars and I guess the only I believe two other questions I think one is I think you've heard me talk a little bit before about access and that's really something that I'm deeply concerned about and I think about our model now which is you know a fee for service model where incentive is to drive volume and we still have major access challenges in a model that's incentivized to bring as many patients through the door as is possible. And so I think about how we model or or reflect on a shift towards a global payment model and thinking about how we're going to you know what we expect to happen with access and wait times and provider productivity. How do those incentives change for provider productivity patient throughput like what how do we think about that. How do we mitigate against access challenges that may ensue and one of the things I think about is before we embark on this model we have to have a pretty good idea of the baseline access challenges we have now the wait times and we don't have a very good system in place right now to be monitoring wait times frankly you know we do the best that we can through the hospital budget process but it's not ideal and really understanding the patient experience and accessing specialty care or even primary care. And so part of what I think about is if we're going to go down this path I think we need to be investing right now in developing a baseline understanding of what the access challenges are now. So we have a mechanism going forward to be monitoring any changes that we're seeing as a result of changes in the payment model so I just want to put a plug in I don't think we can wait until 2026 to start thinking about how do we monitor access because we need a really good baseline from which to move from or to understand any movements from. So I guess it's not really a question it's just a concern I think I have and maybe it's you know maybe it's not going to be a concern that we need to address but I'd like to think about it now rather than waiting. I guess my last question Pat for you is a little bit of you know there's there's the three cohorts and I think about the timing a little bit of our entry into this potential model if it works out and we're selected and the negotiations work right and I wanted to ask a little bit about optimal entry time. I think I asked this a little bit last time but I've thought a little bit more about it since since our last meeting and on the one hand I can see why early entry might be better because our all pair of model agreement is ending and there's you know what do we do in this interim period and we don't want to lose the momentum that we've had on this but the other flip side of that is I think about this community engagement process that we're involved in now and that process is going to lead to recommendations for delivery system reform ways to improve efficiencies reduce some of these bottlenecks maybe create centers of excellence think differently about how we deliver health care and I'm just wondering the timing of making those changes and then on top of that trying to layer on a payment system so just wanted to ask your thoughts a little bit on there's so much happening simultaneously there's the sunsetting of the all pair model but there's also this really exciting opportunities to think differently about how we deliver health care and how do we fit it all in in a way that that makes sense. If that's a. Yeah yeah and I do want to just say agree with you on the access points that you made and the need to have a baseline and that should be part of our monitoring process. You know I think the concerns we've already articulated around the discontinuity we would definitely lose the the blueprint sash funding for sash as you know that's that's that's like the whole model pretty much at least operating costs. You know there's the potential. Well. You know they're just may we there may be a potential to get you know in that flexibility to get some a little bandaid or something. Yeah I'm trying not I think you know I think we're venturing into negotiation territories I think I better just leave it at that but there's you know there's some concerns with this continuity in terms of the transformation work that you all are engaging in. You know I I don't see that as a deterrent because those things you know whatever the recommendations are and whatever uptake there is of those recommendations is going to take some time to implement and that can only help us down the road. If they are transformation activities and actually you know result in better outcomes and lower costs for folks so I that doesn't seem a deterrent to me although you know I hear what you're saying about the complexity of everything happening at once. But this is a complex environment and I do worry a little about saying OK you're all in you know an all payer model now that's going to go away go back to fee for service then go to you know if we want to say we're you know want to try for 2027. I'm not sure it would be worth it because it would be in other states where they're in fee for service and they don't have the kind of model we have it's one transition here we'd be asking people to make two complicated transitions and you know so I think that's a concern when you look at the what we might have to have to lose because really like from an application standpoint would I love five more months to build up an application why yes I would you know five months you know and then and then you know the it's a year difference on the implementation which that's more significant but it's not. Endless and what CMMI has said is that they're going to award no more than five states for cohorts one and two now two has the later start date to but they're going to award no more than five so that would leave like three slots for cohort three or more if they don't award a total five so they're going to keep at least three for cohort three so and you know if it's daunting. It's an unbelievably complicated I mean the presentation we just heard. It's, you know, but Vermont is probably as well positioned as any state to tackle this and it's still complicated and daunting and you know we've we've engaged in complex change before and. And it's a different landscape but you know it is an opportunity. It seems to me. I think it's an opportunity I'm glad we're exploring it. And I think you said something very accurate before we are very well poised to do this given the form efforts that we've done so far which tells me that we probably have a lot of leverage. That's, you know, I this is my last question is actually for shoelay and then I'm past the baton. And this is a little bit more about the details and this is my only question about the details today because I've really got to absorb a lot of this, you know, modeling here but I think one of the key lessons we learn from the all pair model is that having a foot into canoes is really just doesn't doesn't work right and we know that expression has been completely overused but the idea that you know you got to get enough of your patients in a particular payment model. This is the point of alignment that we're trying to achieve here. And I believe that I believe that sincerely so when I look at this the model requires only one commercial pair. And only by year for 30% of Medicare fee for service in it needs to be in a global budget by year for so I'm just wondering shoelay this is more for I think maybe for you but Pat, you have such expertise in this as well I'm wondering. Is that enough revenue to incent the reallocation of resources and the delivery system reform that we want and is there a minimum floor with which we should say this model is only going to work if x% of the revenue is in fee for service which means that we have to get a certain number of commercial payers in and we have to get a certain you know proportion of the public payer revenue in before we can really say that this is going to have a chance at success. So is there a number in mind is there thoughts on this? How do we think about that? You know I think that's a great question and probably we need to ask that to the hospitals from their perspective but from my perspective. I was trying to explain for the commercial side given the number of plans and companies in the commercial one if a commercial payer has very few residents in Vermont like how are we going to think about it we scratch the service service on the commercial participation but we you know end up working really hard on the Medicare side I think we need to come back to it. The other pieces you know it takes time to do those things too right so it may still be reasonable to start with you know substantial public participation and gradually build on the commercial one I don't really have a good sense the pros and cons of doing that. So, you know those are kind of initial thinking but really I think you're right like for a model like this to work. We are asking for major transformation that means majority of the revenue should be on their descent align so that's that's given but what that number looks like would probably depend on each hospitals kind of services and the commercial market that they have. And I don't know if you want to add anything else to it. No, I don't think so. You know clearly having, you know, a hospital having the two public payers and in Vermont that's a pretty good chunk of their revenue and is, in fact, likely for most hospitals to, you know, be the majority of the revenue given, you know, Medicare utilization. But I agree with Shule that you know we have focused on Medicare but we would want to, if we were to move forward very quickly to again with the commercial methodology as well and see what you know gauge the interest. You know, we've had some conversations with our commercial payers and they're part of our technical advisory groups and, you know, so it's, you know, that they're at the table. But, you know, there's a lot we'd have to essentially do the same kind of work for them. Yeah, yeah, and similar flexible we have similar flexibilities there as well. So, in fact, maybe even more so than with the Medicare model. Awesome. Thank you so much always it's always great to hear from all of you and thank you for answering my questions. Appreciate it. I'll have a couple because I'll just go because they kind of relate to some of Jess's. I guess in our hospital budget process we heard a lot from hospitals about how the Medicare amounts weren't sufficient for their financial needs. If the public payers are being capped at this market basket level. How is that going to be enough for our hospitals because historically they've needed to, you know, look to the commercial payers for more money and that's that's sort of been a big part of their presentations. So if we cap Medicare how would that be enough money. So I'll start and truly please feel free to jump in as well. But I think, you know, again, one of the benefits of a global budget is that it provides significant flexibility and how care is delivered. It provides that predictability and