I'll call to order the Green Mountain Care Board's hearing of March 20th, 2024. We have 1 substantive agenda item today, which is the fiscal year 2025 hospital budget guidance. We have removed the agenda item for the copied mid-year request. There was some additional information board members wanted and they wanted more opportunity to evaluate and consider the request. And so we need a little bit more time on that. I don't think we've rescheduled it yet, but we're planning to do so shortly if we haven't already. With that, I'll turn it over to executive director Susan Barrett. Great. Can you hear me? Okay. Chair Foster. Okay, great. Yes. So, first of all, I want to remind the board and the public that we have our primary care advisory group. We will be reviewing... You can't hear me.  Is that any better? That's better. We will be reviewing the hospital budget guidance with the primary care advisory group and gaining their advice on the FY 25 hospital budget guidance. In addition, we have several public comments. I urge folks to please take a look at our page. There are five or six listed, but I will take them off as a reminder. First, the board is accepting public comment on guidance on the assessment of affordability in the review of REITs. We ask that folks who are interested in submitting a public comment that they do that by the end of the day on April 9th for board consideration prior to the board's review of this guidance on April 24th. There are materials linked on our public comment website. Also, we, as Chair Foster mentioned, we extended the period to accept public comments for the COPLI hospitals mid-year FY 24 budget request. And so, please submit any comments by the end of the day on March 25th. We would like those in consideration of this issue before, which will be before the board on March 27th. We are also accepting public comment on the draft FY 25 hospital budget guidance, which we will hear more about today. And then the last two ongoing public comments or periods are on the community engagement for hospital sustainability. Please share any public comments on that process with us. And last but not least is any public comments regarding a next all-payer model at this point, the AHEAD model. Any comments we receive, we share with AHS and the Governor's Office as they are leading the negotiations on that model.  Thank you. We have our meeting minutes from March 13th, 2024. And I will move for approval of those meeting minutes. Is there a second? Second. And on favor, aye. Aye. Aye. Aye. And the minutes are approved with four yay votes and member Walsh absent. With that, I'll turn it to our hospital finance team for presentation of the 2025 hospital budget guidance. And that will be led by Alana Barabee, our director of health systems finances and Matt Sutter, our health systems finance principal analyst and our staff attorney, Russ McCracken. Great. Thank you. All right. I will share my screen. Let me know when you can see it. That's up. Great. All right. So today we'll review the modeling that we discussed last. I'll note a couple of updates to the guidance. As you know, it's posted publicly in its full form, so I won't be reading it to you here today, but I'll be kind of kind of going over the high level structure and some of the updates we've made. I'll talk about the uniform reporting manual briefly, the hospital budget review measures inventory and discuss timeline and next steps. So there are these three materials that I kind of mentioned in the previous slide, but I want to kind of remind folks what they are and the purpose and how they work together. So the FY 25 guidance document specifies how budgets will be evaluated and criteria for whether they will be adjusted and kind of notes some of the kind of content areas that we may be looking at when we evaluate and analyze those budgets. The uniform reporting manual create is a manual for standard definitions for financial and eventually non-financial reporting requirements. We'll talk about this in more detail, but I think there's a lot of future work that we can do here to update this manual. We kind of did what we could this year with limited staff, but it's largely similar to last year's reporting manual. Hospital budget review measures inventory. This is a new document this year that kind of codifies measures that we've used historically or some version of those measures or new measures that we've discussed recently and just creates transparency into how those measures are calculated, the data sources, the years that we would use that and we expect to work towards visualizing many of these measures. I'm not sure how much we can get done this year, but this is kind of a long-term effort and kind of step one. In creating these materials and the budget guidance and benchmarks this year, we have been sourcing quite a bit of input and sharing different versions and asking for advice and guidance. We started this immediately following last year's budget process. I was kind of onboarding at the time, caught the tail end of the hospital budget process, but that was folks afterwards to hear how they thought things went and what could be improved. We also met with the CFO group in November to receive some preliminary feedback on how last year's process went and what they had hoped for this year. We had a series of meetings since then with hospital CFO subgroup, HCA, members from Boz, and a critical access hospital that looked at kind of various versions of the guidance and the metrics list. And as you know, we've had a series of board meetings to discuss kind of the approach in general and last time we met, we kind of went through in detail how we would structure the guidance and it's been posted now for, I believe, a week in its full form. And we're still open to public comment, so there's still time to influence the process. Just a reminder that these materials together kind of balance what we hope to be a predictable but adaptable process. This is not a formula that, you know, we press a button and we know what the perfect budget is. This is a really messy world and requires a lot of triangulating and trying to ask questions and understand broader trends and what's nuanced at the local level. So this guidance really seeks to optimize these things and is certainly a movement in a direction and can evolve over time. So this is slide you should be familiar with. It's the same that we discussed last time, so really the section one benchmarks and the guidance will kind of be the first step.  We might have more questions, but otherwise, you know, we would expect to approve that budget. We will still conduct a full review of all hospital budgets, even if a hospital meets all of the benchmarks, just so we can learn and but perhaps we, as discussed in the guidance, there would be options for exemption to or a public hearing if hospitals do meet all of those benchmarks. If the budget does not meet the benchmark, we will, you know, again start with the budget assumptions and try to understand if those are reasonable and then we'll kind of look into the section two comparative analytics. So really thinking about, you know, why asking questions about what's different about this community or this hospital or what, you know, why would you need a higher rate or lower NPR or higher NPR. So I think that's that's how we're thinking about that. So to Rich, last time we proposed, you know, keeping the NPR benchmark and tying this to the all payer model growth target of 3.5 to 4.3 percent and then hospitals would be expected to justify the benchmark, justify if they exceeded that benchmark in their budget. We talked about picking a either 3.5 or 4.3 percent to have a clear foundry and so I wanted to share some trends with you. This is NPR over time. So growth from fiscal year 17. So the blue chart, blue bar lines are actual NPR. The purple line is the FY24 budgeted NPR that was approved and the green growth line that you see there, the dotted line, is what NPR would have been with a 4.3 percent growth rate starting in fiscal year 17. The orange line is what the growth rate would have been at 3.5 percent growth and, you know, we certainly know we had some challenging years in between. So these are just reference points. It's not saying that's where we should be necessarily, but it's to give some broader context. And then the blue line is the inflationary index that's associated with growing or growth in health care expenditures or consumption of health care expenditures. This is a different, you'll see PCE index. This is a different index than what we talked about later. This is really about volume and price. The index we talked about later is really only about price. So this is representing aggregate volume. So the compounded NPR growth rate since 2017 has been just about 6 percent, just over 6 percent. If we stayed at 4.3 percent, this would bring us to a 3.43 billion in 2025. If we stayed at the 3.5 so that orange line, we would be at 3.2 billion. And so the table below kind of shows, you know, what our benchmark would be if we started with 24 budget and added 3.5 to 4.3. It was just what we've proposed in guidance. We're not saying we should go back to the 2017 rate, but, you know, we need to pick a threshold. So, you know, I think we've been growing a lot more than I think we all had expected over quite some period of time. Ms. Barabakaska, can I interrupt with a question? Sure. Okay. So the 25 line that you have here, that comes out to like 3.7 something billion dollars? Right. And so if we had stayed at the 4.3 percent all pair model target, we're about 300 million above that at 4.3 and about 500 million above that at 3.5. Is that the point here? Yes, that is the point of that chart. Yes. And this 25 fiscal year 25 number you have, that's at a 3.5 percent NPR benchmark? Yes, relative to that purple line that fiscal year 24 approved budget. So that's how many additional dollars we would be adding to the system if we hit that, right?  So, you know, but we're building to what's budgeted in 24. Thank you. So this, you know, trying to understand why we're growing, I think we've spent a lot of time thinking about this, but I wanted to start with volume, you know, we hope that by increasing NPR we'd be expanding access. The chart on the left takes all of the New England states from the data underlying the Nash P cost tool that looks at adjusted discharges by state. So this is a, you know, a crude measure, it's not perfect, but what we're showing here is it's other than with the decrease in 2020, it's been relatively flat where there's not a huge growth in the volume of services being delivered in our state and that's consistent. So the chart on the right is exaggerated in visualization, but just making the point that it's been pretty flat over time with this decrease in 2020, but now in 2021-22 we're catching back up to where we were before. If you look at hospital admissions per 1,000, so at a population level, we know that hospital admissions have been declining over time, and this is a broader trend, and we know, you know, some of this is because we're seeing more outpatient, which you saw on the other slide is relatively included there, relatively flat. When we look at what's reported by hospitals and the discharge data set, we see a similar trend, so it's, you know, that dip in 20 and then it catches back up in 2021. You know, we don't have these data for 22 and 23, so it would be great to kind of see where we are now. Maybe something's different, but this is kind of the latest available data we had as we're developing these slides. So if we look at, you know, so we don't, we don't think it's volume that's driving this growth, but if you look at expenses, you know, we have to to see with more recent data, but if you look at expenses, there's certainly a correlation between the NPR and expense growth over time. So the, we've added here this top green line, which is operating actual