 Good afternoon and welcome to the Green Mountain care board meeting. My name is Kevin Mullin chair of the board and I'll call this meeting to order. I see that we have all board members present and we're going to start the meeting with the executive directors report Susan Barrett. Thank you Mr. Chair. Good afternoon. I want to just announce one ongoing public comment that we've had ongoing since last year actually and that is the ongoing public comment period for those who want to comment on the potential next agreement that we have with the federal government and the MMI on an all payer model. As I've said before, the governor and AHS are leading those negotiations so that so any comments we receive, we will be sharing with our partners at AHS and the governor's office. I also want to let folks know that our March schedule is up on our calendar under the public meeting under the meeting section. You'll see a press release that outlines the schedule we have put forth for the month. And that is all I have to announce today. I will turn it back to you Mr. Chair. Thank you Susan. The next item on the agenda are the minutes of Wednesday, February 16th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, February 16th without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor of the motion please signify by saying aye. Aye. Aye. Any opposed, please signify by saying nay. Let the record show that the motion carried unanimously. Next on the agenda is a discussion on the essential health benefits benchmark plan. And we've had a few meetings to discuss this. And I do know that Emily is on the line in case board members have further discussions. But I just wanted to open it up for board discussion and a possible board vote. So board members, do you have questions or comments on the essential health benefits benchmark? I can go ahead and start, although I just see Tom just unmuted. So you can go ahead and start if you want, Tom. No, go ahead. I'll start and finish quickly. This is a difficult one for me because I think we're kind of missing an opportunity that I think that the result that we have a force to vote on is the minimalist result. It's adding a benefit to a plan that we've had that goes back to 2012. And certainly I know I'm going to vote for this because hearing aids are important and I understand that. But I think, you know, there are some other opportunities like what I've outlined in the past having to do with diabetes prevention that just, you know, I really appreciate what the Blueprints presentation the other day, but the scale is still very small. They're talking about a budget of 650,000 across the state for all their self management programs. And that versus having diabetes prevention as a benefit in the QHP plan that serves. God that we got the numbers today 31,000 people and you do some math, you're looking at millions of dollars in potential savings with the CDC plan. So for me, ramping up that plan as fast as we can makes a lot of sense. But, you know, I've, you know, I'm, you know, so that's where I'm at. I'm a reluctant supporter. I don't think that we've leveraged this opportunity as far as we can. I think that we might have looked into it if we had followed the language that the house that in the Senate gave us, which is to align this with our health care reform. We might, we might have found. Jess, put yourself on mute. We're hearing Tom's feedback through yours. Thank you, Jess. Go ahead, Tom. Thanks. So we might have been able to kind of find some room to enhance the fixed perspective payments within the benchmark plan and get and get CMS is engagement and support for that. I don't know. I have to say I don't know what we don't know. But I do know that that the process that has come to to reside with us has been a minimalist process. And it's been about adding a benefit to a plan, looking at three or four opportunities, boiling it down to one an important one. And, you know, but for that benefit, I'd be voting against this. I just don't think it's it's it's it's well done, but that's that's my opinion. I'm voting for because of the benefit hearing aids. Obviously, I wear hearing aids. So it's one I just really understand. I wouldn't be here with you if I didn't have hearing aids. Maybe that's a good I don't take away by hearing aids that I've got. But, you know, so that's that's where I'm at. And I am going to write a concurring letter because I kind of want to get this out of my system and down on paper. I've been crunching some numbers here that that I think support my case, but maybe maybe in 2005. We can we for the 2005 benchmark plan, you know, CMS has really done the right thing. They've opened this up to states. It wasn't opened up as a benefit enhancement opportunity. We could adopt in other states total benchmark plan, we could adopt portions of another states, or we can put together benefits for our own plan and I just don't think that we have aligned the the this plan, this benchmark plan with our health care reform efforts as much as we could. And this has been an issue that we've raised. I went back and looked at the minutes for 2020 and 2021 and I've raised this issue. Jess in 2020 amended a proposal I made that that the non standard evaluation criteria be aligned with the all pair model and Jess amended it to say no it should be aligned with with our health care reform program. And that we all agree to that so it's an issue that's been there and it's one I tried to kind of breathe some life into but it's not happening and so that's it. Thank you for thank you for listening. Thank you. Other board members. I'll go ahead. I am supportive of the approach that diva suggested, including the addition of the hearing aids benefit to the benchmark plan. I am less. Tom I'm totally I actually agree with you around the blueprint program I do think that the pre diabetes prevention has a lot of promise I would like to see that further explored but I'm given what the blueprint said in terms of trying to ramp up the program and figuring out how to enhance that I'm I'm willing and interested in giving them the opportunity to try that out. I would want us to check back in at some point with them to to understand how that's going and whether we should in the future that are something like adding that to another round of EHB. I'm less sanguine about the process of looking at other states benefits and or partial benefits because quite frankly, I think there's a lot of stress