Good morning everyone and welcome to the Green Mountain Care Board meeting. I'm going to call the meeting to order. Today is part of an ongoing discussion on where we are in Vermont and how we create sustainability for our system over the long term. And with that in mind, we're going to hear from two contractors today. And one of the things that is abundantly clear if you look at today's hospitalization numbers is that our hospitals are strained at what many people believed may have been excessive capacity before the pandemic certainly is needed on days like today and that as we move forward with our discussions that are going to take many years to complete, we're going to need to base decisions based on data and that's really what today is about getting some of the data that looks at a point in time and we readily acknowledge that point in time is a couple years ago but in many respects we could not have used 2020 because of the shutdown and 21 may not be a great base year either but this creates data that will help us in what needs to be an ongoing discussion by Vermonters about how we have a healthcare system that we can afford that Vermonters can have access to and get quality care in a timely manner. So it's one more piece of information in our discussions about making sure that Vermonters have the right care at the right time in the right setting and at the right price and the board readily acknowledges that unlike other industries that just in time isn't what you're striving for you have to be prepared for that bus crash or plane crash or you have to be prepared for a pandemic and the board understands that and this is not to try to force issues down people's throat but it's the start of a discussion that needs to occur and it's something that I'm very pleased to start seeing some of the data points coming back together. So before I turn it over to Elena to tee up the discussion this morning I'm going to turn to Susan Barrett for the Executive Director's Report. Thank you Mr. Chair. I have a few announcements. First the November board schedule will be posted on our website later this week so I'd encourage folks to take a look at that very busy month coming up next week next month and there are several meetings that are not on Wednesdays but on other days of the week. We have several ongoing and open special public comment periods. I will list them quickly here. First the board is accepting public comment on the draft healthcare workforce strategic plan that was submitted by the director of healthcare reform to the board on October 15th. We are accepting that public comment until November 1st of 2021. The board must review and approve the draft plan within 30 days upon receipt so we encourage anyone who is wanting to comment on that plan to please submit those comments by November 1st they will be posted on our website. The second is that the board received OneCare Vermont ACO's FY22 budget on October 1st and the 2022 certification form on August 30th. Submission materials can be found on our website under ACO oversight and under the public comment section of our website. OneCare will present, OneCare is the only ACO present in the in the state right now that has full budget review by the Green Mountain Care Board. OneCare will present their budget at a public meeting on November 10th and the board staff will present their analysis on December 8th. So we want to make sure again you submit your public comment by December 1st so that the board can take and the staff can take those comments into consideration. Last as I've stated several times throughout our board meetings over the last year, we are currently an ongoing accepting public comments on a potential next agreement with the federal government for an all-pair model. We will be sharing all of those comments with our colleagues at the Agency for Human Services and the Governor's Office as they are leading that negotiation. And last but certainly not least, this evening at 5.30pm via Teams, a state panel investigating wait times in the state will conduct a listening session. The panel is looking to hear firsthand experiences of patients and caregivers who are experiencing excessive wait times while seeking health services in Vermont. That information to get on to that listening session is also located on our website and on the Department of Financial Regulation website. So with that, I will turn it back to you, Chair Mullen, unless there are any questions. I'm not hearing any, Susan. So the next item on the agenda are the minutes of Wednesday, October 20th. Is there a motion? So moved. Second. Thank you. Moved by Tom, seconded by Jess. The motion is to approve the minutes of Wednesday, October 20th, 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. Those opposed signify by saying nay. Let the record show the motion carried unanimously. So at this point in time, I'm going to turn the meeting over to Elena Barabee, who will introduce Mark Pedrazik. And this is the beginning of the hospital payment and cost coverage variation discussion. And Elena, I'll turn it over to you. Great. Thank you, Chair Mullen. I'm going to share my screen. Please let me know when you can see it. We see a black screen. Wonderful. There we go. Now we're off. All right. So, okay. So, you know, here we're talking about hospital sustainability and healthcare affordability. So this is really, these analyses are to inform the Act 159 of 2020 Section 4 report on improving hospital sustainability. We felt that it was important to include reference to affordability given the tension between these two that we don't, that we have to pursue multiple objectives. So we'll talk about that a little bit today. But I'm just giving a brief reminder about, you know, what led up to this work and why we're hearing what we're hearing. But first, I wanted to kind of recognize the approach that this work has really required all hands on deck from the board's perspective. So while I may be doing this overview, you know, Patrick Rooney and the finance team, Sarah Kinzler and the policy team, Sarah Lindberg, huge role on the analytics team in helping put this work forward, not to mention hospitals and other stakeholders that have given us feedback along the way that we're really thankful for that and hope that, you know, we can continue to solicit your feedback as we complete this report. So as I mentioned, I'll do a quick reminder, then we'll hear from HMA Burns and Associates. Sarah Lindberg, time permitting, we'll review some supplementary analysis, and then this afternoon we'll hear from Berkeley Research Group on Quality and Capacity Planning. So, you know, why are we here? Rural hospital closures are increasing across the US. This is a statistic that keeps growing, unfortunately, and with 2020 representing the highest rate of closures of rural hospitals across the US. In a recent study done in health affairs published in 2020, the study found over the period that the median overall profit margin of hospitals prior to closure was negative 3.2%, not a margin that we are unfamiliar with. And this is important because hospital closures threaten not only patient access to essential services, but have material impact on the local economy as highlighted in the Rural Health Services Task Force work. So, you know, this is really alarming, given one of our own recent hospital bankruptcies and other statistics that we've continued to witness, namely the hospital, our own hospital margins, which have been on the decline for the last five years. As you can see in 2020, they're still having zero. There's a little echo. So, you know, this is, while it looks like we're back on the incline, this is not, this may be misleading. This includes COVID relief funds, which are not expected to continue in the future and are really not a sustainable means of keeping our system afloat. You know, the reason that we continue to see these declining margins is one that, you know, we continue to talk about, which is the expenses are outpacing revenue growth across our rural hospitals, mean drivers being cost of labor and benefits. This includes travelers, the cost of supplies, including pharmaceuticals, and again, our aging population and increasing means of our communities. And so, you know, as I mentioned, this COVID relief fund and other operating revenue continue to be a larger proportion of the way that we kind of keep our system afloat. So, this needs careful attention if we want to make sure that we prevent any further hospital bankruptcies and potential closures. I think it's important to recognize that this issue around hospital solvency is really tightly connected with Bremontor's health care affordability, mainly in the commercial sector, but everywhere. And, you know, so while hospitals are struggling to maintain their health, on one hand, we can't continue to plug hospital solvency concerns with commercial charges. And that is kind of the unfortunate structure that hospitals are currently living within. I don't, I want to mention this because I don't think it's, you know, we're not trying to point fingers that hospitals are responsible for driving all of this, but I think it's, you know, that the system within which we live, which is still largely fee-for-service, makes this a real challenge. And this is a problem because it has a direct effect on the premiums and cost sharing other expenses felt by Bremontors and Bremont employers and why, you know, we have such an affordability crisis. So really finding a solution to hospital sustainability needs to incorporate affordability at its center. And this is kind of just reiterating that point that we've seen increasing hospital commercial charges over the years, and that this is a necessary component to solving this issue. You know, so according to the 2018 Bremont Health Hold Health Insurance Survey, more than a quarter of those who were uninsured worked for an employer who offered health insurance and 73% of those cited that cost was the only or primary reason they do not have insurance. More than a third of Bremontors under the age of 65 who are underinsured. And then among those who had private insurance, 40% are considered underinsured in 2018 as compared to 27% in 2014. So this is pretty substantial increase and suggests that the issue is only getting worse. And this is also important because underinsured and uninsured Bremontors are more likely to delay care than those with better insurance. And, you know, this is only going to create more chronic and complex needs for patients that if dealt with down the line are going to be not only more expensive, but this will render worse outcomes for Bremontors. So identifying potential solutions, you know, just as a reminder, this work started a number of years ago with the board requiring sustainability plans for six of the 14 hospitals with COVID.  And then the legislature codified their interest and urgency of this matter in their report in 2020 around hospital sustainability, increasing population health and access to essential services. Since then, we've kind of included equity and affordability is key criteria and thinking about solutions going forward. So this is another slide poll that should be familiar. Hospital financial solvency is really about ensuring that hospital revenues are sufficient to cover the costs of operating a system that strikes a balance between efficiency and access in our old Vermont. So we want to make sure that equitable that there's reimbursement that provides equitable access to essential services in all Vermont communities, that there's efficient economic delivery of services and that these are done in an affordable way for Bremontors. And that the kind of end result is that we have improved health outcomes for Bremontors. So it should not be a system that continues to drive to be focused on sick care that we really need to get the right services at the right time, the right place for the right price, as you mentioned before, turn one. So the project approach, current state and gap analysis, this is kind of where we are today and what you'll hear about. So I mentioned a little bit on financial health, our hospital team by Patrick Rooney is continuing to flush out some key metrics associated with hospital financial health that we found in the literature. Today we'll hear from HMA Burns and associates on provider reimbursement variation cost coverage and then later from Berkeley Research Group on community access to essential services and looking at capacity and quality. We've loved the engagement that we've had from the hospitals where we can get it given their severe constraints around COVID and hope that we can continue to collaborate and think about creative solutions to these issues. And then part three will be synthesizing these insights that you will hear today and where we can go next, what are some potential paths forward to improve possible sustainability, equitable access to essential, affordable services and preparedness for value-based care. So I just want to reiterate some points. We recognize that we're still in a pandemic and we're currently experiencing a surge in the capacity across all of Vermont hospitals right now and this work that began in 2020 does use pre-pandemic data and is designed to help inform communities, their providers and the state as we engage in post-pandemic long-term planning. So this is not something that we expect to fix tomorrow and this is really going to take careful intentional thought and conversation across all of our stakeholders. This could also lead to regulatory improvements and insights that could be used in our potential next federal agreement and we want to emphasize that we appreciate all of the work that our frontline workers and hospitals and healthcare workers have committed over this past year and a half and likely into the future. So I'll stop there but I'm eager to hear these insights and I'll turn it over now to Mark and look forward to the continued conversation. Thank you, Elena. I'm going to share my screen if someone could acknowledge. We see it, Mark. Thank you. Great. Perfect. So just to set the stage here, I want to be respectful of everyone's time. I understand that I'm allotted until 12.30 so about 75 minutes. I have about 35 slides. I am going to start with the key findings right up front and then walk you through the levels of detail and granularity as we go. Quick introductions. I'm Mark Pedrosik with Health Management Associates. We're part of the Burns and Associates Division. The odd nomenclature is because I used to be the president of Burns and Associates and we were acquired by HMA in September of 2020. Peter Burns and I, he's the Burns and Associates, he's now retired, but we founded Burns and Associates back in 2006. My brief background, I've been working with state Medicaid agencies primarily for the last 25 years on a variety of issues specifically on reimbursement and more specifically hospital reimbursement, set rates for inpatient and outpatient services for five different state Medicaid agencies and work with some others on some background analytic assessment reports. Probably most important to all of your information is that one of our first jobs at Burns and Associates was to assist Vermont's Medicaid program move to a DRG payment system in a mirror of the Medicare outpatient payment system way back in 2006. And I appreciate actually our continued relationship with all the hospitals in Vermont throughout all these years. It's been very thoughtful and respectful and good insights from the hospitals on all prior projects, including this one. So I have eight key findings. And again, I'll go into the details about the data we've used and some important notes, but just to hit the headlines here, within the data that we looked at, which was three years of data, the hospital's