I'll call to order the Green Mountain Care Board's hearing of April 19th, 2023. Today is a special board hearing. We have a round table discussion from a collection of leaders in the primary care space here in Vermont. We have folks from diverse set of backgrounds that have been working in primary care collectively for decades, if not over a hundred years in this state, and we're really fortunate to have them. So they'll be doing a round table on the sustainability of primary care here in Vermont. And we also today are blessed with the attendance of our congressional delegation and representatives from Senator Bernie Sanders office, Ina Bacchus, who was formerly the director of health care reform for the state of Vermont. And we also have Beth Stearns from Senator Sanders office. I'm sorry, Ina is with Senator Welch. I knew that. And David Sher from Representative Becca Balance office. And I also see David Reynolds here as well. So I think the fact that they're here shows how important this is to not only the state but also our federal partners. And the care board have worked with each of them and their offices on primary care provider issues and health care issues more generally. But we're very fortunate that they're here today. With that, I'll turn it over to our executive director Susan Barrett to go through the executive director's report. Thank you, Mr. Chair, and welcome everyone. I'm excited for a round table discussion today. I first want to start with some public comment periods that we have open. First is on the one care Vermont resubmission of their budget. We're asking for public comments by next Friday, April 28. In order for the board to consider those before they review that resubmission. And then we have an ongoing public comment period for the next potential all pair model. Please share any of your comments with us. We share those with our colleagues over at HS who are leading the negotiations on the next model and scheduling updates this evening. We're going to continue the primary care day at the Green Mountain care board with our primary care advisory group. We have several of the members here joining us for the round table discussion. So they'll be with us through the evening. So that starts at 5pm and it is accessible via teens. There's also a physical presence at our 144 state street office. If folks want to attend that. And then lastly, next week, we will not have a board meeting. So I will see many of you back here in May.  Thank you. Real quickly, we'll take up the meeting minutes from April 12 2023. Is there a motion to approve the minutes? I moved. Is there a second? Second. Any board discussion? And all those in favor, please say aye. Aye. Aye. Aye. Thank you. And the motion carries unanimously and the minutes are approved. I'll introduce the, um, Round table that we're going to have, but then I'll let each presenter. Introduced themselves before I do. Would any of the representatives from our congressional delegation, like to introduce themselves on? Jump in. I'm sorry. name is Jessica Nordhaus and I work for Congresswoman Ballant and I jumped the line on the congressional protocol so apologies Beth. No problem. Thanks Jessica. I never know quite how to do this. Yeah. Beth Stern I'm an outreach representative for Senator Sanders in Vermont although right now I am in DC just around the corner from David Reynolds. So I cover health care seniors disabilities and economic justice. Hi everyone. My name is Ina Bacchus. I'm an outreach representative for Senator Welch and working in the Vermont office and I cover health care and human services issues. Mr. Reynolds I'm counting you in this cohort here. I think you're muted. I'm often better muted than speaking. I'm the Senator Sanders Senior Health Policy Advisor and I'm working on a variety of primary care and workforce programs that are up for reauthorization this year that will be very important to Vermont so the Senator is interested in enhancing them of course. Thank you all for being here and for your interest in this topic. I really appreciate it. I know all the board members do so thank you. So we have this panel will speak to us today about the sustainability of primary care practices and I want to thank the panelists real quick for taking a time out of their busy lives to put this together. They've been working with the care board and with each other to make this possible and it's been I'm sure a fair amount of work. As we all recognize at this point a strong primary care provider community is critical to not only our health but also the affordability and sustainability of our system. Robust primary care environment gives us quick and easy access to care provides critical preventative care that keeps us healthier for longer identifies health care issues that we may not appreciate such as signs of skin cancer or mental health issues connects us with specialists and coordinates our care and they're there when you have an awful tick bite or you need quick advice about what to do or to get a prescription for it and they're there when your child has a super high fever and you're very scared and these are situations that we're all in late for you. They also provide not only critical urgent care but peace and reassurance knowing that you have someone that you can reach out to when you're in need. Our primary care provider community however is strained. Rate increases for primary care providers have been quite small compared to rate increases and reimbursements that we see at other provider types. We have independent primary care practices. We have primary care providers at FQHCs. We have hospital based primary care providers. There are MDs, APRNs, PAs and in my opinion we need more of all of