So if I could get everyone's attention, we're going to start the meeting We're going to start with the executive directors report We have different meetings that we've been having. First is the remount with our Board of Data Governance Council, which is a council that was created by the board a few years ago to govern the e-cures data set as well as the funds data set. And we had a meeting on Monday to review request for data for my medical shopper. And that request was denied, but we anticipate that they will be coming back to request another, to request for data again. We are in the process of updating our application as well as our policies and principles, so we do feel that in the future they may be interested in coming back to apply for the data. In addition, another meeting that we're having is this evening, the primary care advisory group. This is also a group that was actually created by the legislature two years ago. And the initial group was started at 113 in 2016 and the legislature asked us to organize this group to address administrative burdens that primary care providers are feeling in their practice. So this is very related to what we're going to be talking about today. That group per the legislature sunsetted in June of this year. So the chair, because we do not have a health care provider on the board currently, asked that we continue the group as a technical advisory group. So we will have our inaugural primary care advisory group, 2.0 this evening, the 5-7, at the remount care board offices on Skeet Street. The other announcements I have is two upcoming board meetings. One is on October 10th. We will be having our general advisory meeting here in this room. And then lastly, on October 31st, the board will be going on the road. We'll be headed down to the upper valley to Mattis-Gutney Hospital. And we'll be having our board meeting for one, two, four that afternoon at the Mattis-Gutney campus. And if there's any questions about locations, times of any of these meetings, all of these information is on our website. And that's all I have to report. Any questions? Thank you, Susan. Just one other calendar edition on September 27th. Member Pelham and I will be attending an all-day summit on workforce issues in health care at Castleton University. The next item is the minutes of Tuesday, September 11th and Wednesday, September 12th. Is there a motion? It's been moved to approve the minutes of September 11th and September 12th without any additions, deletions, or corrections. Is there any discussion? If not, all those in favor of the motion signify by saying aye. Any opposed? So I'm going to turn the mic over to board member Jessica Holmes in a second, but just to say that this is a topic that has no easy solutions. It's one that, we're hopeful, can be resolved in a manner that encourages people to want to practice in Vermont and encourages providers to want to participate in the ACL and the all-payer model. So with that, I'm going to turn it over to Jess. Great. Thank you very much. And I want to thank all of you for coming. I know this is a very large panel. The topic is complicated and we wanted to get as many of the voices in the room as we possibly could, and so I think we have a fantastic panel up here. I wanted to set the stage a little bit about why the Green Mountain Care Board might be looking at this topic of administrative burden. I went back and looked at Act 48, and the discussion of the purpose of the Green Mountain Care Board, the language specifically states that the board should promote the general good of the state by improving the health of the population, reducing the per capita rate of growth and expenditures for health services in Vermont across all payers while ensuring that access to care and quality of care are not compromised, enhancing the patient and healthcare professional experience of care, recruiting and retaining high quality healthcare professionals. And this is perhaps the most important one here, and achieving administrative simplification in healthcare financing and delivery. So it's part of our role as healthcare regulators to be thinking about these things. And about a year ago, we did a clinician landscape study, and we surveyed about 400 Vermont clinicians to find out basically many different kinds of questions. What were their sources of frustration, satisfaction, or threats to their practice? And across the board, no matter the employment type or the area of specialization, whether it was primary care or specialty care, whether they were independently employed or whether they were hospital employed, paperwork, billing, administrative, regulatory burden were among the top frustrations and threats to practice. So with that in mind, we felt like we had to at least start having some conversations with that. I would like to say that Vermont is not alone in this. This is a national trend. Administrative burden, you know, paperwork is frustrating to clinicians all over the country. But subsequent conversations with Vermont providers in focus groups and in health first meetings that I've attended and other venues that we've heard through our provider networks that we chat with. Administrative, as that administrative burden is growing, morale to some extent may be shrinking and the worry would be that are we going to have issues and more challenges with recruitment and retention, which we just came through our hospital budget hearings and heard a lot about recruitment and retention. So these are issues that are paramount to us as a board and to all Vermonters. We also, through our rate review hearings in contrast, heard from insurers that there are some administrative tasks such as utilization reviews and prior authorizations, which I know we're going to hear a lot about, that they have some value to the insurers. They can be effective cost minimizing strategies to some extent and they're used as a tool to reduce fraud and overutilization and other potential waste in the system. And that such tools, some of these tools, can actually keep premiums lower for consumers. And so we hear that as well. We also are hearing as we move to value-based payment the realization that we have to quantify health outcomes, right? If we want to move to value-based payment, we have to be able to quantify value. And so that requires quality measurement, another administrative task for providers. So there's a lot of competing forces at play and I feel like we have lots of different voices here at the table. And I think the goal, at least for me personally, and I don't want to speak to everybody here, but can we think about are there administrative tasks that are cost effective, maybe those stay? And are there administrative tasks that are imposing undue burden that are not efficient, that are not providing value added, that maybe we can think about eliminating to the extent that it's going to improve morale, improve retention, recruitment and satisfaction of providers in our state. So we need to have a strong, satisfied network of providers. How can we do that? So with all of that in mind, Vermont has always been a leading edge innovator. I believe that. So how can we identify ways to reduce administrative burden without increasing costs and compromising patient health or safety? So I want to welcome all of you today in the hopes that we can come to some path forward, we can think about ways in which we can reduce some of the burden, at the same time be, you know, focusing on bending that cost curve and improving quality outcomes for patients in Vermont. So I'm going to introduce the panelists today. We have Dr. Mark Paluso, who is the medical director at Middlebury College. We have Dr. Faye Holman, who is a family practitioner at Little Rivers Healthcare. We have Rick Dooley, who is at Health First and also PA. We have Dr. Ulger, who is at UVM Health Network. In particular is the VP of clinical operations, associate VP of clinical operations. We have Michael Costa, who is the deputy commissioner at Diva. And we have Dr. Norm Ward, who is the chief medical officer at OneCare. And we have Dr. Paras, who is the CEO and CMO at Melinda Scottney. And we have Dr. Kimberly Kilby, who is the Vermont medical director at MVP. And we have Dr. Josh Plavin, who is the VP and CMO at Blue Cross Blue Shield. So we have providers represented. We have hospital administrators. We have insurers. We have OneCare. We have Diva. Philip, we got it all here. We should be able to figure this out, right? That is my goal. Can we figure this out? Everybody's here. Everybody's literally at the table. Not everybody, but a lot of people. So with that, I thought I would kick it off with Dr. Paluso. And I know you have some slides. So, how about it? Thank you. Can you guys hear me? Just clearly. Good. All right. Dr. Paluso, I know you can be loud. I can be loud. Yeah. All right. So I just have a few slides. I'm going to go through them quickly and can certainly discuss any of them in detail with the panel. The first slide is really just a couple of cases that we talked about. First of all, I should say I was a member of the primary care advisory group that looked at this issue for a couple of years. And I was really interested in the prior authorization issue because I absolutely hate them just to let you know where I stand on it. So the first case, I had a young patient with hip pain. This guy had two ulcers that bled, requiring hospitalizations, emergency procedures. He almost died after the first one. There's no way that when he has pain, he should ever be given a nonsteroidal drug like ibuprofen. So when he came to me with hip pain before he's leaving for a trip, I said, let's give you some celebrex, which is a selective pain reliever, nonsteroidal pain reliever. And he went to try to get it filled and he came back and said that he pharmacy needed a prior authorization. An hour later, I still hadn't gotten after phone calls and logging on to a website, creating an account and doing all these things for this patient. I still couldn't get him a celebrex. He left on his trip and he ended up taking a different kind of medication. He says it was an expired celebrex. I think it was narcotics. And that is definitely not the outcome that we want for that patient. And the insurance company that required the prior authorization covered both hospitalizations for his bleeding ulcers. So they shouldn't know about it. The next patient was another male athlete. He was going to some NCA championships, got some hip pain. I was worried about a femoral neck stress fracture, which can be catastrophic up in the hip. And so we quickly got an X-ray. They oftentimes don't show up on X-ray and the next thing you do is get an MRI. He needed his MRI the next day. We got an appointment slot set aside and the insurance company required a prior authorization. You should know that my rate of getting denied on a prior authorization is zero. I get approved 100% of the time, but I have to do them anyway. So it was Thursday afternoon. The appointment was going to be on Friday. They were requiring a 48-hour review period, even though I requested expedited review. And he ended up, it wasn't going to happen. And then he was going to leave for the NCA championships, not knowing if he could run or not. Now that might not be a big deal to some people, but that's a huge deal to someone that's done that, dedicated their sports career to that for a championship meet. So what he did was, he had the point of the story, is he went to the ER the next day because his insurance company doesn't require prior authorization if it comes out of the ER. He got his MRI. His insurance had to pay for the MRI. And they also had to pay for the ER visit. And all this could have been done out of my office. So when we hear about cost, I think these are the kinds of things that frustrate me. They're just a couple small examples. I have dozens. If you want to see what a prior authorization phone call looks like, we're often asked, hey, call the insurance company. They'll fix it for you. I did want on Monday to see if anything had changed. I usually refuse to call. Go to this website and watch the video. It's hilarious. And this is what happened to me on Monday. So I don't think things have changed that much. They take forever and you don't get the outcome you want. Green Mountain Care Board, as Professor Holmes pointed out, looked at this and I had this slide, as she mentioned it, administrative burden is the biggest threat to people's practices and it's what frustrates us the most, I believe. They did a survey that showed that. The Academy of Family Medicine points out that these prior authorizations present significant barriers to care. They direct valuable resources away from direct patient care. They lead to negative patient outcomes of thinking about the guy that may have taken the narcotic. And that we shouldn't have to do them if we're properly trained and know what we're doing. And I agree with that statement. The American Medical Association and a variety of other medical organizations have a series of principles of this issue. These are all available online and I think at the Green Mountain Care Board website, principle number 20 is of interest to me because it's what the primary care advisory group came up with on its own. And that is let's not have everybody do prior authorizations. If you practice efficiently, then maybe you shouldn't have to do them. And just save the prior authorizations for the physicians and nurse practitioners, et cetera, that don't practice efficiently. And it turns out the AMAs are the same thing. We came up with that independently. If you're interested in what we came up with in detail, that's available on the website as well. We call it the preamble. This was the preamble to build H342, which we tried to introduce into the legislature this year and failed. But the details are in there and I won't go through that document. I think it's about five pages. But it's got a lot of detail and a lot of references to studies that have looked at prior authorizations and found them to be not particularly helpful. These were the recommendations that the primary care advisory group came up with. Eliminate prior authorizations for primary care providers in Vermont. Get rid of them. That's our recommendation after looking at it. The insurance that we're concerned about cost containment, they could redeploy that prior authorization staff to educate providers and patients on appropriate use. Do it as an educational model, but let's not have requires to do it when we get approved 100% of the time. There's medication prior authorizations. There's some discussion about enhancing those systems. The problem is when I'm in front of the computer at the electronic health record and my patient's sitting in front of me and I'm going to prescribe them a medication, I don't know if the formula is changed and so I could prescribe the medication to go to the pharmacy and they get a bill of charge for $300 because instead of a $25 copay. So the smart patients will come back or call and say, hey, what's up? And then we'll go in to figure out why and issue a new prescription hopefully for the same class of medication all designed to save the system money. That's great. The patient that has to go back to the pharmacy and get the new prescription. The primary care advisory group heard members talk about patients that didn't go back to the pharmacy, didn't take the medication, decompensated later, ended up in the emergency room with whatever the issue was and then we have those costs associated with it. None of which have been represented, I think, in any financial assessment when we're looking at the cost that insured, the savings that insurers get. The other two, item three and four, really are about providing educators, providing education from insurers to people practicing medicine to make sure we're doing the right thing because I think we all want to do the right thing. We all want to save the system money and practice efficiently and with evidence-based care. And for those that don't, the insurance companies can educate them a little more strongly or urgently. That's what our group came up with. Here, there's a few emails. These are some copies of emails that in my attempt to get our bill that had the proposal, bill H342, to eliminate prior authorizations. I just pretty much got blown off that didn't get anywhere. But it was an attempt and those are just some emails that I got back from the legislators. You know, when you think about prior odds, one of the things we were talking about is burnout, right? Doctors getting burned out. And that's a really interesting concept because to get into medical school, survive medical school, survive residency, maybe fellowship, you have to be pretty tough. You work long hours and there's a lot of surprises that happen and I got to think that the non-resilient people get weeded out. So when you're thinking about burnout, it's framed as burnout. When you're reading an article, there's something that says doctors are getting burned out. It's not that they're not resilient and yoga classes and meditation and wellness classes, adding those are not going to help. I think it's much better framed in this Boston Globe article that came out this summer that talks about burnout as moral injury. It's different. The moral injury that I think, and when I say doctors I include nurse practitioners and physician assistants, so providers. But the moral injury here is the inability to provide timely care in our system to our patients and having to deal with what the patients come back to us with with their issues. It can erode the doctor-patient relationship. It's incredibly frustrating. It's demoralizing and it happens all the time.  