fiscal years ending in September 30, 2017, 2018, and 2019, we found that hospitals were paid between 87 and 95% of their costs for the inpatient services that were in our study and between 112 and 117% of their costs for the outpatient services in our study. Those payment to cost ratios are also called cost coverage ratios is all payers combined. The overall ratio when we combine the inpatient and outpatient utilization together for the information in our study that is was 101.9% for the year ending in 2017, 100.8% in 2018, and 97.5% in 2019. So this dovetails with the slide that Elena showed on the erosion of the cost coverage. I do want to point out, I'll dwell on a little bit later in the presentation, this 97.5% in 2019, I would consider that the lower bound because we do believe there might be some incomplete payments from CMS for the Medicare ACO members in the all payer claims database that was our source of data. We're not concerned about the Medicaid ACO experience, but a little bit on the Medicare. So this could be a little bit higher than 97.5. However, the overall trend you can see is very close to break even and a slight erosion over the years. Importantly, finding three is the cost shift continues and the cost shift is wide. These percentages show the percentage of cost covered by major payer, Medicaid, Medicare, and commercial for the three years ending in 17, 18, and 19 inpatient and outpatient separately. So you can see Medicaid has been low, but steady about 73 to 76% of the cost covered overall. Medicare, you can see 95% for inpatient in 17, then 89% in 2018, and there's that 82%. So that's the one we think might be a little low here, but you can see it was never 100% even in the other two years. And then outpatient is also quite low. In fact, the Medicare cost coverage is similar to Medicaid. And then commercial, you can see it's more than 100% of the cost covered, but there is quite a disparity between outpatient services and inpatient services, i.e. the 256% is basically saying that the hospitals are reimbursed two and a half times their cost for the outpatient services in our study. It did go down to just about two times cost, but nonetheless, it's quite different than the inpatient side for the commercial payers, which hug are closer to 100% of cost. When we look at this data, the root cause of this change in the cost coverage, yes, costs are increasing absolutely for all hospitals, but the variation itself really is indicative of the rate of payment as opposed to the rate of cost. So in other words, yes, the costs are increasing, but the delta between the payment across the payers is really what is driving this change. And I have some charts to show you to illustrate that. Last few findings, in addition to the wide variation across the major payers, there is also a wide variation the percent of cost covered for each of the hospitals in Vermont. And furthermore, there's wide variation the percent of cost covered for specific services under inpatient and outpatient delivery systems. And I have some charts to show you some examples of that as well. Another item is that we do not see any direct correlation between the charges the hospitals are charging versus their net payments or their cost covered. So even if a charge master for a hospital has grown say 5% year-over-year, that doesn't mean that their cost coverage increased 5%. In fact, it could just as easily have decreased because embedded under the charge master or all the contractual agreements with the payers, particularly the commercial payers. It's important to note, and I will dwell on this a little bit further, that the findings presented today do not comprise the entire hospital budget. So even though I just showed you some cost coverage values, that is not necessarily every hospital's specific cost coverage for the year. Why? Because we use Vermont's all payer claims database as our source and not all the hospital's data utilization for those three years we looked at is in the database. Specifically, the hospitals the services that are included in the database are delivered to Vermont residents only. So we have included Dartmouth in this analysis at the board's request, but keep in mind that that's going to be the utilization from Dartmouth for Vermonters, not the preponderance of their book of business. So i.e. keep in mind that it could be that higher acuity services are represented in the Dartmouth numbers because Vermonters are going to Dartmouth because of more higher acuity services as opposed to say deliveries or well babies or simple outpatient services. Likewise, UVMC is going to have some New York experience as well, and that's not in their numbers. There's also obviously other hospitals on the border that this impacts as well. The services that we're including are those that are covered under Medicare's MSDRG system, which is the method of payment that Medicare uses, as well as its outpatient prospective payment system also called the OPPS. Also about half of the self-funded utilization is not in the database, so that's a large component that we're missing. I do want to point out whenever we talk about the cost coverage or the payment to cost ratios, hospitals are billing a technical side, which is the cost borne by the hospital itself separate from the physicians that are delivering the service. So if there is a surgery, the hospital is going to be billing on the technical side, the technical piece for the surgery room and all the supplies, et cetera, related to the surgery, the surgeon bills separately for her or his time. That professional component is not in this study, just the technical side. Also, there are payments to hospitals outside of claims, but because we're using a claims database, not an all-payments database, the most obvious example is disproportionate share payments that are paid by Diva, Vermont Medicaid. Those payments are not included in this analysis. Furthermore, there is also a hospital provider tax that hospitals are paying to the state, and that is also outside of claims, so that is also not factored into this analysis. Let me pause there to make sure I invite board members to ask questions along the way. I know we want to get through everything, but because this is the key findings, I'll stop here before I get into details if anybody has any questions or comments thus far. So board members have been trained to wait to the end of the presentation to ask questions. So Mark, you're giving us a good opportunity to ask questions along the way. Do any board members have any questions at this point in time? I'm not hearing from Mark, so why don't you just keep going? I'll dig right in then. I introduced myself. You can read that at your leisure. Okay, some background. So our key objectives in this study was to assess the variation in the rate of payment for inpatient, outpatient hospital services across the major payers, as you saw. Also to examine the payment variation across hospitals and major service categories under the hood of inpatient and outpatient to look at the percent of hospital costs covered by major payer and by individual hospitals and major service categories. And then also importantly to assess the reliability of the data sources that we're using in the event that the board is interested in further exploration, we want to understand how reliable our data source is before, you know, determining that this is the baseline, if you will, of the study. I'm not going to redo everything here, but kind of quickly go over some of the terminology that I use throughout the presentation. So an inpatient discharge represents all the services on the technical side that a patient would be receiving while they're staying in the hospital from admission to discharge. Outpatient service, I do want to dwell on that a bit, because outpatient services, the way that they're billed is that multiple services in an outpatient setting can be billed on a single claim by hospital. The Medicare OPPS payment system and DEVA's OPPS payment system effectively unbundles the services on that claim such that let's say an example that there's 10 lines on a claim that's billed, but on those 10 lines two of them are significant procedures. It could be an ED visit and say then ultimately result in an outpatient surgery. And the other eight lines are more smaller cost ancillary services. So those 10 lines get broken up into two services, which, you know, the terminology CMS uses is called pseudo claims, because they're not the actual first claim. It's a pretend claim. And then we roll the ancillary services under those two significant procedures. So what was one claim becomes two claims, but all the ancillary costs are embedded in the significant procedure. And that's what we did here in this analysis as well. Charges, I think everyone knows, but that's the amount that's billed by the hospital. The payments amounts that we're using when we look at payment to cost ratios includes the amount from the payer, the co-pays, and the deductibles, importantly in Vermont for the ACO assigned services. We have what we often call the would have paid amount. In other words, if the claim was paid under a fee for service arrangement that is captured. It is reported in the data, all payer claims database. However, as I pointed out, we believe the 2019 numbers for Medicare only are on the low side. I'm going to talk you through how we determine the costs. And then I've already introduced the payment to cost ratio. It's also called cost coverage. So that represents what percentage of the hospital's costs on the claims we looked at are covered by payments in the system. Prospective payment system hospitals or PPS hospitals, as they're called, are those that are paid under Medicare's prospective payment system. That's going to be UVMC and Dartmouth and some of the larger acute care hospitals in the state, the critical access hospitals are the smaller hospitals. They have a special designation by CMS. And the reason why we're highlighting this here is because critical access hospitals ultimately are paid 99% of their costs. They're paid something up front, and then there's a settlement process later. The settlement process can often be very lengthy in time for the final payment to be received by the hospital for the time period of study. For our purposes today, when we look at payment to cost ratios for Medicare only, and for critical access hospitals only, we have forced it to be 99% because that is ultimately what will be paid to those hospitals. That's not to say that that's true, though, for Medicaid or commercial values. As I mentioned, we use the V-Cure's database as the abbreviation is called. We're using the hospital fiscal year data for three years. Inpatient and outpatient claims, claim status of paid. We also used information from each hospital's CMS hospital cost report. It's often called the Medicare cost report, but it actually includes data for all payers and all costs. There's a standardized series of reports that each hospital's responsible submit, and we use selected schedules from the cost reports for the same three time periods that we use for the claims. We identify the services for inpatient and outpatient hospital. We use the hospital's federal tax ID and the database to make sure we capture because sometimes there's multiple IDs for hospitals. We broke up the payers into these six groupings. You can see Diva, Medicare fee for service, Medicare Advantage, Blue Cross Blue Shield, the Vermont MVP, and all others combined. In today's presentation, we've put all the commercial together as one group, and we've actually excluded Medicare Advantage although yes, it is growing a bit, but still it's quite low vis-a-vis fee-for-service Medicare, so we've excluded it from the analysis. We created inpatient hospital service categories and outpatient hospital service categories for the purposes of comparing the payment variation and the cost variation. Here they are. The inpatient, without reading them all, is effectively based on diagnostic categories. You can see respiratory versus circulatory, etc. They're diagnosis related groups or DRGs. There's about 750 of those categories. Each of those uniquely maps to one of these categories here. On the outpatient side, you can see there, we looked at the volume and the commonality of procedures, of which there are thousands of procedures, and each of those is uniquely mapped to one of these categories as well. On the dataset preparation, we did look at trends on volume by payer for each hospital across each year. We validated the payment amounts. We looked at the one care utilization specifically for that would-have-paid, that's where we determined we are light on 2019 for inpatient, one care, Medicare in particular. We ran our costing logic assigning cost to the services, which I'll go over next and then compare those results over the three years, and then we looked at the payment to cost ratios by hospital by year and by payer. Because we're doing a relatively sophisticated process to assign the cost using inputs from the cost reports, as I mentioned, we also looked at the inputs that were used in the cost computation to make sure there was consistency, for example, on the room and board costs reported by the hospital each year, and there's a differentiation, say, between a semi-private regular room versus an ICU bed versus a nursery bed. For ancillary services, hospitals are required to report the payments and the costs by service, whether it be laboratory radiology, drugs, the ED. We looked at the ratios, I'm sorry, the cost in the charges. We looked at the cost to charge ratio, which is reported on the cost report, at each department level for each hospital for each year to look for consistency there, because we're using that when we assign costs. This gets a little complicated, but let me give you an example of how we assign the costs. So there's a worksheet on the cost report called D1. That's where these room and board costs and their express is a per diem. And so you can see this is not any particular hospital. This is illustrative data. You can see, for example, in this case, the regular semi-private room is $1,420 a day versus the nursery is only $455 a day, as opposed to the ICU, which is almost twice as much as the regular room. And that's pretty common. We see that. And then here's these ratios, and you can see some examples of the different categories that are reported on the cost report and the ratio. So why is this important? When the claim comes in, the hospitals are reporting on each revenue code. So like, for example, $120 is the code for the routine room, which is this $1420. And let's say the case came in and had three days. So at the bottom here, we're going to multiply three days times this $1420 to get the $4,260. And let's say one of the days of this day was in the ICU. So then the one day is multiplied by the $29.36. Likewise, the ancillary services, we take the charges and we multiply by this ratio, because this is the cost to charge ratios, then we can take the charges and multiply by that ratio to get the costs. So I'm showing different examples of charges times the ratios in the blue box to get the cost. And then we add all the lines together to get the total cost for that case. In this case, an inpatient discharge. That's done for every single line on every single claim, inpatient and outpatient, and we're using the values from the cost report for the year to map back to our study year. So if it was a case with a claim that ended sometime in the October 1, 2016 to September 30, 2017 time period, we're using the values in the green and the blue boxes from that hospital's cost report for that year. So it's all this information that's our source is hospital specific, and it's year specific. Another nuance to our analysis