them. But much like our hospital system primary care providers are facing significant financial challenges. They're dealing with inflation and staffing problems just like the rest of our system. They have significant administrative burden yet often very little if any dedicate staff to handle it. They're often the CEO and the provider and the cleaning staff. Our primary care provider community is aging and we're not seeing the levels of reinforcement that we would like and that we need. And we have challenges to access for primary care. It's incredibly frustrating for Vermonters to not be able to access that care. I myself have dealt with this for a number of years unable to get a primary care provider despite calling and waiting on a number of wait lists for that seem to never terminate. And when you're paying thousands of dollars in insurance and your employer is paying thousands of dollars insurance if you're lucky to have insurance it's really frustrating to not be able to get a doctor. It's not appropriate. It's a failing in our system and it's something that we need to address for the sake of improving our health care, the health of our population and ensuring the affordability and sustainability of our system. So the care board doesn't itself directly regulate primary care providers but our work and the decisions that we make do impact those providers. When we make hospital budget decisions, rate decisions, certificate of need decisions, really most of our decisions do touch one way or another primary care providers and of course the work that we're doing with AHS on the new all-payer model agreement also will have significant impact on our primary care provider community. And given our challenges and the incredible importance of primary care providers to our state, we've asked the panelists to inform the board and the public about the current landscape in our state, the impact primary care providers have on our health care system, and to address what they see as possible regulatory or policy solutions to improve our primary care provider community here. In that introduction, I'll turn it over to our panelists and I think we're going to start today with addressing the primary care provider landscape. But first, if folks would like to go around and introduce themselves for everyone, that would be great. Do we have any specific order or, Susan, do you want to call folks out? I can do it, Rick. Okay, great. Why don't I do it? Because I have you on the screen. I hope I don't miss anyone. While we start, I'll go on my screen. Susan Ridson. Hi, thank you, Chair Foster and the board for convening this roundtable. My name is Susan Ridson. I'm the Executive Director of Vermont Health First. For an independent practice association, we represent 62 specialty care and primary care practices located throughout Vermont. We have 26 primary care practices in our network who care for an estimated 85,000 patients. Thank you. Eileen Murphy. My name is Eileen Murphy. Family Nurse Practitioner, 25 years experience, mostly in Orange County and some Windsor County. All primary care, my priority would be that we include and reimburse and support all primary care providers so we can increase access to Vermonters and their families to primary care. Mark H. Good afternoon. I'm Mark H. I'm the Director of Benefit Programs at Vermont NEA. I'm also a trust administrator for the Vermont Education Health Initiative, which provides insurance benefits to 35,000 school employees active and retired and their dependents. Dr. Fay Holman. Hello, I'm Fay Holman. I'm a family physician for the past 29 years in Wells River. That's a town of about 400, so I'll be giving a rural perspective today. I'm also on the primary care advisory group and on the board of Vermont Academy of Family Physicians. We were asked in the intro to say what our top priority was, and my top priority for a meeting such as this is to, you know, we recognize there's so much agreement as Chair Foster was saying about what needs to happen in primary care, and there doesn't seem to be any entity or person who's steering the boat. And that would be my hope that would come out of this type of a meeting is to empower someone who could be some sort of a czar of family medicine. I heard that New York City now has a rat czar to get rid of rats, and I think Vermont should have a primary care czar. I'm not sure who that would be, where it would be housed, but that would be my hope. We don't want to get rid of them, though. We want more of them. Mr. Dooley. Hi, thanks. My name is Rick Dooley. I'm a primary care PA at Thomas Chittin Health Center, which is an independent family practice in Williston. I've been a PA, a family practice PA now for almost 30 years. I'm also the clinical network director for Health First, as Susan said, representing independent practices around the state. My top priority for primary care in Vermont is to increase the funding and the resources going into primary care, not only to sustain the practices we have, but also expand primary care so it becomes an actual coveted option for all positions, PAs, and MPs as they're graduating and looking to pursue a career. Thank you. And Julie Wasserman? Yes. My name is Julie Wasserman. I worked in state government in health policy issues for roughly 25 years. I now am independent and I freelance with health policy issues. Thank you. Jesse Barnard? Good afternoon. Thank you, Jesse Barnard. I'm the executive director of the Vermont Medical Society. We are a statewide physician and PA membership association. We have about 2,600 members and they are in all practice settings and practice types. Independent practice, FQHC, hospital-based, and I'll have an opportunity to talk a little