Okay, I have one o'clock so we're gonna get the meeting started. My name is Kevin Mullen, Chair of the Green Mountain Care Board. And the first item on the agenda for today's meeting is the Executive Director's Report, Susan Barrett. Good afternoon. Thank you, Chair Mullen. I have a few announcements, mostly around scheduling and some public comment announcements. As I've announced before, on August 14th, the Qualified Health Plan decisions will be released. Now we are headed into our hospital budget season. On July 31st, hospital budgets were due. They will be put up on our website as they come in. Most of them are in, and as our staff reviews them and peer reviews the information. So if you check out our hospital budget website or webpage, you can access the narratives and the budget information. I also wanted to just remind folks of the upcoming hospital budget hearings. Also on our hospital budget webpage, there is a really beautiful calendar that Abigail put together that shows each day and each of the hospitals the time that they're presenting, et cetera. These hearings will be done by through teams. We will not be in person. And just as a heads up, we have the hearings on August 18th, August 20th, August 24th, August 26th, and August 28th. If you have any questions, please reach out to me or Abigail. We also have on August 14th, a data governance council meeting. So Tom and I and the rest of the council members will be there. It is also open to the public. We'd encourage you to attend. In terms of public comment, Elena and the team will go through this during the sustainability presentation, but we did receive two written public comments for the sustainability plans. And then lastly, I wanted to let folks know that, and many folks know this, that we at the board have been working towards working on regulatory alignment. And to that, and staff working with a couple of our board members has done an incredible job of putting out a draft, actually several draft white papers on the Green Mountain Care Board regulatory alignment. These white papers are now open and posted for public comment. We'll have a presentation by Sarah Kinsler, who was the person who led this work at the end of September. But I'd really encourage everyone to check out our website under public comment. And if you look under regulatory alignment, you'll see discussion drafts of part one and two of our regular of Green Mountain Care Board regulatory alignment. Also, Sarah Kinsler will be sending out some emails and two interested parties so that you'll have a copy of these in your email. And with that, I will turn it back to you, Mr. Chair, unless there are any questions from the board. Thank you, Susan. Seeing no questions from the board, the next item on the agenda are the minutes of Wednesday, July 29. Is there a motion? So moved. Second. So moved. It's been moved and seconded to approve the minutes of Wednesday, July 29 without any additions, deletions or corrections. Is there any further discussion? Hearing none, all those in favor of the motion signify by saying aye. Aye. Aye. Any opposed? Thank you. At this point, I'm going to turn it over to Abigail Connolly so that she can properly record all attendees of this meeting for the public record. Thank you, Kevin. I'm going to call out the last four digits of your phone number. If you could just state your name clearly, I will take attendance. I'm going to start with 2449. Kathy Colton, VPQHC. Thank you. 4191. Devin Green, Vermont Association of Hospitals and Health Systems. Thank you. 6376. Mort Wasserman. Thank you. 6977. Jason Williams, the University of Vermont Health Network. Thank you. 5010. 5010. I'm going to move on to... Is that a copy, Comper? Oh, sorry, just got back in the phone. That's Tom D. Southwest and Vermont Medical Center. Thank you, Tom. 1-080. Maria Holt, Court of Medical Center. Thank you. 1-9-0-5. 1-9-0-5. Okay. 5-8-1-7. Thank you. 3-4-5-2. Rebecca Copan, Blue Cross Blue Shield. I do have Ham Davis as well. And there are other people that are listed, but their names show up because they're joining via Microsoft Teams. Thank you so much. Thank you, Abigail. So the next item on the agenda, we're going to turn this over to Sarah Lindberg and a whole bunch of other people to talk about geographic reporting. And Sarah, are you taking the lead or is one of your team members? Are you able to hear me? We are now, yes. Okay, great. Good morning or afternoon. Sorry. This is Sarah Lindberg. I'm the Health Services Researcher with the Green Mountain Care Board and I'm delighted today to be providing you with an update from our analytic team, the A team. And what we'll do is kind of step through different reports with different owners of that. And unlike a typical presentation, we would encourage you to interrupt with any questions along the way after each person's finished with their section. So with that, I'll turn it over to Kate O'Neill to start. Hi, hopefully you can hear me. You can see our presentation. So I'm going to kick us off with just a brief summary and update of the Data Governance Council. So the Green Mountain Care Board's Data Governance Authority comes from many sections of 18VSA. And the Board has brought authority for maintaining a healthcare database, including hospital and insurer reported data. And to that end, we have stewardship over V-Cures, which is our eligibility and claims administrative data for Vermont residents, as well as the VUDS data, the hospital discharge data for inpatient, outpatient and emergency department services provided by Vermont hospitals. And that's for both Vermont residents and non-residents. Data Governance covers a lot of concerns. And so the Green Mountain Care Board is responsible for what we've bucketed as these four sets of these categories, risk management, ensuring data privacy and security standards and practices, data quality to ensure the highest possible quality of our data resources, program sustainability, and data release, supporting clear processes for the release of data. And the Green Mountain Care Board created a Data Governance Council with authority to make executive decisions and assign resources. And that council meets approximately every other month. Susan announced that the next meeting coming up is next Friday. It's currently composed of seven voting members. And currently, those members are two Green Mountain Care Board staff, one board member, and that's member Tom Pelham. We have two state agency representatives. One comes from Diva, one comes from the Vermont Department of Health, and then two non-state entity representatives. DPQHC is on our council as well as by state primary care. We have a number of resources on our website. I just called out a couple here, but we have a charter, and that was adopted in March of 2018. And we have a principles and policies document, which we adopted in April of 2019. These are links, but this and more is available on our Green Mountain Care Board website under our data and analytics section. Right now, the current issues for the Data Governance Council include a rule update. Right now, we have one rule and that addresses data submission as well as data release. And we are in the process of drafting an update to that, which we would propose to split into two rules, a data submission rule as well as a data release rule. And we have provided updates to the council over time in terms of our drafting of that and getting their input along the way. We have some policy guidance that we are nurturing at this point in time, including data linkage, defining it for us for the Green Mountain Care Board and the conditions and the limitations under which linkage would be allowed. And also structures for available data release based on intended use. And so we're always looking at that. When we release our data based on intended use, we want to make sure that it's meeting with those concerns that the council addresses. We also always watch and provide updates on health care data related activities at both the state and federal levels. And we bring specific data release applications and data linkage requests before the Data Governance Council from time to time. And that's it for me. I am now going to hand it back over to Sarah. Thank you very much, Kate. So I'm just going to tee off a set of reports that will be releasing shortly. And to do that, I'm trying to do a better job of kind of reacquaining people to some of the concerns that we have when we do health care analyses in this area. So please advance the slide nine. So again, whenever we do an analysis, the place from which we start is, is this a resident-based analysis? Are we talking about for monitors based on where people live? Or are we talking about a provider-based analysis? And that's where the care is delivered. So from our recently released 2018 expenditure analysis conducted by the one and only Laurie Perry, our current estimates for the resident spend in 2018 was $6.3 billion. And an example of a resident-based analysis would be what we're doing when we measure the all-payer total cost of care. On the other side of the coin, there is a provider analysis associated with the expenditure analysis. And that estimated $6.4 billion in 2018. And something that the board does that is more of a provider look would be your hospital budget review, which may be on your mind this time of year. But that would be based on where the care is delivered. So people come in from out of state and they involve Vermont residents as well. And so for people who like to think more in matrices, if you please advance the slide 10, you can see. So on the left-hand side is, you know, whether the person lives in Vermont or outside of Vermont. And on the top we have where the care was delivered, either in Vermont or outside of Vermont. So a resident-based analysis just goes across that row where Vermonters, whether that care was delivered in Vermont or outside of Vermont, we are counting that care. And that's what happens for our all-payer model accountability. And then if you go to the next slide, which is 11, you can see the inverse of that, the provider-based analysis. So the care is delivered in Vermont, whether that care should be delivered to someone who lives in Vermont or outside of Vermont. And again, that's more like the hospital budget process. And slide 12 goes on to show how different some of these measures can look compared to one another. So again, that spending on behalf of Vermont residents in 2018 system-wide was estimated to be $6.3 billion. But we only count $2.9 billion of that or less than half in our total cost of care for the all-payer model. So important things like pharmaceutical spend and government-based activities are not included in that measure. So it might behave much differently than something on the system-wide spend. And again, just for comparison, for one care Vermont in 2018, their actual total cost of care was only 10% of this whole Vermont expenditure analysis spending on behalf of Vermont residents, according to our estimates. So I think wherever we're trying to piece together different reports or numbers, it's good to try to ground yourself in how this compares to the whole enchilada, if you will. And we are not featuring it today, but we do have a visualization that's devoted to the expenditure analysis that is probably worth checking out, if that's what's of interest to you. And then slide 13, maybe where I'm turning it over, I can't quite recall. Oh no, I'm going to tee up the report first. Great. So we're going to be featuring four different interactive reports, which may be helpful to you, particularly as you start reviewing hospital budget submissions. The first is what we call patient origin, and that's based on our hospital discharge data. And that's that provider look. So given what's happened at our regulated hospitals, what has utilization looked like for all patients? Then we'll have a look at our patient migration analysis, which says, based on where people live, how are their dollars being distributed across HSA? So for everyone who lives in the berry HSA, what proportion of those dollars are spent in berry versus Burlington, et cetera, et cetera. So that's a second one we'll be walking through. The third one is actually just a refresh of an existing report, and that's a very high-level look at the all-payer model total cost of care. So that's just looking at that all-payer model metric of the total cost of care based on where people live and also membership. So we'll just give you a quick refresh of that report. And another report to remind you of that we'll wrap up with has to do with a longitudinal look at hospital budget submissions that we tried to put in an interactive report to make it a little more user-friendly, especially for some of these big picture metrics. So I believe now with slide 14, I will turn it over to Jeff Batista. Thank you. Before Jeff gets started, if I could just ask everyone who's not speaking to mute themselves. There was a little bit of feedback during Sarah's presentation. So if we could all just make sure that we're on mute, we should be able to hear Jeff. Thank you. All right. Thanks a bunch, Kevin. So I will be talking about our patient origin dashboard, the first version. As Sarah has, and we'll move on to the next slide now, Kate, if you could. So as Sarah mentioned, this is a look at all the Vermont hospitals and anyone who goes to them. And it's a provider focused analysis. So we're looking at all the hospitals that are subject to budget review. Grace Cottage has been included by this point. So you can ignore that little great bit there. And for those who don't know, Grace Cottage is located roughly between Brattleboro and Bennington up north a bit in the area I'm circling. So we're looking at all the hospitals subject to budget review patients or anyone who receives care at these hospitals, either inpatient or outpatient, or the hospital's associated practices. For example, an outpatient clinic for UVM or CVMC. And this includes out-of-state residents as well. We're excluding emergency department visits, as these tend to take place closer to the, at the closest hospital, not necessarily a choice decision of where you go seek to emergency care. Next slide. So the data is derived from VUDS, which is the state's hospital discharge database. VUDS registers discharges by episode, which is essentially everything that precedes a discharge from arrival to exit. This includes the diagnosis, the multiple diagnoses, and other sorts of variables along those ends. The patient origin dashboard that I'm going to be showing will filter data according to certain characteristics that you see to the right. These include all hospitals as broken down individually. The patient location as defined by the Vermont hospital service area, as well as a recoded