is that it's probably pretty obvious to anyone that the costs are going to vary by hospital for various reasons. But one of the most important reasons is because some hospitals are delivering much higher acuity services than their peers. And so there is a way that has been established to effectively put hospitals on an apples to apples comparison when we're looking at costs. And the term of art is used is applying a case mix adjustment. So you know, I'm sure it would be obvious that UVMC is going to have much higher acuity cases on average than one of the critical access hospitals in the state. So we tend to report the information on average payment per case or average cost per case without applying this case mix adjustment and then with applying this case mix adjustment so that stakeholders can see what is the true variation because of acuity, if among other reasons. And then after we kind of control for the acuity, is there still variation and you'll see our results in a moment in both methods. But here's an example of why this is important. So let's say there's two hospitals and we saw we determined that the average payment for this inpatient stay was $10,000 for both hospitals. The cost for hospital A was $11,000 and for hospital B was $9,800. The acuity or the case mix score is important. If a hospital has a case mix score greater than 1.0, that means that that hospital has a higher acuity than the average of their peers that we're looking at. In this case, all the other Vermont hospitals and the Dartmouth Vermont resident experience. So in this case, hospital A had acuity 23% higher than the average, hospital B had acuity 89% of the average or lower than the average. So then we take the payment and the costs and divide by this number. So after we applied the acuity, the average payment was $8,100 for hospital A, not $10,000. And for hospital B, it was $11,000 and likewise the cost. So on the surface, you can say the payment was the same, but hospital A had higher costs. But after we applied the acuity, hospital A actually had lower costs than hospital B. So that's all we look at it both ways, just to understand the acuity, since that's such a key component to costs. So I mentioned this, we computed the case mix scores for each hospital. And then the way we did that is that because different payers pay in different ways, we opted to use the grouping methodology that Medicare has for inpatient. It's MSDRG or diagnosis related group payment system. And then it's outpatient prospective payment system or OPPS system. So we are not using Medicare's weights for each of the services to measure the acuity, because those weights are specific to Medicare's experience. What we did is we put all the payers data together and recomputed these relative weights as they're called for those categories in those systems. That's why at the beginning when I mentioned that we're only using data in that's paid through Medicare's MSDRG or OPPS system, it's because we wanted to control for that when we computed these all payer weights. And so that's how we look at each individual service, whether it be an inpatient discharge or an outpatient significant procedure. And we determined a weight value for each of those services in Medicare's grouping system. And we assigned that weight value to every service for all payers for that hospital in our database. And we come up with a total aggregate case mix score. And that's what's displayed here. So without having to look at all the numbers individually, keep in mind that the average score is 1.0 in the system intentionally. So if you're greater than 1.0, you have a higher acuity than the average statewide and less than 1 is lower acuity. So that's why you can see on the and this is done for inpatient services separately from outpatient because they're two different grouping systems. So you can see over the three years HFY stands for hospital fiscal year that the overall average hovers around 1.0 when we put the three together it does equal 1.0 and same on the outpatient side. But if we look at it by peer group AMC stands for academic medical center, you can see Dartmouth has the highest acuity scores. But again, that's just the Vermont resident experience. UBMC is higher than its peers in the PPS or prospective payment system from Medicare. And then the critical access hospitals do have a variety of case mix scores. Some are higher because their lower volume and have more specialized services like Mount of Scutney, for example. But generally the case mix scores are below 1.0 for the critical access hospitals. So that's why we want to look at everything both with the case mix adjustment applied and without the application for comparison purposes. So let me stop there. I realize that's a lot of information and a lot of math to go through. But I can start to drill into each of the key findings unless somebody has a specific question. We can always go back to these slides later if you'd like. So I'll pause. Any questions from the board or do you want to hold it till the end? Not hearing anything, Mark. Okay. So as I mentioned in the beginning, the first thing that's very important to note is that this study that we have conducted for the board represents only 40% to 41% of the payments for the hospitals because of all those conditions I set up front. Not everything is in the V-Cures database. It's Vermont residents only. Self-funded is not all in there. It's limited to those things paid in Medicare's payment systems. So and importantly, the professional component is part of a hospital's budget and that is not represented in the study just the technical side. So this is just showing you overall the payment amounts as a percentage of the total budget which we receive from the GMCB had a report that the hospitals are submitting. So no hospital is ever more than 60% and some are much lower. The average is 40 to 41%. So please consider that when you look at the findings. As an example, for the hospital year ending, September 30, 2019, we're talking about $685 million in our database of payments and $558 million of outpatient. You can see the distribution between Medicaid, Medicare fee for service, and all the commercial payers combined. And then you can see the difference between the academic medical centers, the PPS hospitals, and the critical access hospitals. So at the very beginning, you saw that the cost shift and the payment amount was much different between the commercial payers and the public payers, particularly for outpatient. So but notice that a lot of our data on the outpatient side is the commercial side. So that's going to be driving these overall averages that you see to some degree, as opposed to the inpatient cost coverage was lower from an all payer perspective, it was certainly lower for Medicaid and Medicare. But that's what's driving some of the overall weighted cost coverage on the inpatient side because you can see the mix, you know, two thirds of the data is the public payers. This is just to hit home again that charges did not appear to have a direct relationship to payments or cost. So unlike the cost to charge ratio, which we're going to dwell on quite a bit for the remainder of the presentation, I just want to point out, we also committed a payment to charges ratio. And you can see that overall across our study period in 2019 for inpatient, the payment to charge ratio was about 41%. But it varies quite a bit by individual facility. And likewise on the outpatient side, it also varied by facility and the payment to charge ratio is even lower on outpatient. So what that's saying is that on balance overall, 35% of the charges on the bill were actually paid. That's what that's telling me. So now I want to focus on first the payment variation. The next four slides are composed in a similar manner. We're going to focus just on 2019 for illustration purposes, although we have the data for all three years available. There are going to be two boxes on the next few slides. The first box is prior to applying that case mix adjustment. And the bottom box is with the case mix adjustment. The hospitals are ordered in the same format. The academic medical centers come first, then the PPS paid hospitals, and then the critical access hospitals. Further, you can see that the three major payers appear on the stick. Commercial is in the blue, Medicaid is in the green, and Medicare is in the black. So let's focus first on inpatient services only and the payment variation. So what you can see by the grid is that the payment variation, i.e. the average payment per discharge, commercial, the blue, tends to always be highs, but not necessarily for some hospitals in our data at least for 2019. And furthermore, the spread varies by hospital. In other words, Springfield, they're all pretty much the same, the average payment, whereas like UVMC, commercials higher, but the two public payers are very similar. When we apply the case mix adjustment to try and make it more apples to apples, the general trend is that commercial is still undoubtedly higher in most cases with few exceptions, but there is some tightening, particularly on the public payers. The same illustration is now shown for outpatient services in our study 2019. The top is without the case mix adjustment, and the bottom is with. Here, this is where it's really pronounced where the cost shift is happening, in that the average payment for the commercial payers is substantially higher than the public payers. And as you saw at the very beginning on the cost coverage, the Medicare and Medicaid cost coverage is pretty similar. And that's pretty much because the average payment is similar for Medicare and Medicaid for outpatient services. And when we apply the case mix adjustment, the finding is basically the same. Commercial is much higher than the two public payers. And in fact, in most cases, the public payers even tighten closer to each other. So in some cases, like the black box is actually sitting on top of the green circle. So that's the story on the payment side. But now let's look at the costs. So first we'll start with inpatient services. Again, it's 2019. So here, the average cost per discharge, in many cases, Medicare is highest. Why? Because of the age of the patients and the acuity of the services that they're receiving in the inpatient setting. But when we do the apples to apples case mix adjustment, see how many of the sticks, the dots get closer to each other. In other words, the cost after applying case mix is more similar than we saw the same sticks on the payment side. And that's most clear when we look at the outpatient services. When we apply the case mix adjustment, the average cost per outpatient service with few exceptions is very similar between Medicare, Medicaid and commercial. I'm going to briefly go back, look at the variation though on the payment side. Commercial is much higher. So that's why when I said at the beginning on the key finding that the variation is really more on the payment side than the cost side, particularly after we control for case mix adjustment. So that view is looking at all services combined, the inpatient and outpatient setting by hospital, by major payer in 2019. On the cost coverage, this is a bit of a repeat from the beginning, but to reinforce that the public payers in our data represent about 76% of all the services. So the fact that individually the two public payers are paying below 100% of their cost of the hospital's costs, notwithstanding the fact that the commercial payers are paying more than costs, that's the public payers are bringing down the weighted average on the cost coverage in our study. And again, the 87% here for inpatient 2019 is mostly indicative of the drop here on Medicare, which we are a little worried is on the low side. Because you can see Medicaid was steady at 73% and commercial was steady at 110%. So that's really what's driving that particular percentage. The next few slides are displayed in a similar manner as well. So now we're looking at the cost coverage variation by hospital. This is all payers combined. And the color coding represents bands of the percent of cost covered. So red being the most concerning that the cost coverage is less than 85% all payers combined, then it goes 85 to 95%. The gray is like the mid range around actual cost covered 95 to 105. And then the green is most favorable. So, you know, without having to focus on any particular hospital or any particular year, you can see that the overall trend is that on the outpatient side, there's more green, meaning that the percent of cost covered is generally favorable for most hospitals from an all payer combined perspective. But a lot of the hospitals do not have their cost covered. And some are most concerning below 85% on the inpatient side. So when we blend the two together to get the weighted combined, you can see that we have some pinks here, even if they're green on the outpatient side, because the inpatient cost coverage is weighting down the overall cost coverage for the hospital. Now we look at the inpatient cost coverage only, but now we do look at it by major payer and by hospital. And so here it's even more glaring that Medicaid, as a weighted average, as you saw, was paying about 73% of cost. And that's pretty much true down the line for all the hospitals. On the Medicare side, there's quite a bit of red. All the critical access hospitals, like I said at the start, were forced to be 99% of cost. That's why they're all gray. And then commercial, there's certainly some green, but it's not all green. Because remember the cost coverage was lower on the inpatient side, even in the commercial setting, it was about 110%. And so we do see some red and pink as well. The different story on the outpatient side, commercial, it's all green pretty much except for gray scottage. A little bit of gray there. On the Medicare side, costs are not being covered on the outpatient side for Medicare. The critical access, again, were forced to 99% just for Medicare. And then Medicaid, pretty steady, around 71 to 76% of cost. And that's true for all the hospitals. We then looked at it by inpatient service category. Let me try and make this a little bigger because I realize we have a lot of data here. This is 2019 data only. We show when no case mix adjustment was applied on the left hand side. And when the case mix adjustment was applied on the right hand side. These are our categories that I introduced at the beginning. And then an all combined is at the bottom. So what this is telling you, for example, oh, and I should have said that we're using the same coding here. Although I noticed the commercial one became yellow, not blue, but Medicaid is green and Medicare is black. So let's take musculoskeletal. So here the cost coverage for both Medicaid and Medicare is pretty much the same. And it's less than 80%. It's around 75%. Commercial musculoskeletal inpatient stays are more like 118% of cost covered. When the case mix adjust, it didn't really move all that much. Commercial came down a little bit. But that's different than let's say these intensive preemie NICU babies. Here, of course, there's no black square for Medicare because they don't have NICU babies in their database. But for Medicaid, it's about 80% of costs. And commercial is about 140% of costs. But then after applying case mix adjustment, the Medicaid circle goes a little bit to the left. And the commercial goes further out to the right. So we're trying to put these same NICU cases on an apples to apples basis. So all we're trying to show you here is that, first of all, the spread is wide on cost coverage at the service category level across the three payers. And sometimes the case mix adjustment closes the gap. And other times it widens. We do the same thing for the outpatient services. Here it's a little