bit more about our priorities for reform at the end, but I'll just highlight that our wish list includes improved funding and sustainability, support for the workforce, and reduced administrative burden. Thank you. Mary Kate Mulman? Hi, Mary Kate Mulman. I am the director for Vermont Public Policy at Bi-State Primary Care Association. We support Vermont's and New Hampshire's federally qualified health centers, as well as the Vermont Free and Referral Clinics and Planned Parenthood of Northern New England. So I'll be giving the FQHC perspective, as well as the Free and Referral Clinics. I feel like they are often overlooked part of our health system and I want to call attention to the good work they do. And as often, I would reiterate, Jesse, with the priorities, making sure sufficient funding, workforce, I would add the coordination piece across our different sectors of our different parts of the health care system is also an important piece of what we as health centers do. And Dr. John King? Yeah, hi, I'm John King, a family physician in Milton Vermont, part of the UVM system. And I also work at, do hospital work at Central Vermont Medical Center and UVM. And I can't really add to the objectives. I would definitely just be repeating what Jesse Barnard and Rick Dooley said. The nice things about this is there is a lot of alignment in sort of the goals and objectives. It seems like there's a pretty good consistency. Patrick Flood? Patrick, I think you're muted. It looks like you're trying, Patrick, but I can't hear you yet. Okay, is that better? Yes, sir. Okay. I don't know if you can see me, but that doesn't really matter. So my name is Patrick Flood. I started my career as a nurse. When I came to Vermont, I started working for state government, long story short. I was the commissioner of the Department of Aging and Independent Living, where we negotiated an 1115 waiver with CMS. After Hurricane Irene, the governor asked me to be the commissioner of mental health, which I did for a year. After I retired from state government, I ran Northern County's Healthcare, which is one of the larger FQHCs in the state for three years. And after that, I did a stint at a non-profit housing provider in the Northeast Kingdom, too. Currently, I would describe myself as an unpaid and unaffiliated advocate for effective health care. I'd like to add, Patrick, that you also were deputy secretary of the Agency of Human Services. Some people say I have a checkered career and can't keep a job. All right. And last but not least, Mike Fisher. Good afternoon. I'm Mike Fisher. I'm the health care advocate. And I guess, you know, my overall goal would go would be both that people have easier access to primary care and that the more Vermonters can make health care decisions without having to make financial decisions that get in the way. Great. And just for everyone, if you're not speaking, try and mute because we get a little feedback occasionally. And as everyone can see, we have a very deep and broad collection of speakers today, which is really great, representing all kinds of different viewpoints. So I'm really excited about that. I'm going to turn it over to Jesse Barnard, Susan Ridsen, Mike Fisher, and Rick Dooley, who are going to discuss the primary care provider landscape. Thank you all. Thanks, Chair Foster. This is Rick Dooley. Again, I'm going to go ahead and kick us off here. The proverb announced prevention is worth a pound of cure. Rings true for our health system. Studies and anecdotal evidence have shown the investments of primary care result in patient outcomes, reduced emergency room visits, reduced hospitalizations and better overall health. Why? It's fundamentally because of the relationship that we build as PCPs with each patient that allows us to focus on preventative medicine and the patient's overall health status as opposed to just their current disease state. But in order for primary care to be successful, we need the time of resources to build those relationships. I have, I'll talk about my practice. I'm an independent practitioner, but I think a lot of the things I say are going to be applicable to both the hospital employee and the FQHC folks as well. I have about 1,500 patients in my panel, which is probably normal to high normal size for a full-time PCP. And I've been closed to new patients for the last two years. There's not a lot of attrition, unfortunately, or fortunately, depending on how you look at it. My day typically starts with my first patient at 8 o'clock in the morning. I generally see my last patient at 5 o'clock or later. Like most PCPs, I tend to go room to room throughout the day. So lunch is generally taken at my desk, trying to get cut up on charting and messages. The end of my day is spent finishing up on charting, returning patient messages, phone calls, reviewing lab results in correspondence, signing Vienna orders, FMLA forms, disability forms, whatever other paperwork has come in over the course of the day. My colleagues and I generally either work until 6.30 or 7 to finish stuff up, or ultimately, a lot of folks will go home, have dinner with their family, put the kids to bed, and then work for another two to three hours to finish up the day's work. For many of us, our work day isn't just the days that we're in the office. Our day off is considered catch-up time to finish up on the tasks or phone calls that we didn't get to earlier in the week to consult with specialists who we couldn't reach during the week or to complete peer-to-peer insurance and prior authorizations. So 1,500 patients is a fair number. Based on my patient's age spread and current best practice, about 950 of those folks need some sort of annual wellness visit, well-child