And when you read the article, I encourage you, it's two and a half pages. It outlines the issue perfectly. It's a moral injury. It's not burnout. It's not a lack of resilience. And the way to fix it isn't to add wellness. It's to get rid of the administrative burden. So I wasn't surprised when the American Psychiatrics Association came out at their annual meeting and said that the rate of physician suicide is twice that of the general public. Now I'm not saying that prior authorizations are directly causing an increased rate of physician suicide, but I think that moral injury piece is relevant. And we're supposedly going to have a lack of doctors in Vermont. I haven't looked at this in great detail. This is a VPR piece. I know that's been talked about at the board, getting my care board. It's a threat. So if we're having doctors that are having moral injury or burning out, they're leaving practice earlier. And this is happening in Vermont. This is going to be a real issue, especially I think in the rural areas where it may be harder to recruit physicians. My words only, not that of the advisory group. And you know, what does that cost? And Stanford looked at burnout on their physician group and they came up with 60 doctors that were going to leave practice early. And they estimated there was going to cost anywhere from 15 to 55 million to replace those doctors who were leaving early because they were just fed up and burnt out. So just remember that 100% of prior authorizations that I do get approved, but I have to do them every single day. And then ask me why I want to quit practice. And here's my solution. I agree with the primary care advisory group. I think we all need to think like a surgeon. Someone that has a horrible foot infection, we could do a lot of different things to improve that. We could make sure that they're hydrated, getting antibiotics, maybe improve the blood circulation in that area, do all these little fixes and hope that it doesn't get worse. But there are some surgeons who know, you know what, I have to kind of amputate above that infection to save the patient. And that's what I think we need to do with prior authorizations. I think we need to think like surgeons right now and just get rid of them. Thank you for your attention. Thank you, Dr. Paluso. So actually I would love to just hear from the other two providers on the panel if you want to, we'll stay on the thread of prior auth for a second. Is there anything that you both would like to add just on that topic and then I would welcome any other conversation about burden in a second, but about prior auth. So I can talk about it. I would have stayed up and applaud if I wasn't as appropriate. I absolutely agree with everything you said. My success at prior auth is also about 100% and we go through them every single day and they're agonizing on time consuming. That's how your time consuming was only seven minutes and I had my nurse on the phone for 45 minutes, 15 minutes, 55 minutes for a single prior auth. And they always get approved eventually because they're not more than appropriately. I think by nature physicians, VA's and MP's are competitive souls. That's how we got into school and how we got where we are. So when you show someone a chart that shows them they're an outlier, they tend to self-correct it anyway. So I don't think you need to be punitive to an entire group. I think if you show dad, I know some of the insurance and Blue Cross does that. They show dad and say look, here's where you are relative to your peers. And then I'm blind to fashion. I think it'll pull people in the direction they want to go. And I'll start with my specials. I didn't realize how frustrating the prior auth for a certain procedure was.  And again, they always get approved but they're an absolute nightmare of paperwork and faxing and phone calls. And then in the end result is always the same. They always get approved. The flip side is that once they do the distraction, they're also under-reversed and so they get paid less for it. So they spend more time getting approved than they end up with less money on the back side as well. I'll just add that the time spent by our staffs doing the prior auth is extraordinary. And when we hear from insurers that this is cost effective and it decreases costs to have prior auth, I think that's really because a lot of that cost has shifted onto the primary care practices. And I will mention a little more of that when I do my presentation about how the costs really are not captured. I think accurately. Okay. Fantastic. Well, thank you for that. So let me bounce it over then to Michael Costa. If you could talk a little bit. I know you, Diva has experimented with trying to reduce or eliminate prior auth. So I would love to hear from you a little bit about the results of that experiment, the motivation behind it and some of the results. Thank you very much for having me today. Michael Costa, I served as Deputy Commissioner at Vermont Medicaid and Harvard Vermont Health Access. And I help work on our health care reform efforts. And so just to give you the background that the situation for us with provider administrative burden is one, we hear provider frustration on administrative burden and we take it seriously. We don't do it as playing. We do it as an opportunity to be collaborative to try to make the system work better and take care of our beneficiaries. And we want to empower provider-led reform. I think if you take a look at health care reform in Vermont and particularly the all-care model and ACO-based reform, it's premised on the idea that the provider community is the vocal point of reform. And so as a state and as Medicaid, we're really in a position of trying to help providers by being realistic and collaborative about administrative burden. If you take a look at our ACO contract, where we've done some experimentation about administrative burden, the basic premise for our viewpoint is that if providers are willing to take on financial risk, then we should give them more freedom and flexibility, particularly around prior authorizations. And so the ACO contract, which the state started in 2017, tried to deliver on a very simple talking point, which is if you're in the ACO through the waiver of prior authorization. Now that's the situation. The complication is that we had never done that before. And anytime your talking points meet your operations, there's some sort of clash and you have to figure out how it's really going to work. And so the key questions for us were one, how do you implement it? And then are we as state government capable of incremental improvement if it doesn't work the way we want it to work? So what happened? And I think it's useful to just kind of follow where we've been and where we're going. In 2017, when Diva first worked with OneCare to have a prior authorization waiver, that talking point was so simple. It seemed like a term type and the gauges went up. Everybody chose to drive through. That is certainly not the way it was.  What we quickly learned was that process was more cumbersome than prior authorizations. And so instead of saying, oh well, we tried, we went back to the drawing board and said, okay, OneCare, we're committed to that idea, how do we improve it? So we made some incremental improvement for 2018. We said, okay, it has to be an attributed member and a total cost of care service, but it doesn't need to be a participating provider. So in other words, the prior authorization waiver followed the person. Now it still involves seeing whether that person is in the program and it's a relevant service. And so it's simplified a little bit, but it's not totally there. And what we're thinking of trying to do in the future is to, for 2019, hopefully piloting at some point, a prior authorization waiver that follows the practice. So if you're in a non-practice and you're in the ECO's network, to the extent you have one person on your panel that's in the ECO program, we'll just lift prior authorization for the whole practice for Medicaid medical issues. There are some operational issues in trying to bring that to life, but we're really committed to trying to pilot that. Under, and really looking at that as a fulfillment of all care models, goals to try to make it sort of the rules that stand across all three payers and to allow some real freedom and flexibility in the way people practice. And so we're trying to get there to a point where that sort of freedom and accountability match up pretty well. I think the other thing, so the three big lessons we've learned are, hey, we need to be flexible, and I'm hoping we are, and we're really grateful for One Care's partnership as we listen to them about what their provider network is seeing and how we might improve it. Two, communication needs to flow up and down in science. We have not always been great about particularly what we're trying to do, why we're trying to do it, and how it's supposed to work. So we've taken that to heart, and we really want to work with folks. For example, we're seeing a lot of bells and suspenders where people who have a PA labor are standing in four many ways. And so we know we have a lot of work to do to make sure people are educated so they're not engaging in something that's a waste of time for them and a waste of time for us. And then the third big point is we need to be realistic about the limits of administrative simplification. And so we learned something here that we talked about prior authorization labor in a very simple way. There's a gate, it's open. What we learned though is that it really isn't about utilization management in an ACO based world, it's about patient care and safety. So to give you an example, we've now learned that the prior authorization waiver probably has some permanent limitations. And this is particularly true around durable medical labor. Where, you know, if you're setting up a lift or someone needs to get help getting out of bed, we want someone to check out whether that's safe, right? You could really harm someone. So we think there's going to be a small subset of codes that just aren't appropriate for a PA labor. And right now in our initial look at it, it's mostly durable medical labor. And so instead of talking about it as utilization management, we're trying to talk about it as patient care and safety which is for most codes, what your practitioner believes is best is the right thing and we're going to weigh PA. For a small subset of codes, you know, probably as a matter of patient care and safety, continue to require some sort of authorization. And I just give that example as a point of, we all need to have an honest dialogue about those limits of administrative simplification. Speaking for myself, I don't think we're any of our close to limitations. I think there's still a lot of progress we can make collaboratively to get the world in a place where you're spending more time working with people on their health and their concerns and our administrative roles. But I think at some point we'll get to the edge of the water where it's okay, we've gone as far as we can, but even in a capitated world under the ACO, I still want shadowpanes to know what happened, right? On some subset of codes, I'd probably still need someone to check in to make sure that wheelchair fits right so that nobody ends up with soaps. But we are really good at talking to folks and seeing what we can realistically do. And I think most importantly given the culture of state government, I'm really happy that this has been an iterative process and we're trying to make continuous incremental progress to be helpful to the provider. Can you just speak a little bit about the impact on costs as a result of the prior authorization waiver? So in a little bit, for us it's interesting, we think since the prior authorization has been a little way where it's been cumbersome up front, we're not really seeing a change in the number of prior costs, right? And so there is, it's hard at that point to figure out whether it's driving changes in costs but I would say that at some point this week we will publish the 2017 PCO program results. And I think we're going to be really careful about what we can say definitively about it given the fact that it's one data point. But no, it will be interesting to follow that over time. I think like most insurers we do utilization management because we have a hypothesis that one, it works financially and two, war is not always better in health care so just want to be careful about what people get. But we're very much willing to take a look at it. I would also say one of our ideas if you're not weak, we definitely talk about bull carting some folks to the extent some of them score as 100% over a period of time. That creates a persuasive argument that we trust their judgment and there should be a simplified process. I don't think we've got to the point where we're ready to launch something like that but it is certainly part of our current dialogue at Diva about whether that's an appropriate response, particularly for folks that are part of the financial accountability that is the accountable care organization. So maybe I'll ask Dr. Ward if you want to talk a little bit since one care has been part of that conversation about going ahead, how can one care, Vermont, attract providers into the network by