more pronounced. As you saw based upon the variation of the payment side in particular, the commercial, with few exceptions, is always much further out than the public payers. And Medicare and Medicaid tend to travel together. And it's always pretty much under 100% for every category. When we case mix adjust, there is more of a spread between Medicaid and Medicare. And the commercial sometimes closes it and sometimes furthers out. But suffice to say, we saw variation overall by payer, then at individual hospitals by payer, and now even by individual service categories by payer. I do want to touch on the cost coverage in one other way. And that is that, yes, it is troubling that costs are not covered in many situations. But I just want everyone to be mindful that it could be that the cost spread average cost that is for the same service across hospitals also vary. So the whole concept of case mix is that we're adjusting for the acuity of different hospitals for their entire book of business. However, when we control for looking at a specific service, that would indicate that the acuity generally should really be the same for all hospitals for that individual service. However, what we are seeing is that there is also variation in the costs and in the payments to individual hospitals for individual services, not just the whole service category. And so I have four specific examples to show you and that will pretty much close out my presentation. The first one is vaginal deliveries without complications. So there is a diagnosis group in the Medicare system called MSDRG number 775. And what I'm showing you on the top is in 2019, the weighted average payment for vaginal deliveries was $7,518. Four hospitals had payments above that and then others were below that. So there's variation in what the hospitals were paid for vaginal deliveries. But then when we look at the hospital's cost, there was also variation. So the grid here, you'll see this on the next few slides as well. The access is cost coverage. The higher the cost coverage is the further out to the right and the higher the cost is further up. So I have four boxes. The first one is the hospital on average has high cost versus their peers, but low cost coverage versus their peers. And I'm defining low cost coverage in this box as under 100% of cost covered. And I'm defining high cost as that hospital's bar is above the overall average. So in this case, there are four hospitals that had high costs and low cost coverage. There were no hospitals that had high cost and high cost coverage, but that's not going to be true in the next few slides. Then I have three hospitals that are lower cost than their peers, but also lower cost coverage. And then this is probably more of the goal, lower cost, but higher cost coverage. So that would be the aim. That's why it's in the darker green. Now inherent in that, we also want to make sure that even if it's low cost, i.e., the hospital's more efficient, we want high quality as well. So we don't want to lose that those go hand in hand. But what I'm basically saying here is that, yes, there's lots of case mix and acuity differences across the hospitals in our study, but if we isolate it down to a particular service that everybody should effectively be doing the same particularly this one's without complications, we are seeing a wide variation in costs and cost coverage down to the individual service level. I have one other inpatient one, and that's knee and hip replacements. Again, without complications, there's a separate category in the DRG system for those with complications. These are without complications. So again, I'm seeing a wide variety and without crosswalking every single slide, the same hospitals do not appear in the same box on these four exhibits. I'm showing you it varies by service. Here we actually have two hospitals that have high cost and high cost coverage. We did not see that on the delivery side. Then I have two outpatient service examples. One is the mid-level emergency department visits. Yes, there could be lots of different reasons why patients will go to the ED, but the general coding system, there's low-level, mid-level, and high-level. I picked the mid-level. The average cost was $254 for those visits. That's what's shown here. We have some hospitals above that and some below it. Again, we have a variety of scenarios between high and low cost vis-a-vis their peers and variation in the cost coverage, high and low cost vis-a-vis the peers. Again, it's not always the same hospitals in every box in all of these slides. They move all around based on the service. Then we have an imaging without contrast. So level one, there's five levels. This is the lowest level imaging without contrast, an MRI without the contrast. So it's like the most basic of those imaging services. The average cost is $144. That's here. They generally hug the average, but we do have some variation lower and higher. Again, we're seeing variation. Bottom line, we have variation by payer, by hospital, by major service category, and by individual service category. I wanted to close before opening up for questions, some considerations based on what we've seen in this presentation. I invite this for the board's consideration and any questions you may have for me about it. But one is that it does appear that regulating charge masters is really not influencing ultimate percent of cost covered because I don't know all the history of all the different charge increases over the last couple of years. But you can see that even if charges increase, that did not indicate that cost coverage increased in concert with the charge increase. Knowing that piece of information, the GMCB might want to consider developing some type of roadmap to kind of pivot more towards cost and cost variation and cost coverage as a lever in lieu of charges. Now, that is quite an undertaking. I understand. And the data today, I would consider the introduction to that concept. But knowing from the beginning what I said, we did not have, we only have 40% of all the payments in our study. We are missing some utilization from the all payer claims database. There are multiple nuances that would be inherent in moving in that direction. Some of them that to me appear important for consideration is one. I think that there should be consideration given to the type of hospital. In other words, the academic medical centers versus the general acute care prospective payment system hospitals versus the critical access hospitals. I'm not suggesting that every hospital in the system should have or aspire to the same cost structure because they are inherently different if nor the reason than the type of hospital and the cost inherent in that hospital. So that should be considered. Also, you know, we're hoping that the hospital stays sustainable, i.e. cost coverage over 100%. But that doesn't mean that the goal should necessarily be 100% cost coverage for every single service from every single hospital because as seen on the last few slides, the cost even within a service vary quite a bit. Some of them are legitimate based on the structure of the hospital, but others could be could there be efficiencies in some areas versus others. So, you know, the financial which would be on high quality, of course, first, but also efficient i.e. lower costs going with that high quality. I don't think that trying to say if the board wanted to take this route going on a specific cost coverage value is realistic. For example, we want to aim for 105% cost or something like that because hospitals inherently, you know, are trying to manage their costs in totality as opposed to individual services. So there needs to be some recognition that there could be balance there. So perhaps instead, something more like a band around a cost coverage range is something that might be a way to use this as a lever as opposed to a very specific number for cost coverage. And then as you saw, inpatient and outpatient service categories inherently have very different costs as well. So even if the band around a target cost coverage is an area of exploration, it might be that there needs to be different cost coverage bands for different types of services because they're also quite different from each other. And then probably the number one thing is that, you know, again, today is considered the first view of the data. But if cost coverage was considered as a future metric, I do believe that there needs to be an additional level of scrutiny around the baseline data i.e. what is in the vCure's database and what is not in the database for purposes of further analysis. So apologies for going quite fast through this, but I was able to get through it. And I believe we still have time for questions. I'm happy to go back to any specific topic that the board members would like me to. But I will conclude and turn it back to the chair. Thank you so much. I'm going to turn it over to the board members for questions or comments. I have a few just I think simple questions, but so on the page that you're up on right now looking at item number two, you know, referencing how the Green Mountain Care Board might consider using this information. But I have two questions. One, from a hospital administrator's point of view, as opposed to a broad regulatory point of view, what would you suggest to individual hospitals, which kind of look at this and may see that, you know, they have high relative high costs, would that suggest at the hospital level that they should look internally to reduce their costs. But if they're getting low payment from commercial pay payers, relatively, that they should be chasing after their commercial payer, you know, for more equal payment. So I guess my question is, have you applied has this been applied methodology been applied at the street level, and and what you know, which which means the hospital level, and what what have what have been the results. So I have not and have never been a hospital administrator. So I'll start with that. But I would venture to assume that any hospital is certainly looking at this level of granularity at least on a regular basis, because they understand that they are going to make a margin on some services and some for whatever reason might be a a loss to them, and they're constantly balancing. It's a balancing act for them. The exogenous circumstances they're faced with, I mean, they certainly are working to find efficiencies on the cost side, wherever they can. But the payment side, if you're the public, if it's the public payers, a lot of it's out of their control other than lobbying maybe the Vermont legislature for an increase on Medicaid. And on Medicare, they're pretty much stuck with whatever Medicare says they're going to pay them. So you know, really, their only true point of leverage is the commercial side. So my suspicion is that when they look at the balance of their payer mix and the services under their payer mix, they are always looking for ways to strengthen the commercial payment side. And that's why you're seeing that in the outpatient that the average payment is so much higher for commercial than the public payers, because that's their first and maybe only avenue they have for that, while looking at where they can find more efficiencies in the cost. The converse or the other piece to the coin is on the cost side, is that, you know, hospitals generally, unless they've chosen by design to not offer certain services, whether it be obstetrics or deliveries or certain surgeries or what have you, you know, they're kind of all comers for all patients. So sometimes they're because the volume is so low, they're not going to be able to gain efficiencies on every service category because they just don't do enough of them. So I guess that's a whole business model question is, should every hospital deliver every service? I mean, at the moment they all have to have an ED, you know, for emergencies, but that doesn't mean they have to do every last surgery. You know, I don't know the intimacies around what every hospital is covering or offering or not offering today, but that's always, you know, when the rubber hits the road, I think that's where the difficult decisions come. Maybe we should actually get out of this sub component of the business. Thank you. There's a limited amount of time. I do have a couple more questions, but let Jess and Robin and Kevin, so I don't suck up all the time. Thanks, Tom. We'll go to Robin. Thanks. Mark, I was struck by your comment that the cost coverage was similar between the public payers and that that appears to be driven by the payment amounts. And I'm wondering if you could, what that makes my mind go to is some of the federal limitations around Medicaid payment like the upper payment limit. And I wondered if you just had any thoughts or comments about that in relationship to this data and information. And if not, certainly we can talk about it later. No, that's actually a very good point. So for the layperson, there is a specific rule that state Medicaid agencies are bound to an upper payment limit in the aggregate for hospital services. However, the limit really is the percentage of allowable Medicare costs on the cost report. So it is not, sometimes some analysts have compared Medicare payments against, I'm sorry, Medicaid payments against Medicare payments. However, as you can see in our study here, Medicare is not covering full costs either in every situation. So Medicaid agencies are not bound to pay, they can pay more than Medicare. That's the bottom line. They can't pay more than Medicare allowable costs though. So that's an important nuance, particularly if Medicare is sitting at like 85% cost coverage, Medicaid is not stuck to pay 85% cost coverage. They can pay 100% cost coverage. They just can't pay 105% cost coverage. Thank you. That's really, for me, that's very helpful in putting it in context in terms of looking broadly about possible avenues. Sure. That was my main question that popped in my head. I still have a lot, I still need time to digest, of course, a lot of the information since this is our first bite at the apple. So thank you very much for the very thorough presentation. Thank you, Robin. Next we'll go to Jess. Great. Well, thank you, Mark. I mean, this is so much work. I can only imagine how much work and how much time you spent behind your computer and your staff and your team there. Like Robin, I think it's a lot of information that we're going to have to take time to digest. But I think it's really helpful as we think about our regulatory processes going forward, as well as we think about our next agreement with the federal government. I think this is important information for that. And a little bit to some of the points that were made earlier, my hope is that the hospitals and the trustees of the hospitals and the community leaders will also welcome this analysis that you've done. They share the same mission that we do. They want to provide high-quality, low-cost care to their communities. And so I think the presentations that we're seeing now and the presentation we're going to see this afternoon are helping us give this holistic look at the whole healthcare system and may help us find efficiencies and lower costs and improve quality, which are goals that we all share. As I'm looking at this, there was some key takeaways that actually I think are important. And I have to digest them a little bit further. But it's very clear that hospital sustainability is going to be inextricably linked to pair mix. If we're looking at that cost coverage and we see all that red on those charts around what the public payers are covering in terms of the cost of our care, even if we as a board allowed commercial rates to grow at rates that are higher than inflation to cover the cost shift and to cover margin needs, hospitals that have challenging pair mixes may not survive. I mean, that's the reality. If 76% of the of the utilization is being paid by public payers, the cost shift is clearly an issue for financial solvency of our system. So I think this is really important information that I'm hoping Diva is looking at, the legislature is looking at. I'm hoping that we can consider it in our next agreement with CMS and Medicare. I think this is really important as we're thinking about sustainability. It can't all land on commercial payers. They are commercially insured. They're a shrinking population and they can't afford it. So I think this is really helpful. So that's just a comment.  