operating expense with it trended to 24 based on budget. So you can see how that has been increasing at a similar rate. So if we look at operating expense growth, again, this is using the Nash B cost tool data and as aggregated to a state level. So it's, it's total statewide hospital operating expense. So it's again, it's a crude measure, but you can kind of the yellow line across the top is Vermont. So we're, you know, much smaller piece, but we are kind of growing in line with other New England states. So if you look at the right, you know, this is year over year growth in aggregate, you know, we're, you know, kind of in, in the middle there compared to other states. If you look at operating growth per adjusted discharge, you can see that main in Vermont are kind of at the top end of New England states. But in terms of growth, we're rather consistent with our peers across New England. When we look at charge growth over time, you can see that, you know, prior to 2020, there was, it was kind of more moderate 2020 happened. And then there was this big catch up, we know we had inflation and a number of other challenges. And so operating margin, which is that green line took a hit and charges kind of spiked consequently. And so, you know, we can see the real impact of increasing operating expenses on on charges and price. So given kind of, you know, this substantial growth, a staff are recommending that we, we stick to the 3.5% to kind of try to level things out over time. And, you know, again, we kept the language hospitals exceeding this benchmark will be required to justify why they would need more than 3.5%. So this is not saying that 3.5%, that's it. You know, hospitals can certainly come in and say we need more than that. And here is why. But the burden will be on them to prove that case. We also discussed last time a benchmark for, you know, containing prices of healthcare services. So if we really, you know, step one, we say we really need more volume, but we're going to hold our prices down or, you know, improve or lower our prices. So, you know, would be amazing. You know, what is an appropriate cap on what what consumers should be paying for hospital services. And so we we tried to, we came to you last time and asked, you know, what index should we tie this growth rate to? What level analysis should we peg this inflationary metric to? And then, you know, should we buy payer by care setting? And we had this list of inflationary metrics that are quite common across a variety of sectors and healthcare. So the first one is really about GDP and price deflator. The second one is CPI. The third one, which we're recommending, and many of these are quite similar from the consumer perspective, but, you know, others are more about industry and cost and supply costs. So we, because this is about, you know, we want to have a consumer lens and make sure that we're thinking both about affordability and kind of health system growth. At the same time, we adopted one of the more consumer focused metrics. So the fourth one is personal healthcare deflator projected by the NHE. The fifth one is a PPI or the producer price index, employment cost indices and Medicare market basket. So we kind of explored all of these, thought about how, how they would correlate with what consumers can expect or can afford and how variable these are over time. And you can see in the right most column here, the kind of latest metrics that we would be thinking about applying to an FY25 process. Some of these are lagged, some of these are production, so you have to keep that in mind. But what we're recommending is the PCE price index plus 1%. We think adding, you know, this is one of the more conservative measures, but adding 1% will kind of bring it in line with some of these other supply side inflators, but would also give some room to grow. So we know that this indicator catches up over time, but we know because it's a lagged indicator, having more wiggle room, especially as we're trying this out as a threshold would be appropriate. Then we wanted to kind of take some of the, I didn't do this for each of the measures, but you know, compared to Medicare market basket, the NHE healthcare deflator, personal healthcare deflator and the CPIU. And what you can see is that this is actually a more generous threshold. So I took PCE price index plus 1% and subtracted the rates of growth from, you know, these other indicators. And what you can see is it's generally above, except for CPIU in 21 and 22. And that is, so they're, you know, they generally hold over time, but CPI kind of bounces around a little bit more based on how it's calculated. So we applied this PCE price index plus 1% to charge growth over time. This is kind of a year over year look. The blue bars, it is PCE price growth plus 1%. The orange bars are what we ended up approving in the hospital budget process. And then if you look at this from a three-year kind of cumulative average lens, so this is kind of smoothing, you can kind of see that it holds over time, but that we have approved, you know, a chunk higher than where this price growth indicator has been historically. So staff are recommending that as for the section one benchmark that, you know, we set this amount to price, the price in stationary metric plus 1% as of the January 2024 release, that's the most recent one available, which amounts to the 3.4% for FY25 over FY24. So this cap would be a cap on commercial rate increases for each hospital above their currently approved levels, which also would apply as a cap on the, you know, that which hospitals may receive in price from each individual commercial payer. So we really want this to be net of utilization, it's really focused on price increases. And then, you know, the GMCB approved rate increases will be caps, so there's still, you know, negotiation that would happen between hospitals and insurers beneath that. And then similar to the first benchmark hospitals proposing budgets that exceed this growth rate will be required to justify the request and report on productivity by department. And then we, in order to kind of round out some of the, you know, understand some of the assumptions related to rate increases across payers, you know, this is kind of in building on the previous ones, this isn't setting the benchmark, but reporting just wanted to note that we would expect reporting by payer for each major payer, but also by the core service line, so inpatient, outpatient and professional services. The last benchmark included in section one is less of a benchmark, but more kind of like a threshold for operating margin greater than 0%. So that's just saying, you know, we expect that a hospital in order, you know, if it's going to be efficient, would have to manage its expenses. And we would expect that a highly efficient hospital would be able to both bring in sufficient revenue, but also be able to manage its expenses. So again, this is just reiterating a similar slide to last time, but just that the section one benchmarks are what kind of dictates whether we do a full review with potential adjustment or a full review. And perhaps there, you know, might be some questions or reporting if something looks funny, but this is what will dictate whether we adjust a budget. Guidance structure, we tried to consolidate a little bit so we don't have the monitoring section. We just kind of included it all within the contextual information section and then created another section to really detail hospital reporting requirements. So a lot of the previous sections discussed kind of general measures and data sources, but those some of those are public data sources and we wanted to make it really clear like what the hospital is will be required to to report. So that's now in section six. The other wise this is largely the same. You know, I'll breeze through some of these slides that you've seen already, which is really the purpose of the comparative analytics section or section two. So it's really to use, you know, series of data and trends to try to understand, you know, why a hospital might not meet the benchmark set in section one. So this is really to facilitate a conversation. You know, we don't think there are, you know, two measures or three measures or a handful measures that will adequately describe local context. So that's why we didn't set a specific performance benchmark. So it's really about understanding across a variety of financial measures and access measures and community level measures. So we think it's important to have a holistic view of what hospitals are dealing with on the ground. This is a snapshot from last year's budget tool, you know, the types of measures that are included and, you know, feel free to, if you haven't already, I hope that you've looked through that measure set. They have kind of categories and tags and you can filter them, but there, you know, many of them are to do with revenue trends or operating efficiency, financial health, and they're labeled as section two in that tool. Section three will detail kind of what we're looking for in terms of budget assumption. So being clear about, you know, what reimbursement changes are reflected in this budget or not, payer mix changes, service mix changes, patient acuity utilization, anticipated future capital investments, or other material changes and assumptions that staff should be aware of. The narrative we just created, you know, built on prior year, but tried to kind of organize them around background budget questions and then hospital and health system improvement. This is just a snapshot from the reporting section that we kind of pulled out. So this filing checklist should look familiar. It's very similar to last year, but we are going through and detailing more detail for each of these individual items about what level of detail are required to be reported. As I mentioned before, the uniform reporting manual. So now we're to this second companion document. You know, we made a couple of updates this year, but it's largely similar to last year. So we defined bad debt in free care in accordance with the IRS definition. We clarified some of the language around clinical and nonclinical FTEs. And then I think we already started reporting in this way last year, but we were, we codified kind of pulling out and separating the Medicare advantage as a, like in the broader commercial segment and then defining major commercial payer for some of the previously discussed reporting in terms of Blue Cross, Blue Shield MVP, United Health Care, and Cigna and any other payer that makes up more than 10% of hospitals commercial revenue. We think there's future opportunity to improve apples to apples reporting between hospitals. You know, certainly standardizing definitions in the uniform reporting manual would be a great starting place. So hopefully we can find some capacity to do that in the near future. But I don't think it would solve some of the fundamental challenges and accounting differences. So, you know, if we ever really truly want apples to apples, you know, some of the ideas that have been floated a single statewide auditor or hospitals could adopt a uniform chart of accounts, that would certainly be a major lift, but those are, you know, just some food for that. I did want to spend a couple of minutes on the hospital budget review measure inventory. Again, it is also posted for public comment. So it's up there. This is, you know, there are many measures included this list we've used previously and many of them are our standard kind of financial metrics. The table to the right shows you how many measures kind of fall into each of these categories. So section one has the, you know, the three targets and that we just discussed. Section two has, you know, a variety of measures that look at financial health, operating efficiency, revenue trends, and some other related measures. It believes that others bad debt and free care. Section four