revenue. And, you know, if, if care can be delivered in a different way. And if we could do some of that rebalancing of the systems or the primary care is is enhanced and and, you know, less hospital care is needed, then, you know, there is some potential for for not only, you know, we'd want to make sure that the revenues coming in through the global budget were set at a sufficient level allow for trend allowed for aging of the population and so forth. But by the same token, if we can accomplish some of these changes in care delivery, it could also, you know, help us spend those Medicare dollars differently so that people were, you know, whether it's telehealth or whether it's, you know, more primary care there's a there seem to be some areas where we could have less utilization and better outcomes for our for our promoters so I think they're you know I think that's potential but you know a lot of it's around that baseline to and the adjustments that get made and how we can ensure that there's sufficient revenue to start that the trends are sufficient and that the the adjustments that we make are ones that make sense for our state. Yes, I think the other piece I think you touched it on Pat, but avoidable utilization is the highest among the Medicare population so if you think about effective interventions let's say ED visits or inpatient if you have a diabetic clinic that is supported and can handle more than what they currently have it's going to draw down inpatient utilization at the hospital, but hospital is going to keep that payment from their historical level, but they are not going to have the cost of providing that services for that utilization they're going to save from supplies you know they could utilize their nursing staff for other purposes so that's the rebalancing Pat is talking even though on the unit level Medicare may not cover so at the unit level even if Medicare may not be paying full cost on the utilization side on their fixed revenue model they will be potential savings for hospitals to reinvest. So our hospitals are pretty unique in how they're where they're placed and sort of their circumstances right like the rural nature of the state is really creates different opportunities and challenges for our hospitals. How does this model address the rural nature of our state in our hospital structure. So I think you saw in one of the tables that she lay showed that you know there the CMS has given a lot of consideration about how to get safety net hospitals and primary care providers into the model and so you know there. I'll just give some examples for quality measures for critical access hospitals that's an upside only construct for them. They will they will get additional payments for quality. They will not get downward adjustments. They there is risk adjustment that occurs that would occur for both the hospital. You know global budgets and for primary care enhanced payments that are based on you know risk factors and so practices and hospitals that serve more vulnerable populations. Would receive additional funding to try and meet their needs. There's the you know transformation dollars that we've talked about that would help support that work as well. You know I was thinking about when we were talking about geographic attribution. I was when she was talking about that I was actually thinking about what that would look like in a state where there's multiple hospitals and a service area and it seems like it could be more complex. And that kind of an environment. You know whereas in our rural communities you know hospitals know who their communities are know who who they're serving you know there's no question that the move away. From cost based reimbursement is is challenging for our critical access hospitals to think about. And so that's an area you know that I think we want to keep discussing and exploring. But the model does seem to be you know designed to really try and bring some of those smaller hospitals and smaller providers into participation. And there's a you know a few different incentives that should help in that regard. And one addition sorry one more thing in terms of social risk you know they focused on area deprivation indexes but Vermont could propose. Rurality as a factor. So to me that could bring additional resources to our rural providers if we incorporate that into all the adjustments that we talked about. Is there any risk so there's service line adjustments if you add a service line you get an adjustment and I guess one question I had is whether or not that could potentially favor larger hospitals. These are the smaller hospitals because potentially they want more revenue and so they might try and recruit service lines from other hospitals. Is there any risk of that and the problem with that could be that then the distribution of resources in the state gets consolidated. I do want to take power. I think the risk is in the people service to right right now the same dynamics are occurring so we need to think about how global payment is going to change that a little bit and to me that may create additional processes for states to think through the policy so we talked about access relate as we are defining what adjustments will be made for new services. I will give you an example from other models where there is a list of essential services and maybe at 167 work that we're going to hear may give us a little bit more what we mean by transformation and what those new services are. There might be adjustments up front for those services and for others if it is about market shift that could be done at the end of the year to create that barrier in a in a way to avoid some of that consolidation issues like because they have to bring the patients to them as a poster upfront funding for access related services where hospital needs investment and new resources and they are kind of they don't need to bring the patients from another provider. If that makes sense. So there might be different ways of thinking about new service lines in the way you put the methodology together. And then I mean if we if it were not in the first cohort for my was in the second or later. I mean would we actually be going back to fee for service because to me. I think someone said something about we're asking them to make two transitions. But to me it looks like they'll very much be in fee for service. Anyway. Right. Like part of this is going to be in fee for service. Part of it's not. There's one insurer if there's no professional services included. You know. The hospitals so they're going to be in two systems regardless of when they join or am I my misunderstanding that. Well certainly for me I mean yes some hospitals get fee for service now but this would mean that Medicare would go back to fee for service. And you know that that the payments you know the mechanics of the payments would be fee for service. And then I guess I think I think the last although I have many others but one is. You know we have the 167 work that we're going to hear about in the transformation this is going to what member homes asked. There's going to be a report and some recommendations and opportunities of ways to streamline services add services reduce services expand services whatever they there may be. If I'm a hospital going into a new process with a global budget. I feel like I would be disincentivized to want to make those changes before I get my global budget. See that differently. So I do. Sorry. Can I jump in. We don't know the recommendations but to me. If you can link those two streams nicely. If you get a prospective payment if I'm going to close a service as a hospital I may not need to worry about losing the revenue from those services from the get go. Right. Because under fee for service if I shut down I lose everything right at that point. I'm opening a new service for me to earn that new service. I need to bring the new patients. So it's going to take time again for me to build up that revenue base for those new services. So I think without knowing too much detail on that 167 to me there might be a nice alignment if you can figure out how to do it. It is complicated. But to me I think that might be an opportunity for us to really create a dynamic where the transforming like finance doesn't become a barrier for transformation. Yeah I was actually thinking along the same lines that you know that a global budget actually provides a bit of a glide path for those transitions. And you know chances are if a new service is being stood up based on recommendations that come out I think you're getting recommendations in the spring. You know the timing is actually probably somewhat aligned there. Another question I've just heard others ask is why started baseline. Are we considering the proper allocation on a statewide basis. If we start at baseline. So for example there's like two different levels of that. There's one statewide distribution of resources. Right. So do we want this much money of our health care dollars in the hospital system or two within the hospitals themselves the 14 is this the right allocation for what they need today on day one. And then third third level even within those hospitals is that how they should ideally for their community be dividing up and using their money with the services that they have. So really three levels. And I guess the question is really what's the pro of starting at the current baseline and how does that consider the necessary costs to operating for their operating expenses. Yeah I mean I think you know we obviously have some years of historical revenues that this board has influenced based on the information that you've gathered and so you know I mean first of all see that's what CMS has put forth. I think there's some sense to it because it could be a major you know it would be a major shock to reallocate they when you've got years of historic baseline revenues in a fairly highly regulated system. I don't have any other questions I think this is really exciting and I think there's a lot of work to do in the negotiations and a lot to learn. So thank you for keeping us informed and all the work that went into it. Thank you. I'll try to jump in with some questions here if I can I don't know. I'm unusual setup in an unusual location for myself so I hope you can all hear me just fine. So first of all, you know, thank you so much for all the hard work for the last better part of the year. Trying to understand this system digest it and optimize it for for Vermont. I guess the first question I want to just bring up is on Medicare fee for service. I feel like this is the kind of a complicated nuance discussion because while we are you talk about reverting back to fee for service but in many regards but not all I think we're in fee for service now. So, at least it's reconciled back to fee for service if I'm not mistaken is that that that's correct right on the Medicare side yes. So, it's not that we would go back to fee for service we're in fee for service but we would have different reporting requirements and the payments would flow differently