that occurs in the consumer and the Vermonter community when you start switching up people's benefits. And quite frankly, the what even if we took another states plan it would we still have a couple dozen benefit mandates on the books and state law so those those plans would have to be enhanced with our existing state benefits so it I just I don't see as much opportunity as you do Tom given the federal framework but I do think it's important to look at the the diabetes prevention program because to your point it is. It it's really a good way to move forward with health care reform and ensuring that we have for funding prevention appropriately. So that's where I am. Thank you Robin are there other board member comments or questions. If I can just respond to that a little bit I I hope I didn't imply or suggest or state that we should look at adopting some other states plan. My point in saying that is that that that's one of the three paths that CMS laid out for us and that that's just what it is I'm not I'm not saying throw our plan out and adopt somebody else. I think that's part of the benchmark and in terms of the blueprint plan. My one thought that I had is that that if a benefit plan or benefit plan is paying for prediabetes as a benefit. Not only would the blueprint be a provider but it might encourage other people out there in the community to be a provider. The blueprint is a is small as their annual report for 19 for 2019 showed they only had 181 people that pass through there. And if you just do some quick math here and say that the QHP population is 31,300 and 9% of them are diabetic, which is the statewide all pair of bottle average 9%. That's 2820 diabetics covered by the benchmark plan that's over the scale entirely outside the scope of the blueprint. And so this is a situation where my think was build it and they will come if we allow this as a benefit, then people maybe like rehab gym or others would say okay well here's now an opportunity where we can make some money, but but not not do it at the the cost, which is, you know, for diabetes treatment, which is I've, you know, talked to you about Joe's type two diabetes at 5600 as a insurer expense and 22 $2,290 out of pocket. So it's it's there's this a lot of money being spent diabetes and I just think we're we've got to build the bridge to to to draw that down and build it up somewhere else. Other board comments or questions. This is Tom Walsh. Just to build on some of what Tom has said with diabetes. There's a very important component of self care for that which is eating and eating requires teeth. I think we've missed an opportunity to explore ways to incorporate a dental benefit. I've been new to this process, but it's been a little bit disappointing to me that given a once in a decade opportunity. There's only been small, relatively small change hearing aids are important. The research behind why they're important for every argument. There is a similar argument with greater research support for better dental care. It helps with mood. It helps with social interaction. It helps with jobs. It helps take care of yourself because you can eat better. And I just, I, it's been. I think Tom's comment about a minimal, a minimalist approach struck me as being an apt description. I think we would have. I wish I could have figured out more of a way to forward better dental coverage for our mentors. Other board comments or questions. Yeah, hi Kevin. For some reason, just want to apologize. I have been trying to get my camera to turn on and for some reason it is not working. So I apologize. I may log off and log back on after we discuss this. But anyway, my apologies for that. Not sure what the technical issue is there. But I wanted to say that I definitely am supportive of Diva's recommendations on the benchmark plan, including adding the hearing aid coverage. I think it's a small price to pay to improve the quality of life for thousands of Vermonters. I share some of the concerns of other board members, you know, wishing we could have gone further to think about pre-diabetes work and dental coverage and all of that. So I share some of those concerns, but in the end I'm supportive of the recommendations by Diva. Other board comments or questions. Just in response to Tom Walsh, I totally agree with you that dental is very important, but it's not allowed to be an EHB. So it is a separate process and would require potentially a legislative appropriation. So I think for me, you know, I think that that process really needs to be a legislative process because there is the potential for the state appropriation needing to support that coverage for all folks in the individual and small group market. And that's, I don't know how much that would cost, but I imagine it's not insignificant. I appreciate the comment, Robin, and that's what I've come to learn is that there's really, there's a lot of regulations around us regulators and what we can do and how we can do it. And I've come to see that really to get movement on that issue really requires legislative action. I appreciate that. I did want to be on the record as bringing it up as an important issue to Vermonters, and I hope that I hope that gets heard. Tom, I can tell you that it's been spoken about and heard for decades and no action has been taken. And just like Vermonter can't really have the best health without good teeth, it's hard to get a job, it's a number of different things, and the same goes for vision. And yet, despite a lot of conversations for decades, no progress has been made. But for us to try to do that, it can't happen. And the reality is that we're stuck within the actuarial values of the different metal levels. And I totally agree with what Tom Pelham said, because I think that this board has absolutely got to find a way to push prevention programs that would result in health savings to the Vermont system. Tom is absolutely right on this. He's been talking about it ever since he first came on the board, and yet no progress has been made. And I agree with him completely that whether it doesn't matter what the chronic illness that we're trying to prevent, there's so much savings that could occur. And that was the true hope that I had with the all-payer model that there would be so much more focus on prevention. And as Tom has aptly pointed out, whether it's the all-payer model or the blueprint or what have you, the numbers are small. And we have not seen a cross-population