out-of-state value. The locale, which could be inpatient, outpatient, or that outpatient expanded metric that includes the clinics and places like that. The payers are broken down by Medicare, Medicaid, and a recoded commercial variable that includes Blue Cross, Blue Shield, and other commercial insurers. Of course, we have data for TriCare, Worker's Comp, and other types of insurance. But as the numbers get smaller, as you break it down, we want to protect the anonymity of people who may, who could be identified by the particularities of where they sought care. If there aren't many other people seeking care the same way. In that vein, we excluded any combinations of these variables that had fewer than 20 episodes attached. This means most self-pay and free care was excluded as well, though I'd be happy to speak to those trends outside the dashboard itself. Next slide. So I'm going to move on to the Tab Low Visual. I put in two images here for those looking at the PowerPoint, but I'm going to be assuming control and showing you how this works in real time. So can everyone see a map of Vermont in front of them? Yes. Excellent. It takes a couple of seconds to load there. So here we have what the first visual looks like. It is a map of Vermont with an area graph of the episodes of care. So you select the hospital, the locale, the payer, and you can move through time as well and see how those move by market share and geographically. So let's see. As one moves down, the different types of care have different patterns. For example, inpatient care tends to be from the HSA of the hospital, less than particularly large hospital. Outpatient care, you're seeing more people from different HSAs coming in and we have this 10-mile buffer here to represent out-of-state patients. So what you're seeing here shaded is where the patients are from and then you choose the hospital payers, locales, and years over here. Moving on to the second visual. This provides a better perspective of the payer mix by hospital episode. So breaking it down here to all inpatient at Vermont hospitals, we see a general decline in the number of inpatient episodes with the commercial rate taking up a larger share as time moves on, Medicare sort of shrinking as you move along. Now there are plenty of caveats to consider when looking at these trends and a lot of them involve not only hospital decisions, but broader state policy, federal policy trends going on at the same time. If we can move on to the next slide, Kate, that has the discussion points and I'll stop sharing. This is slide 19. So presentation has ended. Someone else has started sharing. Excellent. So this is the, I just want to provide some context for how to read the hospital discharge data. So the dashboard shows the volume of episodes at Vermont hospitals, but it does not explain the trends. However, one can take the data and factor and we're going to factor into our own staff research for regulatory decisions and other board concerns such as the sustainability analysis as it moves forward or not depending on the vote today. And but I'd like to note some factors when interpreting the trends. For one, there were many state chain changes to federal and state programs regulation, et cetera, between the time period that we have the data. For example, the ACA began to take force, many of its provisions. In addition, there were state efforts to redetermine Medicaid eligibility beginning in fall 2015 and that declines with an overall amount of episodes for Medicaid payers since then. Also, technological innovation could allow the same care to be delivered in outpatient setting over time. Medical technology is this moving, it moves along as we measure the data. So it's, we can't really determine whether people are not seeking inpatient care or whether that inpatient care simply moved to a different context. Along with this, some of the smaller hospitals you will see abrupt changes to episode volume. This can be explained by a number of ways. You have to look into the budget documents and other complementary information, but it couldn't involve hospitals that spin off the operations into separate firms, hospitals that change the services they provide, doctors who retire and are not immediate replaced as well as independent and new doctors who join hospitals. Finally, when we're breaking it down to the spatial level of the HSA, the hospital service area, the changes to travel may impart signify population change in the HSAs, not necessarily anything that's been going on in healthcare policy or the hospitals, or simply that the HSA is a poor indicator of the de facto hospital service area. And that is something we can certainly look at with VDH moving forward. So I will pass it on to Lindsay for the patient migration analysis. Sorry to interrupt, but before, I'm sorry, Lindsay, before you take over, if there are any questions for Jeff before we move on. Hi, this is Mord Wasserman. I had one for Jeff. What distortions, if any, are introduced to the hospital discharge database by the fact that it's an episode-based rather than a person-based database? I could give back to you with a more specific response. I would say that I don't believe we have a person-based data, or it would be vCures, which is claims versus vUDs, which is episode, and both have trade-offs in the way that they consider the individual. But I'd be happy to look into that further and get back to you, or punt it to another member of the A team. Thanks. Okay, Lindsay, I think you can take it away. Okay, thank you. And thanks, Jeff, for introducing the patient origin part to this two-part project. Kate, if you could advance the next slide. Yep, so we're on slide 21 now. Yep, thanks. So patient migration is really the second part to this joint project, which we are calling patient origin and migration. This project was approved by the GMCB in December 2019. The scope of patient migration is to help measure the total medical claims spending in vCures that's mapped from the hospital service area of residence to the hospital service area of the rendering provider. This is really a high-level look at the movement of Vermont patients and the flow of expenditures with those patients in and out of their hospital service areas. Of note, for hospital budgets, our team provided just the 2018 snapshot of patient migration. This was given in static tables for non-financial reporting. And so what we'll go over in the next couple of slides is the interactive version and expansion on that initial report. Slide 22, please. So before I get into the nuts and bolts of the table visualization, I just wanted to show some of you are probably going to be some of our end users. So I wanted to show you all some of the back-end data that's going into this report. Of note, the data structure here is curated, will be curated from aggregating claims data. So any observations shown here are purely hypothetical, not based on any existing claims data, just to give you an idea of what the back-end looks like. So we've taken patient ID, age range, gender, month and year of both their eligibility and their claims. It's important that those match up. The primary payer, HSA of residence, HSA of care, the number of claims, claim type, expenditures and out-of-pocket spend. And we've aggregated all of that. And that is what is powering this visualization that we're about to go look into. And I'm going to talk next on slide 23 about the data cleaning steps. If you could advance. Thanks. So the way that we curated these data, we require patients to be 18 or older with a Vermont zip code in the year. The Vermont zip code is what was used to associate the patients with their hospital service area. And I use BDH's hospital service area version four. The claims were claimed to include only those paid and paid by the primary payer. Say that 10 times fast. Claims are inclusive of all services and provider types. So we've got everything in there, not just inpatient and outpatient, like we have in the Bud's data. Pharmacy claims, we do have those, but they're only for retail pharmacy purchases. And so what we're excluding in that are those any pharmaceuticals administered during a medical visit. The data are limited to payers submitting to v-cures. So not included are the uninsured, federal employee insurance, workmen's compensation plans, tricare, and approximately 50% of the self funded market. Although we are getting some of that back. And per request, we include some hospital service areas around the Albany Medical Center and the Dartmouth Hitchcock Hospital. All other out of state visits and claims are summarized to other non Vermont areas. So slide 24. Thank you. I am, so I'm actually going to go through some static views of what is going to be in the interactive visualization. And just as a heads up, that's because I still have a little bit more work to do with scrubbing my data to make sure that it can be a publicly available use file. And we didn't want to put anything in the presentation today that we couldn't immediately give out to people. So, so that's why we're going to look at some static versions of this. But in Tableau, this will all be able to be manipulated. So what we're looking at here is to the left, we have choices of year and hospital service area of residence. And toggling those two options will impact the three views you see. So the center view being medical spend for the residents of the hospital service area selected. So in this example, we're in 2019 for the Morrisville hospital service area residents. We're looking at the total medical spend for residents of Morrisville. And the larger chunks are the hospital service areas of tear where their money is spent. So the largest proportion of spend for Morrisville residents is in for medical is in the Morrisville hospital service area. Second to that is Burlington. That's how you would read this chart. All the way to the right, we have an age and gender profile for the residents of Morrisville in 2019. These are not, these aren't radically different over time or by hospital service area, but I thought this was an important piece to include. And then the bottom half of this first vis answers what proportion of total spend for Morrisville residents stays within Vermont and what proportion goes to providers outside of Vermont. And we've broken that down by payer. And you can see that a lot of Morrisville residents spend stays in state and actually relatively stable over time. Once you're able to go into this vis visualization yourself and play with the hospital service areas, you'll see that this is not necessarily the case, depending on the hospital service area. So this is this first dashboard is for the hospital service area residents. You can go to slide 25. Oh, you beat me there. So this next one is the interactive version of what was provided in the non financial budget guidance. So the way that we read this is the hospital service area of residents are the rows. The hospital service area of care are the columns. And this is you can slide back and forth to see the full list. And on the lower left, you can toggle between all these different options. So to select measures, you'll have the ability to select between the allowed amount, a patient count and claim count. You can select years 2014 to 2019. You can select to look at a particular insurance and or you can select to look at a particular claim type. So you can look at them one at a time or all together to get kind of a global view and you can see the flow of money through and outside of the state just in this kind of chart view. So that's what's in the second dashboard. And then on slide 26, this one is a little bit more specific to a payer breakdown. So here we have the medical spend by payer for the residents of again Morrisville and we're in 2019. So this is just showing similar to the very first dashboard what those trends look like over time. The lower left you can select between the year. This year and this year button will also help you change the out of pocket trends table. So you'll be able to see average and median out of pocket trends by payer and by claim type for those residents. Like for example here you can see that Medicare and commercial are kind of on par and then Medicaid for average and median are lower. And then all the way to the right we have a summary of the proportion of medical spend for Morrisville residents that's spent within their HSA versus outside of their HSA. So that's a little bit different than measuring how money flows in versus outside of the state. This is more looking at how money flows through the HSA itself. So again if you on the interactive version you'll be able to toggle the HSA of residents and the year to change that statement and the proportions. So next slide 27. So the next steps for phase one which phase one version one this interactive visualization and a HIPAA compliant public use data file will be available on our website soon for everyone to use play with. And for phase two which is the 2021 report we are thinking of incorporating a couple of things on patient level risk measures like the ACG risk score by HSA and payer and age. Also adding visit counts to expand on the current measure of claim count. Claim count is kind of a proxy for visit counts but visits a little bit more complicated. And also adding visit types to help get us closer to this question of why patients travel for care. So that's kind of what's in store next and that kind of wraps it up for me. So are there any questions specifically about patient migration? I need to clarify that's directed towards Chair Mullen and the board. I'm sorry about that. Yeah. This is Susan Barrett. Does the executive director have a quick can I have a quick question Sarah? I guess boss it's up to you. Hello. Is it okay with you Kevin? It's really quick. It's actually a clarifying question. It's clarifying. You know how the GOBE decision happened in 2015 I think. I mean when you're looking at comparing like 2014 to 2019 do you think that is going to have an effect on that analysis? Absolutely. Yeah and yeah it's a good flag and we're gonna make sure that we have some that very important caveat in the published version. Excellent. Thank you. Thank you Lindsay. Hi folks. This is Jessica Mendesbol. I'm a member of the data and analytics team and I'm just going to go ahead and give a pretty brief walkthrough of an update to a visualization that we presented last year related to the all-pair model total cost of care. So Kate if you want to go to the next slide. Okay so we're on slide 29. This is just a snapshot. I'll do a walkthrough in just a second but just wanted to remind folks a few things that have sort of been mentioned throughout this presentation but related to total cost of care. This is a resident look and we're looking at costs by