than our current situation. Not that we would revert back to something that that we're not in. But is that is that fair to say like there's definitely an all pair models allowed us to have different reporting requirements in the state but but it's not that we refer back to something that's completely different than what we are doing now. The model now has given hospitals and others who have taken prospective payments because the payments are prospective. They haven't, you know, been able to count on the, you know, non reconciliation. You know, they've been able to work together under an ACO organization to learn about what prospective payments look like to, you know, share in some savings. And they've, you know, been able to do it on a multi payer basis. And, you know, during the pandemic, we certainly saw what a difference those predictable, reliable payments made. And it and and, you know, there were still some incentives in place to provide appropriate levels of care. Going back to a total fee for service basis with no, you know, no prospective payment construct. It's, you know, it is volume driven. It's, you know, people believe that it's part of the reason that we're in this situation, not the whole reason but part of the reason why we're in this situation we're in now, where we've, you know, over the years, maybe not so much in as in other places, but we've seen costs escalate because, you know, in order to get paid, you have to see someone in order to maximize revenues, you know, need to increase volume. And, you know, it that would that would be the incentive under a fee for service program and it's not a model that, you know, folks believe has served. The health care system well from across point of view, or maybe even from other points of view as well. So, I mean, it definitely would be a change for our providers in terms of how they're getting payments and what the incentive side. And I think they, before you go in, you know, I believe in the current system, there is the shared savings component, even though it is reconciled back to fee for service, there is that target and shared risk to the ACO. The way that I see a change is, you know, the current model is focused on individuals, right, attribution and we weren't able to achieve the scale target with all the complicated primary care out of state, etc. But this model is focusing on institutions and hospitals, like all hospital revenue on their Medicare will be on their global payment, regardless of where those patients live. So that's changing the dynamics to an institution as opposed to a patient to capture the full revenue. Going back to fee for service kind of puts, again, back to the same thing about, okay, then it is about, you know, trying to attract and do more of the things that are profitable. And if you are thinking about primary care as a focus point, linking primary care with the hospital is an important dynamic too, because at the end, hospital is going to move in this direction, but primary care is going to move in the other direction. So that's another reason why moving back to fee for service may create long term issues for the system, because then there is not an alignment in the objectives from the provider perspective. You know, one way that I think about global budgets being different than the current system, and I don't know if this is, I haven't really talked about this, I've just thought about it is that in the in all pair model that that shared savings is through the system. And I feel like the incentive on a local level to achieve shared savings is low because well if you do really good work to achieve shared savings, you know, you generate less fee for service Medicare revenue, but that maybe the whole system doesn't generate shared savings you get a payment back in the global budget. If you generate shared savings in your local area, you would keep shared savings to your to your hospital so that's one of the kind of the benefits that I think I see with the global budget methodology over the in all payment pair model methodology. I do think when we just kind of gets to some other questions, which is, when we talk about when we talk about utilization within global budgets though, you know Vermont has this remarkably low inpatient utilization rate for, especially Medicare beneficiaries for all people, all Vermonters per capita, we have a relatively high ED utilization. And so, trying to figure out how from you know from you're looking at the data, especially think on your standpoint shoelace, it gives delved pretty deeply into the data that's available for Vermont. You know where do we our hospitals can be able to to move that our hospitals can be able to reduce and pace utilization further and what would be needed, and how our hospitals can be able to reduce ED utilization from its current standpoint and other specific areas that we've identified that that we can move that needle on. I, I'll take it yes there are lower utilization but when you look at it, you know 20 to 30%, depending on which hospital you are is from chronic conditions. And from the patient perspective, it is better if we can find the right care before they end up at the hospital right. It's a tough thing to do, but probably the right north star that we should aim. Again, on the ED as well there might be some low hanging fruit but a lot of it is going to require coordination and long term investments to be able to shift those services. You know, if you were to give this the higher like at a higher level hospitals were and our systems were designed with acute illnesses right we haven't had major shifts in the way we deliver the care maybe you know in the last five years we did some but at the end I think we need to be bold and think about what is the ailing illnesses our population and what kind of care they need and try to move in that direction, even though it is going to be a hard thing to do. So, so to reduce those chronic condition hospitalizations, especially in Medicare patients. I would assume we would need better primary care resources, especially care resources, home care resources, long term care resources and post acute care to resources. So, does, I guess I'm trying to figure out does does shifting to the ahead model help any of those things directly, or is that are we sort of trying to build in there and incentive for hospitals to advocate for those things to be improved. I would say that the hospitals are strongly advocating on those issues as it is particularly around the post acute care, and not just the hospitals, you know, home health agencies, the skilled nursing facilities. And I think as you know, part of our work together has ever well over a year has been to really focus in on how we can support those systems and being available so that people aren't boarding and emergency rooms or staying in hospitals longer than they need to. There's still a lot of work to do. It's a, you know, that this is another one of the all hands on deck type of efforts that we need to make together, but we have made some progress. You know, a chess did some work around the Brattleboro retreat and that seems to have helped with some improvements are certainly discussions going on around how we can, you know, look at reimbursement for skilled nursing facilities. There, you know, we've, we did some rate studies around home health, adult a other areas of the system and, you know, the legislature that resolved in some increases last year and so that's work that will continue to do regardless but it's definitely going to take a concerted effort workforce is another area I think as you know we've been really working hard to shore up workforce as well and have a number of programs that are in place to try and do that but it's going to take a persistent and concerted effort from multiple facets to deal to deal with these issues that are present not only in Vermont but across the country frankly. And there is some opportunities there I mean those are opportunities it's, but we can, we can't light up in our efforts there. Finally agreed. This is one I guess mainly for shoolay with your work and other states. And having seen gold budgets be implemented and the idea that cost savings and improve and which, which is really the hospital sustainability community healthcare system sustainability benefits that come out of global budgets are really moving into the idea of improving prevention services up front and reducing costs. Those are, those are slow and long and hard things to do. What sort of, what do you think the realistic timeline. For us in Vermont, if we were to implement global budgets in 2025 to see those be the real reasons where we're saving saving money within the system and improving care. I'm getting all the difficult questions. So the timeline I can't really tell Dave but I'll give you examples where there could be some short term savings. Opportunities right so in in Maryland, one hospital. In my dentist to come they looked at their utilization they realized it was dental issues that they were dealing with. They work with their local dentist and open like a day. And that is came and provided services to the community. So that's the short term. That's the way for improving access but also reducing utilization at the hospital. Long term you have to figure out where, you know, how you're going to get that dentist 24 seven or right. So, but there are some places where given the right incentive and support for data and understanding the community, there might be things that we could do short term. Obesity, diabetes, hypertension. These are big public health program problems that require lards in mismanism long term. Another example on the nursing home side. One other hospital created a partnership with the local nursing home. They send their hospital to list to that nursing home. You know, one or two days to take care of some of the patients that will be transferred to the hospital. Right. So, through the rule, like there's regulatory flexibilities that they receive, but also kind of work with the nursing home to create some additional resources for that nursing home. To solve again the short term problems. So, and these build up to a long term solutions. Right. So, in terms of the cost savings, Pennsylvania implemented rural health model, their focus was on hospital sustainability. Not so much on the cost savings. So we also need to think about our goals. What is it that Vermont is doing and given what you mentioned on the Medicare side. If the transformation is the goal short term with the baseline incentives. The trend will go up from the historical right. So we need to be realistic about the upfront investments needed for the long term and, you know, a head has a nine year implementation. So, depending on the negotiations, you know, it's the nine year. The nine year glide path. So I don't, I, you know, that's, that's another consideration to have. So I don't have an answer to you. I mean, are you, I guess, let me, the way I take what that, what you said with the nine year glide path is that say, for instance, that