But the data shown today shows that that's actually not the case. Once you adjust, as you said, for the case mix index, particularly on the outpatient side, payments are higher at some of our smaller hospitals and costs are higher at some of our smaller hospitals. And so I think to your point about thinking about how do we think about holistically this system and ensuring that the care is being delivered efficiently, but that we're also preserving access. I think it's going to be really important to be looking at these things going forward, particularly as we move to value-based payment, where hospitals are going to be held accountable for those costs. Again, we may have solvency issues if some of these hospitals are facing higher costs to deliver care because of declining populations or growing costs. So it's really important. This is just the first step in that conversation in our post-pandemic planning. But obviously we're going to need to figure that out, but we're also going to need to preserve access to services. So there's a lot of work to be done here. I guess those are my comments. My question is around some of your suggestions around looking at cost coverage rather than change in charge as a policy lever. I mean clearly the analyses that you did here took a lot of time, required v-cures, required the cost reports. Historically the board has not used the cost reports in our hospital budget process, but I'm clearly seeing the value in potentially using those. So I'm wondering if you can just speak a little bit more towards how specifically what types of questions we might ask in the hospital budget process or what we might use from the cost reports ourselves internally to get closer to understanding cost coverage and understanding whether it's a reimbursement side issue or whether it's a cost issue, things like that. That's a long question. Sure. So again, I mean I would like to acknowledge that I think that hospital CFOs are looking at a lot of this data already. So it would not be foreign to them what I've shared with you today. Maybe not at the categorizations I did it at, but certainly at departmental levels. So it is a relatively involved process to do the assignment of the cost. It's certainly not insurmountable. Once you have a program to write it, we do follow the same consistent pattern for every hospital. It's just getting the inputs correct. I only mentioned that because it could be something whereby perhaps if there's specific categories of service that the board is most interested in, there could be some type of more simple Excel report that the hospital say their volume, the average cost for that service, the average payment for that service, and the board and its analytics team could look at it at the high level from a self-reported perspective. Then there's always the option to validate things behind the scenes if there was more interest in exploration and all that. I mean, or perhaps one of the team on the board, the staff would like to learn how to do the costing process. I'm happy to share that, our method of how we do that with them too. So I don't think it's necessary. I mean, the board has this discretion how they want the data presented to them. But do I think using the cost report as the source to get average cost per certain services or average payment per certain services insurmountable for hospitals to report? No, I don't. Okay, thank you so much for thought here. I appreciate all the hard work. Certainly. Thank you, Jess. At this point, I'm going to open it up for public comment and questions. Members of the public? Can I ask a clarification question? Sure, Dale. I'll recognize you first. Oh, I'm sorry. I should have just raised my hand. Go ahead. My deepest apologies. Is he suggesting that we should align Medicare, Medicaid and commercial so that all those paying rates are closer together? Or is he acknowledging that's really not possible and hospitals need other sources of revenue to make up that difference? Because I can't ask somebody making $20,000 a year to pay the same amount as somebody making $100,000 a year. I liked his presentation, but Jess is so broad an overview to what is so many complicated issues underneath. Can he help simplify that for me? Was he trying to pull that out or was he just doing the presentation for what it is? Thank you. Do you want to comment on that, Mark? Sure. Well, at the beginning I articulated the asks of us about what to look at, which was payment variation and cost variation and every which way. So that's what we did. To your comment, though, I'm not suggesting that all the payers should pay the same rate of payment for a particular service. First of all, I don't know if, I mean, right now the hospitals hands are tied, particularly when it comes to Medicaid and Medicare, and that the rates are published, you either deliver the service or you don't, that's the payment you get. So back to the negotiating power, I do want to stress that I don't think the hospitals are at a high negotiating position when it comes to Medicaid and Medicare and its reimbursement. So the only true lever for negotiation is commercial payers on the payment side and then maybe finding efficiencies and costs on the cost side. So yes, it's a complicated issue and I do think that maybe one alternative for hospitals is to decide which services they really want to hone in on and maybe grow and make even more efficient and other ones maybe they just say we're not going to do that anymore because the payers aren't paying us enough for it and I think that's the reality of where the state of Vermont hospitals are right now. Okay, thank you. So next I'm going to call on Eric Schulteis and Ham Davis, you're on deck. Eric? Hi, thank you so much for your report, Mark. The comment, well the first comment is just really that board member Holmes, I think as the board thinks about moving into using the cost report data, there are kind of fundamental issues about the comparability of the board's adaptive data that hospitals report in and the S10, the Medicare cost report or the worksheet on the S10 and we had raised the discrepancy several months ago and asked that the board and hospitals and the HDA come together and I think as of right now, at least in my estimation, we don't know why those discrepancies exist. I don't think anyone's trying to game the system, but before we introduce, I think, really good data and make decisions off of it, we need to understand what we can and what we can't do with it. So that's the first thing. I was wondering, Mark, in key finding three, talking about the, I guess, price discrimination between payers, how do you, like when I'm looking at that table, I'm understanding, okay, there's a clear inference that payers reimburse differently, but you moved, it sounded like you moved to a kind of, because payers reimburse differently, the cost shift occurs and the cost shift being that because of this payer differential, they charge commercial payers more and I'm having a hard time understanding that leap in logic from a kind of using a descriptive statistic that this differential exists to a causal theory. So I don't, I'm not privy to nor do I believe I should be privy to all the individual relationships that hospitals have with all the different payers, but let me give you an example of what I suspect might be happening at least in some circumstances. And that is that, I know that the Green Mountain Care Board is regulating charge masters at least in the aggregate. So it's entirely possible that a hospital is charging for the mid-level ED visit the same to Medicare, Medicaid and commercial payers and for that matter each commercial payer individually, but Medicaid and Medicare have established it says we don't care what you're charging, this is what we're paying. So the delta between the charge and what is paid could be a reduction of say 60% below charges for Medicaid, whereas maybe for one of the commercial payers they negotiate what's called a contractual allowance of we'll pay you 10% below your charge for others, we'll pay the full 100% of the charge you give us. You know the relationships can be very different for each hospital for each payer and sometimes for each service. So the baseline charges might be the same for everybody, but the ultimate negotiated rate and I use negotiation quotes because there is no negotiation with Medicaid and Medicare is what they pay. You know the effective payment that's that payment to charge ratio we saw it's like 40% overall. So that was my point was that the shift what we call the cost shift is really because if by promise if Medicaid and Medicare are paying a much lower percentage of the charge that means that the hospitals have to get the pickup of what Medicaid and Medicare are not paying from the commercial payers. So therefore even if the charge is the same to the commercial payers and the cost is the same for commercial payers they're just paying more than their fair share vis-a-vis Medicaid and Medicare. So next I'm going to go to Ham Davis and Anne Sossin is on deck. Ham? Thank you Kevin. Mark my I've got really a two-part question if I can sneak in a second question that way. One of them is that you've got that the you know when you're the cost the whole universe of cost that you looked at were under 50% and there's a lot of reasons for that and I wouldn't argue with any of them but what I'm curious about is this on the first question is this isn't there some way that you that your methodology can integrate at least of the all of all of variables that you've introduced and that's one of the best jobs of that that I've seen but the doctor pet what the professional payments are a huge factor not only simply in terms of dollars not in simply in terms of dollars but simply because the doctors not only get money it's the doctors that are driving what the what the hospital costs are anyway because every one of those decisions that generates a fee there is a doctor decision at base even if it's only listed under hospital services. So I'm curious about whether you could do that and while you're thinking about it one of the things that I'm curious about most is that the as the remount and care board really tries to get a grip on this and this is really the culmination of 10 years of trying to get get our arms around this. The what I think is that there's what I see anyway is two very different business models so that the the academic medical centers are not only doing higher case mix indexes but they are having it they basically have a different kind of payment model and they they tend to they do research they teach students they tend to pay us to pay salaries whereas the rest of the hospital system is much more significantly driven by fee for service so those are my that's really a long question but a great job it seems to me it's one of the best I've seen thank you. Thank you I'll adjust your first question so it quite honestly it just wasn't in our study or asked to include the professional component it could certainly be included I do think it's it's probably the key piece of the missing link of the you know database and just to be clear the 40% or so is 40% of payments not costs the one issue on the professional side is that it's although it's a bit complicated but through programming the wonders of programming we can assign costs to every service on the technical side easily through the cost reports it's not quite as cut and dried to do that on the professional side there are methods and I would encourage if there was interest from the board I'd like you know I think that hospitals should be consulted on that about assigning costs to professional service claims we certainly have the payment side from the claims itself but assigning the cost piece to get effectively a cost coverage for professional services there's more nuance to that it's not the same as the technical side and I think that needs more exploration but is it doable yes would it be perfect probably not but it's doable okay I'm going to call on Anne and on deck will be Mike Del Treco Anne thank you this is Anne Sassen from Dartmouth College and I have a question for board members on the broader hospital sustainability project that this work informs I am aware that health systems are facing a broad range of challenges beyond COVID-19 including growing workforce shortages and a high volume of patient seeking deferred care that said I would like to understand the governor's current position on these challenges would it be helpful if governors got took more leadership on population health initiatives that require broader coordination including mask policies thank you so and we're an independent body and we try not to answer for the administration so I'm going to stick away stay away from that portion of the question but I will say that the board understands that the variation even in the sustainability analysis and really what we're trying to do is have a conversation with Vermonters about what they expect from their their healthcare system we know that if we were to design it today it wouldn't be designed the way it is today which is also true of our education system we know the same thing there but at this point in time what we're trying to do is foster a conversation where we can try to come out with some creative ideas and strategies so that Vermonters have you know the right care at the right time in the right setting and at the right price and we're still in the early stages of that Anne Mike Del Treco and then Dean French good afternoon can you hear me we can hear you good great thank you good afternoon and thanks for the opportunity to comment on this variation study I personally know how much work Mark has done on this and appreciate his clarity and we have a long history of working together so as we navigate this discussion I just want to make sure that there's an understanding that sometimes might be good for a good reason it might or should not exist and then there's times where variation might be completely out of the provider's control so I have a general observation and then three points related to variation planning for the future and finally just some comments on the finding as Mark outlined and described what was included and not included in this discussion clearly from our vantage point public payment amounts continue to be a real problem so to anchor the conversation our provider community continues to face real challenges and just to give that some flavor in fiscal year 18 and 19 seven of our hospitals had negative operating margins in 17 there were eight and we have to go all the way back to 16 where there were just three so clearly cost coverage is only part of this conversation and we shouldn't be confused if we're at 95 or 100 percent what that means to financial operations so moving into my comments related to variations I just want to sort of give some flavors of why variation might exist for good reasons and as Mark mentioned levels of acuity are one of those some others are service mix offered availability of availability of specialty care the increased cost of labor whether or whether or there are primary