Just jump in for a minute and say good morning. This is the this is a joint meeting of the House Healthcare Committee and the Senate Health and Welfare Committee. I'm represent Lippert as I need to rename myself but a chair of the Health Healthcare Committee and Senator Ginny Lyons chair of the Senate Health and Welfare Committee. So good morning everyone. Representative Lippert may I just say a couple of words for introduction. So I think we're really fortunate today to have the Green Mountain Care Board in talking about the sustainability report. As we all know and our work in our very our two committees, we understand that hospitals have been in dire straits, not simply during COVID but prior to COVID a number of hospitals were in the red in their financial situation. And so our committee began to look at this and especially during COVID to understand how can hospitals be made whole and and sustain the needs that they have financially so we've asked the Green Mountain Care Board our committees together have asked through legislation for a sustainability report. And it's gotten to us and we are very pleased to have members of the Green Mountain Care Board with us to go through that report. And as as we have chatted in the beginning before the meeting started, Representative Lippert and I both agree that we will hold questions through the reporting process so we can get through it all but please write your questions down and then we'll have an opportunity to ask them later. So, back to you, Bill. Okay. Thank you. Thank you, Senator. I, both the presentation this morning and the full report are posted on our committee webpage and I'm imagining on the Senate webpage as well. For those who wish to follow at home. And I'd say let's proceed. I think this is a very important issue hospitals are crucial part of our health care system of Vermont and we look I look forward to hearing from the report that the Green Mountain Care Board has put together about sustaining our hospitals in Vermont. So with that, I believe we have with us this morning. Kevin Mullen chair of the Green Mountain Care Board Susan Barrett executive director of the Green Mountain Care Board. And I'll welcome them to introduce others who are with them. We starting with Kevin perhaps. Thank you chair Lippert chair lions and members of the committees. For the record my name is Kevin Mullen chair of the Green Mountain Care Board, and we're excited to be here this morning to present the sustainability report and we look forward to answering all your questions and without further ado joining me today. I'm very fortunate when I go to work every day I'm surrounded by people that are a lot smarter than I am. And so you'll see that the three that are with me today fit in that category and it's a pleasure to work with them every single day. As you mentioned Susan Barrett the executive director is with us. And we have Elena Barrett be with us who is a special advisor on both finance but also sustainability and Elena we're fortunate to still have on the staff she works part time, but she's also pursuing her doctorate at Dartmouth. So, she will be doing most of the presentation. And finally the last person with me today is one of my colleagues on the board and she hates it when I say this but she's the dean of the board, even though she's not the oldest. She's an economist from Middlebury, and that's Jessica Holmes, and I thought we would start off before we had Elena walk you through the presentation is just have just say a few words to tee everything up. Great. Well, thank you very much. I appreciate the opportunity to be here. I look forward to the day when we're all back in person and I'm optimistic the future looks promising and hopefully that will be soon. I did I thought it would be helpful to share a few opening remarks and again I speak as just one board member but one who's been involved in these hospital sustainability efforts since the beginning and as one who is incredibly passionate about making the healthcare system better for Vermont is an amazing place. We have committed state leaders, compassionate hospital leaders, healthcare providers and strong community communities dedicated to improving our healthcare system. I think that's why we're all here today. But I want to emphasize we cannot kid ourselves if we really want to improve a modern self and make healthcare more affordable we need to completely change how we pay for healthcare, and we need to update our delivery system to ensure that it maximizes access and quality and minimizes cost. And the significant payment and delivery reform efforts that we have to undergo are going to require resources, time, and frankly the leadership and the courage to overcome the inevitable resistance to change it's human nature to resist change it's an emotional response, it has a name it's called status quo bias. It's a strong preference for the status quo, and any change from that status quo is perceived as a loss. But Vermonters are not winning right now. Healthcare is not affordable for many families, many Vermonters don't have access to primary care dental care and other essential services. Our mental healthcare system doesn't come anywhere close to meeting the needs of Vermonters and the stories that we hear every day about people's struggles to find care are truly heartbreaking. And as populations decline in certain areas and volume shrink those average costs of care will rise and quality of care may be compromised. Our hospitals are struggling financially, and in response, some are beginning to shed essential services like pediatrics, both Brattleboro and Northwestern recently shed their pediatrics practices this is devastating news investing in our children's health is investing in our future public payers are not keeping pace with inflation and increased reliance on commercial rates to cover rising costs is no longer a viable strategy. Even if the Green Mountain Care Board approved higher and higher commercial rates for hospitals there are not enough for monitors to afford them. So if we don't change course and soon we're going to see more uninsured, more underinsured more free debt and charity care and employers reducing health benefits we're going to see families facing really hard choices between paying rent or buying medicine. And as access is compromised and essential services are dropped population health is going to decline. We're not on a sustainable path. And if we don't act now with intentional payment and delivery redesign market forces are going to take over. Some hospitals may go bankrupt, some may close. Some may come to the state for emergency relief as Springfield did asking for and receiving millions of state dollars to keep its doors open. And those hospitals serving our most vulnerable patients that will fall first, and other hospitals may continue to divest the central services, and it will likely be the least profitable services like primary care and mental health that will be shed first. It's already happening so we need to act swiftly and courageously. Again here in the coming remarks, you're the board is asking for $5 million to support the hard work necessary to ensure a sustainable high quality health care system. $5 million may sound like a large investment but I ask you to think about the cost of doing nothing. So the board offers a path to sustainability, it's global payments and delivery system transformation. Global payments will ensure that hospitals have a predictable revenue stream that covers the cost of delivering high value services in their communities. Hospitals will no longer have to chase fee for service volume and offer low value care to stay afloat instead they can redirect scarce resources to those services that have the greatest impact on Vermonters health like primary care and mental health. They can invest in the social determinants of health which often have a greater impact on health outcomes than medical care, and they'll be incentivized to keep patients healthy and out of the hospital. So global path global payments are a path to both better healthcare for Vermonters and greater hospital sustainability, particularly in rural areas facing declining populations and low volumes. But thinking about how to set and operationalize global payments inclusive of Medicare will take actuarial expertise careful plan planning and negotiation with the federal government so that's $2 million of the $5 million ask you're going to hear about. And it's critical that this payment reform be done in parallel with a patient centered community and provider inclusive redesign of our healthcare system. You want the global payments to support a system that's designed to improve Vermonters health at the lowest cost and the highest quality. So the $3 million of the $5 million ask is really to support the hard work of delivery system reform it's going to be an effort that's time consuming, data driven and is going to require working collaboratively with health systems design experts hospitals and other healthcare providers, community leaders and patients. If we were to whiteboard the optimal delivery system, it's unlikely that we would arrive at the current system. As an example, Dr. Bruce Hamery the former chief medical officer at Geisinger one of the most well respected healthcare delivery systems in the country, shared some compelling insights with the board. So geisinger serves roughly the same size population as Vermont over more than double the geographic area as Vermont, with about the same number of hospital beds, but three fewer hospitals and 300 fewer providers, their service lines are optimized across the system to maintain minimum volume thresholds, where we know there's a volume quality relationship, and access is better ensured through regional transport services and a hospital and a helicopter. So maintaining Vermont's current infrastructure means struggling to pay high costs, high fixed costs in the face of declining populations and spreading are already strained workforce thinly. With a very real workforce shortage we can't really afford to have an inefficient system and the stark reality of a fee for service system is that you cannot rely on volume to cover high infrastructure costs and growing labor costs if volumes are shrinking and care is moving out of hospitals. We need to work with health systems design experts hospitals and communities to explore opportunities for shared services, potentially looking at regionalization of care with centers of excellence that specialize in procedures where we know there's that volume quality and volume cost relationship throughout some examples could some of our hospitals specialize in orthopedic procedures so that widely accepted minimum volume standards for joint replacement or met. Some of our hospitals that may return to excess capacity post COVID pivot to become centers of excellence in mental care when we have an acute need mental health care and could share service agreements satellite specialty clinics and increased investment in regional transport ensure that patients in the most remote regions of the state like the Northeast Kingdom have better access to high quality essential services. We might explore new federal designations like rural emergency hospitals and freestanding emergency departments that might better meet the needs of communities who post COVID may face that return to high costs and excess capacity, especially those that are in close proximity to other full service hospitals, like those near Dartmouth Hitchcock which is currently undertaking $130 million expansion that's going to add about 100 maybe as many as 112 new beds. We're going to draw patients away from Vermont hospitals towards Dartmouth