has, so those are those contextual measures, detail measures on access and other community level data. Many of these are from publicly sourced or the Department of Health, you know, other standard sources and quality. And, you know, so it looks like there are a lot of measures, but many of these, you know, we've used every year until now. And, you know, some of these measures can maybe more or less relevant for certain hospitals. So, you know, it's really hard to tell, you know, what that, if we were to narrow this down, who would be benefiting or losing as a result of that. And then I wanted to turn it over to Russ for a moment on related policies. Great. Thanks, Elena. So two items I wanted to talk about here. The first is there's a amendments and adjustments policy that is a part of the guidance. We have a draft posted. It's substantively the same as it was last year. There are a couple of changes which I will highlight, but I don't think they're very material. One is there's a confidentiality section in that policy and instead of setting out a separate process, I changed it to just refer back to the main guidance so that we're being kind of consistent. And the second in the section about amendments, I changed some language to better track the statute. There was a reference in there to unexpected circumstances, but I changed that to unforeseen circumstances to follow the language that's in the statute governing any requests from hospitals for a budget amendment. So that is posted for comment, but again, it's materially the same as it was last year. The second thing I wanted to bring up for the board is that there is a standing policy on hospital budget enforcement. This is not a part of the guidance that was pulled out of the guidance a couple of years ago and made a separate standing policy that was adopted in March of 2021. That policy largely tracks the enforcement provisions in the board's rules in section 3.401. The policy is really around the board's review of NPR variations between hospital actual and budget. And the kind of the upshot of it is the section of the policy that says that the board may review hospitals whose year NPR FPP exceed the NPR FPP requirement by 1% above or below their approved NPR FPP. That review will not necessarily lead to action by the board. So kind of wanted to bring this back for the board to think about it was adopted sort of at the tail end of the COVID-19 pandemic. And so it may be appropriate for the board to take a look at this again and see if it still makes sense to have this kind of 1% NPR variance as a metric for when the board would more closely review hospitals NPR actual NPR. I did just also want to note that the policy as it stands is explicit that it doesn't limit the board's authority to review aspects of a hospital's budget other than NPR performance and it doesn't review the board's authority to review a hospital's budget performance as at any time as set out in the rule. So if the board doesn't take any action, this policy will continue to be in effect. The board would like to review or make some changes to it. You know, we can certainly do that and doing it in conjunction with the guidance might make sense. So I'll turn it back to you, Elena. Great. Thank you. All right. And this is actually the last slide. So I just wanted to remind folks of where we were in the process. So we posted the draft in March 13th. Public comment is open through March 25th. And then I think we've scheduled, we don't expect a vote today. We'd love to hear your comments and feedback and coming back next week with a hopefully final draft. We have to issue the guidance before the 31st. So really the end of next week is our deadline. But I will turn it back to you, Chair Foster. Thank you. This is really impressive work. So thank you all very, very much. I know you've been working really tirelessly on this. I'll turn it to the other board members for questions or comments that they may have. I can jump in first. So yeah, first of all, big thanks to Elena and Matt and Russ and Flora. This has been a big heavy lift over the last six months culminated in the last crescendo in the last few weeks. So thank you for the hard work and for the I think needed innovations. I really appreciate it. I really actually have a few specific questions on a few slides that I wanted to start with just so that I better understand what we're looking at. So the first one is on slide 10. If it's possible to pull those back up, that'd be great. So just so I understand on the left in the statewide adjusted discharges, are those, is that only inpatient discharges or is that metric include both inpatient outpatient? It's inpatient and estimate about patient. So it's inpatient, which allows us to estimate outpatients. That's what you're saying. Yeah. Okay. But we don't. Okay. It's not. Yeah, it's not exact. It's a it's an accrued measure. Okay. And then on slide 13, where we show this really substantial rise in the operating expenses starting in FY 22, I would think I just was if you would comment on I would think with this high operating expense above the actual revenue that we would have more hospitals with negative margins. Could you comment on what the why we're not seeing more hospitals with negative margins? We have operating expenses that are far outpacing their revenue. I think we have quite a few hospitals that have negative margins. So I can circle back, but I think it's more than half now. There may not be the big one, but many of our smaller ones are really struggling. Or I guess the magnitude of negative margin. I mean this line is I mean just estimating proportions. You know, in FY 23, the operating expenses look what 20% above the NPR? Yeah, I think we can dig into that for you. I don't have that at the my fingertips, but I'm happy to provide more detail based on our actuals. And then slide 21. I was curious if you could if you if you don't have, but if you could provide that'd be great. Just the aggregate growth numbers that the compounded growth of all these, I guess the compounded growth would be the most helpful. We almost stuck that in at the last minute, but I'm happy to get that to you. It does certainly smooth things out. Happy to do that. I can't hear you, Chair Merman. I'm sorry, Member Merman, if you're, I still can't, I don't know, is it just me? Can anyone else here? No, okay. How's that? We're back. All right, sorry, I had weird like audio glitch on this side. Bluetooth glitch. All right. Sorry, so on. And then two slides down, I'm 23 and 24 really. I'm trying to understand these and it's really 24. So if we were to use this PCI price index plus one, and we average this over three years, it's historical up until 24 what the board has done. And then in 25, we're estimating if the board was to apply the PCI PCE index plus 1%. And we held to that that the three year system rate growth would then be just about 7%. Is that, is that am I interpreting this information? No, we're not holding anything. So you're just showing, we're just showing the PCE growth. And this is where our system actually ended up. So this is comparing where we actually ended up to what the inflationary growth was over that period of time. Right, until 24. Until, so yeah, let me check those. Yeah, until 24. I have to check the year label there. Yep. And then I think, is this an estimate in 25 of where the system would be if we had the keep because I think I'm here. Sorry, I'm going to ask Matt. Yeah, you're correct. Dr. Moon, the 25 figures on the slide with the three-year kager, that's that's for the 25. It's assuming 3.4% for all. Okay. Thank you, Matt. Okay. So assuming 3.4% for all the hospitals, a system growth of 3.4% that we're seeing the three-year average growth being about 7%. If we use the 3.4% growth rate, is that right, Matt? Yeah. Okay. The compound average, yeah. I think that's all I have for now. I appreciate it. I think I'll probably have some more comments a little bit. I want to hear what other people in public comment. Thanks. I don't really have comments at this time. I so appreciate all the work that the hospital finance team has done. The data is really enlightening in terms of the trends and the comparative analysis that was put forth. And at this point, I'm more interested in hearing what other board members have to say. I'm interested in public comment. And I think we have a week to think about it. So I'm going to digest some of these slides a bit. But I appreciate all the hard work. A couple of questions. Can you go back to the slide that has the, I think it's 10, the NPR operating expense. Just... Nope. Sorry. Yeah. There you go. Sorry about that. 13. I didn't write it down. So just following up from Dave's question related to the negative margins. I'm just trying to think through with the operating expenses where they are. And the NPR, as many of the slides pointed out, it's the operating expenses over the last few years post COVID that have been driving both NPR and the charge increases. So in thinking about how to move back towards a more sustainable growth rate, I would... It would be helpful for me to understand how do you start to reverse that trend on the operating expenses. So because to me, understanding that piece, in terms of picking 3.5 or 4.3, which is more realistic and reasonable, given where actual expenses are today. Understanding that there are things you can do to moderate expenses. But what is a reasonable trajectory? Like it's... I don't know if what I'm saying makes sense. Elena, but just trying to think about on the ground what's realistic and reasonable in terms of moderating the trend. Understanding that half the hospitals are in the red. I think that's why this is a benchmark that hospitals can justify why they need more than that. So I think this is really about... It's an aspiration. If we don't set an aspiration, I don't think we'll be able to reach that more reasonable growth rate. So I think we really need hospitals to help us think about... I mean, they're the experts in their operating, how they operate. So I can't tell them how to do it. I mean, that's why we're doing this Act 167 work. But I'm hoping that they can really come to the table and have some informed conversations about how we can all work together to do this. Thanks. I didn't have any other questions about slides. I did have a couple of comments on the guidance document, which I will not ask you to pull up because it's too long. So I'll just throw a few things out there. In section D of the guidance, it asks for lots of really interesting information related to... This is my interpretation, so feel free to say this is not what you were shooting for. But when I looked at it, it seemed like it was really trying to get at capacity for change, existing improvement infrastructure, existing efforts with the community. I think that's all good stuff. I am not sure that it's that amenable in a narrative format. My concern is that either you get a 20-page answer or non-answers. And so I'm just questioning whether there might be another format for getting that information and having a conversation about those issues other than through the budget narrative. There are... You went on mute, but it... Sorry about that. Yeah, you're talking about a night format. I don't know how that happened since my hands were nowhere near the keyboard, but creepy. Anyway, so I was wondering if there's another format we might consider to have more of a conversation about those sorts of issues. Not because they're not important or interesting, but because it seems like the narrative format just may not be the best way to collect the information in a meaningful way. There are several questions in that section that are directly applicable to the budget, but a lot of the other ones I would categorize as interesting, but not necessarily directly helpful to me making the two key decision points. So that's a suggestion just because I think that I want