care physicians within the community part of your hospital organization or outside of your hospital organization are also really important some examples where variation can be problematic and should be worked on are readmissions and avoid an avoidable ed visits the real problem comes when there are many times when these two examples overlap and become outside of the provider's control for example the increased cost of labor currently is largely being being driven by workforce challenges and the result is that our traveler use usages up with that comes forces that allow these agencies to capitalize on market opportunities completely outside hospitals control another example is inflationary pressures and great uncertainty related to supply chain costs so our predictability and budgets and expenses really are for many times are at the whim of the marketplace so this these few examples clearly aren't meant to be all inclusive but at the list of why some examples are important why listeners shouldn't conclude that organizations that have higher costs there might be something wrong so we can't conflate low cost with efficiency and I think Mark really pointed that out I wanted to comment on that under the umbrella planning for the future it's very understated to say that the last two years have been challenging for the provider community and and the responsibility prepared you know as we prepare for the responsibility of our providers to prepare for the future is so critically important and whether whether it's another pandemic and I hope it's not or some other health care crisis or just caring for the aging demographics of Vermont is so critically important to this discussion providers need to be financially secure they need to implement tools to promote efficiency in their operate operations and take advantage of things like telemedicine really important recognizing the dilemma of hospital sustainability and affordability should not come at the cost of reduced access and marginalized hospital missions is another important thing of planning for the future so a few comments on the findings and this is my interpretation I just read these this morning so if it's the goal to improve or move off to cost coverage metrics in my estimation the only real lever that the Green Mountain Care Board have has is to restrict expenses whether they be operating expenses at a high level or they look at service lines or where they go into the bands of services cost coverage as as Mark describes I believe that that could have some detrimental issues and outcomes I think it will reduce patient access to services or move them in places where patients can't get to and secondly it will certainly jeopardize hospital missions and dismantle current delivery systems access as we know them today I say this because the only meaningful way to reduce or change expense structures without just sort of nibbling around the edges is to eliminate services and the first services that typically go are considered to go are ones with low payment or cost coverage the outcome would be where Vermont's Vermont starts to export healthcare and in this case we'll still own the cost and no longer have the tools to regulate providers that that and have reform goals met so clearly a lot of work here and I you know I applaud Mark's efforts and his clarity in his presentation and and the board's thoughtful consideration as we move forward so thank you chair Mullen thank you Mike great comments next is Dean French and then it's going to be jessa Barnard Dean thank you chairman Mullen and I'm going to desperately try to frame my comments as a question which is just an illusion so these are comments Mark I appreciate the data you know generally speaking data is data and in this case I would say it's good data and not much to argue with I think the next set of data the board's going to see this afternoon is fraught with challenges that are worthy of discussion I do think when I look at this there's two major areas that I think are interesting one is on Medicaid and having spent my entire career in rural family medicine and unfortunately somehow gotten sucked into hospital administration the question about how does the CEO view this was an interesting one because I have two feet and two sides of a pond but I would say that the Medicaid provider tax in the state of Vermont is conceived of and working in a way that is counter to hospital and healthcare systems success as compared to other states that I've had the privilege of working in in my last endeavor as a hospital CEO we were able to invest in childcare high-end pediatric services in a rural state a frontier state because 100 percent of the Medicaid provider tax was guaranteed to return back to the hospitals and then it was leveraged with Medicaid expansion back to hospitals that were taking care of the preponderance of Medicaid patients and so my hospital had a seven to one return for every dollar we we paid in provider tax back to us which allowed us to have pediatric specialty services behavioral health neuro behavioral health a whole variety of services around women and children's care that on its face wouldn't have made sense but we were able to do that because of the way the provider tax was structured and it didn't harm the hospital so I get to Vermont and I find I pay out provider tax more than I received back from it which is an interesting despite a pair mix which is heavily weighted towards Medicaid so I'll just put that out there I realize it's a larger policy discussion but I think the boards should be thinking about it in terms of some of the data you know you can draw lots of conclusions from data and I can see a freight train coming down the track on some of this data and I would suggest to you when I look at the hospitals around the state of Vermont community hospitals community pps hospitals in the state if I'm in Bennington I have 88% inpatient market share if I'm in Brattleboro I have 85% if I'm in Rutland I have 85% inpatient market share if I'm in St. Albans Vermont I have 53% inpatient market share 53% 47% of my inpatient care is being done somewhere else I would submit to you it's being done in Burlington which is interestingly the strategic plan of this hospital over the last five years has been to divest itself of inpatient services at the expense of quality patient safety and yet the core of an inpatient service cost-wise doesn't change much so our volumes go down but our expense stays the same and so one conclusion would be oh well divestive inpatient entirely and become a rural emergency hospital I would say that would be a huge disservice to the Franklin County residents the other is to leverage our academic medical center to invest in telemedicine services to grow inpatient services at a low cost in St. Albans which is the tract I plan to pursue as the CEO of this facility and that's what you'll be hearing from me in the summer so you need to know that and I think there is huge opportunity for this facility to actually improve the quality of care and keep the costs low by fully utilizing the inpatient beds that we have which is now what we're doing today and if anything the pandemic has taught us is that we need those beds two weeks ago I had 43 adults in 40 exactly 43 beds we didn't have another bed in the facility and we had no place to put anybody you know so it is going you know building more beds centralized in Burlington it doesn't help the residents of Franklin County optimizing the beds that we have here asking the academic medical center to invest in us with telemedicine opportunities and certain specialties is a smart and economically sound strategy and I'll I realize in there maybe there was a question but I did announce at the beginning I didn't think there would be one I appreciate your time and Mark I appreciate your report so Dean thanks for those comments and it's something that the board has seen over time that and I think UVM acknowledges themselves that they need to you know really improve the telemedicine capabilities and we've seen for example Dartmouth with the ability to for Southwestern Vermont and Bennington to for a hospitalist to have a consult with a specialist in about 15 minutes time with video and everything and those are the type of things that if we could catch up with what others are doing would make a huge difference so you hit something that really would improve access improve the quality of the care for the patient because they're getting the care right there without having to travel great distance and it's something that that we hope that you have great success working with UVM to achieve those end results so with that I'm going to call on Jesse Barnard and then I'm going to Richard. Thank you so much. Good afternoon. I'm Jesse Barnard with the Vermont Medical Society and the data that the piece that jumped out at me was noticing that one of the very few areas where for all three payer categories Medicaid Medicare and commercial that was below 100% of costs was for clinic visits so my question for Mark especially with the kind of conclusion that this data may help drive some decisions about which services are offered at which locations or which are efficient to be offering if we're trying to move as a state in the direction of really investing in primary care building a primary care driven system and shifting away from acute care how do we do that when clinic visits may be the least well reimbursed of all by all payers how does that how do you respond to those differing pressures? So your observation is good and I saw that as well I will say that because I have had some experience in looking at the clinic costs in the state of Vermont the federally qualified health centers and the rural health centers there is quite a difference in the average cost for the freestanding non-hospital affiliated clinics than those affiliated with the hospitals so I would be hesitant to make a leap that cost coverage is insufficient or incomplete across the board I think there would be need to be a distillation between the freestanding versus the hospital owned clinics to really get to that differentiation in addition to obviously looking at the professional component side as well but incentivizing primary care I think everybody can agree with that. So next I'm going to go to Richard and on deck is Mike Deltreckel again. Hi thanks Kevin this is Richard Slesky. I wasn't sure if it was you or not I feel the last Richard until your picture came up I wasn't sure. Oh hi Mark it's good to see you again I think this is probably the third study on variation we've done over the past 10 years this is probably the most sophisticated I would say so well done it's a great study. I guess I want to twist this conversation a little bit you can hear me now can you all hear me you know we're four years into the all-payer model agreement with CMS and one of the primary goals of the all-payer model agreement was to transition away from fee-for-service toward value-based payments and so my I think my observation is that this discussion seems to continue the notion that that fee-for-service payments are going to continue over time and that we're looking at cost-to-charge ratios we're looking at these variation in payments and in costs etc when I think may I mean I would suggest that the attention ought to be on how do we actually get to implement the goal of the all-payer model which is to essentially do away with fee-for-service payments for the most part and move toward fixed global payments for the hospitals a capitation or other value-based payments for the providers other professionals etc and I think Mark if I'm not mistaken I mean what you're indicating in your data is that if you look at Medicaid Medicare and Blue Cross Blue Shield and MVP you were capturing almost all of the payments that are being made on behalf of Vermont residents you know so it just seems to me that if we're going to be talking about things for the future or incorporating into the next model agreement it ought to be how do we quickly move to away from fee-for-service payments and I mean from the beginning of our discussions around the all-payer model the agreement with the hospitals was let's not let's start where we are but we're going to limit the growth to a 3.5 percent maybe that's not enough given the extraordinary circumstances of the last year or two but that the hospitals and other providers need to think about changing their business plans and that doesn't necessarily mean cutting out services but it may mean repositioning services it may mean using more telehealth as was earlier suggested and and a cooperative the sense of cooperation and system building among the hospitals and other providers in Vermont I don't think we can do this if we're just thinking about how does this individual hospital maintain all the services it currently has or you know what's it going to do to stay alive or maintain itself as it is it's people hospitals and the healthcare system cannot stay as it is and meet both sustainability and affordability standards so my suggestion is maybe maybe start thinking more about how these decisions that you make soon impact our ability to achieve the goals of the all-payer model or if you think the all-payer model is no longer relevant then let's let's say that so that's that's I guess what I have to say today and I hope that's helpful and thank you Mark that's it was a good presentation your comments are always insightful Mark Richard thank you so much Mike Chair Mullin that was a mistake I've really never learned how to raise my hand so don't expect me to do it virtually okay great sorry about that no problem is there any other public comment hearing none I want to thank you mark for a great discussion and I'm going to place the meeting in recess until 1 30 when we'll start with the next discussion so I'll see everyone at 1 30 thank you all have a good lunch thank you 19 data I just because Dartmouth Hitchcock is not in your database I just went to the medicare cost report to get this and the their last medicare cost report reported discharges from the hospital 18752 and we used your vikers data to to see how many of those were from Vermont the number that we we were able to find were 4354 discharges at Dartmouth Hitchcock that had Vermont addresses now I will note to you that this could be a bit understated because essentially your features data doesn't include people who are the facilities that are self insured so if to the degree that those folks have not reported there could be higher numbers here than that we see so this would be a lower bound but it gives you at least a sense of direction on what the impact would be here the assumptions that we built into this analysis then were that we allow the the Dartmouth Hitchcock increase to be proportional to the to the size of its its current bed capacity Dartmouth Hitchcock hasn't announced publicly that I'm aware of a detailed plan for when it would implement the with all this coming online so we made a simplifying assumption to say that by 2026 let's presume that 32 of the beds are online that they're faith that they would phase it in gradually and that the number of Vermont discharges would increase proportionally across the Vermont HSAs obviously the ones that are most heavily impacted are those that currently have a lot of patients going there the Rutgers HSA for example is is one of those next slide so essentially if we assume that discharge rates are remaining stable let the state is is remaining stable as well and that we're increasing discharges proportionally from Vermont HSAs depending on the expanded capacity of Dartmouth Hitchcock you basically see that it would add a 75 occupancy rate Vermont would need eight fewer beds than we're already projecting so as opposed to a reduction of 80 reduction