that we that within a head, there's that we that the glide path could be designed such that there's more upfront investment in the nine years. Yeah, and I think we should make that to the executive session since it's getting into the negotiation, but ahead has exclusions from the total savings. That's right. They are going to exclude primary care. They're going to exclude transformation funding from the savings requirements. And then it is a nine year program. So at the end of the day, the guardrails of performance in one year doesn't necessarily kill the program. Right. So that's the other consideration in terms of what is the trajectory of savings requirements and how state can negotiate with the federal government. Yeah, I think, I think when I look at when this is presented to me today, I feel I'm looking at more as is this the right decision for Vermont as opposed to can we comply with what the what CMI wants us to comply with. So that's just us, you know, I think there's, you know, I think we're just sort of looking at it slightly from a different perspective but so from looking at it from that perspective. I'm a little bit more comfortable with something you just said, which is that the primary care services are excluded from the shared savings because one of my other questions is, what if a hospital system was trying to invest heavily and preventative services, increase their utilization, you know, we, you know, we have very, we have significant challenges with access to care in Vermont. I don't think we have nearly the problems that other states have with, you know, over utilization, you know, it's very focused in a few areas that increase increasing access might help. So if a hospital system tried to really improve access to care and blew through their Medicare budget and and could could could have caused, you know, harm to the hospital sustainability by or or or increased need on commercial revenue by trying to improve preventative services. And I think when Shulei said primary care Shulei I think did you mean the enhanced primary care payment. Yeah, yeah. So that average $17 p.m. p.m. I want to make sure we're clear about that that would not be included in total cost of care calculations. And yeah, so I just want to make sure we're clear and the trend and similarly the transformation funding for hospitals. Okay. Okay. Yeah. So if there was increased primary care spending that would count towards the total cost of care calculations. Yeah, not counting the enhanced primary care payments that Medicare is going to provide. Yeah. They'd be looking, you know, at claims basically. But Shulei, what did you think about I mean is that, you know, I just, I could see these scenarios where a hospital could get themselves in financial trouble by trying to really improve preventative care. Too quickly. Or does the adjustments, the annual adjustments, is that, you know, a hospital spends a lot more money on. Go ahead. I don't, I mean, I don't think so. I think if they invest in primary care, open new clinics, right, they should prospectually get additional adjustment for new services. And, and eventually not on the same year, but their utilization would come down, right? So they need to, I don't think there is, there is that much of a risk. So, so we'll say we have people who are getting care, and then they get care. And now you're having increased utilization. People who go to primary care providers who haven't seen a primary care provider tend to get more lab tests, more imaging, because they just not had access to care. So, with that scenario, then lead to, that could lead to an increased total cost of care, but it might increase the good care increase, not to increase good care. So, if they, so if a primary, so if, so if say a hospital system opens primary care clinic with 10 primary care providers and you increase the, of all these new patients that come in because there's really challenged getting primary care access right now. And those patients then get lab tests and imaging. The total cost of care is going to go up. Those patients were in the historical terms, ending up in EDs and inpatient setting, right? So, if they don't have access, that's the dynamic that we are trying to break. Short term, there may need to be adjustments, but, you know, I don't, I think that's the right thing to do under global payment. Pat, if you want to add anything to me. Yeah, I was going to say the same thing. Some of, you know, some of the results of not getting primary care, it's pretty quick, you know, people do land in the ED. You know, I possibly some of those potentially, you know, ambulatory care sensitive condition. You know, they may end up inpatient. Once they get primary care, they, you know, they're less likely to land there if their conditions are managed. And that, you know, that's not a year's thing, probably, but you're the physician, so I'll ask you, you know, it seems like while there may be a delay to some degree and seeing that lower utilization, you know, that if they have a medical home, the ED is not their medical home anymore. You know, so. Yeah, by understanding of the literature, people who don't have access to primary care, when they get access to primary care, the total cost of care goes up. But that's my, that's just my understanding of literature. There may be newer literature that's more, you know, that's probably 15, 10, 15 years old. Right. For individuals, for them, yes, but if you think about population health, how much of that is because it's going to reduce their historical, right? So for an individual, you may be right. Like if you're thinking one person, I had one visit, now I'm going to have three visits. I'm going to have EDs, you know, at the end, on the individual side it is. I think the question is at the population level, what will happen to the total cost? That's my, that's my understanding is on the population level. I would never suggest, by the way, that we don't provide primary care for people. I think having primary care services is the ethical and right humanistic thing to do. But my understanding is that people are not getting primary care and now they are getting primary care. You do have an increase in total cost of care because now you get treatment for all the diseases that they weren't getting treated for before. It's better quality of life. It's more ethical. It's the right thing to do. But I don't know if it, my understanding of literature at least, and I could be, and I, again, I am not a primary care physician. And, you know, is that people are truly not receiving primary care that when it gets into, you do increase the amount of treatments you increase the amount of testing. And, and these are these are actually good things to keep you healthy and keep you probably healthy and living better quality of life, better quality of lives longer. I had one, I guess just one more question, which is kind of like, why save the bomb for the last question but it was supposed to be earlier am I, but we kind of end up going in this direction which is, you know, you've been looking at global budgets for a long time, and global budgets has the potential to solve a lot of problems. But what's the downside to global budgets where where the pitfalls where, where, where do we need to double our efforts to to not get into traps if we do global budgets. I'll start and then she'll like jumping could you have way more experience and I do with global budgets but you know the first thing that comes to mind is, you know, the need to monitor utilization and just, you know, make sure that people, you know, we want to reduce avoidable care for but and we want to ensure that care is in the right setting, but by the same token we would want to monitor for utilization and trends to make sure that people are, you know, we're not seeing big changes and you know, access to care. So I think that's really important. That's why we added sort of that fourth category on the performance framework around monitoring. Go ahead. Yes, because point about access measures right so that's place where we really have to be advancing the way we measure measure access and quality. And I mentioned transformation we focus a lot and I personally obviously focus a lot on the financial side, but believe it or not that's the easier part. The issue is once they have the global budgets what the hospitals are going to do and what is the commitment from the leadership and the staff so that's that's place where we need to focus and invest a lot of effort understanding helping and working with the hospitals to really make things happen on the ground. A lot of the physicians clinicians don't know how the hospitals are getting paid right so at the end of the day it's about changing the practices where we need to spend a lot of time. Once we remove the financial barrier from doing the right thing. And I would just add paying careful attention, continuing to pay careful attention to the continuum of care post acute care how can we use this model to support post acute care and preventive care to. Thank you I think I think only Robin's left but Robin even has questions like the mask. Oh Tom sorry apologize Tom. So, so let me let me step in just for some time keeping because we have to do. We have to get to Dr. Hammery. So I connected with member Walsh and lunch and they have kindly agreed to hold their questions and a lot of our questions I think cover some of theirs and and so I think they're kindly going to agree to wait on theirs. We also have a couple of questions from member homes that were for executive session. We're going to wait on those as well and do those. The next time. Pat and Chile are back. So I apologize for that there's a really robust discussion that it has been really informative so I didn't want to so unless Robin or Tom, you would need something today. Okay. All right, so I didn't want to get public comment in. So, so thank you to Robin and Tom for recognizing the time issue. So I will open up to public comment. If if anyone has public comment, please use the raise your hand function. Miss Arnav nice to see you. How are you? Please go ahead. Good afternoon really quickly. The next time you guys have one of these presentations and I think they're just so wonderful. And we, by the way, love the ahead model because equity equity equity. I would like to know the perspective of the Green Mountain care board as to whether or not you guys see yourselves as becoming a signatory. Like the Green Mountain care board was for the all pair model or a regulator. And I'm just trying to get a handle on who's doing what in the healthcare space, especially as people are discussing. So, S 211 and things like that. And so I just would love to hear the Green Mountain care board's perspective on where it sees its role in this future model, not for now, but as an agenda item. And I don't know, Pat, if if Green Mountain care board would be a necessary signatory or we don't have to go there. But anyway, I feel like when you guys were a signatory before. There's just been a lot of role confusion