check, or a preventative visit on a yearly basis. So to fit those 950 folks in means that I need to do five to six of those lengthier visits every day to not fall behind. On top of that, I need to make sure that I have time in the schedule for all the chronic follow-ups for depression, diabetes, hypertension and such. I need to make sure I have availability for acute illnesses for my patients or certainly any mental health crisis that we try to squeeze in on those days. There are just not enough hours in the day for a PCP to do all of their work. In addition, once the health care work is done, the insurance work begins. So practices need an entire billing staff to ensure coding requirements are met, bills are submitted correctly, and then they often find out the payments are then denied until they do additional steps and additional documents, send office notes just to get the payment. And then once we do get the payment, it doesn't nearly cover the cost of what it took to render the service. Referrals are often put on hold until time-consuming prior authorizations are completed and the list goes on and on. Our current system has resulted in a fragile primary care workforce that's exhausted, overworked and under-reimbursed. At some point in the past, it was decided that it was more important to direct resources to hospitals and to medical specialties than to primary care. We became focused on treating the sequelae of illness rather than investing in preventative care and overall health. I wanna share just one brief story with you about a patient. I'll call her Mrs. Jones, lovely lady in her 80s to 90s, we'll say, who's been struggling recently, widowed and moved in with another older family member rather than live alone. Even though she's generally healthy, she was being seen after the death of her husband in the emergency room almost on a weekly basis with various complaints from suppress, sometimes chest pain, sometimes belly pain, sometimes musculoskeletal pain. Almost every visit resulted in some advanced imaging in one way, shape, or form. Several of the visits ended up with hospital admissions for a day or two.  After a few months of playing whack-a-mole, we decided to try a different approach. I decided to schedule her every two weeks to see me regardless of whether she's having symptoms or not. Every two weeks, like clockwork, she comes into my office and then we also set her up to meet with our care coordinator to do some regular phone check-ins. At the visits, we talk about whatever symptoms she may be having or whatever symptoms she thinks she might be coming down with in the next week or two. Over the last year, her emergency room visits are down literally 90%. And I think she's been admitted maybe once the hospital over the past year. Each visit with me reimburses for about 110 bucks. So every other day, every other week, rather, we spent about $2,600 in office visits. That's less than the cost of one emergency room visit. Primary care works because of those relationships, the relationship I have with her that lets her come in and trust me to work with her. This panel was pulled together to discuss some of all these challenges in detail and propose potential solutions that will rebalance our healthcare delivery system to allow primary care to do what primary care does best, improve the health of our entire population. I truly hope that we can together find a path forward. I'm gonna hand this off now to Jess us if you can talk about the primary care provider demographics. Thanks so much. Wow, Rick, I feel like we could end the panel with that. What a great overview of what it's like to practice primary care and what it can accomplish. So thank you. My comments will not be nearly so engaging. I was asked to give a little demographic overview and what I am pulling from is largely from the workforce surveys that the Department of Health has. They're all up on their website. If you just Google Vermont healthcare workforce census reports they do a survey when everyone relicenses. So it's by professional type, by license type. And they ask a lot of really interesting data points. So how many hours a week are you practicing? Do you plan to retire anytime soon? What's your age? What's your specialty? So I will highlight a couple of things that jumped out for me. Unfortunately for physicians, this is from 2018. There was a 2022 relicensure cycle. So that data should be coming out fairly soon, I believe. But I know it takes a while for the Department of Health to compile all of that. So I'm sure these have actually, my guess these have not improved in the past couple of years but we will see soon. So 25% of physicians reported that they worked primarily in primary care. So that means 75% are specialists. If you add up the FTEs, that was about 435 physicians who are full time in primary care. That is a 62 viewer FTEs practicing in primary care in 2018 compared to 2008. So over a 10 year period we lost 62 FTEs in primary care. And interestingly that is compared to a 114 increase of FTEs in specialty care. A lot of that is in hospitalist and ED. And the biggest decrease to primary care was in general internal medicine. So that's adult medicine, adult primary care. 29% of all physicians are over 60 years old. So that's primary care and specialty. In half of our counties, around over 41% of primary care physicians are over age 60. That 47% of psychiatrists are over age 60. 