of 88 so which makes sense at about a quarter of their beds so this proportional increase would would reflect that pretty directly as I mentioned to you Rutland would be the would be the hospital that would be most directly impacted by that I believe because it was I believe an increase for them of four additional beds three or four additional beds that they were being impacted by next slide please so the numbers that I was showing before are all very small and hard to see on these charts so we want to put a larger chart here for you to give you a sense of here's the current license beds for many of these facilities and if you were looking at the bed need that would get you at a 75 capacity this would be the projected reduction that would be associated with that some of those are quite large but again it reflects the fact that some of those hospitals have a a occupancy rate that is is already less than 75% okay I think I'm I think we're ready to turn it over to Beth Greskiewicz for a quality discussion thanks Patrick I'm going to present the performance of the Vermont hospitals under the CMS quality pay for performance programs for fiscal 21 so that's the most recent data that's available and today as we speak Care Compare did update with some new fiscal 22 numbers so as soon as this calls over I'm going to be checking out the Care Compare website um so under the CMS pay for performance programs there's three distinct programs the first one is the value-based purchasing program or VBP and that is comprised of four domains and each of those domains are weighted equally at 25 percent there's a domain the clinical care domain which includes mortality measures and complications the patient perception or patient experience domain which includes the h-cap survey there's a domain for patient safety which includes hospital acquired infections and then the fourth domain is an efficiency domain which looks at the total cost of care for Medicare fee for service beneficiaries the VBP program is the only program that CMS has that allows for rewards so the max potential reward is a plus two percent the max penalty is a minus two percent the interesting thing about the VBP program is that the penalized hospitals fund the rewards for the hospitals that do well so the hospitals that are losing money under this program pay the hospitals basically that are doing well the next program is the hospital readmission reduction program or HRRP that program looks at the 30-day all-cause readmissions for six specific clinical conditions those conditions are AMI COPD heart failure hips and knee elective hip and knee replacement pneumonia and cabbage procedures those this program is a penalty only with a max penalty of three percent each of those clinical conditions that I talked about would be added together in total so it's not three percent per condition it's in total and then the last payment program is the HACRP or hospital acquired condition reduction program that measures hospital acquired infection the NHSN so the abstracted data submitted to NHSN in addition it also looks at the PSI 90 patient safety indicator composite that is a penalty only penalty only program and CMS penalizes the worst quartile in the nation so all hospitals performance is ranked and then at the top quartile they draw the line and those hospitals are penalized we can go to the next slide so this is a summary of key findings and Patrick I'll have you go to the next slide so we can look at the visual while I speak to some of these findings thank you so on this slide we're summarizing for the Vermont hospitals the six Vermont hospitals that are eligible their performance under these programs so we've got a heat map which indicates how a hospital performed and how they rank within within the nation so we are showing quartiles there so the first program I'll talk about is the first column which is HRRP for those six clinical conditions in the table at the bottom I have the financial results under those for the that program so as we look at HRRP we see that all the hospitals except for one hospital received a penalty for fiscal 21 under that program we do see when we're looking at the top table that there are two hospitals that are performing nationally in the top quartile the difference in when we look at that is the HRRP program had a change over the last year or two where you were grouped into a cohort based on your dual eligible population so the table at the top is based on the whole nation so you're being compared against all 3 000 but when we think about the the payment the payment policy that is based on a smaller cohort so you're grouped with more like hospitals in terms of performance based on your dual eligible status the next program is the HRRP program so that's that penalty only program so you can see two hospitals northwestern and Brattleboro are in that bottom quartile and received penalty you can see two more hospitals are in I would say the third quartile the next worst quartile so sort of on the edge there of potentially receiving a penalty in the in the future the third column we'll look at is VVP so the value-based value-based payment program and all hospitals in Vermont except for one receive a reward in that program and even the one hospital that had a penalty was a very small penalty for Brattleboro at about a thousand dollars the next set of columns show the four domains for VVP and you can see that under the HCAP column several of the Vermont hospitals three of the hospitals are in the top quartile for HCAP so that's the patient experience survey and when I look at Vermont as a state Vermont actually ranks 15th out of all the states in terms of their overall HCAP score so that's you know a great place to be when we look at that nationally how Vermont looks on the patient experience the next column is safety which is the NHSN acquired infections hospital acquired infections and we see two hospitals that have no data here there are volume volume limits so if you don't have enough volume you're not eligible for for those measures we have the efficiency measure which is again that cost per beneficiary so you can see two of the hospitals are in the top quartile and three more hospitals are in that next best quartile we've got the VVP clinical care which consists of the measures that are listed to the right so it's the mortality measures in addition to the complication standardized complication rate for hips and knees so as we're looking at the clinical care different measures you can see that we have some opportunity in heart failure and AMI when we look across the state in terms of performance we can go to the next slide the next slide is showing PQIs or prevention quality indicators PQIs are a list of chronic conditions that if treated on an outpatient in an outpatient or ambulatory setting could potentially avoid hospitalization the conditions that are being measured are diabetes, COPD, heart failure, pneumonia, hypertension, UTI and asthma in young adults and all those those conditions are grouped together to to make the the composite and it's called PQI 90 the overall composite this is a per capita based measure so we look at this on a population basis when we look at Vermont as a state overall their PQIs per 1,000 residents is 10.71 which is below the benchmark of 13.06 the lower number per capita is better the AHRQ benchmark is based on age and sex so we do look at a risk adjustment for that underlying population to account for differences due to age and sex. Three of your hospital service areas are actually above the benchmark those are Bennington, Randolph and Rutland so those three hospital service areas are slightly are above benchmark when we look at our data broken down the one PQI where Vermont as a whole is above benchmark was the pneumonia PQI and when we looked at the data in detail we saw that 11 of the 14 HSAs that for pneumonia Vermont had a higher hospitalization rate for pneumonia per 1,000 than the benchmark and that's our quality summary. Thank you Beth so I'm going to turn it over to Patrick in a second to talk about reimagining care delivery and address capacity and quality opportunities. So here what we'd like to do is just provide an overview of some of the other models that are out there in other parts of the country and again we're presenting these for consideration as Vermont policymakers and the hospital industry kind of thinks about capacity planning going forward and the potential to utilize some of these models to meet the needs of Vermont residents so with that I'm going to turn it over to Patrick to walk through some of these models. Okay and I think you stated that slide so let's move to the next one. So one of the ones that is being talked about right now CMS has made some announcements about some possible programs in the future one of which that's interesting is hospitals without walls. This was announced in March 2020 by CMS and it offers hospitals the ability to transfer patients to outside facilities like ambulatory surgery centers and patient rehab facilities even hotels or dorms to receive and still be able to receive Medicare patients under specific circumstances so kind of reducing the need for to be inside the hospital with the full acute care services for the full length of time that has been traditionally the case. They've also announced another model acute hospital care at home where participating hospitals they have to be capable of particular screening protocols and so forth at home for medical and non-medical factors because you want to be sure that the person is safe inside their home. You also want to be sure that some of the social determinants of health that we face are not barriers in those cases like making sure there's working utilities and there's no physical barriers to the person moving and so forth so it involves screaming screening and so forth and also some concerns about domestic violence so there has to be considerable assessment but if that's the case it offers the home as an alternative care setting for acute care. The beneficiaries will be admitted from emergency departments and in inpatient hospital beds and would require an in-person physician evaluation to be able to be able to activate this program. The estimates are that hospital at home has the potential for reducing the total cost of care by 30 to 40 percent so this model in reducing not just nursing services and so forth and other skilled care services within the hospital but reducing lab services and obviously things like food and so forth and it also offers the potential for an increased patient satisfaction and reduced readmissions because if the person can be cared for in place it doesn't require running back and forth when the person's to the hospital as the patient's condition is changing. The obvious implication here however is that if these at home models increase there's less need for acute care capacity in traditional hospital facilities so if and when these types of models started to take hold as I mentioned earlier the the capacity measures that we have would still be would be overstated there would need to be fewer beds than we may be even projected at the at the current stage. Next slide. There are other models also of acute care that are being offered out there that are recognizing the fact that a lot of care is being shifted from hospitals and so forth and the fact that you don't necessarily need full blown facilities offering all services at every single location. One of those that's particularly intriguing I think is the concept of a micro hospital. These are small scale inpatient facilities they have a few inpatient beds so 8 to 15 short stay beds. They perform the same acute care services and emergency services that are done at larger hospitals but typically on a lower acuity basis so they they don't have quite the same infrastructure needs and so forth because if you come to one of these hospitals and you need a more a more involved procedure you would be transferred to to a different facility but they offer the opportunity to offer care to patients in a framework that is that is cheaper and more efficient to operate without having the full blown services available within the location saves money but it does it does affect the access to care for those things and so for example in a state like Vermont where there's physical barriers to moving and so forth one of the questions you would have to ask yourselves is what services can be provided in other locations and what have to be provided on site when you have drive times or our transportation times that are too far for the person to actually access those services so that's those are the types of issues that you know they need to be addressed with it but these types of hospitals began appearing as an outgrowth of freestanding emergency departments in fact I know that I've talked with folks in Tennessee for example who we're looking at for example doing a freestanding emergency department but because of Medicare payment rules and the fact that their their sister hospital was more than 35 miles from the mothership they couldn't do it without losing significant federal reimbursement for their Medicare patients so those are the types of barriers that the federal government's going to have to think about in the Medicare program in addition to just the issue of getting access to the appropriate services can we get them at the appropriate cost and with the appropriate reimbursement rules to make them viable freestanding emergency departments are the other option that that is happening in a number of locations it's not physically connected to inpatient services it has to be affiliated with a satellite hospital within a reasonable distance under Medicare rules in order to receive the full reimbursement that it would be due as an emergency room there's varying regulations depending on where you are in the country around these and so forth but I live in Cincinnati and I know that there's a number of those that have been built around the area sometimes for financial reasons as much as access issues but but they are becoming a phenomena that offers a potential opportunity here there's also another variation on this thing called freestanding medical facilities they're kind of outpatient hospitals and I want to talk about those with a little bit more detail here if you can go to the next slide Patrick thank you this is a specific Maryland issue and since that's been my home I'll mention that to you a little bit as Maryland has entered its own demonstration model which much as you guys have been involved in and so forth they've been fine trying to find out ways to reduce total cost of care and facilities and so forth and one of the issues that has developed quickly under its system which is considerably different with global budgets for hospitals there's been a lot of excess capacity that's developed in the in the system and only only by eliminating some of that can you get some of the savings that were needed they needed to generate so Maryland has adopted a regulatory designation called a freestanding medical facility to allow former acute care facilities to be decommissioned and transitioned into a different clinical delivery model it includes emergency services observation beds mental health and robust outpatient services in fact one of the most innovative applications of this has been the transformation of a specific inner city hospital of Bonsecours Hospital in Baltimore City it was an aging facility that had been struggling financially for number of years it was largely dominated with government payers so you essentially had Medicare and Medicaid that dominated most of it and the rest was the was uncompensated care if the patients were not covered by a by a governmental payer state subsidies were required to keep the hospital