Hitchcock is also going to draw workforce so we have to be planning ahead for that reality. And we need to think and learn more about exciting new delivery models like hospital at home where acute patients can receive care at home but stay connected to a hospital care team through in person and video visits and biometric monitoring. Many patients hospital home maybe cheaper safer and more comfortable. McKinsey report out this week projects that $265 billion of Medicare services will be delivered in the home by 2025. That's about 25% of the total cost of care. So this transition to care at home will threaten the financial solvency of hospitals that remain reliant on fee for service in patient volume so we need to be preparing what's happening in terms of these profound shifts in care setting that technology is allowing. And we have to finally, I'm almost done here, we have to incorporate the learnings from the pandemic right we learned that fee for service does not work in a public health crisis when volume shrinks, so do revenues but fixed costs remain. So global payments would have kept hospital solvent when people stopped seeking care in the hospital. The technological innovation showed that we can meet people where they are through care at home through telemedicine and remote monitoring and we can actually build a 400 bed makeshift hospital in a week if we need to. So as we look to the future we don't need to maintain high cost excess capacity but we do need to make sure that our hospitals have the financial resources they need to invest in technology to invest in essential services and to quickly pivot in times of prices. There's a lot of work to do you're going to hear about some of that work that we propose we can't afford to wait. In my mind $5 million is a small investment to ensure that our payment system aligns provider incentives with desired health outcomes, and that the health care delivery system is prepared for the trends that are coming our way and that it's optimally designed to meet the health care needs of our monitors no matter where they live might be the most important investment healthcare that we make. So at this point I'm going to turn it over to Elena to go through the findings from the report and some of the recommendations that I briefly touched on from the sustainability report. Thank you. I need sharing permission, I think. Great. Thank you. Thank you. So we have an updated version of of what you've received in the full reports we tried to kind of pull out the main, the main points so can everyone see the slides. Elena yes we can and just a comment. I'm going to put a typo in it. So, if folks want to refresh their web pages they'll get the clean copy. Yes. Thank you. Okay, so we'll get started. First I'll give you a little bit from the background of hospital sustainability planning this is not something that you know came up yesterday. This is a topic that's been discussed, you know for the last three years I think at minimum will go through the key findings and then the path forward. So defining the work was an important starting place. There's a lot of places you can go and thinking about sustainability. You know, kind of ground us in a shared understanding of what we're talking about. You know hospital financial sustainability we defined as how can we ensure that hospital revenues or provider reimbursement are sufficient to cover the costs of operating a system that strikes the appropriate balance between quality, efficiency and access and So how can sustainable hospital reimbursements ensure equitable access to essential services for all Vermont communities, efficient and economic delivery of services and affordability and improved health outcomes for volunteers through high quality care. So to kind of you know I think just alluded to this but the kind of summarize key findings based on some of the analyses that we did is that you know without tackling these underlying inefficiencies in the system. hospital financial health is likely to continue to deteriorate, particularly after the federal relief fund sees those were life saver a lifeline during coven and I think as Dr. Holmes mentioned that you know hospitals would have seen a very different reality had these funds, not been available to them. And this problem will exacerbate the healthcare affordability crisis that we're already experiencing and will increase the probability of hospital closure that divestment of essential services. And this is likely to affect the most vulnerable reminders. Vermont has an opportunity to redesign the care that's being delivered and how we organize that care to ensure that for monitors have access to the care that they need an appropriate high quality setting and affordable costs. And we believe that completing the hospital's transition to value based payment models such as global payments will enable hospitals to make the changes they need to ensure the equitable delivery of high quality affordable care to the monitors. So some goals that we had laid forth in conducting this work was to engage in a robust conversation on maintaining access to essential services in our communities. We wanted to encourage hospitals and communities prepare for shift to value based care and understanding the threats to sustainability of our rural health care system. We wanted to encourage hospital leadership boards and communities to work together to address these challenges we don't see this as the job of the state to direct how care should be delivered this is really a community centered effort. We wanted to identify both hospital led strategies for sustainability as well as those external barriers to sustainability that hospitals cannot overcome on their own. So the key findings. I'm going to start here first recognizing that, you know, we started this work well before the pandemic and then as the pandemic hit it created a number of challenges one was, you know, getting the, the kind of engagement and data analysis that we had anticipated at the outset, but you know, given that we couldn't rely on 2020 and 2021 the most recent years of data we really had to rely on 2019 as this was our best estimate of long term trends. The analyses that we'll be leaning on are most heavily focused on the years prior to the pandemic, but that, you know, there are certainly lessons learned during the pandemic that we've already alluded to that should be considered in, you know, that have been considered and will be considered going forward and then and as we learn more about what utilization patterns care delivery and new care patterns look like, you know, these analyses should be updated and incorporated into any path forward. You know, how did we get here this problem is not unique to Vermont. Across the US there have been 181 rural hospital closures since 2005, and this rate is only increasing with 2020 experiencing the highest number of closures of all previous years. This is a study that looked at rural hospital closure, the median overall profit margin of hospitals in the final year before closure was negative 3.2% and I'll show you in a minute, kind of where we were headed with our Vermont hospital system. Hospital closures threatened patient access as we've talked about but they also materially impact the local economy. The community Seoul Hospital closes per capita income falls about 4% unemployment increases by an estimated 1.6% and in addition, every dollar spent by a hospital supports approximately $2 and 30 cents of additional business activity in that community, which in Vermont would have an estimated impact of 2.2 billion. So this is, you know, pretty significant, not just for the health of Vermonters but also for their economic sustainability. And so, you know, we, this really declaring the coal mine, I think was Springfield I think we can all remember that and, you know, I think what we heard from our consultants as we kind of looked at the data was that you know this if absent the COVID relief funds. We probably would have or will experience in the next couple of years another similar event if we don't start planning for an alternative. So, you know, I think we all need to keep this in the back of our minds. You know, this is not something that will just go away or has gone away but we've had a reprieve with some of these subsidies. So, prior to the pandemic, you can see the trend downwards on hospital margins was pretty drastic. So we were down to negative 1.3% excluding the academic medical center. And then this kind of leveled out a little bit in 2019 and then in 2020, you know, with that COVID relief funding we were able to kind of stop the bleeding but a 0% margin is not a healthy place to be. That is another thing we have to keep in mind is that hospitals not only have to break even but they have to find a way to continue investing in infrastructure to maintain their plant, which allows them to, you know, support patient safety, you know, perform quality improvement. So we need to be lean, but lean that we can continue to deliver high quality care so thinking about, you know, how much wiggle room we allow hospitals is a really important consideration. And this issue exists system-wide. It's not just a couple of hospitals. It's happening everywhere. It's affecting everyone. And so, you know, we started with six out of the 14 hospitals but quickly realized that this was a more systemic issue. And when COVID hit, you know, the hospital sustainability planning at the board was expanded to all hospitals.  So I think this explains why. So why does this matter to Vermonters? I think we've touched on that but just to kind of bring it home, affordability in Vermont hospitals primary lever to increase operating margin is really through commercial price. Medicaid rates are set, Medicare rates are set, you know, so this is really where the only place they have to, you know, increase their margin when they're having financial struggles. And this only exacerbates the existing affordability crisis. It affects premiums. It affects foregone wages. Employers have to choose between maintaining a similar set of health benefits or providing wage increases. And this is becoming real. And, you know, sometimes we've seen and we'll show you the statistics they opt out altogether. So this is a really important consideration. Quality. Hospitals in financial distress are known to struggle to maintain quality and patient safety and have worse patient outcomes relative to well resourced hospitals. So that's why it's important to ensure that the hospitals we do have are appropriately resourced and can deliver high quality care. And then access is, you know, we will mention over and over again, you know, financial distress is a key predictive indicator in determining the likelihood of closure, which left unaddressed could, you know, first leave to the erosion of essential services, which we've talked about, such as primary care, mental health and maternal care. So it's really important to get it before it starts down this path. And I think we're already kind of heading down this path and making sure that we can preserve access to these essential services. So left alone, the key finding number one Vermont Hospital Financial Health will continue to decline and this will make healthcare even less affordable or will erode quality of care over time and threaten for monitors continued access to care in their community. And the bullets below kind of summarize these key points that we've been discussing. So, you know, we'll go into detail on why we think this is happening. So one of the reasons you know if we look under the hood how do you get margin on prices minus costs so our hospitals able to cover the cost of delivering care with the reimbursements they receive. So this assumes, you know, of course that we're delivering care efficiently so I think there are questions about that but there are also questions about, you know, what is an appropriate price and what is an appropriate cost so here we looked at it by payer and what you can see is that Medicaid in many cases Medicare as well are not covering the current cost of delivering care to their patients. So down the left you'll have hospitals and then if we take the first three columns it's inpatient services. Those squares that are read are showing a cost coverage below 85%. That means that the prices are 85% of what it costs to deliver care in that hospital. The gray boxes are from 95% to 105%. So this is about break even plus or minus 5%. And then green is, you know, where there's significant margin so that's where we're seeing in the outpatient, particularly for the commercial population is cost coverage of above 115%. That means that the price is more than covering costs by an excess of 15%. And this is important because if you see all the red. And then you see the green, you know, these kind of have to work together.  