expanding some of those PA waivers or other types of administrative burden reduction? Can I say that the PA waivers for imaging procedures and medications were not included in your employee brochure? No, it's still constrained to the total cost of care so if things are in there, for example, prescriptions are not in there. We are having a good dialogue internally about whether that makes sense and about what happens outside the ECO program and so I'd say for us everything's on the table but so far our efforts have been in that ball of services that are inside our ECO contract. But we get that to the extent you're doing one thing one way and one thing another way that that's part of the practice and so we're talking about how much financial risk we're willing to bear in service of really testing administrative simplification of the system. So I want to echo Michael's comments about the cooperative effort that has been going on between one care and Diva in relation to trying to wrestle with thorny issues. When the waiver went into initial formulation in 2017 Diva asked us and we were interested obviously as well to take the sum 800 different codes between durable medical equipment, every single different kind of imaging study that you might get. Certain formally prior authorization requiring surgical procedures and certain laboratory tests. So about 800 different codes and so we created an app using the claims data that Diva would send us to basically trend over time. Okay this is the PA waiver went into effect on February of 2017. What is happening in fact to the rate of imaging MRIs and CAT scans for example. And I think we've shown some of that data to you at the Green Mountain Care Board. So the long story short the trend is basically horizontal flat. Okay so the assumption that somehow no longer having prior authorization would cause skyrocketing services was not worn out. But again to reflect what Michael was saying we're really not sure how many, how the behaviors didn't change. Were people in fact continuing to seek prior authorization anyway because they couldn't figure out whether patient A had attribution or patient B did not. And so we really have not yet had a great test of the premise that removing prior authorization is going to result in increased expenditures and volume driven services. I would also say that the other premise to realize is that in a capitated model at least those entities within one care that are on a fixed payment which reflects the hospitals, the hospital employee, clinicians and the primary care practices that are participating in our CPR pilot the financial arguments for do more, get paid more has gone away. That's not to say that there might still be volume driven motives in the rest of our network that is still being paid for service but we really have not seen that. I want to give Dr. Flavin and Dr. Kilby a chance to respond to the emotional, the passion that we heard from the providers about the administrative burden that prior offs are taking and to some extent some of the experimentation that's being done with one care in Diva with reducing those waivers. I'm curious to hear from both of you the value to you of these waivers, I mean of these prior authorizations and to the extent that you've explored or investigated reducing the usage of that to reduce the burden that it's imposing on providers. Good afternoon, I'm Kim Kilby since finishing my family medicine residency here at UVM over a decade ago. I've been in various positions that look at the intersection between the care of individual patients and the care of populations and that's what led me to MVP. I started there in June. I started in August, which includes Vermont and also Capital District in Northern New York. So I'm happy to be here today. I think there's a couple of things and I'm still learning. However, the MVP is an active negotiation with one care and I think from our perspective we have not become part of the all-payer model yet and so we're certainly looking at that and very excited about some of the work that they're doing with Medicaid and trying to figure out ways in which you can reduce administrative burden and not have a negative impact on patient care decisions and I think from my perspective a lot of what drives some of the prior authorization is cost is important but also the right care for the patient and not overtreating excessive care and that maybe sometimes things don't have to be done. So we're really anxious to really see the outcomes of how that experiment has been going and certainly willing to partner on similar efforts once we become part of one care. I think the providers that spoke, you have 100% success rate with your prior authorization but that's not what we see across the board with providers. Otherwise, I don't think any of us would be sitting here. None of us want to waste time. We don't want to waste our time. We don't want to waste your time. We don't want to waste the patient's time and I think the numbers are different than 100% all the time. You've spoken about radiology and pharmacy and we've also heard a little bit about VME and all of those have different rates of approval and denial. I looked at our information before coming here today and we still have over 20% of the primary care physician radiology requests result in a denial or withdrawal of that request and so I think and there's a variation between primary care requests for imaging versus specialty requests for imaging. They have a lower denial rate so certainly we're interested in any ways to collaborate on what's still going to make sure that we get the right care to the right patient and the right test is being ordered but we know that it's not perfect in terms of the providers always choosing the right test for the patient's clinical presentation. On the pharmacy side I think we are actively working on ways to improve our pharmacy practices at the same time as high cost pharmaceuticals are really driving a lot of strain on health plans but I also think on every part of the healthcare system but we look at our policies on a regular basis. We've removed 28 drugs since January of this year from the prior authorization list and that's constantly changing as drugs come in other drugs come off and then there's just a lot of very high cost medications that it's important to ensure that that's the appropriate medication for the patient and so that's what that prior authorization process is intended to do. I think that you may hear more about this but I think if we go back five, ten years most primary care physicians were really excited about what the potential for electronic medical records that could maybe help reduce this burden and we haven't seen as great results across the board. I think there's some potential for real-time benefit determination when prescribing pharmaceuticals that is another EMR electronic real-time modality that could help and certainly we partner with Pharmacy Benefit Manager CVS Caremark and we're looking at ways we can leverage that. So I think there's a couple of different there's several different topics we're talking about here and I think it's also important to sort of talk about them separately because they come with their own issues and justification and reasons. So I'll just say that MVP really is focused on what's going on in Vermont which is very unique and looking at the benefits and the exciting outcomes potential of what OneCare is doing and becoming part of that process as well. So let me just follow up quickly with that which is I'm encouraged to hear that MVP is seriously having conversations with OneCare that's wonderful news but let me just ask specifically you had mentioned that there are different radiology maybe different than other areas primary care maybe different than specialty care so specifically to the suggestion that was made over here about having a gold card I mean is that something that MVP is seriously exploring of identifying those providers that maybe clear indication suggests that they're not overutilizers they're not prescribing additional unnecessary treatments giving them a gold pass I mean that seems like a compromise in the middle if you're really trying to identify the overutilizers and the unnecessary care identify that and then have the prior authorizations and those that are clear underutilizers or appropriate utilizers How serious are those conversations? There's conversations happen on a regular basis for Vermont we're certainly focused on the OneCare negotiation and arrangement right now and we're constantly looking at ways in which we could have a program that could allow to reduce these burdens and still get the right care to the patient and I think whatever program that is has to be fair and it has to be driven by data and I think that's the data pieces really where some of the some of the it just hasn't been clear yet and again we're very excited to see the data behind the OneCare Diva approach and certainly would be willing to consider something like that if the data is there to support that it's a good idea for our patient safety not just cost So if I could just follow up on that question I feel like I only talked to the good doctor because the doctor that I spoke to is like Ivory Snow they may not have 100% record like Dr. Paluso but it seems like they're 99 point something percent pure and do you have any distribution it sounds like you're collecting data on denials what is the range of the distribution of what you consider the gold standard for Dr. Paluso of 100% what would be the worst case scenario that you have as far as denial rates and what is really the the standard deviation and things like that I don't understand deviation but I have something so to answer that specifically we have a double pair model in the ACO they have a gold carding pilot and in fact you probably know the mountain care board led up pilot as well in radiology but the Medicaid pilot had some parameters in terms of how many and it was specifically for radiology how many studies you had to order in a year and then what was the impact what was your denial rate as it were and so we modeled that with our population here in Vermont if we use the Medicaid criteria I would only be able to using their criteria would be only be able to a gold card 80 providers in the state Dr. Paluso being one of them and just to give you kind of a size the average denial rate is somewhere in the 15% impact there's really very few providers very few that are below 5% and most of them range between 5 and 25% which with the kind of education zone being above 25% and this is using I mean I look at radiology as being a commodity it's appropriate use criteria all of the criteria that are out there are very standard dictated by the American College of Radiology we are actively talking to the ACO mirroring the DEVA approach in radiology but you have to look at well I can talk about administrative burden having been a primary care provider in the state of Vermont and it depends on the eye of the beholder when I was working in Chelsea it was the EMR and it was DEVA pharmacy it wasn't radiology for me it was Medicaid and pharmacy so that you know there's a lot goes into the burden thing P.A. is a piece of it P.A. is one of many ways to control or incent the appropriate use pharmacies it's own animal because it's about adhering to formulary, step therapy quantity limits and safety and it's less about P.A.'s P.A.'s are maybe a mechanism a better way to do that so what providers want what we heard in the primary care advisory group is transparency and easy access and convenience to just know what's within the realm of appropriateness in terms of a formulary to prescribe their patients and a real time prescription benefit program is currently live in Surner at Rutland and Brattleboro it went live about a month ago so we're actually in active contact with them because it will take we're on one side of that program and the providers on the other side and we need to talk to each other to make sure that it works correctly but that will be a significant advance it will be rolled out Epic as another EMR in November I believe and then other EMRs are also moving in that direction and that's a little complicated because there's a middle man within that called sure scripts so Dr. Ward knows so we do need to be in close communication and push on both sides of that issue to make sure that process actually gets to where we want because then I certainly don't see a need for having as much requirements around PA if it's built into the system medical procedures things that are on the edge of standard versus still being studied new procedures there's going to be continue to be some criteria for that I think and a need for that those constantly evolve we retire policies we put new policies on those are less the biggest impact is radiology and pharmacy so if we can step forward in radiology in partnership with the ACO and through the all pair model to monitor utilization educate I see no reason why we couldn't evolve our processes on the pharmacy side I think we can use technology to get where we need to be because that is a very complex thing the formulary at Medicaid versus Blue Cross versus MVP is all very different and that is to some degree of safety issue to some degree of a cost issue radiology and medical procedures are more very straight evidence based appropriate use criteria so that's where I just wanted to start I look forward to the discussion I want to hear innovative ideas I don't think that I think Mark's on the right track but I think it's too blunt an instrument to mandate elimination of all PAs let's work together to eliminate some let's work together to use technology as best as we can he's not wrong in saying God the pair hope it wasn't us the pair who required the PA for celibrex knew the patient had two inpatient visits for a GI bleed and should have had sophisticated enough technology which I admit we don't have right now to identify that that patient didn't need PA that's a great suggestion so I think there's a lot of opportunity how do I make those opportunities happen this is a wonderful couple hours we're going to spend together here but to some extent this is going to be the conversation everybody's going to go back to their offices and we're not going to come up with some solutions that are really workable so I'm wondering sounds like with the live prescription drug in the EMR you mentioned the 80 providers that might get a gold pass my guess is if 80 providers get that gold pass others are going to want that gold pass I mean you're going to start the competitiveness as was mentioned I think could encourage other providers I'm wondering that seems like a really workable potential solution that would be cost effective still because you'd be targeting the group of providers that are overutilizers and relieving the other providers of that burden I'd love to see outside I think one care is a wonderful vehicle to try and reduce some of this burden but I also think that not everybody has access to one care or is going to be in one care for a whole host of reasons how do we also reduce the burden for those providers so this is brand new about three weeks ago that I actually got what I asked for which was a modeling of how we would do this and so that's a question of just implementing it so no I have no problem doing that I certainly also want to look at some alternative models as well because I think that just well that ships away at it it helps a little but if Dr. Ward can monitor