HSA broken down by payer over time. So starting with 2012 and going up to 2018. It is limited to those members that are in vcures. So Susan just mentioned we had lost roughly 70,000 lives with the GOBE decision. So we do have that note in here but just to make mention of that. And this data is tied to a primary payer type. So for example members that are dual eligible are only going to be counted once and we count them under Medicare. And just to reiterate that total cost of care is a little misleading because it is only the sum of some care Sarah likes to say. So Sarah mentioned this in the beginning but the expenditure analysis is a more comprehensive look at statewide spending for system wide. So I'll go ahead and share my screen so we can take a look. Okay let me just back here as can focus to the screen. When you come to the page this is available on Tableau public. So it's published with a tag for Green Mountain Care Board and if you wanted to you could come right down here and link out to a more detailed explanation of the background and methodology for the data. The data is also available for download. So everything is public. The first dashboard is a per member per month look. It's I think pretty intuitive. It opens up to 2018 but you can use the slider bar up here to kind of pick back through. You could start all the way from 2012 and sort of tick through over time to see how per member per month is changing. Taking a little bit to load. The map is also a filter so you can click on the different HSAs and the chart to the right will adjust as you're moving through the map if you wanted to see how those numbers are changing. It's going to default to all payer but if I wanted to just take a look at commercial the map should adjust with those values. I'm not a key. That is changing over time. So this is really a tool that's meant to be exploratory and let users come in here and just get a sense of how things are tracking. I'll show you the the member table but I think we would love to hear feedback on what else folks might want to see in terms of additional data. We've spent some time talking about that internally. If anybody has any ideas we're certainly open to it. The the base data set does have some information on age group and gender so if that's of interest I think that that's something that we could certainly add in. So member table functions pretty similarly to the remember per month and again we can just kind of look through the different HSAs to see how that's tracking over time. We can see the dip in commercial in 2016 and we can also adjust by payer. So that's pretty quick because it's been out there for a while updated with 2018 data. I don't know if anybody has any questions or Sarah if there's anything that you want to make mention of before we move on. Not at this time. Thanks so much and again Chair Mullen if you or the board has any questions for Jessica before we move on we'll take those now. Yeah unless they're clarifying questions on a particular slide we're going to hold all our questions till the end Sarah. Okay. Okay great. I'm David Glavin and I guess I'm next. So I was both shocked and honored to be selected as the anchor for our 18 relay but I'm going to be discussing a few things related not just to a specific report but also just give me kind of just to wrap things up given kind of a general overview of how we're starting to roll out these interactive reports to provide the board and the public's easier insights and access to the data used and in describing aspects of the remote health care system and I also want to show you where they live and how they act how to access them. So if I'm going to go ahead and share my or I'm going to go ahead and share my actually if you want to scroll ahead of slide Kate and then we'll come back to that in just a second here. I'm going to share my screen and start you guys off from our web page here so I'm sure everybody can see this. So I'm going to discuss one of the reports not in great detail this is also a report that's been out for a while it's the Vermont hospital system financial report but I first want to point out how all of these reports both interactive and some of these are not interactive reports but can be accessed through our data analysis and reporting page and on this page we have this section down here called the public reports and through that you'll be able to access our Tableau public website or it will launch you into more detailed elements of each report. So for example the report that Jessica just got done showing you if you click on that all pair total cost of care link that brings us to this page that provides a link to the interactive report which lives on what's called Tableau public Tableau being our platform for developing the interactive reports and in addition to that we also have the methodology and background and are the data that's available for download and I just do want to point out make it make it very clear that I think it's important with all these reports that anybody utilizing anything from these reports should pay special attention to the methodology and background as they'll speak to the specific population and or limitations that the report that the report analyze or that the that the analysis is being reported upon. So you know I know a lot of this goes on as statistics today where people will just do a screen grab of a chart and throw it up there and wave it around and call that gospel and I think it's it's important that that that folks using these reports do a little bit of due diligence and and pay attention to the information that's provided. We're going to try to get a little bit more consistent with this currently not all of our reports have have as detailed methodology and background as as for example this one does here that we've developed but we are we are working to to bring this up to speed bring these this web page up to speed. So that said I want to I want to just point out another report that we recently updated and this is the Vermont hospital system financial reports sometimes called the the hospital budget report that Lori Perry from our hospital finance team develops and in conjunction with that I've developed a interactive report tool that really highlights the high level descriptive elements from Lori's report and provides users with some interactive capabilities and in terms of looking at in this case here like specific hospitals this is a high financial snapshot for each of the hospitals and I'm not going to go into too much detail here I want to encourage people to go to the site and explore these but just to give you a couple of highlights the map on the left hand side of the screen here can be used to select different hospitals and the interactive report will change that the variables and or statistics that are being cited with the exception of these top two static tables and over here on the far right you can toggle the NPR the net patient revenue by year for and this is specific to each one of the hospitals that are being highlighted so we can move to Rutland or up to the UMMC and that will provide users with a little bit of insight into basically some of the high level characteristics for the hospitals. I've also created a couple of other views here one of them is the hospital systems comparison this particular view provides a number of measures or metrics that are that the users work is able to toggle you'll note and oh I should point out four specific hospital systems so each one of these toggles over here provides you access to our PPS of hospital systems and down here the filter will provide you with who those hospitals are you'll notice that there are no values and that's because these these line charts can look can get pretty filled up with data if I put the actual values in there but if you wanted to specifically highlight highlight a hospital just select the hospital here and then it'll bring up the actual dollar values and it looks like I've got to do some formatting up here to add a dollar sign so I'll get that updated and just like I said yet another tool for both the public and the board to be able to use in assisting them to what I like to call data dense information so you there's a lot of information available to you on one view here rather than filing through a large report with you know 25 pages and trying to look for like for back for example like I want to look I don't have a section completely committed to UVM and then all the information in 25 pages you can look at UVM and then I want to pop over to Gifford real quick I can put select Gifford and pop over to that and it provides that data density for each one of those hospitals. Real quick back to our last tab that I want to highlight is just this is the entire hospital system for Vermont aggregated into just a couple of views with the budget values the actual budget values then this filter over here allows you to update the line charts or the line plots on the right hand side of the screen. Let's see oh one thing I did want to point out as well too I didn't mention this at the beginning there are there is some limitations in terms of the browser and we we try to highlight that on each one of our reports we are using what's called Tableau and Tableau doesn't play very well with Microsoft Edge or Microsoft Explorer so if you're experiencing difficulty excuse me when when interacting with these visualizations please use either Google Chrome Firefox or Safari to launch these and view these through as for a variety of reasons Microsoft this product doesn't play well with with Microsoft browser tools and with that I'm going to stop sharing my screen I did want to point out a couple of a couple of other things or wanted to highlight just a couple of other things here well quick let me stop sharing my screen I can figure out how to do that and I just wanted to make a mention of a few things that we're in the process of doing one of them is in the process of enhancing the current reports that are accessible on the Tableau website and also access to the data and the supporting documentation so as I mentioned before we're also trying to rebrand and have a more consistent formatting a color scheme amongst the reports so that people know that when they go into these reports that they're looking at GMCB curated data and reports in addition to that and actually I think I am going to go back to a quick screen share here if that's okay I just realized I forgot one so I do want to point out on the Tableau website this is the Tableau public website these are the four reports that we have so any of those four reports can be accessed on our state of Vermont care board website so I did want to point that out if I was remiss in doing that just a second ago and then whoops finally like I said any feedback regarding these reports is really welcome we oftentimes can miss certain pieces that the public or that the board might want to see and also in enhancing the reports is something that we want to do to make them more interactively or more usable I know one of the comments we've gotten back is that these reports don't necessarily transition well from tablet to or from desktop to tablet our current reports that are on the web are designed more for use on the desktop but we are going to be making the reports available in a tablet format as well so that people that want to use them on tablets can access them and the interactive and visualizations themselves will look a lot better on the tablet form so we're in the process of having all of reports to be available in those dual formats I don't think there is I don't think that we're going to be exploring using them on phones just because I don't think they're particularly useful on that size of a screen and then one last thing I want to do is just just really give a shout out to all of our developers within the A team I know these reports can look very simplistic but they are not easy builds they a lot of the solutions require a lot of planning logic and problem solving that's involved on the back end and our team you know just building these in general and I think as as Lindsay pointed out in just in terms of just that quick view of the data all the team members require a solid grasp of coding and a variety of languages how data structure or how data is structured and also a solid understanding of mathematics and statistics to make these things work so you know I I know they look kind of simple and I know they're fun to use but there's a lot of hard work and and thought that goes into developing these tools and with that I will send this back to whoever will wrap things up I we're at the point now of questions and discussions so we'll start with the board members and Kevin I think we're turning it over to you for that okay I'll go in alphabetical order member Holmes okay great thank you so first I just want to say fantastic and thank you so very much to the the A team having been on the board now for six years I can tell you that the evolution of data analytics has been tremendous and this is going to be really helpful so thank you I'm looking forward to digging in even more and David I wanted to thank you for flagging the importance of having folks look at the methodology and the background section because I do think that there are limitations to any data set that you put together and you know folks could use the data in misleading ways if they don't understand the limitations of the biases or the the you know the populations that it represents so that was really important and I appreciated that one question was for Kate I'm just wondering how many applications did we get for per year now for data use in the data data governance council and what I can't remember forgive me where are we at with conversations around fees for out-of-state users of our data so the for the first question we get I would say a handful of data requests each year we now ask anyone who's interested in the hospital discharge data set public use file to actually file a request is very simple request but we we've learned now how many people request that which is quite a few I would say you know in the neighborhood of you know 30 or more each year so they come in a couple of months and for the data use agreement applications for data release for the limited use non-public data set for but it's limited you know there's not that many there's a couple we actually are entertaining one right now and then for v-cures it's you know it's a handful I don't think it's that many more than than I've seen like I haven't seen it really grow all that much over the years but you know it's a cup it's you know a handful a year in terms of fees we have not pursued that we require fee bill change and we have talked about it as a data governance council in sort of preparation for the possibility of that you