So this puts enormous pressure on hospitals to ensure that commercial payers both cover the cost of delivering care to their population, but also to the populations that may not be able to cover the cost with their reimbursement. So, however, this, so this isn't the same across all hospitals, there's a lot of variation about, you know, what's driving that cost coverage. So if we look at inpatient only to see prices above the blue diamond is commercial. The green circle is Medicaid and the black squares Medicare and you'll have the hospitals across bottom and the average payment per inpatient discharge is on that Y axis. So what you'll see is there's significant variation across hospitals between payers in terms of the price they receive. And then the same goes for costs and you'll see that some, some hospitals, particularly some of our small hospitals are actually are higher price hospitals, and they have to do that often because their costs are so high. And that's often because the fixed costs of keeping a hospital open are so high and that they have, you know, more margin to make up with fewer patients coming in the door. And so, in some case it's even higher than the academic medical center which I think is contrary to what you know many people may be, may believe right now. Whoops, outpatient. So there's similar terms outpatient though there's less variation in terms of the cost. There's significant room in terms of the price which I think you saw in the previous slide all the green boxes. The outpatient is really where hospitals are making up a lot of them. So there's significant variation across hospitals in the extent to which their reimbursements are covering their costs and delivering care. And this is even after controlling for case mix. So, you know, if you have more governmental payers, or you have more commercial population. But, you know, some trends are clear that commercial payments are higher than governmental payments for similar services. Often governmental payments are insufficient to cover the cost of delivering services. And hospitals have to rely heavily on revenues for governmentally insured, who are actually, you know, often more disadvantaged compared to those with a greater share of their revenue coming from commercial populations. And these governmentally insured patients are often those with greater social and physical health needs so you can kind of imagine what that means to the hospital serving those patients. And then another learning through this, the series of analyses and we can, there's some links at the end if you want to look at the data and more detail. But the hospital price regulation in Vermont has some room to improve if we want to more pointedly address affordability. Right now the Green Mountain Tier Board reviews and approves hospital commercial change in charge to the hospital budget review process. However, there's an inconsistent and sometimes weak relationship between the change in charge and the negotiated payments by insurers. So this just means that, you know, the board may say, you know, I want to see a dollar for dollar decrease on this rate, but it doesn't necessarily correspond to reduction on in the commercial rates. So hospitals really have three levers to try to bolster their financial health. And we've talked a little bit about these but we're going to make sure it's clear and then I'm happy to answer. Yeah, I'm sorry to interrupt. Can you just we're having trouble in the room here hearing everything that you're saying, so if you can maybe get a little bit closer that would be really helpful. Sorry to interrupt. No, no, that's fine. It's important to hear. And I'll try to speak up so if it goes out again, let me know. Thank you. Okay, hospital levers to in order to address financial health. So in order for the to balance revenues and expenditures which we just, you know, explained was the driver of margin. They can increase commercial prices. They can reduce operational costs, and they can increase volume of profitable services. That's, that's those are the tools they have to work with and we're going to talk about why none of these are sufficient to address this problem. So, first we'll talk about prices that we talked a little bit of a little bit about but just provide more detail. When you have there's this tension that exists between commercial price and affordability. So hospitals need, you know, this is their primary way to increase revenue. So that addresses solvency but then that tips healthcare affordability and the other direction. And so, you know, this creates a challenge. And we've seen, we've seen this affordability crisis in our hospital budget review here's commercial change in charges from 2017 to 2021. You know, these are climbing every year and we're now at like 7%. And the rate review process that's not just at the hospital level this is translating into Vermonters pockets. And, you know, the commercial rate is, as Dr. Holmes mentioned before is, you know, is not a sustainable lever in and of itself. So there are fewer and fewer commercially insured patients available to cover the growing costs. So that means that these rates are only going to have to increase even more over time because it's such a smaller population of people and shrinking. So in the commercial rate, you know, we talked about leading to higher premiums and you can see over 50% of uninsured Vermonters site costs as the primary obstacle. So between 2014 and 2018, the proportion of privately insured Vermonters who are underinsured rose from 27% to 40%. This is pretty staggering. So if we do nothing commercial prices will likely continue to outpace economic growth making healthcare even more unaffordable and potentially compromising access to care so we talk about hospital closures, but prices another barrier to care. So even if you have coverage, sometimes you're out of pocket costs are, you know, you're making real choices here am I going to feed myself and my family am I going to pay my mortgage or my rent, or am I going to have this really important health service, you know, healthcare. So increasing commercial prices, not a viable option. So without reducing operational costs. So, annually this is a topic of discussion in the hospital budget review process and we hear over and over, you know, we cannot cut our way back to the financial health at a certain point hospitals need to be resource to deliver high quality care. When you have high fixed costs there's only so much you can do and so much cost you can take out of the system. So one of the reasons for some of these challenges, you know, I mentioned small size of hospitals. It's really it's a struggle to cover the fixed costs, particularly when there's a declining population or carries being shifted into outpatient settings this makes the inpatient setting, even a harder financial when recruitment challenges need to hire staffing costs as we've seen with our workforce challenges and, and traveling staff. It's a real, you know, real, real, you know, very big challenge in a hospital's budget as staffing is one of the largest expense line items and low volume threaten hospitals ability to cover fixed costs, as well as inadequate mental health infrastructure and low reimbursement rates threaten hospital financial health and compromise patient health. So these challenges will only worsen as plants age and capital investments become more expensive and workforce shortages put higher pressure on wages and volumes continue to shrink due to declining populations, and as we continue to seek care shifting from inpatient to outpatient settings. So according to the Berkeley research groups analysis so this is one of the primary analyses. There's a series of analyses and in underlying this work. They found that some small Vermont hospital space low occupancy rates pre coven. And then others saw kind of on the other side, you know that they had some capacity constraints so this suggests that there's a mismatch between Vermonters health needs in their community, and how healthcare resources are being distributed across the state. You know, Jessica talked about centers of excellence there are a number of ways that we can think about how to reallocate or how to shift resources to where they may be better suited. And when I say we I mean we as a state in the communities I do not mean we support. So hospital and health system infrastructure has not kept pace. I'm sorry, if you could just lean closer a little bit. Hospital and health system infrastructure is not kept pace with community health needs and the only way to address both hospital financial sustainability and Vermonters access to high quality affordable care is to accelerate delivery system transformation. So, you know, we have to think about how services are being allocated and how Vermonters are accessing that care and ensure that you know Vermonters have access to these essential services in their backyard and then ensuring that they have, you know, high quality access to other services as Jessica mentioned it might require some regionalization and some creative thinking. So reducing operational cost is given the current infrastructure is really not an option for addressing, or for fixing the hospital financial sustainability issue. So what about increasing volume at the hospital level. Increasing volume may be warranted particularly when there are gaps in access we talked about primary care mental health care, you know where their gaps and service delivery in a community, certainly volume needs to be addressed there, but it could also lead to unnecessary care or avoidable utilization so if you look at, you know, where hospitals bread and butter is, we don't want to see, you know, more ED admissions we don't want to see more inpatient admissions, you know, unless they're warranted. And so the organization and delivery of services should be based on Vermonters needs, and what will yield the best health outcomes so this is kind of a key assumption that needs to be kind of taken through health care reform and the shift to value based care has been precisely focused on this issue to ensure that Vermonters receive only the care that they need and ensuring that that care is high quality, and as low cost as it can possibly be. So according to the works by Mathematica and BRG appears that Vermont has a number of opportunities to reduce some of the avoidable utilization says we work to reduce unnecessary care and this avoidable utilization. You'll see even lower occupancy rates at hospitals greater access capacity and this will have even further