movement towards these type of programs, which really could have a major impact on the population of Vermonters. So I just want to thank Tom for continually bringing that forward and just say that it's very frustrating to have been here for five years now and not see the movement that we had all hoped was going to happen on prevention and wellness. With that being said, is there any further board comment or question before I open it up for public comment? Okay, I'm going to open it up for public comment. What do the member of the public wish to comment on the Essential Health Benefits Benchmark Plan? And the first hand I see is Dale. Dale. Hi. So it's one of a clarifying question. The real problem is the AB, we can't really add, I mean, there's also the regulations. I get that too. I mean, you can't add a vision benefit. You can't add a dental benefit. I see Robin shaking her head. I think she knows where I'm going, that means. Yeah, Dale. The legal impediment is not, in this instance, the AV because the AV is a percentage of the total cost of whatever the benefit package is. It's the requirements around how states can choose an Essential Health Benefit and what is or isn't included there. Okay. But it's still driven by the Federal Affordable Care Act requirements. There's always a roadblock, unfortunately. Thank you. Thank you, Dale. And that roadblock is very, very frustrating for everyone. And I'm going to talk about this later in the meeting, but I will bring up that this is going to be an extremely tough year. And I will very much worry about the affordability of commercial insurance and where we're headed. With that being said, I still believe that Vermonters need the proper benefits. And I think that hearing is part of that. I see another hand. Mike Fisher. Thank you, Mr. Chairman. Thank you, board. I just want to very briefly echo what I just heard from a couple of board members. We sat on the EHB workgroup expressed as strong support for considering and doing what we could on dental and ran into that same roadblock that's been recognized here. And so having said that and recognized the challenges that we have and will continue to advocate for improved dental access in the legislature. There are some details that have happened recently that could be noted some modest improvements. But I would join in supporting the Diva recommendation. Thank you. Thank you, Mike. Is there other public comment? Hearing none. Is there a board member prepared to make a motion? I can go ahead and move, make a motion. So I move that for plan year 2024 that the board approved Diva's February 16th 2022 recommendation to create a new benchmark plan, including the existing benefits within the Blue Cross Blue Shield CDHPHMO plan and add hearing aid coverage for up to one hearing aid per year every three years at an annual exam. Is there a second? Second. It's been moved by Robin and seconded by Tom Walsh. Is there further board discussion? No luck with the camera, Jess. No, I can't seem to get it to turn on. Sorry, I apologize for that. I suspect I'm going to have to reboot my whole computer and that might take too long. So I'm just going to be camera free today. I apologize. No worries. Just speak up if I don't call on you when you wish to speak. So with that, I'm going to call the question. All those in favor of the motion, please signify by saying aye. Aye. Any opposed, please signify by saying nay. Let the record show that the motion passed unanimously. And Kevin, before we move on, I was going to suggest it sounds like we have some general support for the concept of further exploring diabetes prevention for the future. And I wonder if, I know Tom Pellam, you said you were going to do a concurrence, but perhaps we can find some common language to incorporate it into the decision. It would not be binding since it is not part of the motion, but it would be certainly indicative of sort of what several of us have expressed in terms of wanting to promote that program. So I wanted to make that suggestion. I think that's an excellent idea, Robin. And I just want to say, Tom, that if we're not able to come up with some good language, I'd be happy to sign this into your concurrence. I was wanted to express my desire to do that as well, Tom. I'm happy to join that concurrence. As soon as we have three or more, it's no longer a concurrence. We'll get the right language. Well, there's got to be a concurrence, but it can also be cut and pasted into a decision. Parts of it. Perfect. Okay. At this point, we're going to change our focus and we're going to turn to a discussion of thresholds for certificate of need. As you know, we have dollar limits that are the triggers for when someone needs to seek a certificate of need. And of course, there is that nasty thing called inflation that comes along. And sometimes those limits have to be raised. We have the ability to raise them within the inflationary limits. And so I'm going to turn the meeting over to Mike Barber, our general counsel for a discussion on that and what our legal options are. Mike, are you there, Mike? I'm here. Can you see the presentation? We can. Okay. Well, I think you've covered the first couple of slides, but so about CON dollar thresholds. There are a number of what we call jurisdictional triggers for CON. Only some of them have dollar values attached to them. So for example, construction of an ambulatory surgical center, regardless of cost, requires review. But I've tried to set out the ones with dollar figures on this slide and the next. So more often than not, the dollar thresholds differ between hospitals and other types of health care facilities with hospitals having the higher thresholds, obviously. So as you can see here, kind of the first one is generally I'll refer to as capital cost. So for hospitals, it's $3 million non hospitals, one and a half million. The next category here, I'll just refer to this as equipment cost from here on 1.5 million for hospitals, 1 million for non hospitals. And then offering of a new health care service or technology that trigger there's operating expense. So for hospitals, it's 1 million for non hospitals. It's 500,000. And I think I'll refer to that as either new service or operating expense going forward. Conceptual C.O.N. triggers have their own dollar threshold. So it's not different for hospitals and non hospitals on the conceptual C.O.N. That's $30 million. And then there is a, I've never seen it come into