know what what structures would fit for Vermont because we have a lot of other states that we can look to in terms of how they structure their fees and and so we've we've done some of that research and explored that a little bit we have not moved forward with that at this time are we an anomaly by not charging fees relative to other states many do charge I don't I wouldn't say we're an anomaly because not every not everyone does and I I think um it it some largely depends on how their apcd their all-parent claims database has been set up in in different states and I think states are newer to this space incorporate a fee structure in their legislation and then in the in the rulemaking and then you know in their operations so we've you know had our claims data for that you know for a lot longer than many other states and and so we're you know we're contemplating that separately I don't we're not an anomaly but I do think that that we have looked at you know five or six or more states at least I've interesting these structures that vary okay and if I could just take on that real quick I just wanted to highlight that I think the people who indicate an interest in the claims database is quite a few but people actually go as far as submitting an application are not very many so to help bridge that gap and get data more usable we're currently developing some file specifications that would be tailored for analytic use so that you don't have to be a claims analyst to use it today yeah great okay thank you my second question was actually for Lindsay you referenced the getting some of the self-funded back with reference to vcures claims submissions and I'm just wondering if you could talk a little bit more about that post the GOBE decision the fact that you had mentioned that some of it is coming back yeah there are some efforts underway to engage these self-insured groups I'm I'm not the most knowledgeable about that there are some other members of our team who who know more about that but we do see uh like the teachers union for example that switched over so that adjusted some of the numbers and then also yeah just in general we are trying to engage those other self-insured because it is voluntary now post GOBE so just trying to get them to want to contribute data for a good cause does anybody else on the team want to speak more about that um I'll just say that we know the population changed the people for whom we have claims and vcures are different pre and post GOBE and so there's different ways we are working to address that um but none will be perfect thank you that's it for me thank you um member lunch thank you um I had uh I noticed that mort actually asked one of my questions in the chat box which is why the team had excluded kids so I'll just highlight that Lindsey answered that in the chat box can I just say that for the purposes of the public meeting it's much better to ask a question in public comment than to do it in the uh chat because I'm not sure how that gets recorded thank you Kevin go ahead Robin sure um but I'll just say that uh um because we don't know how it's recorded I'll just mention that what Lindsey responded was that uh because they were looking at people choosing to to where they wanted to get care it's a different type of choice when it's a child obviously because the parent will be choosing not the child um but I actually didn't have uh any other questions um I thought I'm so excited to dig in and look at this information in more depth than start to learn about some of the trends um so thank you very much to the team thank you Robin uh member Pelham uh thank you um and my applause as well to the A team for doing this um you know I just can't imagine untangling all the complexity of this and putting it in a way uh into a database that you know people can use and trust um that what they're seeing is um is reflects reality but also understanding the methodology that you know profiles the risks my one question is um I would think there'd be a lot of people interested in knowing this and getting very familiar with this um but it's also something that hunt and pecking by yourself uh could take a long time and I'm so I'm wondering if the A team you know will maybe do some training sessions uh do it online you know getting legislative staff and members of the public and maybe reporters and lobbyists and others that you know would naturally kind of gravitate toward using this data but but uh help them over the threshold uh with some kind of sim quest like training um so that that they know the ins and outs um so that's my question probably for sarah yeah hi thank you for your question so um I think that's a really important point and uh one I should have made more clear is that we look at these as kind of exploratory tools and we're we're certainly happy to provide support in learning to use them we also you know we'll have the data sets behind them available for people to peruse on their own um but the the next kind of step in this will be doing what I consider kind of more of a analytical white paper or brief and um what we you know would be happy to do is help tee that up with some guidance from interested parties about kind of the questions that we can be looking at for instance a robust examination of in and out migration um would be something that I think would be really worthwhile putting together which would be kind of figuring out a cogent way to compare or bring together the hospital discharge and vcures data to get some estimates of what that looks like over time so that's that's something we absolutely want to help provide but um you know I consider ourselves in the business of helping to answer questions more than posing them so we um definitely would like help figuring out the best way to address need thank you sarah and member usifer that thanks first um you know this presentation is very helpful especially as we move into the hospital budget timing and and being able to look at um you know some of this hsas and things like that um I really don't have any questions I went through with the team earlier the presentation but just one comment on when you're looking at some of the total cost of care data um and the percentages that show the change year over year one thing um you need to watch out for is as medicare people in the medicare realm increase and if it's offset by commercial or Medicaid the percentage change in total and total cost of care can look much higher than the sum of the aggregate if you know what I mean so if each of them if if uh if they all went up by three percent year over year as far as change year over year for total cost of care if the population shifts where more people go into medicare which is a much higher rate than the percentage looks a lot higher so it's just something we're gonna have to watch for as we go through some of the total cost of care information but all this very helpful so thank you okay at this time we'll open it up to the public for a public comment Hi Kevin I have a go ahead Eric uh this is Eric Schulteis from the HCA so this question is about slide or common is about slide 26 that Lindsay presented I guess I was just a little confused by the average a median out of pocket spend and um so just a few thoughts about that I I wonder if the value of presenting that data is um outweighed or is outweighed by potential misuse so I think when I saw it I both look at median and average so it's like it's a highly stewed distribution um kind of like income perhaps even more so um um you know maybe put a pop-up or something where you could click to look at that but I think also there's a lot of variations between median inpatient outpatient and ED spend and there's some extent to which when I see this it's like a question of is it per incidence is it per annum per plan year and there's a sense that it there's a disconnect between say the 25 median out of pocket spend for commercial with what we're hearing from consumers from what consumer advocates talk about nationally and also a disconnect around the cost of medical care from policy think tanks so like the Kaiser Foundation commonwealth and United States of care so I think um of all the things that uh were presented I think this one for me raised a lot of questions and kind of definitional issues that I felt like made it confusing I just also wanted to echo what the board has said much more eloquently than I could and also what David said that it is an immense amount of highly technical and conceptual work that goes into creating these things and uh you know I think sometimes the simplicity of these dashboards um covers up the amount of work that goes into it and it's not easy to simplify this information in this way and the ATM should really be all of including David and everyone should be applauded because it is a Herculean past to do thank you for the comment Eric I think um you brought up some really valid concerns and I can see where the language is lacking around exactly what is being shown in that table um and also the uh so we can fix that that's really easy to fix and also um that table um was probably the least popular anyway so it's also really easy to take out um and replace with something maybe more meaningful and I for want to be really interested to connect with you in the HTA to learn what other metrics might be useful for you all that we could build into the dashboard instead in addition to adding more clarity um so thank you for the thoughtful back and absolutely circle back and you know at least with some folks down at um the policy shops down at Penn or at the United States of Care I can see if maybe we could talk about how we could measure impact on consumers because it is a really challenging issue and I would love to kind of circle around and brainstorm with you how we could do it great thank you yep okay other public comment or questions question go ahead Dale um she didn't mention how COVID was going to affect this does she have anything in terms of like 2020 data data and going forward um how they're going to deal with the trends will look different so just a broad question how are you going to cope with that uh yeah this is Sarah Lindbergall can take that one so yeah um we absolutely are just starting to get in relevant 2020 claims uh this fall is when we'll get our real first uh robust look in in vcures that's when we'll start getting the relevant months but yeah we fully expect that uh expenditures are going to go down in 2020 we have some early um Medicare data that shows that it's found um probably around the tune of six percent overall um for the relevant months I mean for the year to date I should say so um that's uh we're going to have to address and you know I think depending on whether you are considering actuals and what it means or trying to forecast what it might mean in terms of utilization that didn't happen in its effects the way you deal with that might be much different so something we'll definitely working with a lot of different stakeholders to present in a meaningful way depending on the use could I ask a follow-up question go ahead Dale and pursuing that same line of thought and acknowledgement that utilization will be down there are consequences to the fact that it is down in terms of how that happened if it was ER visits because you can't actually get a doctor's appointment was it a telehealth that didn't really have the ability to deal with the issue as a telehealth issue but was doing its best to do that there's the limit on how many people can be seen a day um there's the team uh or coordinated team delivery system whereby you have coordination of your specialist and your provider um primary care provider if that's fallen apart because of covid are these things you're going to be able to capture because it's going to reflect somewhere that people had poor health I mean I can go on the international level and I can find worry about increases in certain diseases that they can no longer vaccinate for and they're certain it's going to happen and you're going to have other concerns about morbidity and so forth and it is actually related to covid is this hopefully making sense because I just kind of threw a lot at once uh I think I'm picking up what you're putting down and uh the I don't think there's an easy answer there's going to be so many questions and probably not enough time to answer them all so our first task will be kind of prioritizing questions and uh working with the administration I think that our first task will be trying to figure out um where we still might have high risk but didn't have a lot of cases to help with capacity planning um by using some historical influenza treatment trends so I think that's where we're going to start um and then from there I think yeah telemedicine is high on the list and we're working with other stakeholders who are examining that issue um but yeah in terms of the impact on health that's going to be a much more complex knots that probably will take a few years to trigger out okay thank you okay other public comment um hi this is Susan Aronoff from the Vermont Developmental Disabilities Council and um I don't know where this fits in with data governance however just yesterday um just last week when you were talking about the one care budget uh both um board member Pelham and myself commented about some missing data and information from prior years that we sort of surmised was probably out there and available and could be useful for understanding what's going on and um just yesterday one care published a press release announcing um quality measure scores which I shared in the chat box and um when I went to the one care website because I would like to share this information like either with my other staff members or council where I'm a employee of a state council an AHS affiliated council um or even share it with legislators um I saw this disclaimer that I shared in the chat box that says that the data is for the sole use of contracted one care Vermont participants and must not be distributed to other individuals or entities who do not legally hold a binding contract with one care Vermont these materials are confidential and may only be used in connection with one care Vermont activities the use of these materials is subject to the provisions of the business associate agreement and or participation or collaboration agreement with one care Vermont so my question to you Mr. Chair is to help me understand this especially in connection with this tremendous and I should have started there really tremendous presentation by your data team however out I don't know what what to do now with this information I'm wondering if cycling into a Vermont care board could inoculate it so that you could make it public we need to be able to talk about this and we shouldn't have to wait till November to do so thank