utilization, identify outliers and work in a provider led fashion through the ACO I think that's a parallel pathway that we would be willing to go down Before we get off the topic of prior-offs I want to open up the questions to the board about prior-offs but just see if anybody on the panel who hasn't spoken yet or has some ideas about prior-offs would care to contribute any ideas so a couple so some of this is an out-of-life administrative we are also speaking as a provider here but one area where I noticed prior-operations were substantially less of an issue and the reason will be obvious was when I was in the VA Medical Center in Philadelphia and this was just a student but nevertheless and the reason was consistency and you knew what the formulary was and the progression of which medications to be used it was evident space was agreed upon and the other circumstance in my professional career where I've seen a glimmer of that was actually when I started primary care in Vermont and the Medicaid state formulary there's so many of my patients for Medicaid it's at least something you can keep track of it's not perfect we've heard some examples of what ways it can be better but if the formularies were universal how and where to start and I wouldn't have to go through what the patient's coverage used this I agree there's some opportunities for our health records to help us with that I will say that as the biggest provider of services in the state we do not get happy electronic health record technology that is crisp enough to leverage to know the patient's health plan so the University of Vermont Medical Center has not put that in place I think it's unlikely would be extraordinarily helpful the other situation that I think I'm curious in my provider colleagues would share this frustration when you have a patient who's had a chronic condition for years and there's very good reasons that they're on the medications they're on having to go through that prior off on an annual basis is extraordinarily cumbersome and we actually we almost have to pull some staff offline after the first of the year some big costs and it inhibits our ability to take care of other things in the office because all of a sudden we have to have all these people invested in this process and it's the same story as last year right or maybe it's the exact same story that would be easy often we do send the same information but we send that information last year that the story might be a little bit different so if there is some memory built into the system that can understand and I understand it's a little bit challenging to understand that right so you know and it's based on condition change et cetera but having to go through that and in the worst cases is our patients who've been suffering for a long time you know it took us a long time to get to this medical regimen for them and they're getting some piece of I think we have a couple specific patients right now finally we make the medication with a chronic condition due to chronic medical condition because discomfort every time she eats and we finally found the right set of medications and as soon as that gets blown up and it happens with some periodicity she said okay I guess I'll be in a comfortable weekend again for the next couple of months so if there could be some memory in the system ours too like ours as well that would be a big problem so MPP and Blue Cross have three-year prior odds just so you know we don't do annual I get it well it's churn but yeah that was addressed years ago that ships with but we still absolutely see a problem in our practice so it's good and fast that's a great start does MPP have what is the is it annual? three or four chronic conditions like Jim's talking about I just wanted to make a point about the payer that's not on the panel today is Medicare I don't think they're in humans Medicare the Part D Medicare insurance policies for medications than any of the commercial or Medicaid formula so there is no Medicare is not distinguished as being better in that respect because it's the same type of formillary maintenance on the other hand Medicare they don't really have prior authorization they have local and national coverage decisions and if any of the clinicians here providers of care in the state start doing things that are not meeting their criteria often retrospectively they will be denied payment so it's an after the fact you didn't understand the rules you went ahead and did it anyway and we're not going to pay I mean I spent years of my life arguing with the recovery audit contractors and Medicare trying to justify why somebody was sick enough to be admitted to the hospital so it was a retrospective battle to retain the money that you've already been sent and not have Medicare take it back because of conflict about whether something is medically appropriate so I just bring up Medicare because they don't have continuing stay review utilization review in the hospital historically many insurance companies have demanded why does the patient still need to be in the hospital today if you can't come up with a good reason we will stop paying you you can keep them in the hospital but there will be no further dollars coming because we consider them not to be sick enough with Medicare that doesn't happen if you decide they can stay in the hospital they can stay in the hospital because that's the right thing to do I would just add one more thing there's that moment when you're sitting on a panel in front of the state self care regulator and they're like you're the only non-provider lawyer and Medicaid administrator so I would just say that to me gives me one quick advantage which is I don't have the personal history of all this stuff and sometimes I think that strategically we need to do some forgetting because I'll give you just a quick example we've been really trying to re-invigorate our relationship with Dartmouth Medical Center they had some real frustration with us about the way residents got into our system this is evidently something we've been trying to fix for years with us and they weren't telling us it was just kind of one of those conversations where everybody had their grievances and then once we figured out what they wanted we were able to fix that in about six months and that's a long way of saying it's not always the parent to us in these conversations that have been going on for a long time and that's a big thing you want us to solve so I think it does take some forgetting about the past battles to say here are the three things we really want and we can all agree on what the three specific administrative burden problems we want to solve are and we can make some incremental progress and so our team is as guilty of it as any but I'll tell you when I talk to our clinical operations unit they are great folks but they've got some lots of reasons you haven't done this for a decade which is hey let's try to be open to having these conversations in a new way and having some really specific problems that we want to solve and actually with that in mind I mean in some ways if we were to have this meeting a year from now my hope is that the conversation is not the same one and how do we ensure that the conversation is not the same one what's going to happen between now and say a year from now I don't care vehicle seems like that's going to be an appropriate avenue for many of the providers in the state I just want to make sure there's some what are the action center what are the meetings or something that can actually make sure these conversations continue I throw that out there without an answer I don't have an answer to your question okay then we're moving on I don't know that we're exactly moving on I have some things I wanted to say so I'm actually going to Jeff write to you in a second you're going to be my next person I just want to make sure that the board also I want to ask if you guys have any questions about specifically prior off and then we're going to jump to you about other administrative groups but I wanted to kind of go through this be read all at once could I just say one other thing about putting in a plug for scale targets it's just to say that any of the clinicians here the ACO programs they are having the foot in both canoes and they have to have two separate processes so we are hoping to promote as Vermont is with the all pair model trying to promote a larger and larger percentage so that the familiarity of the clinician community will be understanding what the prior authorization waivers actually mean for them so that their staff can become familiar with that so my question is actually related in some somewhat to scale somewhat to Norm's previous point around you know Medicare and Medicare rules but I think is really targeted more to MVP and Blue Cross I'm because what my thinking is to the point that we don't actually have local payers here and in fact the largest group of insured Vermonters outside of Medicare and Medicaid are in the self-insured employer market which quite frankly the state is not allowed to regulate and currently is a very small piece of the ACO how do we attack some of these same issues around prior authorization in that space because I think it would have to come from the insurers who are providing third party administration services to those employers so it would have to be you know obviously to get those lives in that population means that they would have to purchase that as a product and as part of that product would be a implicit buy-in into the contractual arrangements with the ACO which with all the same with the same structure as we might with our health exchange population so I think it's kind of making that approach standard through the product would be probably the way to go because you're right the problem with the self-funded population the client has every right to choose not to pay for the blueprint for example and that does happen and so we need to be able to translate value to our clients in a clear transparent way and we can conjure them and say this is a really good idea but some of our most of our clients are not unsophisticated and so say prove it to me show me the value of working with the ACO why should I be involved now so I think that's a good point one of that point I wanted to add to the scale target is there was a good RAN study about provider behavior and the population of your patients who you see who are involved with the value-based program of some sort probably needs to be more than 30% for you to actually change your behavior otherwise it's just kind of an annoyance and most providers don't have a way of identifying exactly who's ACO attributed and who's not so I'll just PA everyone in a sense in addition if I were to go forward with a gold carding pilot I think about for a second and just to use this example sorry you know I don't know that I don't know off the top of my head if next year he'll have 10 Blue Cross patients or 100 and so just looking at monitoring utilization through one payer's perspective may not be enough especially if you're talking about something like radiology or the standards could there be pooled a pooled approach to that in terms of taking data from multiple payers to identify the gold card do you see what I'm saying I don't know how to do that but maybe Norb can help me think about that but I think one of the problems with this is that it will preferentially identify in a given year those who see a lot of Blue Cross patients if I could just follow up I appreciate those thoughts because to Jess's point like in how do we know we won't be in the same place next year I can actually see a next year where Blue Cross MVP Diva have made great great strides but Dr. Paluso is still pulling his hair out because you know perhaps that's a subset of his patient population and isn't enough for him to really feel the difference which is why if you go back to these small steps towards eliminating the burden I'm sitting here listening thinking when is it going to be done when is it going to change and I don't hear it so I want to leave practice as soon as I can I love taking care of patients but one very percent of what you do is paperwork that doesn't help them sucks the joy right out of the out of the job and I'd love to flip it around and say hey Ramon we don't have to do this we figured it out we took a little bit of a risk financially we said let's get we're to prior authorizations you want to come practice where you can take care of your patients freely and openly we're on board with that let's go come on in I think it should be great and guess what if you're an inefficient provider of care if you don't play by the rules they're going to be coming and knocking on your door and saying hey what are you doing and it would reward the people that do a good job and I think it's a simple solution I think like a surgeon it doesn't solve your self-insured problem though because we could pass that Vermont line and attack that group okay that's too bad it is too bad anybody else on the board want to jump in on anything on prior office just one quick question MVP is the fact that a small portion of your overall business is in Vermont versus New York are you do you feel at all fettered about making decisions here in Vermont that are good for Vermont but we may be ahead of New York in that regard do we feel what was the word I missed the the word do we feel fettered fettered okay limited yeah okay burdened so no I think we look at Vermont and New York as two completely different animals because they are and actually I think how much membership we have in New York state actually is a value add to being able to bring ideas to the table here because it's Vermont is doing some really interesting unique things in a very different way than New York state is doing some interesting unique things with value-based care arrangements around the state so also our membership is growing in Vermont so we are excited about that that's why we're an active negotiation with the all-payer model and to be at the table and I'm looking forward to being at the table with more of the very interesting work being done here in Vermont we had a nice meeting with the blueprint this morning and so learning about those things as our membership is growing again in Vermont is very important to us does that answer your question okay first I'd say I think underline everybody wants to give the right level of care to the patients and I think on both sides but I wonder you know if we you know kind of dive into some of the costs and perceive savings so I think on the insurance side right we may say okay if 20% is denied you know that's a savings but I don't think we have a comprehensive understanding of what all the other costs are that are in the system on both sides so I mean I think on the insurance or on the phone for 45 minutes you know that's costs that you guys are incurring for all of those you know people to manage that side of the service and on the you know practice side obviously you have all those people on the calls as well but not only that people may be circumventing by like we said going to the ER and having all these other ways to maybe get the same thing you know Don so I mean to the system but I don't think we really have an understanding you know I'm just throwing out there of really what the costs are both from the insurance side to monitor it from the practice side and some of the things on the practices side we've brought up is you know we don't have enough primary care practitioners right and if you're