play, but there is an exclusion for expenditures up to a certain amount that are made by a health care facility in preparation for obtaining a conceptual C.O.N. That is $3 million for hospitals, one and a half for non hospitals. As you think about this, just keep in mind that there is a significant exclusion from the C.O.N. laws. We refer to it as the physician's office exemption or exclusion, although it covers more than just physicians offices. The offices of physicians, dentists and other practitioners of the healing arts, meaning the physical places occupied by such providers on a regular basis in which such providers perform the range of diagnostic and treatment services usually performed by such providers on an outpatient basis. And in the context of the wait times discussion, most independent specialist practices would likely fall under this exception. There are two exceptions to the exclusion to be aware of. First, it doesn't apply to offices owned, operated or released by a hospital or a hospital subsidiary or parent, and it doesn't apply to certain types of facilities such as an ambulatory surgery center, diagnostic imaging facility and so on. And then it doesn't apply to projects that are subject to review under 18 VSA 9434A4, which is the equipment category for non hospitals. So that's equipment costs exceeding $1 million. So as you said, Mr. Chair, the board has the authority to adjust the monetary thresholds. In doing so, you can't change the categories of, you know, the types of things that are subject to review. And you are limited to adjusting by an amount that does not exceed the cumulative consumer price index rate of inflation. This slide is just showing you the history, the statutory history for that statute. It's just interesting that it dates back to 2005. Well, 2003 legislation effective beginning of 2005. Obviously before the board was established, it used to specify that adjustments had to be done by rulemaking and could not exceed the CPI rate of inflation. And then in 2018, the requirement that the adjustments be made by rule was eliminated, and the language was changed to say that the adjustments could not exceed the cumulative CPI rate of inflation. And then this slide is just showing you the last time each of those dollars thresholds was last adjusted. And as you saw there, the hospital equipment and new service thresholds were adjusted effective July 1, 2018. So B2 and B3 here. Looking back at the legislative history, it appears that these were adjusted to nationwide median values based on a 2016 report that looked at the 35 or so states that have CON programs and what their thresholds are. The capital hospital capital expense threshold of 3 million was not adjusted at that time because it was in line with the national median. I was not involved in that, but that is what I could gather from from the documents that I reviewed. So moving on to the approach we took here, there's really two kind of questions we had to sort out the first and probably most important one was where do you start from when calculating cumulative CPI? So we decided to start from July 1, 2018 because it appears that all of the dollar thresholds were evaluated at this time, and as I just talked about the two of the hospital thresholds were increased. And then the second issue we had to figure out was which CPI to use there's multiple CPI measures. So we calculated growth from July 1, 2018 using CPIU, All Items, All Cities and CPIU Medical Care, All Cities. CPIU All Items is a measurement of change in a variety of different consumer goods and services of transportation, food, medical care and other things. And it's probably what most people would think of when they think of CPIU Medical Care is a subindex for medical care obviously that it measures changes in total reimbursement to medical care providers. So we looked at both of those just to give you a sense for where they differed. CPIU Medical Care, if you look back, you know, we went back to 2005, it has grown faster than CPIU All Items, but that is not the case from the time period we were measuring. So July 2018 to the present CPIU All Items has grown faster. We did look at the numbers just for the North or New England states rather. But we didn't present that here, I can share that in the future if you'd like. But this range was giving you the most kind of discretion up to this, the highest growth rate we found was this 12.18%, I guess. So moving on to the calculations, these are the calculations for the hospital thresholds. So how showing you how much you could raise those thresholds under the approach that we took. And then these are the non-hospital calculations and then these are the conceptual COIN calculations. And I can come back to those if you would like. But we also tried to give you some data on, you know, what kinds of projects are these thresholds bringing in or not bringing in. You know, if you're trying to figure out whether they're over-inclusive or not, I might be helpful to just give you a sense of that. So this slide is showing how many COINs were issued each year from 2018 through 2021 and how many no jurisdiction letters were issued for each of those years. So for 2018 issued 7 COINs, 2019 5 COINs, 2020 5 COINs, 2021 6 COINs. In comparison in 2018 we issued 19 no jurisdiction letters. In 2019 we issued 8. In 2020 we issued 4. And in 2021 we issued 10. The next few slides here are giving you more detail on the projects that were approved by the board in these years. Tried to briefly describe what the project involved, who was the applicant, why it was subject to review, so what COIN trigger it tripped. And how long it took the board to review the application and issue a decision. So I won't go through them all. One thing I forgot to mention on this slide back here is that these numbers do not include project changes. For example, EVMMC's epic expansion to New York hospitals or the Green Mountain Surgery Center case from I think it was 2019, those are not included in these numbers, but I have noted them on these slides here. So I won't, like I said, I won't go through these individually. I'll just kind of skip to the next segment here. So this is just providing you more detail on the review process and giving you the context for some of those numbers on the prior slides. As you know, the board has 90 days to review and close a COIN application. The time during which an applicant is responding to requests for information