operating and essentially it had an ancient plant that was desperately needed investment and so forth and while Maryland's system didn't have safety net hospitals this is one that kind of was I guess close to fitting that definition at any rate under the existing model these freestanding medical facilities allowed the transformation of this particular facility into a new hospital grace medical center it was transformed you can go to the next slide Patrick um a new facility was built that offered emergency care inpatient and outpatient mental health services renal dialysis and diagnostic services and along with that and the emergency room continued to operate in addition to that there were offsite locations that offered primary care which is was a huge need in the area along with drug treatment outpatient mental health services so this is one where the state was very innovative in applying its federal waiver and this state designation in order to to do something that was a real benefit for the community keeping services there that needed to be there and then finding alternative services for those that had that needed inpatient care which was actually plentiful in Baltimore City so this was an innovative application of that approach and it's one example of how reimagining the delivery system could work and the Maryland model offered that is a nice a nice possibility next slide and is one of the commentators earlier referred to the rule emergency designation is also an option that is being proposed by CMS well it's been required in federal law and CMS is currently working on the is working on the rules for it there's a lot of interest out there in this I know that we've talked with folks in other states who are very interested in the possibilities that this offers there's there's specific guidelines for who's eligible for it and so forth I won't go through below by below on each of these and so forth but it offers the possibility of much like a freestanding medical facility of focusing on emergency services and reducing and reducing kind of the inpatient footprint there so as this says the eligible hospitals are critical access hospitals and hospitals with 50 beds are less and in locating rural areas and so forth so we'll see how CMS operates this and so forth but the idea of making sure that basic services are in place for emergency care with the possibility of transport to a facility that can handle more sophisticated clinical needs than is kind of a constant thing in some of these alternative models next slide and finally ambulatory surgery centers are also something that is needs to be discussed because they offer offer less expensive opportunities for care that can be handled in lower acuity settings the in some of the work that we've done looking at at Vermont just for this for this presentation and for for our work we were seeing that Vermont has the lowest number of ASCs per capita in the country so one of the issues is you know in in deciding where you want to offer care is do you keep it in your current inpatient facilities is it cheaper to move it to the other facilities although one issue that you do have to address is when you free up that when you open a new ASC are you spending more on new capital and getting lower prices there but you're leaving unused capacity is it wise to abandon that existing capacity so those are the types of trade-offs that I think that you need to to to think about but it is obvious over the last several years that changes in clinical services have made it possible to move more out of the inpatient setting to outpatient settings where knees and hips things that used to be done inside the hospital can now be done on an outpatient basis and so forth so and those trends are likely to continue along the way here Patrick I'll turn it back to you here great thank you Patrick so what we wanted to do now was in thinking through kind of where there may be potential areas of opportunity to improve hospital sustainability and prepare for that value-based world we reviewed data across a range of factors many already touched upon by Patrick in the initial capacity analysis and best when it came to the quality piece of it based on analysis we believe that each of these factors is critical to sustainability in a value-based care framework both in the aggregate for the state of Vermont as well as looking at it at the individual hospital level and so what we ultimately did is we created criteria and cut points for each of the factors to determine where there may be areas of opportunity and what we saw to do was create cut points that would show differentiation between the hospitals either within Vermont itself or against some objective benchmark like the PQI one that Beth specifically had pointed out earlier but we recognize that each of the cut points that we chose could certainly be up for discussion depending on how you wanted to look at things and certainly the areas of opportunity which we'll get into are meant to be a starting off point for discussion and there will need to be more discussion with policymakers and industry leaders to determine the best course of action going forward even in some of the areas that may be potentially identified here so the criteria that we used based on the analysis that was previously walked through I always did look at the inpatient occupancy rates for adults and pediatrics the occupancy rates for intensive care units and we looked at those separately because those may separately drive towards different areas of opportunity and recognizing that some facilities don't have intensive care units we did look at the projected bed need for 2026 and how that could potentially impact things the emergency department use rate per 1,000 residents so again that will be by the HSA so not necessarily for the hospital specifically because it's a population based metric similar for the PQIs the prevention quality indicators we did use the some of the information that that mark presented by burns and associates around case mix adjusted average cost per inpatient discharge and that is for all payers now we recognize that the limitation of that is it may not necessarily reflect costs by different service lines which is absolutely something that should be teased out but we were looking for something directionally correct that would point out if there were potentially higher cost facilities versus others when you look at an all payer basis we use CMS star ratings as a proxy for quality but fully understanding to the presentation that Beth gave earlier that there are many layers to quality underneath just the overall CMS star rating but we did want to use something that was objectively used by CMS to at least use as a proxy to help steer in certain directions we use drive time to nearest Vermont hospital so we didn't use the distance in miles but rather the drive time recognizing some of the geographic barriers and other things that may be in place in Vermont that would cause a 10 mile drive to take 30 minutes and so we wanted to factor that in and make sure that that was accounted for as well as the age of plant so that was one thing that we specifically looked at is what is the age of the facilities older facilities may have newer capital requirements and there are other reasons why you might want to try to use use services within a newer type facility for each of these what we did is we looked at by hospital where did each of them fall so using the 2019 occupancy rate for each of the hospitals and then facilities with lower occupancy rates we identified may be eligible for right sizing so do you need all of the beds that you have there currently is there a potential to consolidate services across facilities or is there a potential to transition to a different care delivery model and for purposes of the analysis we had marked red is less than 50 percent occupancy 50 75 was yellow and then greater than 75 was green and you can see the distribution across the different sites with you know the high being up northeastern regional at 82 and then some of the lower ones such as Brattleboro currently sitting at 36 percent a similar analysis for the occupancy rates for the ICU and so you can see the distribution there as well as the various cut points that we used did want to flag one one caveat here which is an NA is listed for Northwestern Medical Center because again this was based on the reports that we were using however and it's our understanding from communications with GMCB that Northwest does have for for bed ICU so we didn't want to to make a change because the we wanted to keep the data sources consistent but we did want to acknowledge that particular fact as we looked at this the third criteria that we looked at is that projected bed need and this is consistent with with what Patrick shared earlier so again just looking at the bed need by each of the hospitals and hospitals with reduced bed need may present opportunities for efficiency and so wanted to factor that in to the overall with red being a bed reduction yellow being no change and green being a bed increase the fourth criteria that we used was the ED use rate per 1000 residents for the HSA the one thing that I want to call out looking at the chart on the right is that Grace Cottage and Brattleboro are both within the same HSA so we use the same number because it's a population based measure for both of those but just recognizing that there are two facilities within that specific HSA we looked at the Vermont average and so if the facility was above or I'm sorry the HSA was above the Vermont average and we marked that in red and we marked it below if it was green now we did look at other states and the ED utilization to compare it but we wanted to use a Vermont specific comparison due to some of the questions that came up around the benchmarks that have previously been used and so we want to just again show the comparative nature of ED usage at the population basis across each of the HSAs the fifth one is the prevention quality indicator so again Brattleboro and Grace Cottage sharing the HSA will have the same PQI overall composite and consistent with best earlier presentation there are three HSAs that do have a higher PQI overall composite than the AHRQ benchmark and those are associated in the hospitals within those jurisdictions I'm sorry the HSAs are listed so Gifford Medical Center, Rutland and then Southwestern so we wanted to point those out as another data point. The sixth criteria that we used was the case mix adjusted average cost per inpatient discharge for all payers and again thank you to Mark and the team for the analysis that they did and that we used for this piece of it. We did create cut points to show outliers and again chose cut points that would show differentiation between each of the facilities to show a distribution across them and so although cost differentiating differentiation exists by payer the stratification by all payers demonstrates still just demonstrates distinct differences across the hospitals and so you can see some such as UVM Medical Center as an academic medical center you would expect that to be a higher cost per inpatient discharge but there are some others Grace Cottage and Montescutty that are flagged as higher cost type facilities and there may be reasonable reasons why those are higher costs but it's at least something that we would say that should be looked into to see if there are opportunities there. For the CMS star ratings we used those again at the proxy recognizing that there are many other ways to measure quality including much more detailed analysis that Beth and her team had previously conducted and so if they were a red red hospital it was one or two stars yellow was three and green was four or five and so you will see that Vermont is fortunate to have some four and five star facilities but there are still some other hospitals with room for improvement. The drive time to the nearest hospital so again we use drive time rather than physical distance to measure this for the cut points if there was less than 30 minutes it was green if it was 30 kind of on the dot that was yellow and if it was greater than 30 that was red and you will see some of the ones in red there is a significant drive time that would be necessary to get to the next nearest facility and we wanted to consider that going back to the access concerns for residents living in those particular HSAs or using those particular hospitals you know that is it reasonable to have a patient have to drive 60 minutes to get to the next nearest facility if they need a specific type of care or would you want to keep them closer. However if there are certain facilities that are closer in distance and have lower occupancy rates does that present a potential opportunity and as we think about the different types of care delivery models that Patrick walked through earlier it's not necessarily saying that these facilities are not needed or that all of the services that are provided are not potentially needed but it is a way to say that there may be different models that could still meet the needs of the community and provide access without causing too much travel time for patients that need these types of services. And lastly as we did look at the age of the plant so the age of the plant for each of the hospitals was considered a higher age of plant may reflect deferred maintenance and a higher need for capital investment going forward and there have been studies that have shown that hospitals with newer physical plants perform better on value-based purchasing measures including patient satisfaction and so when we were looking at this we calculated the state average 14.3 years and so if a hospital was less than that state average they were green if they were on the state average they were yellow and if they were greater than that they were red again to show differentiation between facilities for purposes of comparison. So then what we did is we looked at all of those opportunities and there's a larger grid as you can imagine that stacks all of them up against each other to try to just provide directionally relevant information that may be helpful to dig into further and so we framed these as opportunities so these aren't hard and fast recommendations where we would say you definitively should do these things instead we're saying these may be areas based on all of the areas that we just previously explored the criteria that we used and the factors that were considered to say these may be things that you should consider going forward and so as we've reviewed the potential areas of opportunity we tried to bucket them into four distinct categories. So one are any areas of opportunity around steady state so opportunities given the current demand for inpatient services, demographics and other things like that so if the if the care delivery models you know haven't changed if the demographic trends hadn't changed all things being equal are there any areas of opportunity where we would say that the state of Vermont and the policy makers in industry should really look at these to see if there's area of opportunity. The second one was acute care model changes so that is are there any facilities because of some of the metrics that we previously looked at where we would say the state of Vermont should consider if there's a different care delivery model for those particular sites which could still meet the needs of the population but potentially do so in a different way that may be more cost effective and what you would still want to balance that with the quality of care that's being provided. We did create a third bucket around value-based care so this is focusing on care that doesn't necessarily need to be provided in the hospital if different resources were available and so we wanted to point