15% of primary care physicians either reported they either plan to retire or reduce their hours within 12 months. But here's a I think a point for us to hold on to. 41% of primary care physicians attended medical school or residency training at UVM. So when we talk a little bit at the end, maybe about workforce opportunities, we do know if folks train in state or locally they are more likely to stay here. So a glimmer of hope or something we can talk about for potential solutions. I did also want to share. So the demographics look different for PAs and that's also some good news. We are seeing PAs and I believe somebody was speaking after me about nurses and nurse practitioners. There's a little bit higher percent practice in primary care that the PA data is from 2020. So that's a different licensing cycle a couple of years more current. So 32% in primary care and that was an increase. So in the past 10 years or from 2010 to 2020, there was an increase from 67 FTEs to 93 FTEs in primary care. And only 12% are over age 60. So it is, we are seeing sort of over time as primary care physicians decrease. We are seeing some increase in PAs and advanced practice nurses. So again, thank you. That's a little bit of the demographic background and see was it going to be, Eileen, were you gonna be the one to share some nursing data? I am. Great, thanks. Kristen has a bit of data to put up on the screen and we're gonna start with APRNs just because it's easier to do this visually. So, Jesu was talking about AHEC data. So this is actual Board of Nursing data from this year and so we don't have the summaries, we only have straight numbers. This is the list of nurse practitioners. And if you look toward the bottom it's 1676 renewed their license. So that's how many APRNs. Those are by individuals. So if somebody has dual board certified, triple board certified, there's actually one with four different certifications. They usually add on if they're adult, they might add family, someone might add psych mental health. So that's your total numbers for this year. And if you could scroll down just a little bit, Kristen. This would be 2019. So if you remember that top number was 1600 something, now you get down to 2021. There was 900 APRNs. And then when you go to 2019, it's 868. It's been a large increase. The best numbers we have for 2019 as far as primary care and specialty care, dividing that out, that's about 50%. And if you look at 2021, that's where the age range shows up. Average of 49 range of 27 to 87. No surprise to anyone that APRNs are 88% female. And then if you look at 2019, they divided it just a little bit differently that 22% are 60 plus and 34% in specialty care are 60 plus. So I just wanted to have that out there. The board will have this available to them after and then I'm gonna have Kristen switch over to the RN numbers. And the RN data for 2023 active licenses, 10,779. There are a few that are telehealth only. Just for a little background, I included because this actually shows up in the data. The first issue of license, we have two that were issued prior to 1960 who are still active, 28 prior to 1970. And then the number goes up. So licenses issued prior to 1980, 263. The 2021 numbers have the breakout for age group and practice years. There's in 2021, there was 10,700 RNs. You can see the age grouping here. 55 to 64, 65 and older. And the education grouping, it's about a third we're educated in Vermont for that RN license. Thank you. So I believe I'm next to talk a little bit about the challenges facing primary care. Is that right? Everybody, okay. We've touched upon a number of them and I'm glad we just finished with the workforce because I've identified or we've identified four main challenges to primary care. And the first is a shortage of primary care providers. That is a huge issue as providers retire and burn out. We just don't have the numbers to replace them, let alone expand. And I am assuming we're gonna talk about some of the reasons why that is when we get into the solutions portion. I might fix that. This shortage certainly affects all primary care types whether they be hospital-based, FQHCs or independent. I do think that independence are at a unique disadvantage in this area, however, for two reasons. First, independent primary care clinicians are get the lowest reimbursement of all primary care clinicians and their only source of revenue is payer reimbursement, which is largely non-negotiable. But another huge reason is that independent practices are not eligible for the Department of Education, the Federal Loan Forgiveness Program. So when you have a new doctor who's just coming to practice has a lot of debt and he's faced, he or she is faced with where to work and they're looking at a non-profit hospital and FQHC or an independent practice at the non-profit hospital or FQHC, they can work for the required number of years and have their loan forgiven. That is not an option at an independent practice and that is a huge disadvantage to independent practices in recruiting clinicians to replace their numbers. The other huge challenge in primary care which we've all touched upon is just general under-investment in primary care. It's definitely one of the biggest barriers. It limits the ability to hire staff, invest in new technologies and expand services needed by the community. We also have health disparities and under-investment in primary care often shows itself first in rural and poor areas whose residents are often sicker, don't have the resources to ensure that they're able to take care of themselves as well as they could. And in our network and the independent practice network, those are the practices that have been closing first. We've lost many of our rural primary care practices simply because they just couldn't stay open with the reimbursement and investment levels in primary care there. So that's the issue. Also, huge administrative burden seen in primary care. Rick alluded to that. So to Chair Foster, we have many different insurances, there's