are not counted in calculating that time period. The board has to make a decision on an application within 120 days after the application closes. Expedited review is available for certain types of projects and expedited review process does away with the need for a hearing and allows the board to issue a COIN quickly if it is satisfied it has enough information to do so. So for the projects approved by the board between 2018 and 2021, the board granted 16 requests for expedited review and denied two requests. And even when you include the EPIC project in 2018, which had a abnormally long review period, it took the board an average of 53 days to close an application, and it took an average of 40 days from the time of closure to issue a COIN. Those numbers obviously don't give you the whole picture in terms of how long the process takes, because it doesn't include the time it took the applicant to respond to questions that does vary considerably based on just the quality and completeness of an application and the issues involved. So there's the internal numbers. We did try to look for some external numbers. We don't have an updated version of that 2016 study that I mentioned that informed the 2018 statutory revisions. But we did have time to take a quick look at least at the other states in New England to see where they were at in terms of dollar thresholds. So that's presented on the next couple of slides. So as you'll see here, Rhode Island, another small state has thresholds of $6.2 million for construction or renovation, $2.6 million for equipment, and $1.8 million in operating costs for new services. Massachusetts, the thresholds are not terribly different from here. We've got $1.1 million for equipment and $2.3 million for other expenditures. The hospital thresholds obviously are quite, quite a bit higher, which is not surprising given just the size of some of their hospital systems. We took a look at Maine. These are the thresholds in Maine. If you have questions about how these are applied, I'd have to take that back. I won't pretend to know how each of these is defined at this point. But if you have questions, I could certainly dig into that. And then Connecticut does not have dollar thresholds. Review is triggered by the nature of the project. Interestingly, they require a CON for termination of certain types of services, which was interesting to see. And that is what we prepared for you. I'm happy to answer questions or if you'd like additional data at a subsequent meeting, I can come back with more data. Thank you, Mike. The comparative analysis between the states is helpful. But we are limited to what we can do as a board based on, my lights are flickering here, based on the inflationary limitations. And I was curious if you had a recommendation, one, on whether or not they should be increased, and two, which inflationary measure you would recommend? No, I didn't prepare a recommendation, but I'm happy to come back with one if that would be something you want. Okay. I think at the minimum, they should be increased to reflect the inflationary increases. And in fact, I think that we're in a period now where inflation is going to accelerate. And we've already seen that in existing CONs that have had to come back in because the cost of their projects has increased. So the main question is whether or not we believe our statutory authority is enough, or if we should be seeking additional help from a legislative change that would allow to go beyond that. I'm content with just the inflationary increase, but I'm really curious on what other board members are thinking. Other board members? Robin? I agree we should be looking at an increase for inflation. Personally, I would probably go with the CPI UOL items. Because it has been a number of years since any changes have been made, and to your point, Kevin, about this year's inflation. But I'm interested in hearing from stakeholders, so I'm hoping we can open a public comment period as we normally would do. No action is required today. We have time. Great. I was involved in the 2017 process with Marissa Melamed. We led a stakeholder group to look at changes to the CON program, which did result in a couple of changes, as Mike mentioned, to thresholds. But bigger changes related to the nursing home jurisdiction, which was discontinued. So, you know, I think certainly if there was stakeholder interest in another process, we could do that. I would prefer not to be the person to do that this time around. Somebody else can have a shot at it. But for me, I'm good with looking at, I do think we should do something, and I'm interested to hear from stakeholders about the inflation and whether that's sufficient. Robin, we probably would be doing everyone a disservice if we didn't use your valuable historical knowledge. You like to give me that stakeholder process, I know. Other board comments or questions? I'm a little confused here. Looking back at the chart of when these things were last examined. You know, I see the equipment threshold and the operating budget thresholds 2018. But on that list, it had hospital capital, I thought, at 2003. Yeah, I don't think that 3 million has changed, has it, Mike? No, that was the last, so the last effective date for the change was July 1st, 2003. So that is a change in the statute. But as in the stakeholder process in 2017, my recollection is we were looking at thresholds across the board. So this doesn't reflect that there was a process that might have happened. It only reflects whether or not that process resulted in a statutory change. That's true. So like I said, on the next slide, I think all the hospital. Like Robin said, all the thresholds were evaluated. It looks like with respect to the hospital capital expense threshold, it was in line with what was then the median of 3 million amongst the states that have CON programs. And so I think the decision was not to change that at that time. So Mike, the follow up question that I have to that is if that hasn't changed since 2003 and was not changed in 2017, 2018 statutory change period. Does the board have the authority to do an inflationary increase dating back to 2003? Or are we limited to starting with the 2017 period? Yeah, it's a good question. Something that we wrestled with and I can come back and talk to you specifically about that. I didn't prepare for that today. Okay. We'll plan on having you back. Tom Walsh, I see your hand up. Yes. Thank you, chair. And