you Susan I believe that um that disclaimer was a mistake um I would have uh said that we would strongly discourage the use of the the chat room but you seem to have gotten a quick response so Spencer Wepler if you are online and able to address this it's my understanding that you're removing that disclaimer and that it was put up an error is that correct yes that is correct it's being removed this afternoon thank you Susan you are you are ever vigilant and you catch a lot of errors so thank you I just try to do my job Mr. Chair and at a time like this um access information in real time it just really matters and um I'm glad to know it's a mistake there have been other times when one care has stated things like certain Medicaid money can only go to them at Greenland care board meetings and it's taken forever to have that be acknowledged as a mistake so I'm really glad for the quick response this time thank you thank you and thank you for pointing that out other public comment hey Kevin this is this is Walter hey Walter I just kind of wanted to follow up on the Cleveland map a little bit I just wanted to know what or how will all this mountain of data that you can so obviously collected sort of overdone analyzed by your team how will this help access to health care which is our perennial problem I did not quite catch the question I'm sorry so I think what Walter was asking is how is all this data going to help access to care is that correct Walter uh yeah precisely thanks Kevin sorry yeah I have my reception here can be spotty but um yeah so again I think that that would be a good example of um probably a more robust kind of analysis and that's something that will probably be better served by our health resources allocation plan um and we'll be able to have a whole set of analyses and reports associated with that plan and access is going to be one major indicator there um it's kind of easy to look at it from a geographic standpoint but the true measure of access is a much more complicated thing to measure and so that'll certainly be an iterative process but in the meantime this could give you an indication if it seems like people are traveling more or are traveling less to receive care that could be an indicator related to access changing one area where it will be interesting to see is for certain inpatient procedures whether the ambulatory surgical center is changing some patterns of care up in that part of the state so that we won't start to see until we start getting the next year claims in in complete but I think that measuring access well is a is a really important thing to do but a very not an easy one okay is there other public comment hearing none I want to thank the A team um as always you're on the right track and we really appreciate as board members getting better data and it seems like we're making true progress so thank you so much for all your efforts and hopefully it will lead to better decisions made by the board the next item on the agenda is hospital sustainability planning and I'm going to turn the meeting over to Patrick Elena and Jeff I'm not sure who's taking the lead but I'm sure one of you will tell me yes hi Kevin this is Elena so I'll be presenting the slides today but as as you and Susan mentioned before this is a cross team collaboration so I'm certainly not the only one responsible for this presentation so I will let me know when you can see the slides see if we're still seeing Kate so maybe she'll have to okay there we go okay all right wonderful and I turn up and Patrick and Jeff chime in if I say anything um that requires clarification um so this is uh we're providing another update on hospital sustainability as you know we kind of rebooted this conversation um a few weeks ago you know we put it on pause really as when COVID started because we recognize that stakeholder participation would be would be challenging when we were starting to trying to figure out how to how this was all going to unfold um but then kind of recognize you know with with a series of red flags that we have to get this conversation going again so um we rebooted that we heard some public comment and and we're here again today to provide an update on what we've done with that since then so we'll revisit some of the background of how we got here um show you again an outline of the framework um provide some staff reflections on the public comment received to date um discuss propose next steps and then you know maybe if there's time permitting board discussion potential vote um and then additional public comment so we'll start with you know you know why we're here today and a lot of the the policy that runs through the board um you know Vermont is very expensive as a percentage of GDP Vermont outpaces um the national average in terms of spending on health care so in 2008 Vermont was at 18.8 percent versus 16.9 um the national average and this slide I'm you know I'm sure you're you're accustomed to seeing at this point but you know it's no less shocking um you know since 2005 there have been 170 rural hospital closures nationally uh with with that rate only increasing leading up to COVID um in 2019 25 percent of rural hospitals were predicted to be at medium to high risk of financial distress and um we acknowledged last time you know this recent study published in June that looked over the course of 2011 to 2017 showed that you know in that study period those that closed in their final year before closure had a profit margin of of negative 3.2 percent um so you know all the red flags are here and you know as a national level Vermont is is no exception to this this troubling trend um as you've seen you know our our operating margins have only been on the decline uh where revenues um are you know operating sorry operating expenses continue to grow when operating revenue um is unable to keep pace so um in terms of growth so that's why the way you can see our margins um on the decline so you know COVID only exacerbated this situation and and demonstrated you know the challenge of our fee-for-service system which is is disproportionately affecting rural hospitals and rural hospitals are are more vulnerable um due to you know or more vulnerable to shifts in utilization and um you know foregone revenues because of their thin margins lower liquidity lower occupancy rates and higher like reliance on elective procedures to cover their fixed costs so this does not leave us with a lot of room for error you know and the federal and state relief provided to date um has been very helpful in addressing the cash flow needs of the hospitals but we have to remember this is only one time money and is not going to solve this issue um and and there are you know pockets that still haven't been um kind of made whole you know some have and some haven't but you know this problem is not going away uh so I think you know we have to keep our eye on the on the prize and and you know you know keep working towards value-based care you know especially because you know at a federal level this is not going away but in the meantime we have to figure out how to evolve past fee-for-service system um and this brings me to this latest slide and um you know this is just a preview of what may be coming in the hospital budget process you know Patrick and the hospital team will go into much more detail and and provide much more robust explanation but what you can see here is that over the last couple years you know from 2017 to now that the change in charge requests have only increased so this year um the submitted um amounts you know and we don't have all the data in so again this is an estimate and a subject to change was around 6.9 percent you know where in previous years we had around two and then increased to three um three percent and now it's 6.9 percent that's quite staggering so you know I like to use just as an analogy of the balloon where you know we get squeezed on one side it has to come from somewhere so as you'll as you're well aware the change in charge is is a way that um hospitals or the lever they have to really make their budgets whole um and this is just not sustainable it's not sustainable for the providers it's not sustainable for um consumers and you know we really have to figure out how we're going to solve this problem as a state so I just wanted to revisit some statute that guides the work of the board and um these various processes so you know our five our five key criteria um you know to improve the health of the population reduce the per capital rate of growth and expenditures while ensuring access to care and quality of care and I think this is where where we are right now enhance the patient health care professional experience of care recruiting um and retaining high quality health care and achieving administrative simplification so um I think these are all really important things to keep in mind um particularly access to care and quality of care which is why I think we are um talking about sustainability today you know it's not just financial stability it's it's making sure that for monitors in each community have access to care and access to a high quality of care so part of the board's duties are to review and establish hospital budgets which you will be um you know back into the full swing very shortly but through this hospital budget process there's kind of two key pieces that relate to this work one is around h-rap which I think we will only find tighter connections as we move forward but in h-rap you know it's the board shall um identify for months critical health needs good services and resources um and that information should be considered in the hospital budget review and then you know the board needs to look at hospital budgets that are established should promote efficient and economic operate operation of a hospital so it needs to make financial sense hospitals need to you know work efficiently um and then you know hospitals need to to kind of hold up there at the bargain so um we can't do this by ourselves we need to understand the budget the financial information you know scope of services volume of services utilization information whether or not they're they're providing new hospital services or programs depreciation schedules and other information the board may require so you know I'm not going to read this but this you know there's a there's a whole host of information that the board should consider and can consider when establishing these budgets and understanding service line um is is certainly a part of that so you know I'll pause here I think we've seen these goals and we've tried to make them more concise um over the the last a few times we've presented this framework but I think we just want to make sure everyone understands you know this is this is about engaging in a robust conversation you know the board can't do this work on its own and and I don't think the hospitals can do this on on their own either I think there are a lot of systemic um challenges that we must highlight um through having this conversation as well as you know hospital specific but really the systemic the systemic challenges um and and the goal of this conversation is really to ensure community access to essential services and and identifying ways we can remove barriers to the sustainability of our healthcare system I think it you know would be remiss to say that we you know wouldn't use this and thinking about what our all-payer model 2.0 would look like and I think we need to think about um lessons learned what's working for our providers what's not working for our providers and um sustainability needs to be at the center of that conversation especially as we continue to move away from fee for service towards value-based care how can we ensure that hospitals have sufficient resources to provide essential services um number three and I'm on slide 11 I'm sorry I'm really bad at remembering what slides I'm on um so slide 11 number three we we have to encourage hospital leadership boards um and communities to work together to address these challenges it's likely that this is already happening um but we just want to you know to make sure that you know if it's if it's not that that's something that we voice is important that this is not just um you know an exercise for the few it's going to take all hands on deck um and then identifying this process should allow us to identify both hospital led strategies to right size hospital operations um in the face of many of these challenges but also identify the external barriers to sustainability um that need to be addressed by you know other stakeholders so the framework um I think today you know some of and we'll go through the public comment and kind of where where we're suggesting we go next but I think one one thing is that the framework we feel is is still the right framework I think we can talk about the details and how we um roll that out and implement it and what data we collect but I think we need to kind of revisit um and and remember kind of these core core buckets so you know the financial health of the hospital I think we still see the green mountain care board is providing hospitals with financial indicators um you know along with state regional medians benchmarks where relevant um and identifying those metrics for which hospitals at risk and ask hospitals to identify strategies to improve in performance um you know whether or not that's in there in their control or not but they need to help us understand what it will take to get them to to a better place um you know and I think this this first bucket you know we foresee doing all the data work and all of the analysis and then this is just where the hospitals would provide commentary or their thoughts or strategies they already have in place we would love to hear about those as well um the second bucket is about you know ensuring provision of essential services this stage will ask hospitals to assess the provision of essential services in their communities identify service gaps um and develop plans to ensure the sustainable delivery of essential services as we move to a value-based world so I think the key here is thinking about you know the value-based world and and what we need to be successful when when you know when we're talking about high quality and we're talking about population health um the sustainability of other services so this stage seeks to eliminate the efficiency and quality with which hospitals deliver other services so beyond the the defined essential services um we're using the AHA definition I think that that will still stick um but how the delivery of these services supports the hospital's ability to operate in a value-based world um so essentially the stage we're asking hospitals to conduct service line optimization viewed through the lens of value-based payment not fee for service um