doing less of this on your job then we don't need as many more to fill you know it's not always the practitioner somebody else in the office but you know there's a whole bunch of different things in there so you need then less recruitment and stuff so I'm just throwing out you know in general and maybe it's something whether the board can help follow up on but you know how do we understand from a cost side what the true costs are because we you know we think kind of the savings but that's that's really businesses felt that overall this wasn't increasing their costs why couldn't they do away with the prior costs too you know if they looked at it as it's really not saving costs I mean it's I don't expect an answer but I'm just kind of throwing out that you know it brings up with this team that's up here and you know and a lot of smart people in the room how do we figure out you know really what is the cost of this in total there's other ways to get costs out of the total system that met to the same place you know rather than just if we took prior off the way insurance rights might go up because you know we're now paying for more maybe but maybe there's some offsets with you know eliminating groups and things like that I mean it's leap of faith but possible solution from Michael with a gold card type program we've heard responses from insurers but the ACL really is a coalition of the willing and for it to be willing the providers really have to be excited about participating in your organization and at the end of the day the cost of your organization has to be less than the overall saving so what is one care environment where doctors don't have to seek prior authorizations as often and have you had any success well first the the fact is that we're not taking risk on pharmaceuticals so our participants and you know as a practicing family doctor as well trying to keep track of 40 different Medicare Part D formularies the Medicaid formularies the Blue Cross formularies the E formularies and all the different phone numbers that one must know to call those many many entities that is I think as Josh stated is the the biggest burden and the most hassle is the pharmaceutical and we don't have much leverage in that area so setting that aside I think you've you've heard our our best efforts with Medicaid to try as best we can to inform our network about these about these issues it's as we've said mentioned already it's tough to socialize something that is you know a small percentage of your practice to be able to have processes in place that everybody understands I've already mentioned that the the capitated model of where you are at financial risk and doing a procedure or ordering a device that is of questionable medical indication will come back around to adversely affect the so I would also suggest that that uncompensated care or uncompensated duties are another sort of thing that we are talking about here but haven't named it as such the fact that the family doctor and their staff is being asked to do work and pay an hourly worker let's say to sit on the phone for 45 minutes to the benefit of you know on the commercial side the employer was seeking lower healthcare costs to the insurer seeking less expenses to run the program but it's on the backs of basically uncompensated care for people that are benefiting none financially from doing these tasks so we are trying as best we can the other distinction here is talking about administrative burden and I don't want to jump ahead to the the fact that we are in a population health care model evolutionary base so that there are tasks in fact the ACO is asking of primary care clinicians and specialists for that matter that reflect trying to elevate the care of our patients within a more coordinated system interacting in an organized way with community agencies for example and that has been you know people have complained about our requests to use care navigator for example and that's considered a burden as well so I think we have to make a distinction between administrative tasks versus tasks that are at least we're trying to pay for those tasks in terms of our complex care coordination program for example making payments so that those tasks are are connected with a reimbursement for doing them I think the problem is we're in an environment now where it's just another task provided that this is a task and since we're the last ones in it feels like it feels like we're strong that both can impact comment on that a little bit you know at one primary care advisory group meeting I said okay we don't seem to be getting anywhere what if you just said let's stop doing as doctors you know I go around the states all the hospital organizations when they have their staff meeting and say let's stop in 2021 let's just say we're done and you guys figure out how we're going to survive without them without the pyrots and the response was that will never work because doctors won't do that to their patients you're not going to deny your patient care because it for something you think is a waste of time leading to moral injury leading to career dissatisfaction maybe leading them to have adverse outcomes or delays in care you're not going to do that to your patient and so the theory wasn't going to work I think any solution that you come up with has to take that into account because we all want to do everybody here wants to do the right thing for the patient sitting in front of us right the patient sometimes doesn't know they don't know really what the right thing is so any solution has to have an education component about what to expect I use an extreme example watch football on Sunday guy goes down and gets his cute cusser there he goes into the tunnel he'll get his MRI in five minutes Johnny on the football field high school football field thinks he should get the same thing and then they go to the emergency room and they said yeah I got my CT scan which was completely not indicated if you go by appropriate use criteria but they don't need to because it's a neon repeat that anyway I don't know if you can follow that but we have to be all educated providers in the public what's appropriate if it's going to work so their expectations are met and they don't take everything solidified radiation or a medication or something I want to if I could just echo echo that the the statement about the emergency rooms you know there are clear criteria for instance for when you need an x-ray of your of your sprained ankle ERs never follow those those people get x-rays before the provider even sees them there's your x-ray on your way in the door that you it is you are hard pressed to get in and out of an emergency room without a cat scan of your brain if you have a headache it's very frustrating as a primary care doc to be judicious about use of technology and see your patients get wildly over treated in emergency rooms and boy if you wanted to do something to help morale in primary care start asking for some adherence to to guidelines in emergency rooms and sometimes CTs are dangerous there's literature out there about ionizing radiation of the brain leaving cancer later in life it's theoretical but it's out there and we use that argument that a Canadian CT role works for head injuries and things so let me actually one of the things I want to make sure to hear about other issues besides prior odds and I want to move on to that but I do want to say that I hope this is the last conversation that we have about this and I think we've learned a bit here and we'll have to figure out if there's steps that we can take but I hope that there's steps that we take in here among some of the groups here and these continuing conversations will happen so it's about yeah thanks I'm Fay Holman I'm a family doctor in Welsh River a small town over on the New Hampshire border and have been in practice there for 25 years and I just wanted to spend some time about another aspect of administrative burden in our day practice and that's quality measures and I want specifically to talk about why when you're looking at quality measures you may not really be looking at the data that you think I know we have complained bitterly people in primary care about quality measures over the last few years and I I'm afraid that it might be sounding like we don't want to be measured or don't want to be looked at and I assure you that family docs are very interested in their quality of the care they're providing and especially when the data that they're looking at is accurate and shown to have I have been asked at one of these meetings previously to come up with some ideas for quality measures that I would find useful and I actually will have an answer for that for you today but I want to give you three reasons why when you're looking at quality data you may not be getting the right impression from them you may be looking at erroneous or misleading data the first is about the true costs of collecting the quality data 7.7 full-time equivalents or 7.7 primary care providers that's doctors and nurse practitioners we have 6.6 full-time equivalents of technical support so almost a full-time person per provider who helps us with the IT the informatics which is actually the electronic record itself and medical scribes who input data day-to-day with the patients if you're looking if you're hearing from people who are improving the cost of care you have to ask some critical questions about what was included in that cost of care whether that one-to-one ratio of support technical support to provider is really a use a good use of our resources I also want to mention that in that almost one-to-one ratio I didn't include the time that our front desk and our nurses spend with prior offs and that the providers spend with the quality data in the computer so this is really just strictly technical support a second example I'd like to give about the data the quality data that you're looking at being fraught comes from an experience in my own I'm going to give you two examples one of where data can look a whole lot worse than it really is and one of where data can look a whole lot better than it really is and the one about looking a whole lot worse comes from my own experience when last year I was given a number of results in saying that I had 90 patients who were overdue for colon cancer screening I was really concerned about that I think I'm pretty thorough and have long-term relationships with my patients and I wanted to dig into that to see what I had been missing why I would have 90 patients that were out of date and I'll go through this quickly I'll just mention four of them were not my patients they were just attributed wrong in the computer 75 for colon cancer so they just shouldn't really even been in the print out but they were why they could get a list of people starting at age 50 but not cut it off at age 75 I don't know but it wasn't done so that got me down to about 54 patients 11 of them when I actually looked one by one individually into the computer had actually done adequate screening with something called a fit test that's a little kit that you take home sample to your provider 11 of them had done it and it had had a negative normal result but because of some technicality about where it got logged into the computer it has to be linked to a certain code it has to be in a specific box for someone doing informatics to find that data so 11 of them were up to date with fit but couldn't be found in the computer and four of them were up to date on their colonoscopy and couldn't be found in the computer and again with a little easier to understand it's done off-site it comes to you on a piece of paper the colonoscopy report someone who touches that report who scans it into the computer has to remember to open up a whole new box in the computer and mark that the colonoscopy is up to date and that had been missed on four of my patients an additional four had a fit test at home I'd seen them within the last month they just hadn't turned it back in yet an additional two had colonoscopies on them and they just hadn't been for their colo yet there were eight people who had decline screening even after discussion of the risks that's their right there's not much we can do about that and so then I ended up in the end with 25 patients who were out of date two of them had been given a fit test and hadn't returned it to us that's something we could work on in our office to sort of follow up on the people who don't return them 16 of them 16 were overdue for their routine physical that's when you deal with things like getting people their colonoscopies and that's another thing that we changed within my office to try to make sure people over 50 were at least showing up for a preventive care visit once a year and being a little more proactive about bringing them in three of them had come to their physical exam their routine physical with a very acute problem shortness of breath muscle weakness someone with a leg wound that hadn't healed in five years so they didn't see me about it so there were three of them who came with acute problems and the preventive care visit sort of got jettisoned and that's a learning point for me I should not try to do too much on that visit and that's a little hard for patients to understand they would like to be able to come once with their list and get everything taken care of so there were a couple of things there that I could do differently to capture in the end with all of those scenes for regular routine care and had forgotten to get them their fit test or recommend their colonoscopy so three and the report said 90 initially the vast majority of those numbers had to do with informatics and data collection not provider behavior and I suspect that that would hold true for all different providers there's no reason to think that that isn't typical so that's an example of quality data looking alarming and actually being and the other example has to do with quality data that looks fantastic and actually might be a little bit alarming many of us in the electronic record era have resorted to using templates for our visits these are pre made visits for diabetes for instance or congestive heart failure so that the office note has everything pulled into it already when you start with the patient and by that I mean the patient is already in there the review of systems that's when you invite a patient to tell you anything that might be bothering them shortness of breath yes or no chest pain yes or no and those templates have the patients answers and the results of what you found on your physical exam already in there and plopped into the note before the patient walks into the room that's how we sort of keep our heads above water in primary care many of us the idea is that you're going to go in afterwards and take out the things that you didn't ask and take out the things that you didn't examine on the patient and human nature being what it is when you're running behind and you're underwater if your note looks done you're probably going to move on to the next patient there's a tremendous amount of inaccuracy with what's getting documented in patients notes and specifically about quality measures one of the things we're graded on is whether we do in a diabetic foot exam you are likely to record under the skin section of physical exam that the skin integrity is good there's no breaks in the skin you are likely to record under vascular that you can feel pulses that there's circulation to the foot and under neurologic you're likely to record sensation whether