thank you, Mike. This may be more of just a question helping me to understand the length between the length of time that we take to review certificate of need applications and the changes that we're discussing with the due to inflation or otherwise. I'm wondering if someone could just help me understand that if we're if we make a change or don't, would we anticipate that speeding up or slowing down the process as you outlined it? Yeah, it's hard to say. You know, I could see that if we increase the thresholds significantly. And these are not too significant of changes we're talking about here. If they were increased significantly, you could. Maybe we wouldn't be reviewing more simple ones and just be reviewing complex ones and that would increase the time. But that's just kind of speculation. It's tough to say. Okay. That's helpful. I'll keep thinking and if you do come back, maybe we could explore that a little bit further just the pros and cons of what this might do to our the efficiency through which certificate of needs go make their way through the board. And I think that the problem with your question, Tom, is that it would depend on how many CONs came in in any time period that the staff has to deal with. And so that affects things and the complexity of the request affects things. And I think that basically, at least in my mind, what this discussion is within our existing authority is just not taking on additional projects that would not have met the threshold five years ago, but that would meet it today because of the inflationary pressures that are seen. So I don't think it does anything truly to speed things up other than if it truly limited and based on the dollar values that I've been seeing, I don't see it being truly limiting. That's helpful. Thank you both. Other board members questions or comments. Yeah, Kevin, can you hear me? Sorry that you're still here. Go ahead. Okay. And again, my apologies for my camera. So this is hugely helpful, Mike, and I really appreciate it. I would support adjusting the thresholds. I think there have been significant inflationary pressures that should be accounted for in these triggers. I have a couple of questions. I guess one would be if we did round, I mean, if we did adjust the thresholds. One of the questions I would have is would we use actually these dollar amounts as computed, or would we round down? I guess that we can't round up, I think, because the statutory language says that we are limited by the CPI adjustment. So rounding up would probably exceed that. So I guess that's one question. Would we round down or would we accept these numbers as computed? Maybe I'll let you answer that question and I'll go on to another one. I think that's a question for your fellow board members. You could do either. That would be up to us. In terms of thinking about the timeline, and I know that part of the lengthy timeline in many instances is the disparity in the quality of the applications that are submitted. And I'm just wondering, could we consider, is there ability to consider starting the CON clock when the staff determines that the application is complete? Because I think some of that, you know, they submit the application, but then it's incomplete and there's a lot of back and forth. I mean, could we just start the time clock and say, it's not complete yet. Here you go. And when it's actually deemed complete, that's when the clock starts. Is that something that we have the ability to do? I don't think so. Not the way the statute is written. So I believe the statute starts the time from the application receipt and we have 90 days to close it or to say that, you know, despite it's not being complete, we're going to continue. I can come back and give you some more reasoned thoughts on that, but I don't think that's possible given the statute that we have. Okay, well, I guess one of the things that we're going to like parking lot ideas and maybe a parking lot idea could be to make a recommendation at some point to the legislature around just adding some language that would allow the time, you know, the clock to start when the application is deemed complete. So it might require just a minor adjustment to statutory language. I'm not sure if that counts as a technical change. What? But no, it doesn't. Robin's saying no. To me, it's actually kind of a big change because of the culture that the board and quite frankly before the board, Vishka has developed around CON, which is that the staff try to helpfully work with the applicant to complete the application. And I mean, to me, that seems like it's a small wording change, but it's kind of a big process shift. Well, I guess I'm not suggesting that the staff not help the applicant. I'm just suggesting that the clock doesn't start until the application is complete. So I wouldn't, you know, I would still expect our staff to help applicants understand what a complete application looks like and help them through that. But I'm just sort of thinking why not start the time clock when that application actually is completely complete. But anyway, we can, if it doesn't sound like that's a possibility, then I guess that's not a possibility. But maybe Mike, if you can look into it a little bit and Robin, think about it. I think it's a possibility. I just wouldn't call it technical. Okay. And I would say that there is currently, so there's two clocks, right? There's the 90 day clock and then there's 120 day clock. And what you're talking about is the 120 day clock. So once we close an application, once it's complete, we have 120 days to issue a decision. And I just want to say that the board's policy has always been in my time here to try to help the applicants as much as possible to try to be as expeditious as possible. And never just worry about being within time limits, but to try to deliver a CON in an expeditious but as thorough a manner as possible. And that's something that we continually strive to improve upon. Are there other board comments or questions? I guess I just have one kind of further comment or question. It's actually more of a comment and it's a bigger picture comment, not to be addressed today, but just maybe, again, maybe a parking lot thought. You know, I think as we think about what CON laws were designed to do. It's really to reduce, you know, costly duplication of services and improve quality through making sure that there's regionalization of surgeries and procedures where we know that