the information. I just am not... I want it in a way that is most meaningful for everyone. Let's see. I had some specific questions around a couple of questions in the budget section. And I've raised this two years in a row about the facility fees question. I'm not... I still don't really understand why we're collecting this information and how it helps us in our decisions. Facility fees are driven by Medicare payment policy. So I was curious if this is meant to be trying to get at commercial payers that may have adopted Medicare payment policy. So that's just a question. And on the penalties to CMS question, are we truly talking penalties? Was it meant to capture, for example, quality adjustments or... I just wanted to make sure that we really were asking about penalties versus other sorts of adjustments that CMS might make and wanting to understand a little more about that question. Sure. Yeah. Thank you. I think those were the bigger questions I had. Thank you. Thanks. Yeah. And I'll take those back and follow up next. Thank you, Robin. If I can just hop in on that last question that Robin had. I do think it's important for us to understand if a hospital has received a penalty because of equality, readmissions, rates that are too high from Medicare, I do think that should factor in as a... I'm under something we should understand going forward. If it's happened frequently, if it's been readjusted back up, what is the process there? But I do think it's an important metric for us to follow. Thanks, Jess. I guess I wasn't seeing that as a penalty more as a quality adjustment. So, penalty to me means you violated something and there's a legal consequence. So, maybe it was just me being overly technical and reading that term. So, that's why I was asking the question. Right. No, it's a great question. And maybe the term should... I mean, we can work on the question better. But there's a quality adjustment. I have no questions. I believe you're breaking up. I can't really hear you. I'm wondering. That's a little better. I don't need to comment.  The public, we have no idea what Chair Foster just said. I think he said, I don't need to comment. We'll go to the healthcare advocate. Okay. That's what I thought. I heard. Thanks, Mike. Good afternoon, Sanfayesh for the Healthcare Advocates Office. I'll be brief. I just wanted to thank Elena, Matt, Russ and Flora for some really great work. I will say in my time at the HCA, this is the most evidence informed and rigorous guidance that I have seen. And I know they'd probably be quick to point out that this is a byproduct of continuous improvement over the years. We'll probably submit a brief technical comment about an affordability metric that's a little bit different from the one that's proposed to be benchmarked to the commercial cap. But at a high level, the main comment I want to make is about the process itself. The HCA thinks of defining a successful process as one that's participatory and not performative. And when the success is not based on whether or not we get everything that we want, is whether or not we were heard. And there were multiple clear opportunities for feedback in a transparent way. And we certainly feel that way. So we want to thank the team for leading the process that is conducted that way and look forward to providing a comment on it moving forward. So thank you. Thank you very much. I'll turn off my video in hopes that it helps with my audio. Is that okay? I'll turn to the public for any comment via the raise your hand function. Mr. Davis, please go ahead. Ham Davis. Can you hear me now? That's my fault. Can you hear me now? Yes, go ahead. Sorry about that. Yes, sir, we can. Okay, I have four comments. I'll go as quickly as I can. The first is that consistently since this board has been operating in its current configuration which started in 2017, I think it's a huge mistake to consider this simply as a system, one system of 14 hospitals.  There's two systems, not one. And then maybe two and a half if you consider the New York side of UVM health network. But the hospitals, the UVM network has a completely different business model from the 11 community hospitals. And they operate completely differently and treating them the same is just going to get you, in my opinion, nowhere. Secondly, one of the issues is, one of the huge issues that is happening now and is confusing the legislature, the administrative, the Scott administration, the whole thing. One of the things when you look at the cost, especially federal, looking at federal benchmarks, the critical question is whether what you're looking at is age adjusted or not. If you look at something like the Kaiser Family Foundation numbers on which state is most expensive, Vermont is one of the three or four most expensive, okay? Now, if you just take that, if that's just raw data, okay, then that's one thing. But it isn't. The fact of the matter is that Vermont is one of the three or four oldest states in the union. The average age in Vermont is roughly in the mid-40s. Now, whether you use the average or whether you use the median, then different as we all know. But there's not very much difference between them. Most states, our average age is in the 30s. And so by not using, by not age adjusting, okay, then you completely, then you're just not taken into account what the reality is. Vermont is hugely old. It's even old. It's not just all over the state.  I know something about, I'm one of them. And so in any event, by not using, by not age adjusting, okay, that I don't believe a single thing that you have to say about what's going on in the healthcare system has to be age adjusted. Number three, two years ago, Mr. Chairman, you told me that, you told me an answer, which I appreciated, that the huge volume of data that came in from something like 400 pages, that came in from a half a dozen national consultants into the Green Mountain Care Board on October 27th and 21, and you said specifically you weren't afraid of that. Well, I have to say that I think you are afraid of it because I haven't heard a word about it. What that data is talking about is the quality that's going on in here. There's three different quality measures that all cohere to say that the UVM health network quality is way higher than the rest of the state, all of it. And so the fact of the matter is you're not touching that. And if you can't use that data, okay, then you're not going to get anywhere trying to regulate this system. The fact of the matter is you're not moving the needle at all. Actually, the way medicine is getting delivered every day is not changing at all according to what your board is doing. If you think it is, you're just kidding yourself. Fourth, I'm almost done. Fourth, I'm writing a book about this, okay? And what I'm doing is I'm making all kinds of judgments. I can be wrong. I don't know, you know, whatever, people can disagree with me. In conventional journalism, which doesn't exist anymore really anywhere in the United States and certainly not in Vermont, but then it's a journalistic principle, okay, that you give the people you're talking about a chance to reply to what you say. They can object. They can tell, they can argue with you. They can tell you you're wrong about something.  I will do that, okay? But it's very hard to get through the people now. Very hard. I get calls when I make calls into your system. I get called back. One out of every 10 times. And mostly that is Kristen, who's doing a great job, by the way. In any event, in any event, if you, I will send when I have a specific question for some, for a member of the board or a member of the staff, I will send it through Kristen. I have already done that once for one member, okay? But I will do it for all the members. And it's your choice. I have nothing personal. You have, I have no problem, no problem if somebody doesn't want to talk to me, that is fine. I know a lot about that. I covered the whole Nixon administration. If you think that journalism is a problem now, you should have been in the Nixon administration. Anyway, thank you, Mr. Chairman. Thank you very much for your comments and thoughts, Ms. Gutwin. Hi. I just wanted to make a comment about the statistics, which, by the way, I thought were well presented. And in most of it, I could understand. So that says a lot in your presentation. With the statistics looking at both inpatient and outpatient of a hospital and, and separate from all the rest of the outpatient services of a community, it's like looking at the cost of healthcare in a vacuum. So if, for instance, if services are shifting from inpatient to outpatient, but your metrics only look at the outpatient of the hospital and you're looking at expenses that are broken out between inpatient and outpatient, you're not able to understand cost savings that may, well, not may, that definitely exist in outpatient services that are non-hospital based. So I think it's a good sign that actually inpatient care is decreasing because for the healthcare system to save costs, if we can shift it to outpatient and in that outpatient shift, there is more affordable healthcare than we're looking at an overall decrease in cost to remonters. So I don't see a way for the Greenmont Care Board to do it just looking at the reports that I see because it doesn't include what is outpatient services non-hospital based. And I think that that is a good thing to look at, especially now because outpatient services, businesses are still at high risk of going out of business. I know that we have lost a spine business. So now the only choice patients have is a hospital based spine service. And the other thing too, for me, I have a knee injury and I want to have surgery at UVM. And to schedule an appointment, you have to see the PA first. That's understandable. You can't see a surgeon. Their dates are three months out for the first visit. And then I called Evergreen Family Practice and they could see me within three days, which I did. And then same with MRI, that wait list is far longer than what I have, which was within 24 hours. So it's critically important for the Greenmont Care Board if you can't get reports on the outpatient services and every outpatient service the hospital provides can be provided by another business. If we don't consider that, then we look at the trajectories. We see the expenses of the hospital growing far, far higher than what we have in outpatient services of other businesses. So in other words, as I have said before, hospitals used to do hospital work. They used to take care of the sick and injured that couldn't be handled in doctor offices within the community. When the hospitals have encroached upon outpatient services, then what we have is a grab of services that aren't more expensive to deliver, but more expensive. And I even wonder, I mean, my theory is if a business, a hospital has now both outpatient and inpatient, if inpatient is struggling, maybe their outpatient prices, the cost of now basically four times what you would have to pay to a non-hospital base is to shift money from outpatient to inpatient. And I really think that hospitals getting back to focusing on their core duties in helping them to be sustainable, like we can sustain hospitals better if we basically allow other providers to do outpatient care where possible so that we can save money to raise the price of hospital services and inpatient care. But what we cannot do is we cannot not think about these businesses in the outpatient realm that are non-hospital based because we had testimony that Blue Cross and Blue Shield says we can't raise rates to anyone when the hospital basically has the majority share of cost increases. So that's my comment. Thanks. Thank you very much, Mr. Del Treco. Thanks, Chair Foster. And thanks, board members and Elena and your team, him and Susan Tuffax to follow. So I appreciate their comments as well.  