as to whether or not you guys are reformers and promoters or regulators. And I think there were a lot of goalposts moved to support the success of the all pair model by the regulators. And as someone who was a skeptic and still am and concerned about how Medicaid was sort of hijacked to support the all pair model. I just would love to know what you're planning to do going forward. So, food for thought and thank you so much for spending all the time. I thought today's discussion was one of the best healthcare policy discussions I've heard in Vermont in a really long time. I just thought it was fantastic and deep and rich. And thank you Pat and Julie for all the work you're doing and the agreement and care board for all your robust questions and onward. Thank you for saying that Susan and obviously Pat and Julie are real experts. I will just note that probably our two biggest healthcare policy wonks on the board didn't even get to ask questions. So it's that's that's high praise. So thank you for that compliment because our big guns were saved today with their, their big health policy minds. And I would just say to briefly address your questions we can get to others. I think some of the role of the board questions may be discussed potentially by others or maybe even us during the s to 11 discussions. I think there's a hearing notice. I know there's a hearing notice for Friday where some of that could be topical. The other thing I would point out is I think that the NOFO may have details on some of this and and then the last piece I would say is that the care boards role and what we do is assigned to us by the legislature. So our role in this is to collaborate with AHS. So that's that's where we fit in and what we're doing. And we are decidedly a regulator as well, of course, but I appreciate the comment and it's a it's been a topical discussion since I applied for this position. And I think it's a good one to have. Right. Any other questions or comments. Walter, it looked like you came off of mute, but I don't see you and you usually pop up. Yeah. Hey, I apologize for the noise. I'm at the State House and a big party just descended. So Pete simple. I just wish this could be so simple. All the time I've been listening to it for three hours. My God, why does everything have to be so complicated. Keep it simple. Well, I think there's a lot of value to that perception. Enjoy the State House party. Okay. Any other comments or questions? Oh, sorry, go ahead. Okay. Anyone else? Chair Foster, can I just highlight the schedule for the next time we're in front of the board on this topic? It's scheduled for February 21. I have am in the process of sending an email asking to extend that time of that meeting or the agenda item to be able to sort of allow for more more discussion as needed. That will likely be the last time we're in front of the board prior to submission just given the last couple of weeks prior to the notice of funding opportunity submission. I just want to flag that that's we'll make it a longer agenda. We'll give it we'll give it more time. But we'll be back on the 21st. Great. Thank you. Okay. You know, you guys are doing a lot of work. So thanks for taking time out of your days to help educate and teach us. Pat and Julie, thank you. Thank you. All right, we will not skip a beat here and turn to Elizabeth Sutherland. Dr. Bruce Hamry and Marissa Melamed. Thank you for waiting. I can't hear you. You're on mute Marissa. Can you hear me now? I had the double mute going on. Okay, can you see the screen? Yes, great. Okay. So I'm going to try to keep this short and hand it off to Bruce and Elizabeth, but just for some background, we're here today to get an update on the Act 167 community engagement updates. First, again, my name is Marissa Melamed and I serve as the project director on the Green Mountain Care Board staff for this project. We have hired a great team to do this work. We are into or through phase one and into phase two of the project. So it's a good time for an update. And we want to hear some of the things that have come up on the road. I'm going to move ahead here. You've seen this slide several times before. It's always to keep people oriented to the several sections of Act 167 or the several work streams. I'm going to introduce the Oliver Wyman principles that we hired to complete this work who may already be familiar to many of you, but we have Dr. Bruce Hamry and Elizabeth Sutherland. Dr. Hamry is a is the leading partner in the project. He's a clinician with over 50 years of experience in healthcare leadership and healthcare systems and transformation, particularly in rural hospitals. He's also familiar to many of you through his three years of experience in Vermont with COVID data modeling and health services wait time report. And he is joined by Elizabeth Sutherland, who is an expert in examining health disparity and overcoming health equity barriers. And they have been leading all of the meetings and design and development of this project. Since we began in August. So that's when the contract started. The first several months ran through several months of engagement plan development. That was a robust process with extensive stakeholder engagement to put together a plan for how Bruce and Elizabeth and team we're going to go around the state and talk with stakeholders and everyone in the healthcare landscape to glean information on their experiences in the healthcare system. In October, the project moved into the phase one round meetings, which were an extensive and statewide series of listening sessions targeted to community members at large providers and members of diverse populations. Those meetings ran from October 24 through November 21. We're going to see the numbers on how many people were engaged with an outreach to and participated in those meetings on the next slide. We're currently now in a data synthesis and analysis phase, which runs December through March, where the Oliver Wyman team will use the data collected from the listening sessions, combined with relevant analysis of health systems claims and hospital discharge data to inform preliminary options and recommendations for hospitals. And the round two meetings will commence in the late spring likely may and run for several months. So what you're going to hear about today is findings from those discussions in the round one. In data synthesis and analysis, but the information you're going to hear about today is mostly the quantity, sorry qualitative data that was gleaned through those interviews and community meetings. So we're really pleased with the numbers of people and organizations that were engaged. We had over 1800 participants across all stakeholder types in these meetings. There's an average of 52 participants per community meeting, including the statewide meetings. There were two meetings held in each HSA. So all 14 HSAs had a community meeting for the community at large and then another meeting targeted to providers. There are also additional more targeted meetings going on at the same time, which Bruce and Elizabeth will talk with you about. There were over 100 organizations that were contacted through our outreach contact list. And to date, the count when this slide was put together was 93 or over 93 public comments written public comments received. And I won't go through in detail the numbers here on the right, but this is just kind of one way we sliced up the different types of meetings to understand who we outreach to and how many participants there were in the different groups. And with that, I'll turn it over to Dr. Henry. Great. Thank you very much, Marissa. Mr. Chairman and members of the board, thank you for the opportunity to give you an update on our progress. Before we begin, I'd like to really thank the many Vermont healthcare providers, not only nurses, physicians, but EMTs, pharmacists, dentists and many others. For taking time out of their evenings after a very busy day to offer their experience and advice. We also need to thank the many Vermonters who took time out of their days to share their lived experiences with seeking, obtaining and using healthcare in the state. During this effort, as Marissa noted, we've also had the chance to talk to the leadership and board members for each of Vermont's hospitals. Without exception, they were a professional and knowledgeable group of people doing the best they can to serve their communities while working within a very dysfunctional health system. The participation of Mr. Mike Fisher, the state healthcare advocate in many of these community and provider meetings was invaluable. And certainly, last but not least, I need to thank Marissa and her group. Who have helped to guide my team through the complexities of the various state agencies and healthcare organizations in the state. As well as the groups and representatives of the groups experiencing health inequity. So let's go to the next slide. Marissa. So, we'll talk briefly about the goals spend a lot of time on the work completed to date with the preliminary findings and just to reemphasize Marissa's point. These are entirely based on comments made during one or more of these meetings. They are representative comments they're not. We obviously can't include them all, but they do reflect the themes that are involved. Next slide. Okay, so we were asked or directed to develop and conduct a process that was data informed patient focused and community inclusive. With the data informed part thus far, we have reviewed as many of the prior consultant reports to the Green Mountain Board and other state agencies, including those on workforce and mental health. We've reviewed the state Vermont State health plan, the various community health needs assessments for each of the hospitals and so forth. We've also reviewed data made available through the Green Mountain Care Board, including the hospital budget submissions, the vcures data and so forth. I think Marissa has expressed to you the extent of our patient focused and community inclusive efforts, which I think have been as complete as time and availability of the those groups could be. We have been asked to produce some outputs from this process and remember we are only part way through it. And those goals were to reduce inefficiencies in the hospitals to lower their costs and I would say constrain cost growth. Improve population health outcomes reduce health inequities and increase access to essential services and so we're going to start with going through one by one. The nine essential community health services listed by the American Hospital Association will then go to the diversity. And in equity issues and to some of the financial considerations. Next slide. Okay, so the first one is access to primary care subject to a lot of discussion over the last few hours. And each slide starts with some representative comments from some of the participants. You'll note the second one here. No one is taking new patients. There's a one year waiting list for new patients. We've heard other numbers up to 18 months. So there is