and then strategic planning so the purpose of the final stage um is for hospitals to reflect on the analyses of the prior three stages and discuss their plans for sustainability in a value-based world so it's really about drawing kind of across these three um three um you know insights three categories and and looking forward so public comment um we received one written public comment from the HCA and they recognize that this work is critical to ensuring Vermonter's access to essential services as well as the challenges to the proposed timeline and the proposed timeline was the timeline proposed a few weeks ago um a second public comment which we received recently and there was a lot in there um but you know we just for simplicity's sake included the two key recommendations um from VAHS was to assess each organization's sustainability within the hospital budget process which collects ample data um already and is well designed to account for the factors of informing hospital health uh they also asked that we rethink and postpone the broader conversation connecting sustainability with reform and transformation until after the annual hospital budget process is complete this would offer space for more thorough and public dialogue about what the process should look like and achieve um and then you know so we'll I think we'll address that both of those through our um our reflections in the next few slides um but we just wanted to recognize some other public comment we received um you know verbally at the last meeting um there were some comments about conducting a system-wide capacity study um before we start engaging in this work to project demand for services um and then you know I think there was recognition that this framework was very robust very detailed and represents an ideal but hospitals may not be tracking information at this level of detail so that was um an important consideration so you know just to kind of reflect on what we've heard I think you know staff stand by the spirit and the timeliness of this framework um we still think it's really important you know many of the red flags have have been raised and and we think we need to continue doing this work but recognize um and and you know take seriously the comments that were made about how we actually move forward um and you know we really the reason why we stand by this is really ensuring the provision of essential services in our communities as we move away for fee-for-service and toward value-based care you know you know there's the federal government is not moving away from value-based care um and if we don't prepare now you know we're not going to be in very good shape um you know in all Vermont hospitals should be in scope um this is a question about a broader system and it's not about one or two hospitals it's really about all of our Vermont hospitals um I think there was another question that um had been circulated about how the board will use the details of this framework so just so we're very clear I think you know having this more nuanced information will allow the board to make better decisions as it relates to hospital budgets and determinations of NPR and change in commercial charges if the board can understand um the challenges hospitals are facing and where cross subsidization of service lines is happening you know maybe there is a rationale for providing um change in charges in one area that might not make sense in another but without this information it's it's hard to justify um in such unsustainable increases at least until we can find some more systemic answers to to these challenges um and then finally the lessons learned through the details of this framework could you know could inform the development of a second proposal we're not the only signatories on this model but I think having more information will allow us um to have those conversations and think critically about what's working or not working um in our current health reform effort so and then two final um reflections you know I think we recognize the variation in hospital technology and resources and we look forward to working with stakeholders to understand these constraints and the nuances of capacity planning and service optimization at each hospital so you know we understand that not everyone has a cost accounting system we understand that there are various allocation methods which make service line analysis challenging but I think we need to understand that and if hospitals aren't able to produce the level of detail that we're hoping to get out of this exercise that we have um you know a robust conversation about a proxy or or or understanding how decisions are made on a local level I think that's really the just at the end of the day um and then you know I think we agree that a system-wide capacity study recognizing demographics and population dynamics is an important companion analysis but you know I think we can't forget the work that we're already doing at the board which is around HRAP health resource allocation plan understanding you know the resources on a community level this isn't just a facility analysis this is really about what's available to the community and where the gaps in might be and gaps and you know capacity might be but I think you know if there if there is an opportunity to do a capacity study in a way that doesn't duplicate what we're already doing I think that's something we're certainly looking into so you know the proposed timeline we we took into consideration kind of the needs that we have identified given how these data will be used as well as the feedback from our stakeholders that the proposed timeline is is unrealistic and I think we have to also recognize here this is again just still a proposed timeline that you know certainly with any COVID resurgence or any attention needs to be you know turned to the immediate needs of serving you know on the front line that is is the most important however I think we need to recognize that we need to start working now if we're going to affect our FY 2022 hospital budget process and that if we're going to have any insights about hospital you know sustainability in order to inform our all-pair model 2.0 proposal development our agreement requires that we submit a proposal to CMMI December of 2021 so that's really just around the corner and I think starting this conversation now will allow us to have a robust stakeholder process throughout the course of the next year or so as we kind of start putting together more details of what that might look like so with all of those caveats and just a reminder that phase one the assessment of hospital financial health is really where GMCB will be doing most of the heavy lifting there providing the the data the analysis for hospitals to then provide commentary back and we're proposing around you know the end of December 2020 phase two ensuring the provision of essential services would you know we would be great if we could have that back sometime in March that way it could inform the hospital budget guidance and those two pieces would be the main drivers of of that guidance and then phase three the sustainability of other services as well as you know what that would be in May along with aligned with the non-financial reporting or could be embedded within that or we can talk about that in more detail but phase four would be planning you know for sustainability in a value-based world bringing all that together drawing these larger insights and then having you know a more robust conversation about what what that experience has been like for providers who participated in healthcare reform and now we would love to have that information back by you know by July of next year so that would be in line with the hospital budget process for 2022 in terms of our proposed next steps so GMCB staff would continue examining the nexus between sustainability planning as we've outlined these kind of forming stages and atrap and exploring the system-wide capacity study so making sure that you know if we you know if we do kind of pursue a capacity study that it's asking the right questions about the community level and be that it doesn't duplicate work that we're already doing and then GMCB staff to work with stakeholders to continue understanding the hospital specific reporting constraints so as mentioned before I think you know we recognize that all you know all hospitals have different systems and there's varying levels of capability for tracking and reporting on certain information so I think we need to understand that in a more detailed level and then you know continuing identifying and documenting opportunities for continuous improvement to support our proposal development for 2.0 along with our signatories so again you know recognizing that we're not the only ones but we are one of one of three and that we have our duty to bring forward the best information we have to make that successful so I think you know taking all of this together the potential board vote today could be to approve the outline of the framework so those four stages the adjusted timeline which are all approximate and subject to you know anything that were to happen with COVID over the next few months but this would allow staff to fine-tune feasible deliverables for each phase and begin any necessary data collection analysis and we think about that we you know we're it's really about you know a trap and and what we already kind of have access to and then I think there is a conversation that needs to be had about you know extending the framework to all hospitals and you know I think you know from conversations with legal the formal board vote might need to be postponed until the hospital budget process as this was initiated in the hospital budget orders but I think we could at least have that conversation today about the spirit of of the framework and extending that to all to all hospitals I'll pause there I think someone's not please mute yourself if you're not yeah that might be helpful now um I don't have any specific questions um you know I think this obviously is happening a little bit a little bit later than what we had hoped for but because of what's going on with COVID and everything else I mean I think we have to have to delay the process um I would just really you know reiterate that um you know the goal is to have a sustainable system and that you know for for my time on the board what I've seen is you know many hospitals continuing to miss their top line continuing to lose money and relying predominantly on commercial rate to try to make up the difference and it still doesn't work because there we have optimistic top line and and missing on the bottom line so I mean I think it's really important that we get to a place where we have a sustainable system and looking at what's done at each hospital and then the quality metrics as well as um financial will be important thank you for this somebody's still not on mute yeah somebody's still not muting themselves I'm gonna mute everyone this is Abigail um so if you are making a comment for your phone just remember to hit star centers yeah it almost sounds like a radio or a television setting background thank you Abigail next we're going to member Pelham thank you Abigail um I just have a couple of questions um one is uh I mean I feel caught between a rock and a hard place here because I you know don't have any direct experience uh you know at a hospital but I imagine it's pretty chaotic and um you know hand to mouth in a sense on the other hand I feel the sustainability issue um especially as it relates to the cost shift and payer mix is vitally important um pre-covid um you know we had eight or 14 hospitals in the red in 20 at the end of 2018 and in terms of operating margin and seven to 14 at the end of 2019 with one hospital filing for bankruptcy so to me there is this isn't an academic exercise there's a real world going on out there um and a lot of uh you know hospital margins are are are thin or non-existent um and I I use this statistic um and because I think it's so powerful a point is that if you go back to slide five uh really quickly that one right there if you add up all of those numbers uh over the five years they come to 329.2 million dollars you know of of margin over the five-year period of that 329.2 million dollars 295.8 of it went to one hospital and that to me is uh a uh an indication of the of the failure system-wide of um of fee for service and and so the transition from where we are in 2019 to where we want to be in terms of all-parent model uh 2.0 is something that is is is going to be you know uh take a lot of effort and a lot of collaboration and so my my question my first question is um do you have Elena in your mind you know how that transition might unfold specifically within this sustainability effort to walk us away from fee for service and the kind of distribution of money that we see in this chart to um a value-based system where most of the money is being spent um uh through that those that mechanism I think that's a good question um Tom I I don't think we have anything like that yet I think you know we're working like I said we're one of three signatories so we can't do this alone I think the other missing pieces are our providers right I you know we have to engage in a robust stakeholder process if we're going to build a proposal that makes sense but one thing we have heard is is capitation you know so I think if if we want to if we want to make sure that we can have a value-based system that allows providers to continue providing essential services and excel in a value-based world we need we need to to decouple from volume and so I think how we do that is is a question what you know what should go into that capitated payment is is to be determined but I think that's where we have to focus our effort and figure out how we can stabilize this system so I mean but so the bottom line is you think that we can get there within the next year and a half to two years I think we can work with our stakeholders across the state agency and at the provider level to think through that together I don't think we can do it by ourselves and I and ourselves being green mountain care board but I think we can come up with a proposal by 2021 you know I think we can can at least start that effort and my only only other question is looking at I forget what slide it is I think it's slide 12 and looking at yes this framework so phase one was the financial health of hospitals and so I'm trying to think near term next six months is there going to be a second wave in Vermont is there not going to be a second wave we've got college kids coming back we got K through 12 opening up but we've also done incredibly well and every Vermonters I think should be proud of how well they've done you know during this but it seems to me that most of