I think we have, Vermont has an economic crisis on our hands. Vermonters can't afford health care. Vermonters can't afford groceries. Vermonters can't afford gas. Vermonters can't afford their phone bills. It is an across-the-board problem. This is the first time I've seen this deck in presentation like most. I think the perception of SAM is not shared by me. I think we need more context. I think we need more work. And if we look at the timeline that was laid out, I think some of it isn't sufficient. This is the first meeting we're having on the 20th and we're going to approve guidance in 10 days from now. So I think we need more clarity and more predictability in the space. When I think about some of the slides that I've seen, there's great data and information. There's great data. There's not a whole lot of information. I'd like to ask why that operating expense growth is growing. What are the elements driving that? It was stated that an organization that can manage operating expenses is highly efficient and we are the experts. However, when we do talk about those drivers and concerns, it's met with those aren't realistic growth rates and we can't continue to grow this way. Again, I think we have an economy and economic issue. I don't think it is solely a one organization or one industry issue. When I hear the comments around Blue Cross Blue Shield not being able to afford or pay other physicians, that's highly concerning to me. We need to look at the holistic picture and what is happening and it just can't be one person gets paid versus the other. This is a race to the bottom. So I'd like to ask for a few things. One, we need to recognize what drives expense is when a patient shows up at our hospital. If a patient doesn't show up, that's the cheapest form of health care and especially if there's care is delivered outside and they're not avoiding care. Just make that comment. So we are looking at how do we care for our community? We want vibrant communities around the state of Vermont in every rural corner and we're focused on caring for our patients. So I think we need to deconstruct some of the information around hospital expenses and growth. Deep couple that from what might be considered highly efficient and I know, Chair, I appreciate you being at our board meeting yesterday. There are 96 measures. There's no way on earth. Any organization can measure 96 measures, understand what they are. I actually feel for the Green Mountain Care Board staff, how do you analyze 96 measures and be effective and efficient and productive at that? I think it deludes the point of what we're trying to do in a data driven way. Furthermore, in that space of those metrics, I think there's challenges with some of the benchmarks. I think there's challenges with not knowing the inputs, the numerators and denominators and I would like to avoid with at any cost what we ran into last year during the budget presentations in July, August and decision making where there was a lot of confusion around those measures. So I would ask one that we, when we approve guidance that were that those measures and metrics are clear, I would ask for a reduced set of measures and metrics and benchmarks and if that can't be accomplished within the March 31st deadline, I think there needs to be some reasonable no later than date set. We know that July of last year didn't work for a timeline and I would like it to, I would ask respectfully, could we shoot for April 30th? As we move into past April 30th, our organizations will start to be looking and managing and modeling ahead model details and I'm worried about the capacity of our organization. So I know I was lung winded and I don't usually filibuster like that, but there's a lot here and that's important. I appreciate the work and collaboration and I just think we have more to do here and we don't have much time to do it. So thank you and I appreciate the time. Mr. Deltrack, I'll have a follow-up question. I'm sorry I can't be on video with my reception here. Do you have a set of the 96 measures that you would like to see removed or that the hospitals think are not productive or relevant? Thank you for that. I know that there's been a small work group looking at some of those and I think we can work with Elena and her team on that because I do think there's many measures that are very important and there's some I'm not so sure about, but the answer is yes, I'm happy to work with you on that. Okay, yeah, I would definitely be interested in which ones you think we should remove and definitely take that under consideration. So send that in for sure, I think it'd be helpful. And then just for context, the benchmark, the only two real benchmarks are the rate and the NPR and the way I look at the measures is if the hospital is going to be above those, these measures are something they can point to and rely on to justify that request. So for example, if they're low cost, low prices, low expense growth, whatever it is, the justification for board members I think is strengthened or at least for me it is. So they're really things to kind of help hospitals know what could be relevant to changing board members' minds to support a higher rate increase. That's how I think of them. Yeah, I appreciate that and thank you. And again, I think for us it's about how do we care for our communities in the most effective way? You know, we're looking at healthcare in a very holistic way, housing, what our local towns and city streets look like, workplace violence, patient safety, and those sorts of things. So I appreciate that. And that's why I ask for a careful look at, we can't just say operating expenses are growing and a highly efficient organization could control those. I think there are multiple factors in play. We are at capacity. I think we're looking at maybe some of the wrong numbers. When I hear we have three ICU beds left in a day, I am concerned about the care for Vermonters. So is it utilization driving expenses? Is it workforce? Never mind travelers, but the need for more staffing, nurses, doctors, PAs, environmental service people. When I walk in these organizations and look at shelved cafeterias and places where patients can't get a healthy meal, I am concerned. And that's where we're headed. And I agree with the sustainability and affordability conversation, but the choice is access, which is challenged, or having creating more problems with those access issues. It's simple to me, and it's very complex with all of the details. Thank you. Great. Thank you. Mr. Stanislaus? Thank you. I'm Mark Stanislaus from the University of Vermont Health Network, and I just would like to echo some of the comments that Mike Daltraco said and add on to a couple of them. First thing I would say is this is a lot to digest. So I just appreciate all the hard work, but this is a lot to digest. So I just have some high-level comments for consideration. This is nowhere net to be encompassing of all of the comments to be very clear. But the first thing I would say is there has been a lot of reach-outs. And that is very, very much appreciated of the conversations from all levels of leadership, from the staff at the Green Mountain Care Board, to the members of the Green Mountain Care Board, to the chair of the Green Mountain Care Board. But there is a struggle to see how all of that reach-out and input carries over to this guidance. So I just have to echo what Mike said, because while not being in all of those conversations, but being aware of them, that doesn't mean that we don't have a common purpose together. But by saying that, I'm just reacting to there was a lot of comments at the beginning to say, all of these reach-outs happen. And there's a struggle to see where that feedback flows through this guidance. So I just wanted to share that. So I'm just going to go through a very couple high-level things. I'm just looking at slide seven and slide eight. And there's a lot of reference here to the all-payer model. And I know we could talk about percentages over and over, but we have to move to occur population-based tracking. That's been said many years now for many times. That's what the all-payer model is built on. We're mixing and matching stats here that are apples and oranges. So I just want to say that. Jumping on some of the expense trends, too. I also think that needs to be population-adjusted, because if you just look at slide 15, there are some of those New England states that have outmigration. There are some that have in-migration. And from an expense perspective, I think it's very important when we look at expense trends that are built into the hospital's financials, that there are some expenses in there that should be carved out when we take a look at expense trends. Well, there's retail pharmacy expenses that does not tie to net patient revenue. That is something completely different. There is provider tax trends that's a cost share to a governmental program. There are other cost share expenses that relate to governmental programs. And if you were to take those out as an example, I bet you from 2021 to 2023, the actual expense growth would be at least $100 million less. So I think the expense items that are being shown, as it relates to the true hospital expenses and care to those patients that are seeking at the hospitals, I don't think they're fairly presented in some of these slides. So that's something I would tease out there. And as we think about commercial growth rate and how we think about that and how we manage it, I would really caution the process that it would be best to have a conversation to say, why are those expenses in there? And when I take a look at slide 25, there's just some components of that in doing this business now for 30 years that it just doesn't relate to how hospitals get paid. And I'll just point out a couple of things that when you look at rate growth, it needs to be actual to actual. Well, there's no budget in there. Okay. Saying that you need to look at hospitals productivity by department, when it comes hospitals don't get paid by department, they get paid by encounter. So, you know, there's just aspects of this that even if we wanted to do it, I don't know how we practically could do it based upon how we're paid. And then if you just go to slide 27 in just kind of thinking out loud, it's, I think it should be how do we create a sustainable health care system to meet for moderate needs. There was very little in this on how do we balance some of these numbers against the care needs for Vermonters. That's ultimately, you know, what our shared purpose is. So I think that is something because what happens when those against this guidance, how do we come together in a conversation? And there's no perfect answer here on either side. But there's nothing in this guidance about how do we work together to meet the increasing health needs and access needs of Vermonters. And there's nothing in here about what does it mean to be a financially sustainable hospital and how does that balance against. So, and I have to say that what Ham said, aging has a big impact on the resources that it takes for hospitals to provide care to aging patients. They seek care more often. It's more intensive care. It's usually in a higher care setting. So there's no easy answer to all of this. Okay, I also want to say that. But I think for us to work together to find a solution that we do need to put this down on paper on how we come together to tackle it together. There needs to be a little bit more of a strategic plan on how we do it together to just reference one benchmark. And I would also like to remind everyone, there's some specifics in here about the commercial payers, but hospitals have a lot more patients. There's a lot more Vermonters that don't have commercial insurance. So significantly more. So, so when we welcome the conversation on how we can balance all of this together, how can we how can we make I think the affordability that you are trying what to refer to is like how do we can how can we can control the growth of healthcare compared to other benchmarks. But very much welcome the conversation. So I just wanted to point out some of those things and I'm sure that we're going to be following up what was some written comment and I would just like echo what Mike said. There's so much here that anything that can be done to expand this deadline to fairly comment would be extremely grateful. And I also think the Vermonters seeking care would benefit from it also. Thank you very much for this opportunity. Thank you and any suggestions you have would be welcome. So please definitely send them in. I don't know the rules around extending the deadlines. I think it's in statute. I'm happy to look at that might make it tougher to get your budgets together because I know you're working on them now if this isn't done. But we can certainly I would be interested in whatever suggestions you have to recognize those points that you made. Is there any other? Oh, go ahead. Mr. Snaslaw. Actually, thank you, Chair Foster again. So like I would just like to say something. When hospitals put their budgets together, the analysis done on this guidance is done afterwards. So us building our budgets or or say you changing the way the hospital budgets are built is we anticipate what the volume needs are going to be.  