there's some volume quality relationship and also to reduce the potential for cream skimming of private patients that might, you know, jeopardize the facilities that disproportionately serve, for example, Medicaid or uninsured patients. And I think if you look at the academic literature, which is pretty extensive on this topic, there's mixed results in CON effectiveness. And I think despite noble intentions, CON laws, you know, do restrict competition. They protect incumbents, particularly hospitals have potential to, in some cases, drive up prices and stifle innovation, right? So this is what the literature sort of suggests and has evidence about. So there's mixed reviews on its effectiveness. And I guess my parking lot idea is, as we think about accelerating to more fixed perspective payment and value based payment. You know, should we also be thinking about the role of CON and how that might evolve where it's, we know, we want to evolve that CON process as providers become more accountable for cost and quality. There's going to be less incentive for that duply costly duplicating costly services. And there's going to be more incentive to ensure that volumes are high enough to maintain quality because of the payment shifts that we're making. So I guess I would just say, I wonder if as we're thinking about our regulatory process that we're evolving to be more aligned with value based payments, should we incorporate how we view CON in there as well? So that's kind of a bigger question that I'm throwing out there. Other board comment or questions. Yes, this is Tom. Tom Walsh, that's my comment to Jess's question. I would say, I would also say yes, but given that we're talking about five to 10 or maybe five to 15 applications. This would not be my personal priority for our staff time focused on regulatory integration. I think hospital budgets and ACO budgets are bigger fishes to fry than CON given the limited number of applications that we get already. So that's not to say it's not important, but we have limited bandwidth and this would not be my number one priority. Other board comments or questions. If not, I'm going to open it up to the public for comments. And I see Dale's hand raised Dale. Yeah, first I have to say Tom Tom I can relate to the hearing aids. Mine broke. They were broke for two weeks then they spent a week in repair. I was lost. It was really rough anyways on to the I'm giving away my age here. I've seen live through rates of high inflation or actually I also called it fast inflation because it's done always the magnitude. It's the pace of the inflation and what they're describing, I believe is a fast pace inflation. And what I remember happening is projects would come in with the estimated costs. And right as they were considering it, it was already out of sync to what the actual cost was going to be. So some some of the things that they did is they would had the budget. So that it would say if inflation goes to the point where it's going to cost more than this to complete the project, it has to be re evaluated. The other thing that became a factor is lead time for delivery of supplies because that would literally determine what the actual cost was going to be of the product. So if you've got a high rate of inflation happening rapidly, and they suddenly say we can't get this to you for six months. You've got a different cost. So I don't know what the board wants to do with this just because the economist. I mean, I just want to throw that out there that for anybody that hasn't lived through fast pace inflation. It's a slightly different nature in terms of how that works when you're trying to do projections than what we may be used to. Thank you. That was my comment. Thanks, Dale, and I can relate. We ordered sliding doors two years ago that were supposed to be in within six months. We're still waiting. There you go. Yeah. Other public comment. Other public comment. Hearing none, Mike, I think you you know what your homework is where we'd like to have you back. We'd like to have a public comment period opened on the issue and I'll ask Kara to open up that period on our website. And Mike, I don't know what your schedule and the board schedules are, but I'm sure we can coordinate this and get you scheduled either at the next board meeting or one within the next month. Okay. Thanks, Kevin. And we just restate what I think my homework is. So you'd like advice on. The starting point and whether you have the authority to go back to the last time each specific threshold was last adjusted. Yes, I heard from a recommendation on the correct measurement of inflation. Okay. For what we're regulating. Anything else? I don't think so. Okay. Thank you, Mike. Appreciate it. Thanks. Can I also just chime in for one last suggestion? I'm just looking at the participant list. I do see the hospital association is here, but some of the other impacted parties are not in attendance. I'm wondering if we could just do a little outreach to home health and other provider types that would be impacted just to let them know this conversation is happening in case they haven't caught on that we're discussing it. Mike, perhaps Abigail from the CON team could reach out to, I would say the organizational parties such as VOS and BNAs and so on and so forth. Thanks. Okay. Is there any old business to come before the board? Hearing none. Is there any new business to come before the board? And I wanted to bring up an issue that I want to begin the public dialogue on. And it's something that I think is of great concern to all Vermonters and especially commercial ratepayers. And we're starting to see the effects of what is happening in the workforce and healthcare. And we're seeing that not only are we seeing high traveler costs, but in order to have equity for Vermonters working in those positions, a few hospitals have already had to offer significant pay raises and retention bonuses. And we're now at the point where at least a couple of the hospitals have come to the board and have begun to raise questions about mid-year adjustments. And in one case I've already asked for a mid-year adjustment and we'll be having that discussion over the next few months. But I think it's important that I bring it up today under new business because there are further ramifications. And that is we are in the middle of a legislative session. It's at the halfway point. But I just want to make it clear and this is just from one board member. I'm