a shortage and as noted previously, practitioners are aging and retiring. And there is a lot of concern on the part of the provider community about their inability to help patients get care. And we'll come back to that in some other areas. And so that that is causing what is called moral injury. That is, you feel devastated that you can't get your patient to an appropriate specialist or hospital to get the care they urgently need. There's also a shortage of advanced practice clinicians. No in-state training for PAs and not a master's level program for advanced practice nurses. Somewhat lengthy training for doctors of nursing practice to get a clinical certification, but very importantly for all of the state efforts to educate medical assistants, RNs and others. There is a shortage of both instructors and clinical sites. And that also nationally is a major roadblock to producing more of these needed people. There is another feature in primary care and indeed for most of all the physicians. And that is that administrative complexity reduces their clinical time available. One of the quotes from a practicing doc is he or she said, I spend at least two hours a day doing prior authorization and pre-cert and arguing with insurance companies and state agencies about things. And if you consider that a doctor in those two hours could have seen either four or six more patients, that means they could have had somewhere over the course of a year between 700 and 1000 additional patient visits. So this is a matter that might be corrected in fairly short time and have some impact on access. Another is the cost of this. Another physician noted that his office has had to hire four support staff for each clinician. In order to handle the paperwork and all the other things that they are responsible for. In addition, everyone's experiencing difficulty in recruiting new professionals to the state. A lot of it has to do with housing and we have heard reports of advanced practice people sign on the dotted line, come to work, spend three to six months in a hotel because they couldn't get housing and then they left and went out of state. Additional issues, lack of childcare, poor support for elderly relatives, and relatively low pay, at least as perceived by those reporting. So this is a data point we need to validate. Next slide. Okay. Psychiatric and substance use treatment. One mental health advocate noted that an emergency room is not the place for mental health care. And mental people who have mental health issues give up after they go to an AD and are treated as though they have a physical element rather than a mental health issue. There is a shortage of psychiatrists and mental health professionals. Had several instances cited of psychiatrists and others leaving for better paying jobs elsewhere. There have been comments many about very relatively severe difficulties in having licensed clinical social workers and other mental health professionals who are licensed and have practiced in other states. And their ability to obtain an unrestricted license in Vermont. This was noted in a mental health report, but the mental health group was given five years to fix this. A shortage of mental health beds for acute and chronic needs. 194 beds available. Roughly in the state and 23 additional for children. And this is a quote from a state official. I would note that of those beds 30 are now closed for renovation and other things. And at another hospital, they have 14, but they are double rooms. And so typically they said they can only serve eight to nine patients because they have to of course put. Men with men women with women and at least reasonably similar diagnosis. So. Shortage and another issue other than lack of inpatient, which causes boarding. Is lack of intensive outpatient treatment and daycare services. Lack of group housing. For appropriate patients. We talked to 1 community. Where they were had just gotten permission to build a group housing. It took 5 years to get through the regulatory processes. Difficulty in finding transport for suicidal patients. The police cannot take them. So they require an ambulance to go and ambulances as we'll hear about are in short supply. And lack of appropriate facilities in emergency departments. For acutely ill. Mental health patients. Next slide. Emergency and observation services. Key point for avoidable hospital use. One of the directors and we spoke with most around the state, not all. This person said many patients that are labeled avoidable actually must be seen. They come from skilled nursing facilities. Police. Social service agencies and others and they have nowhere else to go. The hospital is the. In a sense, the court of last resort. As noted in the prior set of discussions. A recent estimate by another consulting group a couple of years ago. Was that 30% of ed visits were potentially preventable. By availability readily ready availability of primary care or community based mental health services. However. Those eds are often crowded and holding patients who need to be transferred. To for another level of care either to another hospital. Or to a mental health facility or they're unable to go home. One hospital reported a need to use eight beds in their ed out of I think it was 15. To board in patients awaiting transfer and this was not an uncommon. Report another hospital reported opening 12 new ed beds and having eight of those. Occupied by people who were being boarded within four weeks. So an urgent matter. Observation beds are also commonly used for boarding. And specialty coverage for ed patients. Where people could get advice perhaps take care of the patient. In the local hospital and then send them home. Is difficult specialty coverage telehealth is expensive. Sorry is helpful. And is used by some hospitals others have reported. It is too expensive for them to afford next slide. Okay prenatal care. We did not in the general community comments. Have any mention of inadequate prenatal care. I'll turn it over Miss Sutherland in a minute for the diversity issues. But I would say the review of the state vital records. Which report the prenatal care that women receive by. By month prior to delivery suggests that generally prenatal care is available and used. There are exceptions for women under the age of 20 certainly. Elizabeth do you care to comment on these other two points. Yeah I think the only thing I would just call out and keep eyes here me. Okay. Hi everyone. I think the only things that I would just call out is that. While the data isn't there and you'll hear this theme later. There still is. There should still likely be effort into try to understand why the why there is this. Variation. It's not. Something that the rest of the United States isn't experiencing. But it is something that. Is is impacting those that we've interviewed. Not from a personal standpoint but from their. Opinions on where they would go to. Have and receive childcare. And then this final bullet here I think is similar to the transportation. Barriers or gaps or challenges that we that we've heard across other services is that. You know UVM is great. Others facilities are great but the the wraparound. Services provided when you're few hours six hours eight hours away from your home. Doesn't seem to be thought through particularly when going to the NICU. And so it's kind of just like moving and transferring in the family will figure it out themselves for how they're going to get there and. By nature of the of the state that's kind of the situation we're in but it is it's a challenge and so you'll see you'll hear that theme to and a couple other transportation areas but. Right thank you. Next slide. Okay transportation. Is a huge issue it is not only. An issue of inequity in terms of access and availability. It is also having a major impact on the. Efficiency and effectiveness of the hospitals and the care providers in the state. One of the local care providers noted that in their area. Almost 20% of patients did not have a car. And this was a rural area. Another community member said ambulance services critically important. And there is not enough ambulances to go around. Which increases wait times. For getting service and as we have noted from ed people getting between hospitals so personal transportation. Is often lacking. Inability to afford the gas if money for gas if you have to travel and hospitals are often supporting this. With coupons and things. A public transportation may not be available when needed the movers that are used for Medicare patients and others. Are available only during work hours. And need to be scheduled 48 hours ahead so of course. If you have an urgent issue. Need to get to the doctor's office. Primary care office or or ed. It's not that service is not available to you. Bus routes may not connect together well as we've heard. And we've heard routinely that patients who are taken to the emergency room by an EMS service. That transportation is paid for only if medically necessary so it's medically necessary on the way to the hospital. It's not on the way home so there's no transport for the patient at midnight when the ed says you can go home to get them home and the patient winds up. Sleeping overnight in the emergency room waiting area in many instances. Availability of EMS transportation for inter hospital transfers apologize for the typo is sporadic. And we've heard stories of people calling 19 or more different EMS services to find an ambulance crew that is able to take a patient somewhere. One EMS service actually 31 was the max. One EMS service reported spending a number of hours with the patient. In their ambulance waiting to take the patient into the emergency room because the emergency room was full. So this is that all levels. Patients often need to travel long distances we talked to heard from one gentleman. His spouse had a significant health care problem they had to go to a major medical center. And he reported that within a year he spent they spent $5,000. And for hotel costs and transportation costs and traveled roughly 8000 round trip miles to get care. So as Elizabeth noted earlier in a rural area access to certain services is very difficult. And a lot of that cost falls on the person. Not on certainly not on the system. Next slide. Diagnostic services. A timely access to have your issue. Diagnosed. One physician noted that in their local area there was a six month wait time for a colonoscopy. Colonoscopy obviously being a recommended preventive service. And so this issue is something we'll look at in terms of how well is it done what are the potential numbers of people who maybe don't have access to this. A specialized diagnostic equipment. For example, for primary function tests is often not available in the smaller hospitals population may be too small to support it. There is a universal problem having the technical help to actually administer the test and that's true across all the sizes of hospitals and nationally by the way. Hospitals are dealing with this by trying to jointly hire or share both the specialist. And