that patient has diabetic neuropathy or not so all of those things are captured in your physical exam but to get credit for it as a quality measure there's a separate box that says diabetic foot exam yes, no it has nothing to do with the quality of exam it just puts in the date that you did it it doesn't give you a right and a left foot it doesn't even give you the choice if your diabetic happens to only have one foot but you get quality measures for that box being ticked naturally on the diabetic templates that box is all in there ready for you so if you're looking at data on a provider that says 100% meeting the requirements for the quality measures the first question the first thing you might think is that must be a fabulous provider fabulous physician but the second question ought to be where did that data come from was it real there's a whole second conversation we could have about templated medical notes that talks about the cost to the system and that's separate from this quality issue I would encourage you when you go to your provider next time to ask for a printed copy of your note and see what things they've documented they've said and done and you've told them in your note from that day you'll be amazed but it allows up coding and up billing and templated notes I think are not generally done for purely money and cynical reasons but they certainly can be used that way that's a conversation for another day but get your notes and look at them you'd be interested in the story on the other day when we talk about this about my daughter's $680 sore throat visit to an urgent care center so I'll just wrap up I know I'm taking a lot of time by saying that quality data is an enormous administrative burden to us in primary care and it's a really really questionable accuracy often please bear in mind the extra labor and cost to the practices that it takes and the decreased for patients that we're able to see because we spend so much time on it and when you really want to think about quality measures that don't require a lot of administrative burden but might be very effective in confirming that quality care has taken place I think it's two questions one does do you have a primary care provider with whom you have a relationship and have you seen them for preventive quality so I'll stop now I just do want to say that in our practice we're the only practice for 30 miles that provides opiate that provides a mat program for opiate addicts we're the only place you can get OB care for a 30 minute drive we take new patients insured uninsured whatever insurance you have we take walk-ins we do home visits the whole shebang in rural Vermont we're an irreplaceable resource in our community and I appreciate you being interested in our experience and I hope you will continue to seek and hear our voices thank you thank you certainly do want to hear your voice and at least in my mind that ratio that you described is rather shocking so but I'm wondering if anybody else on the panel would like Dr. Perez respond to that for the last 90 minutes I can vouch as a former hospitalist at Dartmouth Hitchcock and in Windsor I can vouch for Dr. Holman's care taking care of her patients and the quality is just fantastic just a clarification despite wearing a suit I'm still practicing medicine if you have the misfortune of needing to be admitted to the hospital Friday night in Windsor I'll be the guy admitting you I fled Boston 18 years ago where I was practicing primary care in one of the Beth Israel practices because the environment the administrative burden was getting too high in Massachusetts so I came to DH continued to Dartmouth Hitchcock continued to practice primary care mixed in a little bit more inpatient care and then the administrative things often happen in New Hampshire and Vermont the stresses of Southern New England worked its way up and I fled primary care and just became a hospitalist about 10 years ago I found the I found the work undoable to be to be honest now straddling the world of administration and practice I feel oftentimes that I am smothering innovative projects that some of our clinic docs want to do because I know I know about the added administrative burden that these projects will entail we have a fully comprehensive EMR in Cerner I was part of the go live big bang team at Dartmouth Hitchcock we went live with Epic the CPRS team at the VA which someone had already mentioned when I was in Boston as well and helped to build an EMR at the Beth Israel a homegrown EMR and what's been touched on previously is that the early EMRs which really were built for quality safety didn't have the pressures of pursuing meaningful use dollars behind them they were much more physician centric and I think easier to use less onerous but as meaningful use dollars came onto the table larger firms larger platforms like Epic like Cerner and the myriad checkboxes and checklists that you now have to work through came into play because hospitals and larger health systems became dependent on other non-operating revenue which comes from meaningful use and once you get a fully comprehensive EMR it becomes that much more challenging to engage in something else if it requires one of my doctors to log out of Cerner log on to whatever it is care navigator workbench one for those that are really wonkish the vital database any other non-system formulary I just can't ask them to do that and five years ago I would have said well you know what I'll just hire you ascribe to work in this EMR but what we've seen historically is folks that had scribes also had some productivity incentives with it we decided to go the other way we got rid of all productivity incentives pay our physicians a flat salary but with that I can't afford scribes so it's the constant push-pull and as we move into all three risk programs for 19 you know I the added risk of having a one to one ratio of support staff to physicians I just don't think we could management but being somewhat data-driven I'll share some of the true data and some off-the-cuff remarks when Epic went live at Dartmouth Hitchcock one of the Epic medical directors told me that they expect 7 to 10 percent of your medical staff to retire when we rolled out the EMR that was a level of attrition and we realized that and these were folks that had to be older near retirement but probably had a couple more years of good solid medical practice or surgical practice and it was actually more in the surgical realm where we lost urologists and a few other docs because of the EMR burden so you lose 7 to 10 percent of your physician workforce one of my colleagues at Dartmouth Hitchcock George Blyke who exists in the Quality and Patient Safety realm had a study published two years ago in the Annals of Internal Medicine primary care physicians and also primary care or orthopedists that served them and cardiology that served the practices and found that in the typical day these physicians were spending about 27 percent of their total time on direct clinical care 50 percent of their time on the EMR and the desk work I presume the other 13 percent was spent on the phone with IT trying to get help and then at least in my case complaining about the EMR while in the exam room with patients in the exam room often times with your laptop another thing that I really struggled with was figuring how I was going to communicate check boxes and fill in the EMR only about 53 percent of the time in the exam room was spent on clinical face time and about and 37 percent of that time was in the EHR in the room and of the cohort of those 50 plus physicians that kept after hours diaries of their work it was at least another one to two hours of after hours work each night devoted to completing the record getting the notes done because people like me build policies around getting clinical documentation done and as been stated by the docs on the panel and providers on the panel we care deeply about our patients we want to do the right thing so we're getting our notes done at 7, 8, 9, 10 o'clock at night I don't think it's a coincidence that the rise of EMRs and the rise of physician burnout rates are happening at the same time when I query my my physicians at Montesquotney Hospital and Woodstock they say the same things shouldn't take 30 clicks to order a flu shot for a patient but it does and when I'm recruiting docs now folks just out of training finishing their family practice residency finishing their internal medicine residency they're not looking at as soon as they find out I don't have scribes they're not looking at our practice and then I spend the rest of the interview saying but it's a flat salary and we don't have incentives productivity incentives and it's a great place to work in 30, 60 minute visits but I'm constantly back tracking because they know and what they're hearing from their mentors is basically primary care is undoable you need to have a scribe you need to have tech support you need to have this so to close I don't have answers for this I think we can bite off small parts of the apple I think one care will and I'm a believer in full disclosure I'm on the board of one care as well I think it will help tremendously I share concerns about scale targets and getting there and as also as a being responsible for 400 plus employees I understand that one care needs to provide value if we want to add to our attributed lives and move self-insured programs over we need to make sure that we provide value if I ran a for-profit company with 400 employees I would you know I would probably be looking at well what's your prior off process and because that's cost saving and that's going to be a real challenge it's going to be a tight rope as we move forward but I think I think there's hope and I try to give that message to our primary care providers you know I'm transitioning back into some primary care and doing some MAT work locally so I think we can get there but it's it's going to take some work Dr. War do you want to actually to be any more to that since one care has just come up and it's part of the mechanism by which we're collecting quality measures and you know care navigator has come up as you mentioned earlier and part of this that is EMR to some extent you know EMRs are evolving and I think that they were not always designed with the user in mind I think we hear that a lot and I think my hope is that EMRs are going to evolve and become more user friendly but in that transition and in that process we're seeing the stress and the you know the emotional cost and the time cost for providers to be working through these systems and is there a way out of this you know that time the scribe the need for scribes the technology going to help us out of this I would just say that Robin and I had a teacher at the Dartmouth master's program who was sort of in Washington in the early days of EMR and you know the failure of interoperability requirements on the part of the vendors of the builders of the EMRs I mean it's basically just an ignoring of regulations that would have required us to have a much more sensible system so I agree with Faye that the finding the data in a way that's economical enough to go and get the data is really really important and in terms of the quality measures likewise we've tried to emphasize quality measures that are based on medical claims as much as possible to try to avoid the burden of literally going into the chart and having humans harvest the number out of some box so it's not it's not perfect it's often process related rather than outcome related it looks at you know we have stakeholder groups who want to be sure that they have a quality measure that somewhat reflects the spirit of their topic it's hard to argue with did you screen for smoking did you have well controlled diabetics and I basically agree that those are kind of the bread and butter the foundational elements of try to measure how effective the system is but we need to get a lot more sophisticated in our data collection and then it's also important to say that that using the claims data we try to build reports for example around use of post acute care services so that we can see whether one community uses a lot more skilled nursing facility after a typical Medicare admission compared to another community or a surgical procedure to me that's the kind of quality measure or I'll say in a different way it's pointing out variation that and I don't know we all don't know where the right answer is there is a difference who's right and who might be wrong or is there in fact let's at least try to standardize and understand why one community seems to be doing a lot more of acts compared to another community so I'll stop there I'd like to speak to your point because I think you're listening to and I agree with everything that's been said Dr. Coleman I don't know you personally but why there's I can tell here you speak you clearly have a presence with your patients I want to be your patient anyway it's good I'll go for colonoscopy I better but and I don't think we maybe have in terms of educating our physicians and training around how to interact with the EHR and my point is moving towards they expect nothing less than to interact with the EHR we've probably missed out on creating some of that skills that I think you clearly have so that's a topic for discussion but I I agree strongly that the technology in the medical field has lagged under technology substantially and I think we've moved through a very uncomfortable period of trying to do something with what is inadequate technological infrastructure and so while that makes most of us want to go back to our days where I was certainly not in digital data but how I was trained I was trained in a very analog system and not that long ago we think about the amount of data we are managing for particularly our sickest patients there is nobody in any other any other industry that could manage all that data that's so highly individualized out some sort of pretty robust mature data system and that's what we've been trying to do is why it's so stressful now the the the horizon that I see that gives us hope is that we have a lot of technologies I think in particular we want to do investments which we use but they have invested over the last couple of years they understand and this is a little bit it will be like showing the money and I'll believe it but at the same time starting to see it where they are investing significantly in the user experience and we also there are some really robust data that shows in addition to having that technology there are other things that really improve provider satisfaction with that of operational systems you set up around it and the training that you provide around it there are really good data around physician satisfaction provider satisfaction and the kind of training you can invest in those providers to use those systems so I see a lot of hope on horizon and I would never want to work in a situation where I wasn't completely amp EHR I wanted really really good EHR so I totally agree with some of that sentiment the challenge and I could break you down I'll speak only for myself but I think that really great EHR experience is very expensive to produce it takes a lot of investment not just in money but also in time and it's longitudinal it's not something you can pop up like a tent it takes years to get to the maturity of and we're on a journey still I think we have a lot of I'll give an example in a moment but we have a long way to go to improve it but one of the examples is Dragon