So set another way. We take a list of patients we are serving today, the patients that are coming to us because they need care. And we take the expense relationship to that today and we build that moving forward. And there are some volume trends that are built in there. So so you know, so I don't think if we extended this deadline. And there's a lot of CFOs on this call here. But I don't think it would impact the hospital or how the hospitals build their budgets because you know, we really focus on what the care demands are on the hospital. And then we build the budgets up from. So thank you very much for the additional opportunity. But so I thought I would just kind of throw that out there because I don't think that would impact hospitals at all if that deadline was extended. Great. Okay. And I assume you're with a hospital. Yes, I'm with the University of Vermont Health Network. Okay, great. Thank you. Any other public comment? Good positive. I just asked for a quick clarification from Mr. Stanislaus. He suggested modeling, removing provider tax, outpatient pharmaceutical growth. And there was one more area and I was writing it down and I missed that. There's another cost here that was related to a governmental program that we can follow up on that I think everyone in the state actually is part of our net patient revenue. It is the GME, IGT payments. So I think if you did those expense trends and when you took those out, you would see a really, really different trend line. Thank you for asking, too, by the way, Dr. Merman. I'm going to follow up on that, too, if you don't mind just to make sure I get it. I mean, I understand that. Would we need to make adjustments to other states, too, for particular things? Or would this, are these only particular to Vermont? I know some of them are, at least one is. Or do the other ones have other things that we need to change to make them apples to apples or no? Well, I would say I'm not sure either way. I would say that there are a couple of those categories that we'll like. First of all, I don't know what other expense or what other states with the provider taxes, but at the end of the day, there's a lot of comparison in here. I'm saying this is the expense trend compared to the revenue trend. So ultimately, I'm just saying there are expenses in there that don't tie to the revenue trends. And so all of the retail pharmacy expense, that is built through, in other states where we know, and in this state, it also goes through pharmacy. So I don't know what their structure is, but I'm telling you that those percentages don't relate to the NPR trend. So if you're going to connect those two, and also depends on if some of those expenses were already in their base before to if it's new. But I'm just saying it would be interesting to take a look at what the total growth would be. And since the University of Vermont Medical Center drives that trend growth for the state, I just think you'd see a different a different trend line in a lot of these, you know, that doesn't mean where you it may or may not be where you think it should be either. So Okay, that's helpful. Thanks for clarifying. I think that's all we have for comment. I appreciate everyone attending and listening and sharing their views. Is there any old business or new business for the board? And is there a motion to adjourn? So moved. Second. All in favor say aye. Aye. Aye. And we are adjourned. Everyone have a nice day and hope we get to enjoy the snow. Thank you. Of proposing its own methodology. So I think depending on what the state thinks is the right way to tackle that, we could try to negotiate something. So we could go into that sort of the considerations in more detail in the executive session about the, you know, potential negotiation levers. I think that's all I have for now. I don't want to say last time. So pass to somebody else so it doesn't get too late here. Just a couple of quick ones. So so far, we've sort of been the high level of sort of the goals and here's what we're trying to do and here's what, you know, is on the table. I think getting into the substance and the meat of like how it's going to do those things and what the risks are and all the more substantive points of how this would work, I think will be really helpful in the coming months as we evaluate this. So for example, if we talk about avoidable utilization and that's a key, you know, component of making the program work well, what utilization specifically are we talking about and where is it going and how is it getting there, right? And so for example, I mean, we hear about all the time the problems with hospitals discharging patients. So if we're trying to avoid ED utilization or post acute, put people in post acute care that's appropriate, do we have that? And if we don't, what kind of risk does that create? This might be like too simplistic, but I understand the whole theory. But so you're trying to put more money to preventative care, but it's not so simple as changing the payment model and then all of a sudden you'll have the preventative care or the long term care that you're going to need. So like a hospital can't just get rid of the orthopedic surgeons it has and add mental health and long-term care and primary care. They have people that work there that do things and just rejiggering is much more complicated. So I guess understanding sort of the risks and abilities to make these changes so that the program and model works well would be really, really helpful going forward. And then I think, you know, a lot of what member Holmes said, I thought was really thoughtful in terms of like the evaluation and the analysis of what we're doing. So I've been looking at bills that we get for our contractors and I've been looking at coag funding budgets and it's a tremendous amount of money. And I guess understanding what the financial investment is for the state to do it.  But just to do the application, to do the negotiation, to then come up with a regulatory process for then like hiring contractors to track all of the total cost of care and the quality, right? Then on top of that for a hospital to be able to make the transformation, a hospital to have two budgets, a hospital to have two budget review processes, the airport to have two budget review processes, all of those expenses are quite massive. And I want to make sure we're understanding all of those. And they may be like a great investment because there are additional monies that are really important to the state here that we could get. But just really understanding them on a granular level, I think would be beneficial. And then also considering the scope, right? Because if we're talking about whether or not it's a mandatory program or a voluntary program or whatever it might be insurance, not insurance, all those costs are much better when they're spread out between 14 hospitals that are participating with full commercial participation, right? So they might not be bearable or worth it if it's two hospitals and no commercial. They might be a really good investment if it's the entire system. And then that also goes back to my first concern or question, I guess I should say, which is whether or not it will work and whether risks are to it working. And if it's only one hospital with 30, 40, 50% of its money, maybe it doesn't solve as much as we had hoped. So then there's an opportunity cost. And that I know you, Pat, for sure, have no capacity to work on any other really substantive reform things. I know our staff and board members don't either. So we can't do other things because we're very focused on this. And that might be the best thing we can do. But if it ends up being a really small scale and scope, it's just something to consider. I guess the last thing I would just say is that access measures, the utilization points that members Walsh and Holmes made are really important to make sure that we're not losing access and that the model works for our access issues. But then the protection for commercial. And how do we make sure that we don't have really huge, large increases on the commercial market here in the state that we've had for the last several years? And how do we protect against that in this model? So I don't have any questions. If you want to respond, you can, Pat. These are just kind of food for thought things to kind of keep track of as we go ahead. Thank you, Chair Foster. I'll just respond very quickly. The question about how we can address things like avoidable utilization given some of what we're seeing in the healthcare system. We've touched on this earlier, but it's really a multifaceted approach where we look at what can the state do to help shore up those systems. And I can assure you that we're quite focused on that. What are some of the investments coming into the system under a model like this? And how can we best use them? And recognizing the longer time frame in this model, I think does show an understanding on the federal government's part that we're not going to be able to make these changes and solve all these problems overnight. But if we focus on them, we can resolve them over a time period of a few years. Yes, I think we have to look at what the financial investments required would be and then your linkage of that to scale and participation levels makes a lot of sense. We have to determine whether it's something that we want to move forward with. And if so, how to encourage the appropriate level of participation and then just would reinforce your last two points that access measures are going to be key. And we want to know what's happening with utilization. Sure, if there's potentially avoidable utilization, are we seeing a reduction in those areas? Maybe partly because of improvements in the system. Are there areas where we want to keep an eye on whether people are getting appropriate care? Absolutely. And ensuring that we can address affordability in the commercial market is essential. So thank you. Yeah, and something that turns on the negotiation. So you had on slide 11, you have so many of the benefits, right? And all those benefits, influence reimbursements, continued recognition, low cost care, baseline recognizes, past savings, all of those, not all of them, most of those turn on what we get in the negotiation. So how much return on our investment as a state we get will really hinge a lot on what that negotiation looks like, I think. Absolutely, yeah. Maybe stating the obvious. I guess I'm starting to get stressed about that as I'm sure you are. Yeah. Okay. Well, thanks for bearing with us all afternoon here. You're really patient with us and I appreciate it a lot. No, I'm happy to be here and I'm, you know, open door for questions. So thank you for taking the time. I'll open it up to public comment via the raise the hand function. And Oh, and I just want to say that I would like to go on to executive session if we think we can save a few minutes for that. Yeah, but I think it's appropriate to do that after public comment. Yeah, I didn't want to keep people waiting or been patient. Ms. Wasserman. Hey, how are you? Julie, are you there? Can you hear me? Yes, I'm here. Yes, I'm sorry. I just had to click on my camera and my mic. Thank you so much. Boy, long day, lost to absorb here. And I have a number of comments I'd like to contribute. As you know, I already submitted a critique of the ahead model to it to you and it went to the agency of human services as well as the governor's office. In that critique, I propose that we forego the ahead model. Why? Because it does not address Vermont's most pressing problems. And in my view, it will distract us from doing so ahead does not address our dwindling supply of primary care physicians. People can't find a primary care physician and it doesn't even even acknowledge that or address that.  