negative impact their financial health, yet another reason why we need to get ahead of this issue. So under the current payment system which is still majority fee for service, doing the right thing for Vermonters will harm hospitals financial health. So thinking about paying hospitals differently is getting at this issue. So here's kind of what some of this, and there are a number of analyses that can highlight this issue further but proportion of revenues and avoidable utilization and impatient. When we look at impatient and what you'll see is that we have in some areas upwards of 33% of hospitals revenue that could have been better served in another setting. So increasing volume of profitable services is not a viable strategy. So if we look at all of the hospital levers that that we've been discussing, it does not appear that they have the tools necessary to improve their financial health and guarantee their sustainability. So that's, you know, that's kind of where the passport come from that this is a systemic issue that requires a systemic solution. And here we go. So the support for value based care. You know, I think we need to remember that pre pandemic there was, you know, already kind of a shift towards value based care, and we'll talk about how well we're doing or how far we've come. But this is not going anywhere. You know, we've seen as a bipartisan effort we've seen continued, you know, support and, you know, recommitment to this effort. And, you know, Liz Fowler, the latest CMMI director, even went so far as to say we need to find a way to bring everyone along we cannot have fee for service remain a comfortable place to stay. So if we do nothing, and it becomes even more uncomfortable than it already is, I don't even want to imagine what that will do to our health system. So we need to find a way to make sure hospitals are prepared that they're being paid and under value based payments. And, you know, we've even seen the HA has been advocating for global payments, since as early as I think 2014 they came out with this report. And this is a way that, you know, they've seen and that we've seen a number of places is able to keep access and rural communities that could otherwise not keep access available to those populations. So where is Vermont in our transition to value based care. And, you know, so there's two canoes, which I kind of like this one where we have the status quo on earth. We have this boat. It's a lot more fun to be in the boat. It's fun for everyone. So, you know, at a certain point you just need to jump. We need to rip the band data in 2017 we're at, you know, 2% in value based payments and by 2020 we've made some significant progress we're now, you know, almost to 16%. But I think, you know, there's this, there's this hesitation now like where do we go next. But I think, you know, we need to continue evolving we need to continue down this path and I think, you know, if we can, if we can get all the way in the boat, it'll make hospitals lives easier it'll make patients lives better we can actually focus on delivering care to patients and prioritizing health outcomes rather than trying to keep our doors open. So Vermont must accelerate its transition from fee for service to value based payment in order to address hospital financial sustainability and ensure vermonter's access to high quality affordable care. And then quality improvement. So through these analyses we looked at quality. I think we've talked a little bit about some opportunities to reduce some avoidable utilization. But what we found is that, you know, there really isn't consistent reporting across hospitals in terms of some of their quality and patient safety outcomes and, you know, different measures so we've actually been through this work partnering with the APQ are convening a stakeholder group to establish a hospital quality framework, and to look for opportunities to streamline administrative efficiency and to really get a better sense of hospital quality across our Vermont hospitals and then compared to other benchmarks because, you know, comparing academic medical centers, you know there's, there's challenges with the different kinds of hospitals that we have. So we look forward to that framework and being able to incorporate that into the board's regulatory processes. So this kind of solidifies, you know that statement so there are opportunities to improve and streamline hospital quality measurement and some preliminary evidence suggests that in some areas the quality of care being delivered could be improved, but I don't think we can really set out a full path until we have that measurement, you know, figured out. Another key finding related to COVID or key findings is really that COVID has put, you know, the stress that COVID has put on our health system has highlighted not only the existing failure fee for service, but also the strengths of our system, you know, particularly that providers were able to pivot so quickly. And as Jess mentioned, building a makeshift hospital in a week scaling up ICU beds, accelerate widespread telemedicine. The minimal flexibilities that our system does have we took advantage of that. And I think there were a lot of funding sources that allowed that to happen that wouldn't have existed otherwise and we need to learn from those experiences and think about ways that we can create more flexibilities to, you know, further this these innovative and nimble capacities. And then second analysis of long term trends must focus on the years prior to the pandemic with recognition that data and analyses may need to be updated as the pandemic becomes endemic. So that just means that at some point these data will become stale and we will need to update the analyses, particularly as we can gain more meaning from the data that we are having that we will have going forward. So pads forward. The first and kind of key recommendation is that we need to accelerate the shift to value based payment and delivery. We need to implement a hospital global budget and engage in community and delivery system transformation. So hospital global payment as we've talked about preserves Vermont's access to services by establishing a sustainable funding stream for hospitals, particularly important for those low volume facilities. It eliminates the two canoes and allows hospitals to focus on volume or value, not volume, and allows hospitals greater flexibility to deliver cost effective high value care in more innovative ways. So it would allow hospitals to think about how to incorporate hospital at home to deliver telehealth to do all these things that are financially challenging right now. And it offers a glide path for transitioning to value based pain and care delivery. This doesn't have to happen overnight. You can create a global payment that kind of gives hospitals time to get used to it and then thinks about, you know, what are the right set of services that should be under this model. So there's a lot of work to do to think about, you know, what that global payment looks like and how it is constructed. And then community transformation delivery system transformation that is intentional patient focus and based on global payment system can ensure the efficient delivery of high quality care. This would improve equitable access to high impact essential services promote delivery system organization around low cost high quality centers of excellence. And this would provide our first I think real opportunity to improve healthcare affordability and quality and expand for mantra's equitable access to necessary care. So what do we need to do that. We recommend investing $5 million in one time funding to design and implement this global payment and care delivery transformation. So on the global payment side, we, this is in line with Donna Kinzer's recommendation would be to design a predictable flexible and sufficient global payment to hospitals regardless of payer so that they could focus on delivering this high quality affordable care. And then we would need to find a way if we want to include Medicare in that global payment to incorporate that and support a federal. So our next federal agreement with CMMI to include Medicare in that payment. And then the community care delivery would would have a series of of work streams associated with it. So redesign facilitation we would need to bring along some experts and health systems optimization to facilitate patient focus and community inclusive redesign of our health system to reduce inefficiencies lower costs, improve population health outcomes and increase access to essential services. This would require some analytics to support the delivery system transformation as well as regional stakeholder community engagement. I mean that's where a lot of this money would go is, is really engaging with communities and making sure that we have a well documented well understood grasp on what communities need and how their needs are currently being met and how they could be better met. And then we need technical assistance to support hospitals, hospitals and communities in change management. And even if we have a plan and what we what looks good and what could work, we still need resources to actually make those changes on the ground. So this is not an insignificant process or insignificant tasks is going to require a lot of work and a lot of, you know, a lot of stakeholders and conversations ahead of us. The second recommendation is really to incorporate quality into the hospital budget process. This will allow for a better understanding of which hospitals are using their budgets in a way that is more value based or not. And again, this is, you know, it needs to follow the work that we're currently doing with VP, VPHC and the broader provider community. So the second recommendation number three is to ensure sustainable Medicaid payments. So, with supporting divas efforts for professionalized Medicaid reimbursement methodologies and appropriate the necessary funding. So there are potential enhancements to the budget process to consider medical inflation and sustainability of those payments. And we'd also like to ensure timely reporting from diva to GMCB of any Medicaid impacts on hospitals to ensure their inclusion in the hospital budget process. So that is what I have. I will pause. I can always go back to a slide if that would be helpful. That was very helpful. Thank you for that. For going through that so comprehensively. And I think we have time for questions. I'm going to ask one question of you in the beginning because I know that with any change as I think Jessica Holmes said early on, there's tension and some resistance obviously we all feel that we feel that in the Senate and in the house when we make decisions and I can't imagine what the, what if the anxiety is like out in the hospital world right now. So, but I do have a question you've listed some figures for global payment reform so you've got about $2 million investment there. And then you have a $3 million investment in the transformational work. The question is the time you expect it will take the board to complete its work, or all of us to complete work on the global payment piece. And then the next step so what's the timeframe that we're looking at here. So, if the money is appropriated in this year's budget. It's really important that we get started right away because the clock is ticking we have asked for a one year extension of the existing agreement with the federal government. And that will buy us some time as we try to come up with a more comprehensive model, including global budgets for the next agreement and the reason why it's important is, we need to try to convince everyone that this is the right way