the work in phase one will be done by the green mountain care board staff it's not there isn't a lot of put you know on to hospitals between now and December 20th and and obviously if there is a second wave in Vermont all bets are off I think in a lot of in a lot of places but but would you share that opinion that most of the heavy lifting in phase one is going to be done by the green mountain care board staff yes I would and I think you know yeah yes I'll just leave it there yeah I think we're you know as I mentioned we will be doing all of that analysis we will be compiling that data and I think where we're asking for the hospitals participation is really to help us understand the barriers or why you know why they're in this certain level of risk so providing additional you know color to that financial analysis thank you Elena okay member lunch thank you um the I wanted to just comment on the 8th h-rap connection because we did do an initial collection of data in h-rap from hospitals although um the team who which the the team of just man disable um the team of one or two um if I think we had another staff member help as well um did there were some holes in that data so I do think it's important for for the teams to work closely together so we're not doing multiple data requests but we do need to clean up the remaining h-rap data and I do think they are well crosswalked so I don't think that's a difficult task but um something that I think is really important and that would really be reflected of the second and third pieces of the framework I would say um I just wanted to make that comment about h-rap um on the financial health when I went back and looked at the financial health dashboard it looked like a a number of those indicators are things that we are already collecting in the hospital budget process and so um to the extent that the hospital is reacting to that information in their presentation in next month or actually this month it's already August isn't it um I think we should be trying to pull that information as well out of those budget presentations and transcripts um so that we're not asking them to respond again to something that they already talked about now um but overall those were really my couple of comments um I do think I do like that um the timeline I do think there needs to be some flexibility in the timeline to react to circumstances I would note though that um on on trying to figure out how to ensure that this information and process is we're learning from it for moving forward with apm 2.0 on top of the submission of a proposal and then the negotiation there's also an 18 month medicare implementation timeline so to the extent um that we think there are components of changes to the payment methodology we need to keep that in mind and so sooner the better in that sense because it uh the the medicare apparatus is not easy to move and as we have already seen uh with some of the new payment models um they do have operational hiccups along the way which we should also expect so I guess those were my top of mind comments yeah thank you Robin those are very helpful I think um you know point points one two and three well taken um you know we will we have intended to go back and do a deeper dive with atrap um and then I think that's a great idea you know we can just you know copy paste what we learned from the hospital budget process and kind of say you know has has anything changed if not you know thank you and then here the remaining items to alleviate that administrative burden but um yes on cms you know the 18 month especially if we're you know trying to do a capitated payment that we don't already have in place here that might be um you know that whole 18 month period thank you thank you Robin member Holmes think you're on mute Jess Jess we didn't hear anything are you we still can't hear you radio silence I'll end Jess and Abigail unmute her oh yeah so Abigail sent me a text saying I can't unmute her she'll she'll be trying to call back in so let's just give it a minute can I just chime in I had one other thought while we were can you hear me now yep we can okay go Robin that's fine okay I was just gonna say um I do um I do like uh the I I mean I think I've said this multiple times so not to repeat myself over and over again but just one more time at least I do like to me this this does need to be a practical exercise and not theoretical because it's not going to be helpful if it's theoretical so I think the data constraints and capacity constraints are important and if that means that we have to get a higher level of data so that we still have information that's useful that to me is more helpful than um you know trying to work in a more detailed level where we have vastly different information hospital by hospital it not being able to compare it is going to be a challenge for us and how we look at it on a system-wide basis so um I I I just wanted to put that out there is that I think as staff is working with stakeholders to figure out what exactly makes sense um for me that it needs to be very practical in order to be useful thank you Robin very good points Jessica thank you Kevin first I was unmuting myself but it didn't seem to be going through so I hung up and called back in um so I guess you know I don't have any questions I want to thank Alina and others for working on this um and I guess my point is given the vulnerability of our hospital system right now and given the current state of our economy which may get worse in the next few months and the fact that healthcare costs continue to outpace inflation I feel as though it the time is of the essence to figure out how we're going to make sure the Vermonters have access to high quality low cost essential services in their communities and we need to make sure that our our hospitals have pathways to financial sustainability in a value-based world which we are moving towards uh you know at at higher speeds and I think that the importance of having more information about what it takes to deliver essential services in each of our communities is paramount to our negotiations with the federal government for an all-payer model 2.0 and thinking about rural sustainability as one of the goals of that uh next negotiation so we need more data and understanding of what it takes to deliver those essential services so these sustainability plans are a first step in that direction so I support the outline of the framework I support the adjusted timeline I support obviously the need to further adjust the timeline should there be a resurgence of COVID of course we should do that um but I I believe that the outline of the framework is the types of information that we need to make better decisions as a board to ensure that Vermonters have access to care that they need and to make sure that hospitals have the resources to deliver that care and you know so I would um be happy to make a motion that we uh approve the outline of the framework and the adjusted timeline and delegate to staff working out some of the finer details about what the metrics might look like um and so that they can begin the data collection analysis that will be required for phase one is there a second to that motion second did you have any other uh points Jess because I do want to open it up to public comment before we uh vote on anything that's fine yep no I don't have any other comments does any other board member have any follow-up comments hearing none I'm going to open it up to the public comment go ahead I like what I'm seeing but I just want to voice a strong reservations around I haven't seen none of us have what the hospitals are going to present although as a board you're much closer to what that looks like than I am from where I'm sitting um I like Jessica's point about you don't know what the economy is going to do that's on many different levels uh you also don't know what the community responsibility and what society will do going forward how they will respond um you don't even know how schools are going to respond yet which could be a huge contributing factor going forward as to what's going to happen within communities um I just don't know if we're getting a real grasp of this that's my concern I'm wondering if this isn't going to run away from us um I don't want to see it do that but I think it's a valid concern so that's my opinion um at that point thank you Dale we appreciate that I see that jeff teamon has his hand raised jeff yes um thank you mr chairman um I appreciate the opportunity to comment in this conversation today um I've obviously made comments several times on this issue before both in writing and before this board um in in these meetings we submitted a letter yesterday obviously that was featured in your presentation um and that reflects the thinking of hospital leadership throughout vermont um that's why the letter included the signature of every hospital president or CEO including dr john brumsted who I'm not sure is able to join the hearing today um CEO of uvm health network but ask that if he's not able um that I convey his support for the letter um that we sent earlier um as I mentioned many times we support sustainability planning done in the right time um and in the right way uh what we don't support for the reasons that I think we've made terribly clear um is a new regulatory framework that we view as onerous um especially for hospitals already saddled with annual budgets and managing a pandemic I did appreciate the comments made today by Elena and others on the sensitivity to the potential for another um outbreak or COVID related development that causes us to need to take our attention away from these matters but I would just point out that that almost implies we're not doing that now um and that is that is just not the case um while we've been sitting on this call um I have received eight emails from chief medical officers about a testing issue COVID issues are happening right now very much um and just because we're one of the great states that's a little more effective actually means that some of our work can be even more intense and more important to make sure we stay that way um as we said in the letter um if sustainability is about health reform and I think several different purposes and goals were mentioned today and in previous meetings um that that really deserves a separate public dialogue um that includes more stakeholders because whether we're informing the all payer model or just looking at service optimization around the state that needs to not just be a hospital conversation that needs to be a provider community um and government partner and community based conversation as well um you know I think when the all payer model was developed one of the phrases was that it's provider led um and it's important to distinguish that from being led by um a regulatory body um and then finally as Elena pointed out in the sort of statutory justification for this work um a stated goal of GMCB in the statute is to achieve administrative simplification in healthcare financing and delivery um I think it's pretty clear that this kind of framework adds to administrative complexity and cost um and therefore goes against GMCB's stated purpose in that sense um I would also just point out from a sort of logistical standpoint that stage four under the revised timeline does appear to take place um as hospitals would be preparing their their following year's budget so so still a lot of activity that would be taking place at one time um so with all of that and our letter in the record um I thank you for listening um and please know that that the hospital association and the hospitals we represent throughout the state um are committed to getting through COVID are committed to um moving to a health system that works effectively for every Vermonter um and with the right goals and the right timetable I'm confident we can work together toward that goal thank you so much for the opportunity to speak today thank you Jeff we look forward to working with you and your members to make sure this is done right so thank you as always thanks Kevin I think that uh Mort Wasserman has his hand up Mort did you have a question looks like he's muted still it shows up as Richard is that you more yeah it's not it's not me I bet it's some other Richard like you know I go by more Kevin this is another Richard that's uh yeah uh can you hear me yeah this is Richard Slesky oh hi Richard hi how are you so thank thank I I've been listening to the conversation it's great to to be part of uh these conversations again um one I did want to mention that I have I did send public comment to the board I think I put it under hospital budgets but it I think also belongs under the sustainability question so I hope you've received that and have had an opportunity to look at it um okay and also I just on that point a question can the public access these public comments that go to the board um I couldn't find a way to look at I assumed there were other comments and I haven't been able to find a way to look at those so if there is a way I would hope that that could be accomplished so I'm not sure if Christina is on the call but if not Abigail could you um provide Richard with a link to the public comments so um we don't always post public comments um and but if you would like them posted Chair Mullen we can do that but yeah and just so everyone knows like public record requests you can always ask for public records through our website you email um gmcb.publicrecords so if there's something not on our website that you think is um public we are required to give it to you through a process um as long as it's not confidential material yeah I think it would be nice if they could be available more easily than through a public request public records yeah and I was just going to say anytime this is Susan Barrett anytime anyone would like to receive any information or is having a hard time finding something on our website please reach out to to me or Abigail so as much as possible we'll try to air Richard on making sure they're posted yeah that would be great thank you Kevin um my the substance of what I wanted to say I guess today is that um I mean I I think um well I mean with all due respect I think this discussion in some way seems to ignore the fact that we have entered into an agreement for an all-payer model with uh Medicare and the agreement calls for a phasing in over time uh of movement movement toward an all uh value-based payment system and I think until we make um more progress moving more enrolled citizens into the ACO and into the all-payer model we're not going to be moving sufficiently away from fee-for-service which in my opinion is the root of many of the problems we're facing today and I think was exacerbated um by the COVID uh experience um when you have hospitals that