I suggest you look at that slide and check off the items on that slide where ahead will actually address the issue. Ahead does not address affordability. It does not address access and it does not address wait times as have been addressed. People have mentioned those today. Ahead does not address the critical lack of funding for mental health and substance use services. And ahead also mistakenly focuses on fee for service and volume when the actual problem appears to be hospital prices. Many people are concerned about ahead's global budgets locking in current and historical hospital spending. And it denies Vermont the opportunity to address arbitrary hospital prices, reference based pricing, extraneous hospital costs and unnecessary ER utilization. And all of those areas are areas for potential savings. And those are off the table once we go with ahead's global budgets. And also under ahead's global budgets, hospitals could potentially withhold expensive care for patients who need it most. Ahead model will dramatically increase administrative costs and complexity. Something that we should be working to do the opposite. It's a very complex convoluted model and it will be very expensive as some of you have mentioned. Regarding ahead's primary care investments, I'd like to suggest that the $17 million that has been discussed today needs a thorough analysis. And you know, is the $9 million from Medicare for blueprint in or out? We need to know that sooner rather than later. I don't think we would want to wait until negotiations. That's a pretty important piece. A third of Medicare enrollees in Vermont are in Medicare Advantage. So they're not even a part of that. I don't know if they were included in or not in the $17 million. Another point is that hospitals are saying that they are not interested in participating in the ahead model unless AHS oversees their budgets. So if that's the case, and the Green Round Care Board continues to have its regulatory authorities over hospitals, and also hospitals all in the majority of primary care physicians, there could be a pretty low participation of primary care physicians for that $17 PMPM. So my point is that there's a lot of variables here and that I think it's dangerous to throw around the $17 million until we have a careful analysis of that figure. In addition, we know that given the majority of Vermont's primary care physicians are work for hospitals, what guarantee do we have that those investments won't go to the hospital's bottom line? Now the same thing happened with one care and their primary care investments in 2023, 2024, and also in prior years. As we all know, there's a pending legal action, but we still don't know if that roughly, I don't know, $20 plus million directly supported primary care as it was intended or did it bolster hospital revenues. Most importantly, there is great concern that a head would in some way disenfranchise the Green Mountain Care Board by shifting oversight of hospitals budgets to the agency of human services. And also I might add the hospitals. We need to clarify where the locus of hospital budget control would be with the head model before we move much further because if a head means that the Green Mountain Care Board is disenfranchised and does not oversee hospital budgets, that would be a pretty significant piece of information to have in terms of whether or not we want to go forward. So I suggest that instead of pursuing the head model, Vermont should do a number of things. I think we have a lot of options open to us and all of them are within our purview. One would be to strengthen and fortify Vermont's primary care physician workforce through aggressive recruitment and retention initiatives. Another would be to pursue initiatives that improve affordability, improve access, and improve equity. I think that we could spend a fair amount of time in Vermont focusing on initiatives that actually reduce the need for hospital care, reduce the need for hospital care. We all know what that is. We all know that increased access to primary care, increased access to mental health services, and home health all would help to reduce the need for hospital care. Furthermore, we need to immediately increase funding for mental health and substance use services. A case in point, since August, the Howard Center has closed four programs and they've suspended an additional two programs. So six programs in all. Those programs are Centerpoint, Intensive Family Based Services, Autism Toddler Community Program, Public Anibriot Program in St. Albans, Act One, and the Bridge Program. Now, is that not a wake-up call? I think we have to pay attention to that. And I hope AHS is aware of this because as we all know, they fund the DAs. Other ideas for ways we can move forward is to standardize hospital prices through reference-based pricing. It's a proven rate-setting method. We can develop initiatives to identify and eliminate avoidable hospital care and unnecessary ER utilization, as I've mentioned. And one other idea is hospital capital expansion. Hospital capital expansion is one of the big drivers of escalating costs. We could think about creating a statewide global budget for hospital capital expansion. So in conclusion, I think we should forego the AHEAD model, which potentially removes hospital budgets from the Green Mountain Care Board, hands them over to AHS, which I'm hearing wants the hospitals to set their own payment methodology. That's not too reassuring. And also, forego the AHEAD model, which will lock Vermont in to an untested model, untested model for nine years, nine years allowing for little to no progress on Vermont's most pressing problems. And it's apparent from today's discussion that there has not been enough analysis of what the effects of this model would do. In fact, it's woefully inadequate. And I think in order to move forward, we need some analyses as Member Holmes suggested. But one of the biggest problems of all of this is that there has been no public process on the AHEAD model. In my mind, it's a bit of a travesty to be locked in to an untested model for nine years without a public process to vet the merits of this initiative. Legislators have no idea what AHEAD is. The public, who we're supposed to be serving, has no clue. And even people in health care don't know about this nine year initiative. So I'd like to conclude by saying that we need to initiate a public process with all the affected parties, especially Vermonters. And the AHEAD model needs to be fully vetted in the public arena. Thank you. Thank you very much, Ms. Wasserman. Mr. Flood. Good afternoon, Chair Foster. Can you hear me all right? We can, yes. We can hear you. I am having a little computer problem. If the connection is not good, I'll shut off my video. But I want to add my voice to those that are concerned, very concerned about proceeding with this model. I have to agree with what Member Walsh said earlier that this model is not tightly aligned with what Vermont really needs. And I think that's absolutely true. This, to me, is just another very complicated, very expensive model that will take up all our time and energy, and we will not get to dealing with the issues that really need to be dealt with. There's no mention, really. There's no significant mention in all of this of mental health. There's no significant mention of long-term care. There's no significant mention of services like home health. And without those services being robust, all the focus on primary care in the world is not going to change our health care system. And I believe it was Member Holm who pointed this out, that it, you know, if ours cannot refer to effective services, then what have we accomplished? Now, the 17, you know, dollars per member per month is very seductive. And in fact, it could be really helpful because it's one of the things that we know primary care needs. We know primary care needs. But we also know from what the doctors tell us, the primary care needs a relief from the administrative burden. I see no attention to that in this model. We know that primary care, as I just said, needs referrals to effective services in the community. I see no addressing of that in this model. There is reference to making referrals, but it doesn't do you any good if there's nobody to refer you to. And I think that probably all of you saw the recent letter from four emergency room doctors who were pointing out just how bad boarding has become in our hospitals because we don't have services to discharge people to. And in fact, we don't have nurses on floors enough to discharge people upstairs. That's how bad our system is getting. And this model is not going to solve those problems. And in fact, what it's going to do is distract us. You know, primary care has never been the problem in our healthcare system. It's never been the issue. The issue, as I think most of you actually know, is hospital costs. We heard earlier about hospital pricing. I don't see anything in this model that's actually going to deal with the costs or hospital pricing. We know how to do it. As Julie just mentioned, there are techniques we can use to do that. This model doesn't address it, in my opinion. I haven't seen enough evidence to it. And the whole avoidable care problem is not addressed. It doesn't even come up. The word avoidable, the term avoidable care is not mentioned in any of this. I have to comment that I appreciate the effort the board made in the past year or so to address hospital costs. And I find it very ironic that the thank you you got for that was a bill in the legislature that was going to teach you to be decorous. It's ridiculous. We are focusing in the wrong area. We know what to do and we're simply not doing it. So what I would like to ask the framers of this model is for specific measurable outcomes. Don't tell me that care is going to give us $17 per member per model. Tell me what we're going to accomplish by that. Before you approve this model, I think you should ask them for measurable outcomes, for example, like how many more doctors are we going to have in this state? And by when? How many people in this state are going to have access to a primary care physician when they need it? And by when? I don't see anything like that. How many people in this state are going to have ready access to highly affordable mental health care? But I don't think you're going to get answers to those questions because I don't think the framers of this model have even thought about it. But we need some kind of measurable outcomes here or I don't see any reason to pursue this model. So I think you can tell I really we're going this is just another boondoggle. We spend almost eight years now start to finish on the original all-payer model and we have