different prior authorizations, there's claim edits, there's different formularies, there's forms, there's different quality programs. All that takes time. Most of that work is uncompensated and it just takes time and resources away from direct patient care and it is a huge contributor to burnout. If we wanna improve primary care, we need to do something to really take care of this administrative burden, it's huge. And then last, but not least, in the US we have overall system design limitations. We have not prioritized preventive health or public health like many other countries have done. So we have a sicker population, we have a lot of folks with diabetes, hypertension, they're coming to their primary care, provider who need to manage those conditions and that takes more time and resources. We also have a highly fragmented system and again, the primary care practice is helping patients with coordinating their care and communicating with different providers and because of our fragmented system, that work is that much harder. And then we also have a really costly system. So patients are faced with high deductibles and copays, so they might delay care, making them sicker, again, more for the primary care office to manage. And then it's also a hit to the primary care practice itself when the cost of health insurance premiums keeps going up and up and up. You have to, the practice wants to cover health insurance for their employees and that costs money and the money that you spend covering those things takes away from the services you can provide in the practice. So those are all huge barriers and I invite the other panelists to chime in if I've missed something or you wanna expand on something and I'm sure we'll talk about this more, but those are the main barriers. I am again, I'm Mike Fisher, I'm the healthcare advocate and I think my job today is to speak a little bit more from the Vermonters perspective. So healthcare advocate runs a helpline. We get thousands of calls a year, around 3,000 calls a year in people who are having any number of different kinds of challenges accessing care. We do get calls from people who are having challenges finding primary care, maintaining a relationship with primary care providers. And as you might guess, those calls have the complexity that families have. But a couple of disclaimers, I think it's important to always note, nobody ever calls us and tells us everything went well. That doesn't mean that there aren't great interactions happening that people aren't managing to get to their primary care docs or their providers and getting good care. I think it's just important to say that. I also can't tell you the scale. My office, the data from my office provides a little bit of a canary in the coal mine like dynamic. We get calls from people who are being challenged finding a primary care doc. But I think I could look up how many calls we got in the last year on that, but I don't think it would be all that instructive because of the universe of people with that problem, how many new to call the healthcare advocates office, would argue relatively small. Couple quotes of things that people have said to us. My primary care doctor wanted to do some standard blood work. I'm putting off getting it done because of the potential cost. Living paycheck to paycheck, I don't have an extra month's worth of rent and utilities to pay for the medical bills. I avoid going to primary care. And one more, due to medical debt, I don't have health insurance. I don't have a primary care provider, prescription lenses with an updated prescription, a dentist or access to credit. So those are three Vermonters voices. And then I'll add in the most recent household health insurance survey. Fear of medical debt impacted household decisions when accessing primary care for close to 20,000 insured Vermonters. 25,000 when we're talking about dental care. So I think there's a bit of a, I often wonder what does it look like to the primary care provider when the person in front of them is so fearful of receiving care, because they're fearful of the bill. And again, I know there are great providers out there who are attuned to this. And I also know that there are plenty of situations where the provider is not attuned to it. And there's a disconnect. And so I'll tell one story. This one comes, recent story that came to us. This one comes out of a dental setting, but I'm convinced it happens throughout the health care system. The provider said, I want you to get some X-rays. And the patient said, no, I don't want X-rays. And the provider ultimately said, I can't work with this person. I'm not gonna keep them as a patient. And so that person lost their relationship with in this case, dentist. And so I tell that story, it's unfortunate how often we hear stories like that where people and their fear of debt and their fear of the bills lead to a loss of relationship with the provider. Now you might say, and lots of people on this call know, hey, wait a minute, aren't there ACA protections for preventative visits? Aren't there plans available on Vermont Health Connect that have first dollar coverage? I'll just see if this works. I'll just flash the menu in front of everyone. It's complicated is the answer. And that even though some people have some protections from a first dollar billy, the fear continues and the confusion continues when people get bills that they didn't expect. So I think I'm gonna just sort of sum up and say, thank you, Chair Foster, for talking sort of personally about the challenges of finding primary care. I think any number of us have had that kind of experience in this room. But I want you to imagine for a minute what it would be like if you were dependent