aren't are are denied the opportunity to provide services other than emergency services they are unable to generate revenue and so you know I mean that's just exacerbated the problems the financial issues that the hospitals have been experiencing so I think the the faster we can move away from this fee-for-service model I think the more opportunity we will have to address the issues that you've been talking about today in terms of the sustainability of the of the uh health healthcare system and and the issues that I see in that regard are that you know we have we have hospital employees who are self-insured hospitals that are in self-insured plans we have the school system we have the state employees uh who are continuing to be in self-insured plans many of which are not enrolled in the ACO and there's about 160,000 people I think that are in this self-insured um bubble that you know I think need to be encouraged to take advantage of the opportunity to move to what we think is a more efficient and higher quality uh healthcare system so and I think that falls to the Green Mountain Care Board to the hospitals and to the administration to to start to you know publicly encourage the movement of these individuals or or these businesses to move employees into these systems I also have a question about where the money is that the insurers collected in premiums that were not paid out to the hospitals and how that that money is that apparently was not paid in for services is being considered in the development of rates of the insurance rates for next year's rate increases I think the issue of the hospital sustainability um and this this plan uh to do all this research could be I think more easily addressed once we move to a value-based payment system that's not dependent on fee for service um and I think there are opportunities today not waiting for another year to begin thinking about which services are non-essential which are low volume high cost that those could be incorporated into the budget discussion uh as it when it begins this August so I think there are things that can happen now and that we shouldn't be waiting for another year to start to think about how we're going to do this but by that time we will not have met the goals of the all-payer model agreement so I I encourage the board the hospitals the insurers the administration to really be sitting down together and I think Jeff Teeman made this point this isn't just a hospital issue I think this is an issue uh for our administration the green man care board and others to really be sitting down together to figure out how are we going to meet the goals of the all-payer model in a timely fashion and what are the services that are essential for the hospitals to be offering to ensure access uh efficiency and high quality services and I think a focus on cost management rather than revenue production is a shift in focus that ought to occur soon so I'll stop there but those are some of the thoughts I've had in in watching this this whole process very well said Richard thank you I see that Susan Aronoff has her hand up yeah so this is just a reminder Mr. Chair and I don't know how you've divided the responsibilities between green man care board and agency human services but as you work on the next iteration of the all-payer model I hope you keep in mind that there's a statutory requirement at this time around because you have to add the Medicaid funded long-term care services that have not yet been part of the financial service targets because those have to be added there was a statutory requirement added that your process in coming up with APM 2.0 has to include the stakeholders of those services who in the provider led effort as Mr. Soski could well attest we're not part of the discussions then and hopefully we'll be part of the discussion going forward because to bring up the auditor's report um it hasn't yet been shown that the value that there is a value in the all-payer model that there's a return on the investment that exceeds the investment that the Medicaid losses of over 17 million in 2019 free COVID have to get a fair hearing and it's your job the green man care board's job to assure that the costs and benefits outweigh you know that there is a return on investment and if you ever come up with a way to assess that denominator in your last slide show from last week of the administrative cost versus you know the value of the all-payer model I hope you'll also take into account the areas where the quality is gone down where access has gotten down where costs have gone up where the uninsured rate is going up where Medicare advantage is going up those are all populations that can never be in will always be out so this model that you're going in on all in on that so far only covers a third of all Vermonters has shown itself to be expensive and ineffective and yes I am trying to track this as best I can I'll take Spencer at his word that that was a mistake to shield that data but there's reasons why this data is hard to find and the A stands for accountability so I hope we get there thank you thank you Susan other public comment can I Kevin this is Elena I just like to because it's been said a couple times I just want to make clear that this is not to replace the all-payer model 2.0 stakeholder process that this is just an opportunity just want to highlight another input to that process so certainly like I've mentioned before we are not the only signatories on this model that this would just be another opportunity to provide some input to that thinking so Susan I think your comments you know and and Jeff and everyone else yes there will be a robust stakeholder process and we are working on getting that rolled out which is why we need to also get this rolled out so that we can have all the best information as we move forward okay other public comment more Wasserman can you hear me I can more and I saw your hand raised but I wasn't sure if it was from the earlier it's hard to keep track so there were two very provocative public comments on this issue of sustainability recently one by Bill Schubart and one by the estimable Ham Davis both and I read in Vermont Digger that really called for either closing hospitals or demanding hospital affiliations some really terribly difficult conversations which are going on right now in this meeting I hear them and and all people are of good will I guess my feeling is that you know the Green Mountain Care Board isn't the only player here it's one major player but it has a lot in the way of carrots and sticks available to it I believe and the board members need to consider where they can best exercise the use of those carrots and sticks as we go forward in a decision making process that is bound to be painful and difficult the other the other point is that the other power you have because of your the respect that people have for you and yes people do respect you is in the area of moral suasion to work with those folks where your powers do not extend to partner and make things better and I would love to see a more public discussion by the board the board's website is a very passive entity all websites are passive I would think it would be good to see board members or the board perhaps collectively speaking out more and addressing things on the need to go forward because we are in a crisis and the epidemic the COVID pandemic is an enormous opportunity and it is may get in the way of reform but it actually reveals very clearly where healthcare reform needs to go that's all thank you more other public comment it's Walter go ahead Walter I just wanted to echo the persons who before me asking about where the insurance companies um how their money has gone that they haven't paid out in all of this COVID stuff and why they're asking for a raise and to tie it in and wonder if the all payer model is really the way to go here with after this crisis and with hospitals all in the in this crisis mode because here we are trying to you know we're not getting any raises and all of a sudden these insurers want more yeah I'm not going to comment Walter because we're in the middle of deliberations on rate review and that question would have been better asked at the public comment period for the rate review process but we hear you Kevin can I get a comment this is ham go ahead ham I think that I think that I understand that the Jessica Holmes motion is on the floor I think the board ought to approve that my view is I I think the idea that we're just scrambling ahead here that it would just way too precipitous or just moving too fast I think it's just completely wrong we started working on this problem officially in 1983 we've had the all payer model has been on the table since 2013 in its most modern iteration and I just think that it's the most obvious thing in this world is that you can't we cannot do anything with this system until we get the kind of information that you that is required by the sustainability framework you simply have to know whether the these heavy end these high end service areas in small hospitals make any sense even volume whether the volume is enough to maintain medical sharpness okay and then whether the unit costs make any sense and in many cases I'm sure they don't but let's see the data let's see the data and and not even the idea that we shouldn't even look I think is just the mistake the second thing is that the whole idea that the COVID has to stop everything I think that's way overstated the COVID load in the hospital system has been astonishingly low now I don't mean that the money that they had to give up by closing down specialty services isn't a factor but a lot of that money has been made up by the federal government and and mostly the service levels are back to normal even UVM which was ready to fill up Patrick Jim had a tiny number and so the the reality is the you're going to have to get at this you're going to have to get at this issue and the question is there'll never be a shortage of reasons to not do it makes sense to me to go right now it's not it's not impossible and if we can't figure out the kind of question that whether if we can't even figure out whether in various there's enough volume for quality that's the most that's the most basic quality test the quality quality systems are really primitive that they don't really mean much we all they do at this point is the filling boxes but at the cost level if we if you can't even figure out whether what you're doing what your product is and what how much money you're going for doesn't make any sense at all then you can't do anything thanks thank you ham and and I hate to come to the defense of the hospitals but I don't think that the point that was trying to be made was that the the hospitals were overrun with COVID patients the point was the incredible amount of work that went to make sure that the hospitals weren't overrun by COVID patients the amount of work that where departments were torn apart because that's where negative pressure rooms were to create the capacity to treat COVID patients that the continuing struggle for testing the continuing struggle for PPE these are all things that hospitals are dealing with continuously and I think that was the point that Jeff Teaman was trying to make not so much that hospitals have patients out in the hallways because of COVID but um your your points are very well taken thank you ham other public comment other public comment I have one more go ahead and listening to the comments that have been made it feels like this comes back to that sustainability issue that was mentioned in right review um and and another board can't comment on this I'm just commenting that as a reference point to start coming up then and I knew it would come up in hospitals I think there is a much larger discussion and in fact schools is coming up in schools a private school versus a public school how do you fund a public school how do you keep it sustainable where do the funds come from it comes from the community I think there's a much larger conversation that's going to break at some point or we're in trouble if it doesn't which is to simply understand systemically that healthcare can't be funded the way in which it is funded and it can't be funded solely by the state the federal government itself probably other stakeholders as well I just don't have a complete list in my mind need to wrap themselves around the fact that what COVID is bringing out is healthcare is more of a fundamental public good ingrained in every part of our lives from our schools to the stores we walk into and we need to own it and fund it because it is not solvent as it now is on any level that is a conversation that I don't know it feels at times like it's 30 years in the future but the crisis is now is now and I'm kind of hoping COVID pushes us over the edge as far as the realization of the real problem we have and what the solutions are I'm also worried about the cost in lives to get there that's it thank you Dale other public comment if not I'll bring us back to the motion that's before us which is to approve the framework as laid out in the presentation to delegate to staff to move forward with the sustainability process is there further discussion from the board I would like to add just some reference in in this vote you know that we recognize that it's an unknown road ahead relative to COVID and that this effort needs to keep a reasonable eye on any extra burden that that might come along with it with a second wave I'm sure that's understood but it just you know I you know I think it helps to be explicit about that this isn't you know we're just not going to keep charging forward when you know hell is breaking out you know in terms of a second wave other other comment from board members is Mike Barber on the line I am Mike do we need to have a roll call on this or I can't predict what the outcome will be so I don't know what's unanimous so you tell me yeah let's do it that way uh so member lunge yes member Holmes yes member Yusufer yes member Pelham yes mr chair yes thank you for that roll call Mike and thank you Elena Patrick Jeff for the hard work that's gone into this so far and I look forward to working with the hospitals to make sure that this process is done right and that nobody's time is wasted in this process and we're also not uh overworking the hospital so um we'll walk that fine line and I'm sure that um if we cross that line that we'll hear very loudly from people very quickly with that is there any old business to come before the board is there any new business to come before the board hearing none is there a motion to adjourn so second it's been moved and seconded to adjourn all those in favor signify by saying aye aye anyone else anyone opposed hearing none um have a great day everybody and uh we'll keep plugging away thank you