Dragon is a is a dictation software it's the you type while you talk kind of thing Dragon is terrible you have to train it it doesn't it has crazy mistakes and so very few people used it well in the last year so we've adopted a technology called Dragon Medical One which is the new version of Dragon it is so much better than Dragon it is it knows Dragon medical jargon I can put in orders with Dragon Medical One it's like a virtual scribe and there is it is a little bit so in the room and I have to navigate to the things I say look you know forgive me I'm going to talk about advice but I want you to listen I said this is Jones today I want to make sure she takes this medicine you're going to eat this kind of food and I'm going to see you in two months and all those in the screen I give her a copy and I say okay let me fix it all happens in the room I put in orders and my wife said I have a practice she said I would love that and she that's not something that at the scale that she practices in that she can invest in having her office so I think this is the kind of challenge we're facing with technology we have to practice with technology but it's expensive and there's a big spectrum of the quality of the technology Michael did you want to talk about records? I'm just going to I have a couple of comments first of all I appreciate Dr. Holmes comments tonight I was the quality director for Health First when I was writing my titles down like network director or something and so I do a lot of work with quality with taking quality what the quality measures were with all these panels that we did not earlier and trying to figure out and anything that is discreet like Rome said if you can pull the human bone and see this up a lab result it doesn't require me that's great if we can reduce those that's fantastic I do because the same thing that I've said for several years now is that when we see improving quality measures I think we're seeing improved box clicking documentation and unnecessarily actual improvement in quality of care for a lot of these things but there are some different methods human bone and one-season diabetics I think are the they're kind of well-hanging improved they're easy to to get they're easy to act on and there's improvement in that so you know there's some like that there are others like having a DMI of under 25 which is what you know what's you had to counsel there about 25 now I'll have to guess that probably 85% of my patients have a DMI of over 25 so they're 25.1 and I'm actually documenting there discuss that and exercise health habits with the patient for his DMI of 25.1 about this big around so that's a little frustrating I think for the for the documentation the templates one of the things for insurance and for reimbursement most of our notes are most of the things we're putting in there now are not really being used clinically with anyone after us I know when I look at my notes I look at the assessment plan there is four pages before that that no one ever looks at except when the insurance company audits them as far as I know so a lot of those template-driven notes are driven by that whole process and I'm not talking about those of office visits and going straight I don't know if that's something that is feasible if that makes sense but reducing some of that need to put in lots and lots and lots of verbiage just as they're putting in to get to be able to justify the time we spend for the patient to document I don't think people are using templates like Dr. Homan said maliciously I don't think we should for our patient the billing appropriately and we're putting this added burden of documentation on top of that to justify the payment for the service that I think they were providing and the other thing with the EHR I have a lovely relationship with Scrives I love the idea of a Scrive I love the idea of walking in talking to my patient walking out and having the note done the med and I'm just not willing to sacrifice that so our practice doesn't use Scrives and I don't know if that's sustainable I think that's a sad position to be in where I feel like I have to put a third person in the room just through the work because I can't do it myself it's not why I went into medicine I think one of the problems with the robust EHR as Jim says as they grow as you bring out a new provider you're a very well versed in that number well versed in that because we've grown with these systems they're so complicated and so nuanced that you can't possibly train someone for every little piece of it and so I I fear that as turnover starts happening that's going to become even more costly in an incomplete process so I comment on those various things and Michael you were going to comment as well sure just really briefly just Medicaid's going to take really seriously Gordon remember Holmes's question of hey what's different a year from now and so we're really happy to work with anybody who has ideas specific ideas to try to incrementally reduce provider burden over the next year just three other really quick things I'm really confident that we as a pair can hedge the financial risk of ending prior authorization we can do that that's not hard but I would say we would still need a way to ensure appropriate utilization and that's one of those things that in an integrated health system we're not comfortable doing our own we want to work with other folks you know what and then also we go to the legislature because the taxpayers fund our health plan if we're going to guarantee payment for capitation there is a natural inclination to ask for more access and quality measures so I think all of us have to take seriously the question of what is success because right now it's shown me your access and quality measures and I can't have that's not what providers want to do then last I have one of my other hats is to be the executive sponsor of the state's HIT but we we tried to build a report that's going to come up November about the state's HIT direction on use cases so what people need the technology for and a big moment for me was we were having a dialogue about we could have technology do this we could have technology do that and the provider said I just you know what I want out of technology I want to be able to make eye contact with my patient that's what I want out of technology HIT policy investments people focus rather than technology focus because it's been technology focused for many years and many millions of dollars and we do not have a lot to show so we're trying really hard to make it more people focus anybody from the panel want to add anything to the conversation around either those topics of PHR burden or quality measures anything that I just the last primary care advisory group meeting I think we presented to the board and I think I said that exact same thing whatever you do as you go forward whatever you do to get some part of our patients face to face and spend more time doing that please do that we'll tackle this test of whatever you decide so I echo that strongly I really think about it in terms of the data about texting while driving that your absolutely can't pay attention to the road in your phone at the same time and that's how I fill with my computer every time I have to move the cursor open a box check out whatever search for a document I'm breaking breaking contact with my patient I'm not listening and I'm not making any contact we haven't yet mentioned patient-entered data you know we're talking about clinician burden certainly the creation of systems where the patient has arguably the most vested interest in a high quality outcome and us growing tools that will allow patients to not only enter in clinical information as far as history and symptoms and complaints but also to feed back frankly on patient-reported outcomes I've been really impressed with the opportunity of you know there the outcome for any given individual reflects how the treatment may or may not have been appropriately matched to their value system and so somebody whose value is dictated maybe a less invasive procedure but ended up with a more invasive procedure might be pretty unhappy and vice versa so I think that as we move forward in trying to understand what quality measurement in healthcare means a customer the patient probably needs to be much more included in contributing to our understanding of their satisfaction of their system So actually Michael I may see the question is that part of the conversation around the HIT plan is focusing more attention on patients entered data is that part of it? Yeah I think that's going to be part of what we talked about for another word I think just to talk about the exchange of technology in Vermont the state's not been very clear about what its goals are so we're focused on what we want whether we can deliver it our provider better off and that our provider better off and so we're certainly having a discussion about what is the right way to get data in and it's not just a presumption that it's a DHR a doctor or a practitioner enter DHR and then also just talking about what one of my partners that do think we're doing a good job cleaning up the program but we might be cleaning it up for the world that existed in 2009 instead of 2019 so we're asking ourselves questions about what patient registries look like what are the conditions specific resources how the text messages fit in all this and so we're at the beginning of that conversation but trying to be really careful about what we go down we do not want to go down HIT's extended technological lessons any board members want to ask any questions about that topic DHR quality nope okay are there any and I want to be able to open this up to public comments and all of that as well but are there other areas that we haven't touched on I think we touched a little bit on provider burnout physician burnout and the role that administrative burden plays there I think as data ever increasing data around EMR ZHR's admin burnout admin contributing to burnout I always refer back to an IHI paper published not too long ago and encourage our individual practices to and providers to ask what matters most to us as we practice what are the impediments within our practice I think I'm not sure it may have been a Dustevsky quote all unhappy all happy families are the same all unhappy families are unique in their own way or unhappy in their own ways there can be unique impediments in each of our practices and if we can commit to a systems approach and I think most importantly especially in small role practices tap into system resources or other regional resources around improvement science folks like Norm and Robin have gone through either CECS or TDI that's the Dartmouth Institute I think primary care practices are right for green belt and black belt projects to improve process workflow if you do some mapping of what a patient does and the touches of all the members of your practices on that patient before they get to you as a provider and after they leave you as a provider there's a lot of room for improvement that can be hard I know if you're practicing in Wells river it may be challenging to reach out to the value institute but you know what there are tough interns out there that'll be happy to come up and look at your practices and do internship work and not cost a penny and I know that I'm always happy to help direct folks to rural practices so that they can take a look at it so I would just leave it at that burnout we've got to we've got to combat burnout and looking at each individual practice as a way to do it have any thoughts from any other panel something that we just didn't touch upon some questions we didn't ask we did talk about facilitated communication between PCP practices and other practices that's a huge time sufferer in terms of the day both from everything from putting time into notes and lab to make sense with specialist with an emergency chance review because of miscommunication or poor workflows on either side to getting notes back that aren't as helpful either from ED or from specialist that don't really address the issue that was there difficult lab being drawn multiple visits because patients didn't get their questions in for the first time there's a lot of documentation and communication issues between these and these and specialist some of that leads to prism and some of that so you have a sense that you can there's a horrible solution to that so it's it's a big don't work we're working together and it is something we absolutely need to address even internally I will say in the University of Toronto Medical Center there are three or four different ways for meeting a specialty notes back and the least favorite way is to get them all three ways because then you get different ways and I can imagine I have a vision for a very mature system where the actual things go in one pile the FYIs go in another and wouldn't that be nice? that would be fantastic and that's a big you know we're working on that and then we have to work externally we're working with our colleagues who have different technology platforms and I think how we solve that challenge is important one of the things that when we went around and asked people one of the challenges particularly around and we're we're asking specifically about access they were saying gosh it takes two or three months to see specialist acts but the bigger gripe is actually how long it takes just to have the appointment assigned and you know that it's been a week and you still don't know what the appointment is and I actually I shared that concern and so we looked at how what that and it's like it's a little over 11 days on average some places it's doing really well and some places are doing worse than that which is really not acceptable and one of the ways we spent the last couple months figuring out even within Epic until we have full Epic this is getting a little in the nuance so forgive me but it's important that we were not using the Epic scheduling technology to its fullest extent so starting next week actually we have a go-by date we're setting the standard of three days to get back to the referring clinic about this is going to discuss we want Rick to be able to communicate his patient if you do not hear within three days then you call next right after we want that standard we want to we're not going to meet that standard right away across the board but we'll be able to measure it and then we work towards the standard one of the one of the challenges of the specialties where we have the number one the forced access and number two the most sub-specialties neurology for this example we've talked about that in this room before where and because they're doing a lot of provider review before the physician sees the patient but before it's even scheduled because they're looking at well this is something that you can see sooner I'm working with those docs to create templates how do we expedite this we don't want to put up that barrier at the same time they're trying to steward their freshest resource which is understandable so that's so one thing that we're putting in right away next week the more so I expect to hear from you and I'll let you know and I'll leave for that matter but the so hopefully we'll see movement the other piece that's going to be about I think a three-year journey is to have a vision access center we have a vision access center right now it's not universally used by all of our specialists but what we're the vision for so it's a very underdeveloped I don't even go and describe it