to go and make everybody's rowing in the right direction. So, we would envision that the conversations would begin starting this year, starting this summer, and that work is going to take at least a year. And I think that, I don't know, do we have a slide with us that shows the timeline that we gave to the House of Appropriations Committee do we have that Susan. Yes, it's at the end Elena, we do have in the presentation, a slide with a potential timeline. Senator Lyons, that would be great. Just to take a quick look at that. There you go. So, do you want to talk us through that just briefly. So, with the one year extension, the deadline for the proposal for the subsequent agreement would be pushed out to December 31 of 2022 so this year. And then throughout 2023 would be the negotiation process. So target for Medicare population based payments would be to turn that on January 1 of 2023. So that we would need to start certainly the work as Kevin mentioned as soon as possible to do that design work so we would be prepared to have something in the proposal by December and then we can work out the mechanics. So this is for the payment. This is just for the, the initial $2 million investment would be used during this timeframe for looking at global and all payer model extension. I don't see it just the $2 million because I think without the $3 million for the facilitation of the discussions at the local health service area level that you're ever going to be successful to get everybody working in the right direction so I think that they have to happen simultaneously in order to for it to work. Okay, I sort of understand that I do understand that but we'll have to process this going forward. Obviously, the, the conversation about change about transforming individual hospitals and then geographically services across the state I think is extremely challenging. So, and so I'm just, I'm hoping that you've thought through the process so that there's less resistance to change and the pushback. And that's facilitated by someone that has medical experience, preferably a doctor who has run systems but that that would be the type of facilitator that we would hope would be able to engage the communities in the conversations because we need somebody that will be respected by the medical community at large to be the facilitator of these conversations. Yeah, absolutely. All right, we, why don't we take the slide down and then because I see there are questions Mari you representative you had your hand up first representative quarters, and then representative Houghton, and then Senator Hardy in that order. Oh, well no I missed one before Senator Hardy, Senator black representative black, and then Senator Hardy. Thank you. Elena you mentioned in your presentation, a few times centers of excellence, and in my work I'm familiar with centers of excellence in terms of specific areas of care like cardiology centers of excellence, geriatric centers of excellence. I want to talk more about what centers of excellence you are referring to you, the big you, all of you in this report, and not in too much detail but give us a better sense of how these, this part of the proposal would would help. In a general sense, you would want to focus on those service lines that, you know, are, are struggling are kind of under threat because they have low volumes right and that there's this volume quality relationship so I think that would be, you know, when we talk about surgical procedures we talked about orthopedics where volumes matter and delivering outcomes. I think those would be the place where we'd start, but I think this is the kind of analytics work and community based conversation that would be required to kind of identify specifically, which services. We need to come together on but it needs to be both informed by you know what is the right threshold, like what delivers better outcomes, but also what communities need and what they can, you know, so we're not, we don't want to just move services without having, you know, transportation in place or some kind of there needs to be a whole system approach to making sure it will work for Vermonters in every community. So, you know, it's hard to say exactly what that will look like, but I think starting with some of those services that, you know, are tied to volume and quality would be a great place to start. So centers of excellence is our programs that incentivize hospitals to improve outcomes and meet they have to meet certain criteria established by some accredited body to attain the status of a center of excellence is that correct. I think that's all how we define center of excellence can be broader than that I think it okay idea is just that there may be regionalization of care that would allow us to provide higher quality care, how exactly that works I think would be developed through this design process that we Okay, thank you. Yes. Representative how. Thank you. So this may seem like a basic question but I just want to make sure we all have are starting from the same baseline. So we've been working on value based payments for several years now and obviously we've shifted a little but not enough and I get that. But, but when you talk about global payments, I guess what's the definition and how is it the same or different from value based payments. That's a good question so I will go back to, if you don't mind the land network slide. So, for those of you don't know the land network there is a whole range of value based payments that exist. When talking about this is a framework that was kind of put forth by the learning action network, which you may have seen before but if you haven't category one is kind of where we are fee for service there's no link to quality it's just, you come in the door there's a price for the service, or payment for the service category two is a fee for service with link to quality and so there's a number of ways those can be constructed. So you're still paying based on volume people coming in the door to get services, but you might get a bonus based on outcomes or quality of care delivered. And then this kind of ramps up and what you know the theory is that a population based payment that is just a payment to keep someone healthy. It's supposed to cover all of their services would allow providers more flexibility to, you know, focus on giving preventative care, rather than bringing patients through the door and so, in that sense it's more like giving an allowance to a provider or set of providers to keep people healthy, and make sure that they're getting, you know, the right care and the right time at the right place. Which, you know, just gives them more flexibility than in the fee for service model, but also, you know, they're more accountable to the outcomes and actually delivering, you know, high quality care and ensuring, you know, better outcomes for their monitors. So if I may follow up so that I believe has been our goal. And again, we were doing it with, you know, carrots and not sticks. And so it's been a slow process so in regards to the payments were the first part of this sustainability plan would be to move faster the people who are not there yet in a way that works for the whole system. And at the same time looking at, you know, the sustainability of the care and the quality, parallel to that. But basically you're saying we just need we need to move to these global value based payments faster. And I, you know, why that hasn't happened there. There are a lot of reasons but I think this is a natural evolution like I don't think you can go from category one to category four overnight so you know we've been moving along this path. Providers have been getting familiar. You know we also need payers to get familiar, but I think we're at a point now where we're saying, you know, we've gotten familiar we're getting familiar and now is the time to jump, because we can't drag this thing out forever. Or it's only going to kind of hurt us at the same time. Yeah. As you said before, let's take the can we take the slide down and then continue. Thank you that was helpful. Okay. Representative black. Yes, thank you and thank you so much for the comprehensive presentation. So, I sort of furthering on representative questions question. I mean, I, I guess I sort of see value based payments differently than global budgets. And it sounds almost as though it's, you know, moving faster the trajectory towards value based payments. You're also ultimately talking about what seems to be a comprehensive Vermont health care system, you know, sort of changing the services that are provided in certain areas. You know you would talk at the beginning, you're particularly good in orthopedic surgery then you become sort of a center of excellence orthopedic surgery. Well, I mean, ultimately to get to a global budget. Is that what we're looking at is looking at our whole, all of our hospital systems, and having them all work in different ways for whatever region, and then a small follow up to that because the one thing that I didn't notice in your presentation was, where do you see one care of Vermont fitting into this model. So, I think if I understood your first question correctly, I, you know, I think a global payment is a mechanism that will allow providers to make different choices that may benefit Vermonters more than under the current system. I think in our current system or where we are in the middle of this transition, there's still requires providers to work together. You know, we don't have a single system here. We have a lot of independent providers trying to find ways to work together, and I think if that's the paradigm then we continue down that paradigm this is just yet another place where we need providers to come together and work together with their communities to figure out, you know, so this is this is kind of it's a little bit more. So if you had a central system that process would be different but the goal is the same, but I don't think you, you don't, you don't need a central system, but it would certainly be more streamlined. But you can get there I think with the direction we have. In terms of the ACL, I think you can do this global payment and this care delivery with an ACL or without an ACL. So I think, you know, the ACL has been really helpful in getting providers like we've said accustomed to these kinds of challenges. But I think, you know, depending on how their role continues, you know, this is we need to do this work anyway. There's a value for all for one care, or any ACL moving forward, if they're providing the right data analytics in the right care coordination because for any of these global payments and any health service area to be successful. There needs to be better coordination of care so that if somebody is released from the hospital that they're being seen through the visiting nurses or sash and so the coordination that an ACL could provide in the data analytics that they could provide. There's a very useful role, but if a local health service area doesn't find the value in what they're getting from the ACL, they could do it in a different way so there's really a role for an accountable care organization, but it's not locking that role in, at least in my mind. Well, there can be more than one ACL in our state, I think people may not understand that the private organizations that can pop up wherever. Representative black, did you have a follow up. Thank you very much. All right, Senator Hardy. Thank you madam chair, I think Professor Holmes had something she wanted to add to that last point. Thank you. I know I didn't want to interrupt. I just want to emphasize that the recommendation here is about funding and intentional and thoughtful process that