almost nothing to show for it, my opinion, nothing. And we're going down the same road again. So without a whole lot more evidence of accomplishment and a whole lot more explanation of how we're going to solve the real problems for doctors are facing, I think that this board should say no and not pursue this model. Thank you. Thank you. I have one comment in response and I actually had a question. So one I've heard obviously of the interests in having the model regulated differently or not regulated or regulated by someone other than the Green Mountain Care Board. I wouldn't support that. I think it would be a less attractive model if that were the case. I think the regulatory apparatus and structure is really important to make the model work well. So to that comment and question, I would not support that. And then the question I had, reference-based pricing has been brought up a couple of times, more than a couple, a number of times since I've been here at the board. And I have to say it's quite attractive to me. I think there's a lot of fairness and predictability to it. And I guess the question is for either Ms. Garovitch or Ms. Jones, in our design of our methodology, could we put in a reference-based pricing component? So some of our hospitals are very high, like 290, 300 percent of Medicare, others are quite a bit lower. Could we set targets based on reference-based pricing and incorporate that into our methodology? Did I take this? Oh, go ahead, Shirley. Sorry. Yeah, I think there are options to construct a global budget, right? So the issue is we start with the historical and how much adjustments you'd like to make. So that's one decision point. Currently, the way we were envisioning is that we do efficiency measures where we look at how efficient hospital is from their operational cost and then make payment adjustments accordingly to all payers. The issue with reference pricing or any controls on the prices that the rational behavior will dictate that they would try to maximize with higher utilization to maintain the revenues. So that's why an all-pay rate setting in Maryland moved to a fixed budget model because, A, as they squeezed the prices, they found out that their utilization went up, right? So at the end, that's the balance, but where you start is important. And there are options in incorporating some of those price adjustments if the state would like to go in that direction. So global budget concept is flexible in a way, right? So we are trying to control both prices and utilization at the same time. You can fix the prices as you start or you can fix it gradually over time. So there are multiple options under the methodology. Yes, I think it's true. Our problem is more price than utilization. And so if you're saying lowering price gets you more utilization, which I understand, that sounds attractive to me and like a good way to go about it because we want more utilization. But obviously, let me finish. Obviously, you don't want to go bonkers and then you're not there. So how do you design it such that you lower the price, get the utilization you need, but then not have it kind of blow out through the roof? Right. I think you're right. Like how do you define what utilization you want, right? So you don't want unnecessary utilization. So you don't want wasted services as well. And in the current model, if you just do reference-based pricing, you do not have policy levers to manage that aspect, right? So that it becomes the current incentives remaining, you squeeze down on one side and it will pop up in another. So there needs to be additional mechanism to orient the system to provide, I would say, a quality utilization rather than overall utilization increase. And that goes back to still general concepts around global budget and what you measure and where do you want the transformation happening within the hospital sector. Could you pay less for certain utilization above certain thresholds so it like minimizes the attractiveness of? Right. That goes beyond Medicare reference pricing. So that is kind of leaning towards more rate setting methodologies where you do determine the rates based on criteria other than the cost of services, right? So one is to cover the cost and then you may want to say that, you know, we will provide more than costs for services that we need it or high quality or high need. Okay. So other public comment? And I accidentally, I skipped over the health care advocate and I apologize. Hi, Chair Foster. This is Charles Becker. I'm here for the health care advocate today. We have no comment specific to the presentation. I would just say that we did submit a comment letter to the board and to AHS at the end of January. I didn't see that posted to the Green Mountain Care Board website. So maybe some of the folks here on this call haven't had an opportunity to see our letter. And so perhaps I should email your assistant to see if we could get that added to the website. Well, we'll double check on it on our end and we'll reach out if there's an issue. I apologize. We'll make sure we have it up. Thank you. Okay. Thank you so much. Thanks for talking. Chair Foster, would you object if I made a couple of comments in response to Ms. Wasserman and Mr. Flood's comments? Yeah, definitely. Okay. Yeah, just a couple of things. One, in terms of hospital budget review statute, it's very clear about where that responsibility lies. And I just want to clarify that AHS does not have interest in hospital budget review. So statute seems very clear. I mean, we're interested in the process of the outcomes, but we're not interested in doing it. In terms of primary care access, I would just note that the idea, I totally agree that that's critical. And the idea of the investment in the AHEAD model, both in terms of overall statewide investment in primary care and the additional PM payments would be to provide resources that would hopefully improve access to primary care. So just wanted to mention that as well. And agree that there are other aspects of the system that aren't directly addressed by the AHEAD model, although the intent is certainly to see partnerships and resources with other parts of the system. And just to note, and I think we've covered it a bit today, but that there's, these are big problems and require multifaceted responses. And so AHS is certainly focused on improving system of care and access to care in the system and so forth. So just wanted to mention that as well. Thank you. Thank you very much. Okay. I don't see any other public comment. I think we can wrap it up. One more. Kim Fitzgerald, Mrs. Fitzgerald. Yes. Hi. Thank you. I'm Kim Fitzgerald and the CEO for Cathedral Square, one of the statewide administrators of SASH. And so I just wanted to just make a comment that I really appreciate Pat's representation of the concern for SASH if we don't move forward. And I appreciate the board members bringing up, you know, contingency planning, if we don't move forward with a head because we have not heard of any other funding mechanism for SASH moving forward outside of a head. So I just want to appreciate the effort and energies you're putting towards to considering that. Thank you. Thank you. And thank you for your work there. We were able to visit, was it October or so, and it's really not really lovely. Thank you. Any other public comment? Okay. Great. Ms. Jones, thanks for spending the afternoon with us, long meeting, and thanks for your patience. So if I could jump in, I don't know if people have time or appetite for the second session at this point of the day. So maybe I can bring that up in old business next week if it would be nice if Pat and Shule were there because I think they could provide some important additional information. So I won't move that today, but I will just say a couple of things I've been holding off on saying. Trying to make sure everybody else had time to talk. So I think one thing that I just want to maybe provide some reassurance on is CMMI does not have the authority to change the state's regulatory process. That is purely a state law issue. So I don't think that that is a possibility under the head model. In the discussion today, I heard a lot of conflation between commercial price issues and Medicare issues because I don't think that the issues are the same across every payer. And so I think as we continue to refine our discussion, we should be thinking about Medicare and we have to think about the whole thing, but we also have to think about the payer specific issues. And I think with Medicare, as we talk about a lot, the state compared to other state tends to be low cost. And so a risk there in the ahead model is we need to make sure that our total cost of care negotiation results in a reasonable Medicare total cost of care. To me, that's the most essential component to this. And that's something that's difficult to talk about in the public session because it is so heavily negotiated. So that's part of my anxiety about wanting to do the executive session because I think I want to talk about that with others. And I think to the points that others have made, like in commercial, the issue has been price. And so when you're thinking about and in terms of the commercial design, like that is not a CMMI issue, that is a state issue. So we have a lot of opportunity to think through what makes sense for the state there. Understanding, of course, that will drive providers crazy if there's not reasonably aligned incentives. So I'll leave it at that given the hour. But I hope that we will be able to go into, we don't have a meeting next week. So it wouldn't be next week. But I hope that we will be able to talk about the Medicare total cost of care considerations because I do think that, for me, is the key component post negotiation that will need to be evaluated. And I'd love to share some thoughts about that. Thanks. Thank you. Maybe what it will make sense for us to do is actually just dedicate a full board hearing to executive session or something so people don't have to wait around for us to go in. So it's off-putting to me. I can only imagine what it's like to be trying to participate. And I did just want to give a nod to the public comment and the effort that people put in to critique and provide feedback. It is so massively valuable, right? I've said this for a long time since I've been at the board, really. Sometimes it's like the best thoughts and ideas are from my other board members, staff, guests, but also the public. So this is your own time as far as I understand it. And so thank you for doing it to try and help us make this as beneficial as we can or to make extremely right decisions. So thanks to everyone for sticking around and doing that for us because it's really valuable public service. All right. Any old business or new business other than missed lunches? Okay. Is there a motion to adjourn? I'll move to adjourn. I move to adjourn. I'll second. Second. All those in favor say aye. Aye. We are adjourned. Have a nice evening. Thank you. Thank you, everyone. Thank you.


Welcome to All Hands Update. I'm Petty Officer James Stillopeck. These are your headlines from around the fleet. Changes are coming to your leave and earning statement. The expanded leave or lose law that allowed service members to carry up to 75 days of leave from one fiscal year to the next will expire soon. Service members with more than 60 days of leave will automatically lose any excess on October 1st, 2015. There are some exceptions to the leave or lose law. Check with your command admin to see if you're exempt. The 50th annual Sea Air Space Expo is coming to National Harbor, Maryland, April 13th. The expo is hosted by the Office of Naval Research and Navy League Science, Technology, Engineering and Math, or STEM. The expo is geared for students grades 6th through 12th and encourages students to pursue careers in the STEM fields. For more information, visit the Office of Naval Research website.