acquire the equipment needed to do these tests in rural areas. Access to certain specialty services and tests at the two major referral centers. Dartmouth and. UVM are limited and particularly for non emergent care. A timely access to interventional cardiology. Again, we've heard stories of patients with what's called a STEM a which is an indication of acute myocardial infarct in one of the major arteries of the heart. It's being placed in an ambulance and sent five hours. To a hospital that could do that procedure. The standard of care nationally is one hour. So medically unacceptable. Patients with unstable engine who should have a rapid evaluation because of shortages in. Equipment availability have sometimes had to wait three or more days to get that intervention. Problems are that are common to all hospitals. Including the two referral major referral centers include lack of enough specialists. A shortage of technicians as I've noted. And obtaining timely pre certification for testing and treatment. I note that Congress acted, I think, or CMS acted today. To tighten that up for Medicare beneficiaries. Next slide. Home care. Home health agencies have had to reduce their services. Because of a lack of staff they they can't compete. For wages with the hospitals and other employers. And that is based in part on poor reimbursement. And so several of the nurse all the nursing home nursing home health agency people that we spoke with. Sighted that as a problem. Next slide. Dentistry again a major problem. And a community member just said look. Many doors are slammed because dental providers won't accept Medicaid. This is in spite of the fact as Mr Fisher pointed out in some of the meetings. That the state has recently raised. Rates of to pay Dennis for Medicare or Medicaid. Beneficiaries. That was done I think in last July, maybe a little early to estimate that impact. It's a statewide problem. It is particularly severe for children. And Medicaid patients. The lack of preventive dental care clearly shows up. In the potentially preventable ed visits. And I would note that when major dental work. Is needed for children they often have to be put to sleep. They have to undergo major anesthesia. Which is a health risk. And not available in all hospitals pediatric anesthesia. Particularly for small children is a specialized service next slide. Okay robust referral structure. Can you get a patient. To a specialist when they are needed. And primary care doctor said can't find specialists for my patients now. It's functioning very poorly. This is not a change from work that. The state did with some of my group a year and a half ago. Shortages of virtually all specialists at UVM and Dartmouth. Long wait times for routine services. Often usually they can meet emergent needs. Although there are a number of instances where patients have had to be transferred. To Boston, Portland, Maine, New York City. Large hospitals in Connecticut. To receive those specialty in patient services. Recruitment of all medical and surgical specialists. Is problem statewide and at Dartmouth. Communication from the specialty groups back to the primary care providers is poor. We've heard a number of comments of the state health information exchange is. Intended to help rectify this. It's still under development. The primary care folks have said. Does not deliver adequate accurate medication lists. Or a list of currently active diagnoses that they'll get a list of 30 diagnoses and they can't tell. Which ones the patient really has it in the near term. And that the med lists are often well out of date and represent drugs that the patient is not on so. The lab results are much better. But with those two elements, other two elements lacking. Timely decisions about treatment are difficult. Note the hospitals and the physicians are on a number of different mrs. And they're really dependent on the health information exchange to connect with one another and transfer information. Same issue with getting consultation notes from specialists. And. An additional note about the. One care was not considered by the docs. To be timely in getting the information they needed to provide care to patients. So getting a list of who has diabetes. Who am I trying to take care for. Trying to take care of for those preventable issues was not considered to be good. A complicating issue with all of this. Which really impacts specialty availability is that the specialists say, look. I take a patient who has diabetes has epilepsy. I get them stable. They are on meds. They can go back to their primary care doc, but the primary care doc can't see him. He doesn't have room. Or the advanced practice person feels uncomfortable. So the result is the patient keeps coming back to the specialty clinic. Which means that new patients don't have access. Excellent. Okay, costs. Well, as you've heard costs are universally considered to be too high. A lot of opinions about why this is high hospital costs. Poor access to early treatment and preventive care resulting in patients with more advanced and severe, thus costly disease. Number of the emergency room physicians and specialists commented on that. Repetition of tests and that was commented on by both patients and physicians. And then the widely held view that both hospitals and insurance companies have a profit motive and drive want to drive volume. Hospital costs clearly as the board has already heard from its. Budget hearings staffing costs are huge. There are increased costs of employment that of getting employees and retaining employees because of national shortages. Use of travelers to fill in nursing vacancies and various technical areas. And the use of essentially travelers locum tenants. By hospitals to staff certain physician services or. The use of telehealth with attendant high cost that is the person providing the telehealth. Charges the hospital more than the hospital is going to get reimbursed for. And then on the hospital part of the 340 B funding the federal drug program has been reduced that often accounted for a significant part of the hospitals. Excess of revenue over expense. Next slide. Elizabeth. All right, thanks. So just rounding out some of the observations wanted to dive a little bit more deeply into some of the barriers to health equity that we're being being experienced by typically marginalized or smaller populations and so to get started. We worked with kind of the list to the left as our guiding principle for those that we wanted to engage reach out to hear from either directly or representative in areas where we weren't able to connect in person because of language, especially because of language barriers. And so, big thank you to many folks on the line here for helping kind of stitch together the different groups across the state to get in touch with these. See in touch with perspectives and hear perspectives from from the groups on the left. Through about 30 targeted interviews. About half of those were with smaller groups and then the other half coming from community community sessions. We identified three kind of trends in terms of areas for improvement. There were bright spots that we heard I know that the focus here is really was the opportunity of this presentation. We certainly did hear some bright spots around different in different HSAs providing access and providing coordination for members of the groups to the left. But this is homing in on, you know, what we heard as areas that recommend attention, prioritize attention to decrease the health equity barriers for these groups. And so those three areas are around culturally competent care, culturally competent and psychologically safe working environment so the patients and the employees, and then coordination with with caregivers and community services. And so just diving into the first one around culturally competent care, a couple areas. Obviously, there is a large. And as we mentioned before, I think I'm the prior speaker, the rurality, and then the economically disadvantaged. It's a big, the large number of people, and they have different experience with the medical system and those that are not economically disadvantaged and in very rural areas. And I think one of the things that we noticed and this is, I would say coming more from the working environment is that when we would bring up the term health equity with groups that we're speaking to leaders. It's kind of all about race and ethnicity. And it didn't seem like that, you know, thinking kind of beyond race and ethnicity for health equity reasons was something that was part of the typical conversations. And so that's why we're kind of coming at this as the culturally cultural competence here in that while there are a small amount of non English speakers, there, they do exist. They're growing within Vermont and so translation interpretation resources was a big gap. There's a there's a lot of kudos given to the language justice project. But they are not. They're not able to reach everyone and also not quite available to at all times within the hospitals. I see a hand up. Oh, and do you want me to pause real quick. I had two questions on the boxes in the bottom. I just wanted to clarify make sure I understood it correctly. So the ones that say hospital exec. Is that actually mean an executive a C suite level person from a hospital. Yes. Okay. And one I just didn't quite understand everyone in Vermont has a snow plow. What is that supposed to mean. I'm kind of in the first on that first double click bullet point here, you know when we're bringing up how are you thinking about caring for those that you know have tough time getting to your services during inclement weather. That was the response. Sorry. Sorry to interrupt us want to clarify. No, thanks. Yep. Absolutely. And putting it there because I think it's you know some of this stuff is I can see that. Good to talk about good to bring this up because I think that this highlights the areas where some cultural competence training for staff about how they're working with patients and then how they're also moving to the next one I think here about the just psychologically safe work environment. I haven't done walkthroughs of the hospitals yet but what I've heard is that there are the public in some places you might find policies front and center around zero zero tolerance for hate towards workforce. Heard a couple stories that folks when they do experience when clinicians do experience racist comments or hateful comments it's the typical kind of responses well we'll just give them someone else to care for. And well I know that you know everyone deserves care at the same time there there are some rules and ways in which we can make our employees feel a little bit more psychologically safe as they're performing this job on the front lines. And then I think the last of the lack of coordination with caregivers here. The needs within needs that are best served outside of the hospital as we mentioned before particularly around mental health substance abuse housing challenged and other SDOH issues. They