not speaking on behalf of the whole board. But as one board member I feel it's inappropriate for the increased labor costs affiliated with healthcare due to the shortage that currently exists of the workforce. That all that burden gets placed on one subset of Vermonters and that being the commercial rate payers. And I think it's important that at least I send a message to our colleagues both at the federal level and at the state level that it doesn't seem right that population that we've already burdened with over 40% premium on actual costs of healthcare. Be the one population that has to solve all the costs related to the workforce issues in the state. And so I just wanted to bring this issue up and maybe other board members wish to talk about it as well. But this is something that I feel all payers have to come to the table to. And this is something that must be dealt with. It's not something that is going to go away quickly. We can't bury our heads in the sand because if we did that there's a huge access problem. Because no longer are there the professionals needed to care for Vermonters as they get sick and need healthcare. So board members I'll throw that over to you if anybody else has any comments they wish to make on this. But I would hope that we could begin a conversation with government payers to try to send a message that this should not just be on the back of a subset of Vermonters. Kevin it's Jess I'm wondering is it worth can we request a meeting with legislative leaders and potentially you know folks from the governor's office to identify if there's any additional one time funding that might help or other sources of federal assistance that might be tapped into to cover this. Is that an important question Jess and I'll just say that I have testified in the legislature and I did a calculation based on the $10 billion that New York state is allocating for healthcare workforce. We're not alone all the states are spending dollars trying to fight this problem. But if you take that $10 billion and you divide it out over the 22 I can't remember if it was 22.4 whatever the population is up in New York I came up with $494 per person per capita in the state of New York. If we were to use that same figure in Vermont the dollar amount that would be spent on the healthcare workforce issue would be about $315 million. So much smaller scale than the $10 billion but still $315 million is a lot of money. And yet when I do the math on what I've heard so far I'm only seeing about a little less than $40 million being spent in Vermont on the healthcare workforce issue. So I brought those issues to committees in the legislature but maybe we should be sending something formally to the leaders of both the House and the Senate. And I would hope it could come from the entire board and not just from one board member. I would add to that Kevin that you know in terms of like getting the governor's office involved and the legislative folks involved but also the folks at Diva rates rate setting. I mean I know they're one of our partners and stakeholders etc but rate setting is the vehicle through which the cost shift occurs and you know as I've played around with some of the Medicaid numbers and certainly I'm doing it through binoculars. You know where if you look at 2022 versus 2023 on the emergency board's Medicaid plan, the projected decrease in enrollees versus the rate increases for each of the Medicaid eligible segments is a winner from a budget point of view for Diva. Now I don't know if the governor adopted those emergency board numbers I you know as they flow through but I'm just you know a little not suspect but just you know that some of the intricacies of how caseloads and pms pms work that they they can work to the advantage of of the state budget and to the disadvantage of providers. So I'd yeah I'd like to have a conversation with the Diva folks that actually are in the trenches, not necessarily deep in the trenches but you are the folks that you know make these decisions. I think the the math that you brought to the meeting you had is very telling and I think we're, you know, maybe starting the process of coming out of the pandemic and it's they bear. Many issues and healthcare and what you're talking about with how we support healthcare, the workforce, I think is. Two Vermonters who are going to have to pay for those changes I think it's very important and it's a all hands on deck type of thing so if we as a board can proactively reach out. I just support that I think that's a really good, really good idea. And I'd like to be involved be helpful anyway I can. Any other comments from the board. I don't really feel like I have anything else to add other than. I know that you have periodic meetings with delegation staff so I'm sure you've brought the issue up to the congressional delegation it seems like that's likely to be obviously not a quick solution but probably the appropriate venue for the Medicare. Area. So just thought I'd throw that out as a thought. It definitely is and I don't want this to be sounding as negative towards our delegation because our delegation has done phenomenal work, especially during the pandemic to bring dollars to Vermont to keep hospitals and other healthcare and they've done incredible work and in addition to that there's the dollars that have flowed to the state that could be used so I just want to make sure that we don't come across as being ungrateful because we have been the beneficiaries of incredible work done by our federal congressional delegation so but I do think that Medicare needs to raise reimbursements to more accurately reflect what is the reality and it's not just a reality here in Vermont it's a reality across the country. So Kevin is the next step then maybe to try and convene a meeting identify who should be at the table and convene a meeting. I think probably the best thing is since Susan's picture is right in front of me to ask her to have staff begin working on a plan on how we move forward with communicating out to our governmental partners. Our concerns. Is there other comment from the board? Is there other new business? Is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn. All those in favor of the motion please signify by saying aye. Aye. Any opposed signify by saying nay. And I just want to remind the board that we do have a discussion on CON deliberation that's scheduled for three o'clock and I'll see the board then. Thank you.