what it does because what it could do is much greater so what we're looking is a single point of access where we would take this scheduling so to create a universal experience for our providers and put it in one place so we can standardize the experience for everybody and so our goal is to take the scheduling away from the cardiologist clinic the surgical clinic et cetera and put it all in one patient access center that can A, schedule a appointment right there on the phone and then B, say here's the date and time but based on our internal criteria oh it looks like there's an x-ray we need that we don't have and working with a lot of our community providers we have the particularly when it's things from the primary care around we don't ask primary care provider for things they're not interpreting which is another conversation having a care specialist so the idea of that patient access center would make it clear like this is the one place you go the challenge because as a primary care provider I am selfishly in any way concerned about primary care provider we're engaged and for all the access reasons that we all know about so as much as I went whether you're employed by the medical center or not I was to be able to enter a referral to see one of our specialty surgeons and then you come back away and assume it's going to be done I also want our specialist to say oh gosh alright here I'm seeing this person with problem x this is something that's within my wheelhouse and I have all the those two experience so that means taking the scheduling function out of that specialist's office that's a big step that's something that they have a lot of anxiety for a lot of good reasons and so we have to meet those counselors with them to make sure that we're not because all of a sudden their day is oh I had 15 minutes to talk about a patient getting a very complex surgery that's going to create a lot of dissatisfaction on that end so it's a complex journey we have to take it I will say this is not something that we have that starting that three-day referral diet standard is the beginning of this longer journey we have allocated it's on this retreating plan we have allocated resources to it so it's the goal we want to meet I much more comfortable to talk about this I want to be able to come back in one year two years three years and be able to demonstrate that progress but nevertheless we have that vision and it really should it really should be clean for both heads of the basketball system so I don't know if that gets to some of your point but we're also in we're in one month but you know if you give us the name the demographics the chief complaint insurance information we should be able to give you an appointment and we'll collect other data after that but there are still some people with analogue processes you have a digital processes that just want to know have some of that basic information so we have that really interesting workshop coming up with that that we have some community partners public comment or any other board comments or questions yeah quality measurement because I think this is an area where at least the state partners have tried very hard to try and align quality measures to the extent that again you know the state is not in control of the federal government or the you know a lot of the federal requirements so I don't know how much that actually gets felt at the provider level but I do think that's an area that we as a board and have been as mindful as we we can be on the state level around for example making sure in the all peer model the quality measures were not new they weren't you know something that wasn't already being collected and again to the norm's point earlier were as claims based as possible so that you don't have to have someone to manually collect those again I don't know how that is felt at the provider level but I think there has been a lot of efforts to try and do that to the extent possible at the state level anybody else no okay I guess you know again I think I hope that we do meet again in a year from now and there is some progress I think I just jotted down a couple of notes that I'm optimistic about and I think we didn't I'm optimistic that our carriers are going to think about some of this gold card I know there was no commitments on your part but there sounds like there's some move forward starting to think about how do we streamline some of this prior authorization work there and really focus on the high utilizers and perhaps think more about that I'm optimistic that maybe some work will be done there I'm optimistic about the partnership with OneCare as well and achieving more scale and getting more providers into OneCare and thinking about how we might be able to reduce administrative burden as we achieve more scale and OneCare is moving some of that risk from payers to providers there's less need for some of that utilization oversight from the payers side I'm optimistic about Dr. Parris you mentioned some of this you know there are resources out there that can be tapped into thinking about how to you know maybe some of this addiction you know technologies available some of the EMR is evolving and maybe there's ways to lean processes in practice transformation thinking about that so I'm optimistic I hope that these conversations can continue and you know as we're doing the work of the board this will be in the back of our mind is what we're doing adding to administrative burden as a state and as you know health care regulars think about reducing administrative burden I want to open it up to public comment and actually maybe I will turn it over to Kevin at this point and just you know open it up to public comment on this topic here Sure Ken Thank you I think that this is another robust conversation and really appreciate the war in particular Jessica Holmes for being so optimistic because with some people who have worked on this topic there's reason to have some skepticism and I used to be attacked being a cockeyed optimist so please consider that with some of the comments and then what is since 2011 when the Green Mountain Care Board started this is the second go round of a really focused discussion about prior authorization and I think it's unfortunate that the board during the first conversation didn't take more tangible steps frankly there was no better opponent particular opponent better educated than I am on the subject and Alan Ramsey who was a board who spent a year and a half lobbying the board and others to take some tangible steps and I think that's unfortunate it doesn't in any way reduce the importance of the conversation because healthcare is complicated but it's so complicated that sometimes you do nothing and you get paralyzed so that's a conversation to a large extent prior authorization in my opinion is not a value added to the healthcare system and so I don't want to mince words I think it's done more harm and good and my orientation is more as a mental health advocate for many years so it probably goes back to about 1985 that I first started seeing the misuse and the cost of prior authorization not totally from the perspective of the practitioner but from the person who's missing from the table here there's an imaginary chair over here it's called the consumer the patient who doesn't know any of this but I can tell you that based on my experience of about 20 years and I think we really paid over 20 years of legislation some really tangible steps in the mental health field when it came to the negative aspects of prior authorization but I will tell the board that I would say that prior authorization is often simply reduces a barrier to accessing treatment and put it out there and say it that's one of the mechanisms that prior authorization assert it also has what I'll call and I'm being very nice and kind a very subtle way of influencing clinical decisions that often aren't in the best interest of the consumer who's sitting in that imaginary chair consumer doesn't know it but for a lot of reasons the practitioner doesn't want to go in a certain direction because prior authorization is such a hassle that it's not worth going in that direction and I can also tell you and again this is skewed a little bit from the mental health field but I have a feeling it encompasses all of the prior authorization systems it's also an imperfect system I'm glad that people are interested in the cost of prior authorization I'm aware of over many decades actually where the folks who were actually doing the prior authorization checking were either poorly trained or influenced frankly more by the financial aspect of whether we approve a certain treatment or not so I just want to add that because it hasn't really been mentioned maybe as bluntly as that it doesn't mean it's all bad but that's part of what we're talking about and we talk about prior authorization so you know one of the concerns that I have is that this conversation which is very robust and everybody really is working to try to address these issues I'll call this the conversation of the phenomenon in Vermont of snow in April you know you get that incredible heavy downpour of snow April 2nd for some people some people it's terribly impressive but to a logic then it just evaporates and that's really been what's the history of conversation about prior authorization people sort of deviant really try to understand to come up with ideas nobody's really seriously do anything of major consequence but it's going to evaporate and so to the board and particularly to Jessica Holmes who was so optimistic be a little less optimistic and a little more cynical and we may get somewhere that's money commentary back I do have however you know just a few more comments and then I'll call it a proposal you know I've sort of been spinning out some proposals lately but it's better to have tangible things to react to than just this big idea maybe he'll be better in a year so one of the reasons that it's been very difficult to move this issue and you know it's not really something that comes up that often here is really what I put in a box of the politics of health care and the politics of health care really means that the insurance industry particularly across the shield is incredibly powerful and they're incredibly powerful over at the state house and a large extent the reason there hasn't been either legislation or movement there has been some very good legislation in movement in the mental health area but in general it's because of the power of that industry and they will not or historically they have not been willing to support really any major change in prior authorization maybe around the edges and I can I can tell you right now as a person who's been 30 years sort of around the state house that primary care physicians and psychiatrists are much less powerful and have much less knowledge of how to work the system over at the state house so it's totally predictable that a piece of legislation would not get through you'd hire me as an consultant for a thousand dollars a day I would have waited seven days to tell you it's not going to pass don't begin so to get to the point that I want to make is I would propose to the Green Mountain Care Board that I consider sort of the following notion as it thinks about prior authorization there are other important topics that theme up to be during the secondary part of the conversation but one would be to reduce the use of prior authorization by 80% in one in over one year period in Vermont's healthcare system somebody's got to do it it's not going to happen in the legislature I could predict and the Green Mountain Care Board would have to go out on the level a little bit to do that but it would be a very interesting experiment to say there's enough room where some of the arguments have been made that are really worthy there are certain areas where prior authorization really could play a role but the goal is just as we have like in the energy field we have a goal after one year we're going to reduce prior authorization and I would say we should call it the Alan Ramsey Act because he would be very worthy of that proposal and the second part would be to change the system that we have now and make it more of a system where if you think about prior authorization what you're really trying to do is identify what I'll call outliers it should be an outlier system it shouldn't be across the board so you want to kind of have a system it's not that complicated with all the money we put into computers and all the brains we have to create a system that says we want to look at the outliers but I want to also say that being an outlier isn't totally all bad there are some people who may be frankly following a regime that most of the medical field won't agree with there are also some positions who may push for certain interventions that may be worthy of trying and I think that would create a more robust conversation about the quality and the use of prior authorization so I hope it's not snow in April this conversation goes back in the legislature 30 or 35 years it really hasn't mature at all that much in my opinion and we now have we have a board that's empowering to help set and chart some directions and so it's incredibly worthy conversation very complicated like everything else in healthcare but if you set a standard we say 80% reduction in prior authorization from what we have now keep the 20% refine that so it really captures those areas where it's absolutely either needed or this value added so the end line is I'd love to hear the board make a statement I'd be happy to draft it if you'd like to like the board to say and say in the big picture prior authorization does not a value added to the state of Vermont for consumers and for our healthcare system so that's my comment thank you Ken I was beginning to worry that it was going to snow before you got your proposal out as you know I think I was in the trenches with you on a few of those attempts at trying to pass legislation to restrict the use of prior authorizations and I always felt that there was a powerful group that was working against any change and here we are 10 years later and we still haven't seen the change we saw the the little pilot project but that was about it other public questions or comments if not is there any old business to come before the board is there any new business to come before the board may I just say one thing absolutely I actually just want to thank everybody for I know all of you took a lot of time out of your day and it was very informative and helpful for me and I imagine for many of us in the room and I just really want to be cognizant of your time the value of your time and appreciative of your spending some time sharing your wisdom with us and I don't think this will be the end of the conversation thank you thank you I just wanted to I saw Lee Bryan and the audience from BQAC and I neglected to say that part of our primary care and comprehensive payment reform model is to try to get some services within primary care to open under the hood and make sure that things are as efficient as possible to try to make the process as smooth as possible so thank you and thank you Jess for putting together this excellent panel I think we've learned a lot progress has yet to be seen but I think that some key players are at the table and we will continue to have this discussion moving forward is there a motion to adjourn so moved it's been moved and seconded to adjourn all those in favor signify by saying aye aye any opposed thank you everyone