will involve examination of our delivery system and a different way of paying for care but it's really patient centered that process it's going to include hospitals providers and community leaders and in conversations, it's going to be informed by data. We need experts and health system designed to look at that but the reality I just want to say is right sizing or wrong sizing or market adjustments are going to happen whether we plan for them or not right populations are declining fixed costs are growing and cares moving out of the hospital. And even if the state doesn't move to global payments right away, the federal government is so hospitals are going to be held accountable for cost and quality and if they don't pivot and adjust for the trends that are coming financially. We're going to start to see the market forces at play with hospitals potentially going bankrupt closing seeking federal state funding to keep their doors open cutting essential services. So this recommendation is about having a very thoughtful community inclusive planning process so that we can take advantage of federal funds that may be available a new federal agreement that's coming our way. And an understanding that the trends whether we like them or not, those headwinds are coming in our direction and if our hospitals are not prepared. We are going to see some, you know, consequences that we may not be able to live with so this, this recommendation is about getting everybody together using data, using expertise, and really doing thoughtful planning. It's consistent with what the consultant that the legislature hired recommended and it's consistent with the number one strategy that Donna Kinzer put forward in her report to the legislature. Just to say we have not had a chance to review that in our committee yet, but we will. Yeah, well and I will insert be I know Senator Hardy's waiting. That our committee is looking at that in the context of our bill are as 285 committee bill. So, ultimately, hopefully it will get to the house some point. Senator Hardy. Thank you Madam Chair, Professor Holmes and chair chair mullen sort of stole a little bit about what I was going to say, which is great. Jessica and I were talking last week about this and I underscored with her how important I think it is that this be a community led process. And that, yes, there needs to be a well respected medical expert slash consultant, but it really needs to be community driven, because all of our communities have different needs and different personalities and as anybody who went through the school administration process knows it can be a disaster if it's not done well. So, I think it's really important that it's a medical expert paired with a community based expert that leads the, the conversation starting this summer in everybody's communities. The next thing is what Kevin just said about this pairing well with the recommendation from Donna Kinzer. I feel like in some ways right now we're in this position where we're throwing spaghetti against the wall to see which what sticks. And, you know, we have a ton of ideas floating around in our committee and a lot of the pieces of spaghetti is in my mind are falling off the wall, but this one is sticking because I think it's really important that it came from both you on the Green Mountain Care Board and from Donna Kinzer's report and it makes it gives it a lot more credibility in my mind. So I'm just wondering in that sense. What else for what other pieces of spaghetti stick to the wall, besides the global payments and your proposal today that you've heard that we should be pairing with this at this time. I don't know if that's for Kevin or Jessica or Elena or Susan, but just wondering what else is out there that given the tight timeline for for change right now to. I'll jump in very quickly. I, I can't agree more with you about the global payments. I'll add another layer of alignment and that's the federal government, certainly not speaking for the federal government, but in our conversations. They are very interested in moving to global payments so that add another layer to that alignment. I would just say for from our perspective is we are looking from build building from the sustainability work and making sure we're we're hyper focused on the sustainability of our hospitals and the and the communities around them. So, I wouldn't have anything to add I think we have enough fun or play with this. Well, I think that one thing and maybe Elena you want to talk about it but the Senate did put money in the Budget Adjustment Act for benchmarking so you might want to talk about that Elena. Yeah, and I think that was another one of Donna Donna Kinzer's recommendations that would pair nicely to give you kind of a hospital and beyond hospital look at where these costs are coming from. That would that would overlay nicely I think anything you have in the works on primary care I think that's outside of us but both during any investments in primary care mental health, you know hospitals are just one pillar of the system. So ensuring we have robust investment in prevention. You know is and social determinants of health is really essential to making sure that we can get people the right care setting at the right time so hospitals again are just one piece global payments are important but this is, we need a system wide view. Thank you. Another thing that has been discussed really is the expansion of blueprint as well. And so for example blueprint does a program for diabetes care and, and yet most people in the state don't even realize that it's available to everyone. So those are the type of things we can't stop what we're currently doing I mean we have to keep pushing forward in the current agreement to try to focus on prevention and wellness and treat people. So for example in diabetes treat them when they first show signs of pre diabetes don't wait for them to have a wound or God forbid need an amputation and, and so this all has to occur while we're still trying to make progress in the in the value based system that we're already in with the all pair model agreement so there's a lot that's going on. And unfortunately one of the problems that has diverted people's attention has been the pandemic it's no secret that our healthcare professionals haven't been able to focus on, on much else other than trying to keep the doors open at their institution and keeping people well. So hopefully we're coming to a point where people can start to focus their energies on moving forward to, you know, having a better healthcare system in Vermont so everything is all intertwined together and I, I hope that the spaghetti doesn't all end up on the floor. I'll just throw a couple more ideas out there or points out there, just like global payments may help move us in the right direction for hospitals and hospital sustainability I do think thinking about the primary care system and primary care capitation might also be similar and helpful we have to ensure that we have the appropriate workforce I think there's so many initiatives I know that are being discussed at the state now about ensuring that we have pipelines for workforce. And so I think those are really, really important efforts, and certainly if we don't manage the workforce shortage, the acute workforce shortage that we have now and understand the burnout that healthcare providers are facing right now, and our impending retirement because of our aging workforce population if we don't deal with that soon and now and yesterday. It's all related to this because our hospitals in some ways are struggling financially because they are paying for travelers that are far more expensive, right, then their permanent workforce. And the wage pressures are only going to go up as the national we have face a national workforce shortage so in our hospitals may not be at the best leverage to be able to bargain for those, you know shortage positions. So, if they don't have the financial resources to do so so workforce shortage is really important to manage and deal with and find creative solutions for. Yeah, workforces underlies just about every single conversation we have so that very, very much appreciated comment. Representative Lippert has a question and then I have a question. I'm very pleased that Jessica has mentioned workforce development because that is something where we're focusing a great deal of attention healthcare workforce and have, but need to do a lot more. And I would. So my view is that that is complimentary with an e complimentary to the to this proposal, it's not. Right, run in counter it doesn't run encounter veiling method to that as as do I think some other initiatives that were where we might in the near term want to strengthen mental health services and services that we know are a diarly diarly under available to Vermonters. So there I think there are, there are, there are initiatives in the near term that are critical, as we enter into this larger what I personally hope will be a larger planning process. The other, the other, the other process that leads to sustainability. So, two things I want to just also just know. One is that not everyone has been maybe fully aware of what happened with Springfield hospital.  And, and I think there's, there can be an assumption that everyone knows what you know. And that's not the case. And so I would even maybe ask for there to just be. If someone I don't know if anyone's prepared to do just a brief thumbnail description of what we went through in the legislature what the agency human services went through what the entire system went through with the. You finally was a bankruptcy declared, but with the potential failure of the Springfield hospital. And as you said you're using that as an example of what could happen further, and yet that's very real. I can give you a little thumbnail history of it. During their hospital budget process, which occurs in the summer they had a hearing in August. They reported that they had a year was that Kevin, Kevin, I think you put it in time if you can. I'm maybe the years, it would escape. More than two years ago, I'd like to say 18 but somebody's going to have to. I don't, I've lost track of time these last years. The past is not existed. Yeah, no, we're all struggling there. So, in that round in their budget process. The executive team presented a budget that showed that they had 106 days cash on hand. And they were less than transparent with the true financial picture, and the problem first came to light when a former legislator gave me a call. I don't know bill you probably remember john fall it. I know I'd not well but yeah. Yeah, so he called and said listen he said I used to be a board member down there and I'm hearing from people that there's a huge stack of checks that are sitting on the CEO's desk that haven't been paid and they can't even get oil delivery at one of the clinics. So, we started making calls and finding out what the heck was going on. And it became clear pretty fast that they thought they could manage the situation and they couldn't so I don't know if you can tell you're a chess us spring field. A plan was put in place where a chess provided some relief in the in the form of provider taxes and other dollars that were were let there. A management team was brought in from the outside to run the hospital in the short term and figure out a plan for moving it forward. And they did enter bankruptcy. They were one of only four hospitals in the country that were both a hospital and an FQHC, they ended up splitting into the two separate entities, and they have emerged from bankruptcy. They have a plan. Short, medium and long term. I still worry that the long term viability of that institution is