are driving up utilization and so working to coordinate the community services that can support these needs can decrease your utilization if that coordination is run a little bit better. And then the admin resources also something to call out here required for patients in the community health nurse programs to have access to Medicaid or getting coverage for certain things or the payments covering. The reimbursements covering those working at the nursing homes or what to sit in a room with a patient while they're doing telehealth just isn't sustainable from a cost perspective. And so I'd say that this is kind of our three main areas of observations for where there's opportunity to improve the health equity equitable access for these diverse populations but also kind of for all of our mantras as well. Anything that first. Well, as you said, you know there are some bright spots here and in some of these other areas and we'll, you know, we'll get to those in the phase of thinking about what potential solutions are. Some are reasonably quick. For example, signage right one of the things that that we heard is boy, you know, if your language is other than English you can't understand the bill you get from the hospital. You don't know that there are interpretive services available, or that someone will assist you and applying for financial relief from the hospital. So some of those things could be fixed in a couple of months. Other things will require a lot more effort. Let's go next slide. Okay, so just a thought here because we've listed a lot of problems and you heard an extensive discussion about global payments population based payments. I've been in that for 30 years and helps people set them up. These are the things that you really need to think about to make that successful to optimize your chances. One is tight alignment of financial incentives among all participants and one of the things that the hospital and some of the primary care folks noted in the discussions was those those incentives are not aligned. Critical access hospitals get paid 101% of Medicare based on their fee for service. They're critically of federally qualified health centers get paid based on their prior years budget. And so they are also incentive to, you know, send care elsewhere if they can't if they don't have it in their budget or, you know, to help get help doing, doing certain things from the hospital. The caring of adequate and timely clinical information the biggest immediate saving in any population health matter is caring for the chronically and multiply ill. The preventive services are important, but they take time to pay off. One who was the first head of the Medicare Center for innovation taught me that you need adequate resources for primary care mental health and preventive service in the community. I talked availability of referrals so that you can get expert help and appropriate levels of care other than expensive inpatient beds and covered by the previous session as well. That the availability of tertiary and other services to support those local hospitals is needed. Also note that currently a lot of that is provided out of state. And just as an example, if someone goes for cancer care to Dana Farber, the Medicare payment for inpatient services is 42% higher than it will be at UVM and for ambulatory services it's 37% higher. A GAO report on that about six years ago, seven years ago. Next slide. Okay. So where are we. We are awaiting the availability and validation of the 2022 hospital discharge data. Because as we think about what options are for improving services and efficiency and effectiveness in hospitals. It's the most current data and certainly nothing that is well within COVID or prior to COVID. We are having another consulting group. It's a different part of Mathematica and we're delighted to have them to work with. We are looking at these sorts of issues. The number of dual eligible individuals that those getting eligible for both Medicare and Medicaid in each service area because special attention to those groups can significantly reduce costs. We're looking at the total volumes both inpatient and outpatient of certain surgical procedures at each hospital. The volumes are important measures of quality. If there is data on 13 or 14 of these, including in critical access hospitals that if you're below a certain volume the complication rates go up. And the physicians in these groups that we've spoken with agree with that. We're looking at volumes of potentially avoidable ED visits, hospital admissions, what those diagnoses are, what alternatives to current primary care services could be made available to help reduce those numbers. Estimate shortfalls in care by looking at mammography and colonoscopy rates as measures of things that are readily available to population level. Look at the number of people leaving Vermont, which are dollars leaving the state for care that could be provided in Vermont. And just as an example, there are instances which will quantitate of people being sent from Vermont to a small hospital, not Dartmouth, but a small hospital in New Hampshire. And if you send them to a 30-bed hospital in New Hampshire, certainly the treatment of that pneumonia, whatever could be done in Vermont, were capacity available. So we're in the process now of taking this information that we've presented, the reports that have been done, the data that is being analyzed and will be available. And then devising potential solutions. And I think there are some. The difficulty is the major ones are going to take time to really come to fruition. And so we'll then formulate those and then have those hypotheses analyzed for their potential impact. I've begun to schedule visits, personal visits to each of the hospitals, and we'll get those conducted over the next probably two, two and a half months. But I intend to go up, meet with a hospital leader, tour the hospital, ask some questions, meet some of the other folk, and really look at the ground. After we have the hypotheses formulated and tested, and we're going to try to predict the effect of these things on access to care, the hospital finances and sustainability, and potential to improve equity. We will do this, however, in a fee for service world, in the current world, the questions that were asked earlier about what will this look like in a global payment is in the purview of the other, the Mathematica group and the experts you heard from earlier. Next slide. All right. And then in May and June, we'll get to meetings in person with a joint session of the hospital leadership team and their board to present what the options might be and get their feedback. And we will also do that in a separate in-person meeting, town meeting style in each hospital service area for the community members to get their feedback and any additional suggestions. And then after that, we'll reformulate those options and then bring that to the Green Mountain Care Board as a set of options and recommendations. So, Mr. Chairman, that concludes our presentation. We're happy to entertain questions. Thank you both very much. It was extremely informative. I'll open up to the board members. Why don't we start with members Lunge and Walsh first if they have anything they can take the floor first. This is Tom. Thanks for the presentation. Very informative. I don't have any questions at this time. I have a question, but I don't think it needs to be answered today, but I'll just throw it out there. I'd be interested in understanding the assumptions that go into the fee-for-service world because, as was discussed earlier, we're currently in an all-pair model world, not a true Medicare fee-for-service world. So, I'd be just interested in more detail on those when that's available. Yep. Thanks for the clarification, Robin. I misspoke it'll be the current environment, right? Thank you. That's it for me. Thanks. I just had one. So, your report will have things that hospital systems can do now and identify some gaps and opportunities. Is a part of your report also identifying strategies that the state can think about that's outside of the hospitals or is it just particular to the hospitals? No, sir. Thank you for that question, and I should have said that. We would anticipate several levels of recommendations. One certainly would be for the local hospital. The other would be to your group and the state for changes in, for example, EMS services or the way that certain people might be paid or the information system, whatever. That would require either a legislative or regulatory change. And I would also say the third level would be potential changes in some of the federal things that you might either consider negotiating for as you think about a new payment model or refer to your senators and congressional folk for their help. Great. Thank you. I don't have any other questions. It looks like member Holmes is all set. So I will open it up to public comment via the raise the hand function. And I'll start with a healthcare advocate and Mr. Schulteis. I'll just keep this very brief because I'm looking at the time and I'm sure everyone has to get out. Dr. Henry, Dr. Henry and Ms. Sutherland. So we, our office has been working on one of the low hanging fruits you mentioned. So the stuff around the patient financial assistance that comes from a bill that Vaas and the HCA championed the other two years ago now. So you might want to call my Dr. Henry because our efforts along those around plain language and notice is actually pretty well developed as a rollout plan. And that was meant those minimum standards were meant to make things around language access and some other things a little bit. Clearer than the rather vague IRS regulations. Thank you. Yep. Thank you. Well, we will certainly get back to you guys. But remember, these are comments that reflect the experience of the. Yeah, or the another group. So it may be older experience, but certainly what we heard. Oh, it's, it's, it hasn't been implemented at all yet. I'm just telling you that that low hanging fruit is being grabbed. Great. Great to hear. Thank you. And thank you, Eric. And I failed to mention earlier that how helpful Mike and the healthcare advocate group has been. So that was been really helpful as we have attended many of our meetings. Providing real time guidance to those that were asking questions about things and sharing experiences so just sorry for not saying thank you earlier but very much appreciate. Thank you so much. Any other public comment. Okay, great. Thank you. Dr. Henry and Miss Sutherland and Marissa and Hillary. I really feel like this has been a bright spot of our work in the last year. We've learned a lot. Those meetings went exceptionally well. We all attended many of them. And it was really robust discussion and this is extremely informative. So thank you. This is really important work. Thank you. Thank you. I think that concludes our agenda today. Is there a motion to adjourn? So moved. Second. And all those in favor say aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye. Aye.