there. They have, I think, somewhat benefited by the fact that other hospitals are at capacity due to the pandemic. And so if you look at today's numbers, they're okay. But I still worry in the in the long term on that and a lot of people had to help them and their lenders had to lose millions of dollars through the bankruptcy process to make sure that they had a viable path forward. And I think that it's something that we would never want to see repeated. And so there were changes that were made in the process on what had to be reported and such and it's it still doesn't mean that we're not going to end up in a similar spot with another hospital. Chair Mullen, I don't want to interrupt the flow right here. But we are getting close and Senate Health and Welfare needs to move to another Zoom meeting. We have our own meeting that starts at 1030. We want to take a little bit of a break before that. But this is all extremely helpful to understanding why we're concerned so concerned about all the hospitals across the state, Springfield being a model for concern. And so I did have one more question. And if it's all right with you, Chair Mullen, I would ask the question. And then we can come back to the conversation around Springfield and the concern about bankruptcy for any one of our hospitals in the future. And I know that House health care is going to continue on with a conversation with you. So they'll be able to get a full report. But my question actually was about the planning process that you have and then utilizing the data available through quality metric analysis to make determinations about care and knowing that it's going to have to be with the hospitals, with the practitioners and with the patient in mind. How right now that that data is the claims data is not fully robust. So how are you going to move forward? And it's to the, I think it's to the second level, you know, to the quality analysis and to the transformation piece. The what I call the $3 million piece. How are you going to capture more data to to move forward? So I wish we had brought Sarah Lindberg, who's the head of our analytics team. Just just to we'll have to follow up on that because we really, you know, it's just a question and perhaps at some point we can catch up with that that would be helpful. Maybe I'll just add a quick point here is that in some ways that's why we need a health systems expert to help us identify what exactly is the type of data that we need to better understand, to ensure that we have an efficient delivery system with that's the highest quality. So we have claims data to be sure we also but that's why we need to be inclusive of hospitals they have far more data than we do and we need a health systems design expert to help us think about exactly what data do we need and what do we look at and how do we think about. Okay, right and we'll get to that and we'll also, as we're working on 285 we're also working on primary care, we're trying to look at the blueprint for expansion, all those things that we hope are going to stick so we'll bring you back into our point and try to to move forward, but Senate Health and Welfare can now leave we have a six minute break. And thank you, thank you Representative Lippert and thank you. Green Mountain care board and all representatives it's been a pleasure thank you very much. I think it was wise for us to do this jointly thank you Senator Lyons and we will we will in the House Healthcare Committee. Let's take a 15 minute break will be luxurious. I think we were actually on our schedule, we'll let our senators take off to go to their next zoom commitment. I want to say I do appreciate that the flexibility, I believe the folks from the Green Mountain care board are going to be able to continue with us to that's correct to we stay on the same link. Chair Lippert you do what I'm going to


Everybody forced here right been a box of 2022 Chronicles WWE for Jason C. We go Jason It's fine to undertake her auto or something Discord, what is discord Kelly Kelly on the legends auto origins legends auto Kelly Kelly nice Ray Mysterio to 99 on the On the one base card base parallel and a John Bradshaw Layfield to 99 elite red Phoenix 102 of 199 a You you Lisa or you listen Leon Leon Leon Leon Malik blade Kelly Kelly head it does kind of sound like a Football play call. Oh season ticket Jenny auto to 25 Jenny to 25 nice card stock on that one actually to 99 Randy Orton origins out of nowhere Mella AJ Styles Must be Harry's brother Ginny and Shayna Baszler. Howdy Roddy rest in peace Bob Wharton Aliyah on the panini black Alba fire last one Hollow is Terry Gordy Briggs J. Uso Jake the snake And dude love and that'll do it. Thanks again Jason. We'll get those out to you


Now, we are going to study learning to live according to gender norms. Learning to live according to unjust gender norms and expectations is a limiting for girls and boys. However, evidence suggests that gender norms have a particularly profound impact on the agency and empowerment of girls and on their expectations for the future. These gender norms are made for parents, parents, and communities. What do they have to do when they grow up? If they are a girl or a girl, what are the things for them and what are the things for boys? So, parents themselves tell them about their expectations. Now, if they tell them about their expectations, then they will learn to live according to their expectations. In a recent US study, researchers found that by the age of six, girls were learning the common stereotype that associates high-level intellectual ability, brilliance, geniusness with men more than women. Now, this is an American study. Young girls heard from parents, parents, teachers that boys are more intelligent, girls are less, or girls study arts and girls study science or mathematics. So, from the beginning, you will inculcate a stereotypical thought into them that what can one of them do? So, they try to do the same. If they are left open and they are helped to explore themselves, what they like to do, what they can do, and it is important to say that they can do everything to the children and to the girls that they can do everything. Yes, if there is not much moral work, then they should be allowed to do other things. So, in 2016, a Yarnesiv study found that the types of household course commonly undertaken by young girls like preparing food, cleaning, and caring for others not only set the stage for unequal burdens later in life but can also limit girls' outlook and potential while they are still young. So, the first thing is that they see the gender role of their parents, their mother, what they are doing, they are doing house course, and the other people's help is their job. And their parents' help is their job. So, what they will learn, they will learn. It is not bad to work on it. But what we want to say is the definition of it. That we have to end its distinctiveness. If we want to do the household work, then both the children should be involved in it. If we want to serve the elders, then both the children should be involved in it. So, one of the role identity will be to serve the elders, to serve ourselves, to manage ourselves, to clean ourselves. So, we will take all the responsibilities equally. Household activities earn less esteem and less worth as compared to earning activities, and it narrows girls' ambition. And if we say that the children will only do household work and the children or the elders will not do household work, they will only do outdoor activities, then we ourselves did not only restrict them, but we also told them that there is no importance of house course and the importance of which they will do it, and the importance of which they will do it, the boys will do it. Now, it is a very interesting thing in our society. As we have already told you the findings of a research study, that boys do not only do household work, they only do household work with the children. So, it means that if a boy does not even start earning outside, if he is not earning outside, then he will not do household work because he does not want to do it. So, this is such a thing about which awareness should be created. From the beginning, when the children come to our pre-school, when the children are playing with toys, then our attempt is that they will gather together. And when the time comes to clean the room, they will gather together. And when the time comes to share things, then they will all share together. And when there is a time of someone's help, then they will do everything.  This distinction or distribution is not right. So, from the beginning of the day, we have to train the children that in the coming days, whatever responsibilities are related to their parents, whether it is related to the house or outside the house, they can all do it equally. They have this capability and responsibility. They should do it.


Superoffice Marketing is a tool for mass distribution and tracking of emails. Using Superoffice Marketing, we will show you how you can send a mass mailing in five simple steps. We will show you how to create a mailing, choose a template, add your content, review your target list, schedule and start the mailing and track people's responses. For this mailing, we have created a selection of all decision makers who have not attended any of our seminars this year. Selection is a great tool to create your target list. We will create a project in Superoffice CRM to automatically track the people who sign up for our seminar. When we create our mailing, the first thing we need to do is to create an invitation. As a starting point, you can use a template or copy an existing mailing. In this example, we will start with a template. When you edit your invitation, you also have the possibility to personalize it. And when you insert links into your message, the system will track when the recipient clicks on it and you can also specify various actions. In our scenario, when a recipient clicks on the link to sign up for the seminar, that person will automatically be added to our project so we can follow up on him or her later. Now, we are ready to choose the target group for our mailing. Target groups can be based on CRM selections, projects, individual contacts or an import list. You can review your target list and also see how the email will look for each individual person. We are now ready to start sending the email. After the mailing has been sent out, you can watch the dashboard to get live statistics of the results from your mailing. At a later point, you can go back to the project and use it as a target group for a new mailing, such as a reminder mail right before the seminar. Using Super Office Marketing, we have now shown you how you can create a mailing, choose a template, add your content, review your target list, schedule and start a mailing and track people's responses. This was just an introduction to show you how you can send a mass mailing using Super Office Marketing. For more information, go to the Help menu in the Super Office.


The new Walther WMP and that's what we're looking at today. It's new from Walther, it's a 22 Magnum. For those who don't understand, the 22 Magnum moves so much faster than the 22 Long Rifle and it is a lot louder. Full-size handgun, ergonomics of Walther, I love it. They call it cross-directional texturing. 4.5-inch barrel, you can see it has lightning cuts in there, it's not ported.  The website says four and a half pounds, but it feels much lighter than that. A hammer-fire gun, a two 15 round magazine, right side and left side magazine release and separate trigger guard releases. The MSRP 549 slide is aluminum and it is optic ready. If you enjoy no recoil, this is really cool.


YouTube team keep it clean What's going on? It's engraving here with another video and it is like really dark outside I mean, it's not dark instead of dark It looks like it is getting ready to rain. I know they said we're not supposed to be feeling the effects of everything until like Like I think late Saturday or Sunday. I mean Saturday Sunday But it looks like we getting something right now, but anyway, wow, we got 32 people in here already man I didn't even get started yet. Let me get started cuz I want to waste anybody's time. Anyway, let me introduce myself Let me do this thing early right now Team keep it clean. What's going on is engraving here with another video and I'm like literally fresh off of work I got stuck there a little late, but it's all good But it's engraving here with another video and me I'm engraving this. This is my YouTube channel Engraving vision. I'm a Ravens fan, but I'm not a fan of these dirty jokes that people are playing on my team I don't like that especially when the joke fails So um, yeah, I appreciate y'all man. Yeah, we definitely gonna be doing our best to stay safe Look at this line at the gas station. Look at this line at the gas station Let me see if y'all can see it. Look at this line at the gas station Look at this line at the gas station. It literally wraps around look at it Look at that Look at that crazy, man crazy Crazy I got gas last night at like 1 30 in the morning and this is not the The car that I drive to work is not like our family car anything and it has a half a tank But our house is literally like right up the street from my job. So Worst case scenario, we wouldn't be using this car. Oh, I accidentally honked the horn I think we wouldn't be using this car anyway if we had to go like go somewhere depending on how the hurricane is but This car is straight. So this this got a half a tank. So I'm glad I got gas last night Look, let me keep showing you this line, man. It's still going. It's still going It's still going it's still going and people are still lining up Let me let me show y'all this stuff, man Another gas station right up here. Look at this line. Look at it It's still going Still going this is for next station, man This is for another gas station It's getting crazy out here, man Still going now. Um, just really quick We all are getting to see this stuff like this is real life This ain't the stuff on the news But because you know how the news they only show you like half of the stuff and whatever You get to see from a different point of view. Um, but anyway, really quick on a happier note The joke that got played on the ravens people. That's a man. That's what y'all doing Somebody went on the ravens website the ravens wikipedia page. Why they got these these apartments blocked off But anyway, somebody went on the ravens wikipedia page and what they did They made a little update and they said that the the owner of they said that the the starting quarterback Is joe flacco. They said the head coach Is john harbaugh, but they said the owner of the baltimore ravens Is ben roethlisburg Now see i'm all for a good joke. I love great jokes. Love it. Um, but Jokes are usually better when they have truth behind them Jokes are usually better when they have truth behind them if Now if this was like a couple years ago Well, actually more than a couple years ago because actually the ravens have been owning big ben and them for a little while now It besides the game last year, but if this was from a couple years ago, then it would have been like, okay I get it. Yeah, big ben owns owns baltimore because we just can't beat him for nothing But those times changed a while back and for a long time Um for a while big ben had just been killing us over and over and over and over Um, any time he was the starter in the game, we would just always find a way to lose But that's not the case anymore. That is not the case anymore. Especially like in the last four or five years I don't know what exactly what exactly what the record is, but it's definitely in our favor with big ben. So um, it is yeah, it's not Big that the it is the joke would have been funnier and it was still funny I ain't like that. I ain't no uptight fan or nothing like that. I love jokes like that. It's funny It but it it would have been more fun or it would have been actually less funny if it was true But it's not true. So it is it's not really a sting with it. There's no sting with that. So Good try whoever did that. I'm sure it might be a subscriber on here One of y'all might have one of y'all stealers fans might have when it updated the ravens, uh, their wikipedia page Maybe I need to go mess around and do something to that stealers wikipedia page Maybe I just need to do that. Maybe I will I'm gonna see about that But um, anyway, I just wanted to share that with y'all nothing major nothing serious anything like that um, I'm about to go get a haircut um That I had that hurricane just a little quick side note that Was it one of those islands? um, and it had stuff underwater just just killing stuff man Um, I didn't hear about any deaths. I'm sure we probably I know I heard about two. I mean heard about two deaths two people injured. So um It's like How did I explain that because you never want to hear about anybody dying? um Because death is like the worst thing to absolutely deal with the worst thing um But with it only being two, um, that's I can't say that's a good thing because it's not but it's good that that number is not super high Hopefully it hopefully it won't increase um But people just got to be smart man People got to be smart. I was supposed to be at my barber shop in 615. I ended up getting stuck at work So I'm I'm pulling up here right now. So um, I will check y'all later on And appreciate y'all man. Y'all can hit me up on twitter if anything Send me a dm if you want to still talk about something or just say what's up And I'm about to go in the barber shop. Love y'all


Hello and good morning to day one of the no spend in March I just woke up and took the dog on a walk and I figured I would just talk about the no spend for just a minute because I edited my video yesterday and kind of realized that I Left a couple of things out. So here's what a no spend means to me Obviously you have to pay your mortgage and your light bill and like all of those things However, I'm gonna be eating out of the pantry and the freezer as much as possible to eliminate hefty grocery bill at the end of the month and then also it means no extras. So extras are like Dining out planning supplies things from Michaels, you know like home stuff things that are not a necessity So it's just kind of fun to see like how long you can go without those things And then kind of at the end of the month like do I really still need it, you know so for instance like if I ran out of the shampoo that I normally use I Would search my stash to see if I had another bottle or Maybe I have something that is just like not my favorite, but I could use it for a week or two That's kind of what I'm talking about. So just kind of using what you have and using up what you have so I want to give you guys a little tour of the freezer and The pantry and the pantry is horrible you guys like I know That I had shown you my pantry organization when I first moved in and everything was all hunky-dory and It looks crazy now. So I think this stems from just being so busy now that I'm not busy I can eat out of this thing and then also like holiday gatherings. I kind of just shoved everything in here and Let me turn you around and I'll show you now. So every shelf is like extremely deep and Yeah, so It's insane you guys like I Just don't know like this is a bunch of like baking stuff and like other random things like I have a water bottle in there Like I don't know why and then these are like just bags of things like most of that stuff was for the holidays And they like never ate it and then moving into the freezer the freezer is actually not that bad I've got some meats and some like pre-packaged things There's some ice cream randomly. Maybe we should eat that some edamame and then also like a bunch of veggies and I think I might make a blueberry cake at some point this month because I have the stuff for it I just never have made it. So I think I'll be good with this and then The side over here. I just keep like bags of cheese when they're on sale I have these waffles that I might eat and then also I have like Uncrustable because they're like my favorite fave. So anyway, that is what I've got going on with my whole Eating situation. I think I'm gonna show you guys what I eat to maybe Um This is not like a super healthy Situation this is like eating whatever you have and making it work I'm gonna try to make it balanced with like grains and veggies and all of that good stuff But there's probably gonna be a lot of pasta involved Just FYI because I have a lot of it and it keeps for like ever so that's why it's in the pantry But I think it's kind of fun to see like what people make and it's weird because It's not weird, but it's challenging because I'm single so most of the YouTubers that do this Usually are married and have kids or just have kids and so or at least I'm married and So it's a little bit easier to make a big batch of something and eat it for only like one or two days Where if I make something I have to like eat it for the whole week So yeah, it's a little can be a little intense with the eating thing and then I get sick of things And you know, it's never good and don't get me wrong I love leftovers, but leftovers for like four days is just like not my idea of a good time So anyway, like I said, I just woke up I am going to make my breakfast right now and then I will show you guys what I am munching on and Yeah, we'll get this day started. Sorry this day is a little bit long but I just kind of wanted to explain what a no spend meant to me and the progress in Or not the progress but the before shots of the pantry and the freezer so you guys could kind of see I will see you in just a moment. Alright, so I just made breakfast and here's what I'm having I'm having a cup of tea and if you guys are interested My favorite tea is the twinnings twinings. I don't know how to say it English breakfast tea It's good. Anyway Okay, so I'm going with my staple my peanut butter toast and people always ask what's on it And I put flaxseed on there. I'm going with a couple little pieces of cheese because I had them on hand and I might as well Eat them up and then also I have two pair halves in there And yeah, I don't like my food to touch and these are really juicy So I'm gonna eat those and yeah, so this is my first breakfast and I'm sure I'll have a few more breakfast that look like this so Stay tuned for lunch. Alright, so it is lunch time and these have been in my refrigerator for a while and I think I just need to like eat these up obviously I'm not gonna eat all of them. I probably just like I think I'm just gonna have two of these and I'll have a Coke I may have some like chips and salsa because I have salsa that is Like almost expired like it's gonna be expired like by the end of the month So I just want to like eat up stuff that just you know has been sitting in my refrigerator or pantry for like way too long So again, this is not like the epitome of health obviously, but um, yeah I'm gonna have two of these and a Coke for lunch and Maybe some chips and salsa not sure yet, but maybe some chips and salsa later So it's dinner time and to be completely honest It's like almost seven o'clock and I am just like not that hungry. So I'm gonna go with my Staple I'm just gonna have one of these on crustables and I'm gonna keep sipping on my bottled water that I always do and Yeah, I think that's gonna be my dinner. I might have some crackers or something if I get hungry later, but I don't know I just haven't really been hungry today, but I've been working on things as You guys have seen earlier in the day. I posted a couple of videos So anyway, I think I'm gonna have one of these and I just took it out of the freezer So now I'm waiting it for it to thaw out. So it'll be like, I don't know 20 minutes or so, but Wanted to give you guys an update about how much money I've spent today. So let me show you Okay, do you guys see that $53 and 24 cents? That is how much money I have spent today this is my City bill that is my like water and sewer bill. So I Spent that much today. That's it. I didn't spend any money going out or getting gas Or anything like that. I actually haven't left the house yet today and I don't think I will so just wanted to let you know I am down a $53 and 24 cents for the month so far Hope you guys are enjoying these videos and I will be back tomorrow to share more. Thanks so much for watching And I'll see you tomorrow. Bye guys