on Medicaid's non-emergency Medicaid transportation to reach your provider, or what it would be like if you were dealing with pain management and you're looking for a primary care doc who's gonna help you with your need for some opiates. Or what it would be like to look for a primary care doc. Let's say you just lost your relationship with your primary care doc because they closed up their shop and they gave you 30 days transcription, transition prescription to find a new primary care relationship. What it's like to feel the pressure of 30 days before you run out of your meds and the challenges of finding another primary care relationship. Think of, I'll stop there. Those are the kinds of calls that we get, the kinds of challenges that people face when they call our office. And I look forward to the rest of this conversation and being a part of it. Thank you. Thank you all. And Mike, I think you're right. There's like a real sense and feeling of hopelessness in those situations, right? I mean, my situation was fortunate. I had health insurance and I was healthy and I have a car. A lot of people don't. So the feeling that they would happen in that situation is really, really hopeless, I think, and really difficult for people. Thank you all for that. I really appreciate all of those words and the Rick Dooley story was really touching to start off. I'd like to move to our second topic, which is the impact primary care providers have on our healthcare system. And if my notes are correct, we've changed this around a little bit, but Fay Holman, Eileen Murphy, Dr. King and Mary Kate Mulman will speak to this topic. So Fay and I coordinated some of our content and we did not coordinate with everybody else, but it's gonna flow along very nicely with all of the comments that have been made so far. Most of what we're talking about is based on the primary care advisory groups work for the last number of years. The board has those priorities in their packet so we won't go through them here and Fay had one comment to add to that. I wanted to make just one comment on the issue of prior authorizations. I have experienced and I know that often when we talk about how difficult the PAs are that providers are sometimes seen as just kind of complaining, not wanting to be told what to do by somebody else. And I just wanna make it clear that the prior author issue affects three other direct goals of PCAG. One, Sue Rizdin already talked about very clearly it's the economics of running a primary care practice. My practice has 3.5 full-time equivalents and we have a one nurse nearly full-time doing prior offs and trying to get meds paid for. That's a really silly way to spend healthcare money. The other effect is provider burnout and Susan mentioned that as well. We know when you know what's best for your patient and have to kind of fight about it day in and day out to get it to happen, it's really demoralizing and demoralizing is part of what leads to burnout. And then finally there's the issue of patient access. If we had a one more nurse actually circulating and doing things in our office and we had less provider time spent on the phone trying to get the prior offs through, we would have more access and be able to see more patients. So I did wanna just make that comment. And I have one other quick comment that's kind of in the good news department and that is, I hope most of you know that Lamoille Health Partners which is the FQHC in the Stow Morrisville area just got a half million dollar planning grant to try to establish family medicine, rural track residencies throughout Vermont at different sites in Vermont. That would bring 10 family medicine physicians to the state for training each year and historically about 60% of those will stay nearby to where they trained. Currently we are only training six a year in Vermont. So this is an enormous increase and I think really good news for primary care. It's very preliminary, two years of planning, three years before you actually have someone with a degree but I thought good news was worth sharing. So I was gonna go through next, Kristen's going to put something up on the screen for me here. We wanted to go through the services that primary care offers. Many people are probably not aware of the breadth and depth of this. We cover ages across the lifespan, preventive care, well-cares, screenings, population health and panel management which is going through the panels and seeing who has their hypertension in range, non-arranged, who needs followup, diabetes, heart failure, asthma and other quality metrics of urgent and acute care. There's a long list of procedures I'm sure many people don't know that can be done by almost every primary care provider regardless of license. Chronic illness care and prevention, reproductive health care, OB and maternal child health, mental health, counseling therapy and medications, substance use disorder what we call MAT and is in going to transition in time to MOUD or medications for opiate use disorder. The community health team is a huge piece of what we all do. They have self-management classes for chronic disease, different clinics will do food resources, clothing assistance, tobacco cessation and then coordinating, connecting the patient and family with the community resources that are out there, legal, insurance, access to computers, gas, aging resources, maternal child and then the dental health. The other thing is there's a lot of primary care services out there that are done by folks who are not maybe RNs, physician assistants, physicians, nurse practitioners. There's also women's health, there's nurse midwives, clinics have dentists and dental hygienists, there are naturopaths, dietitians and then when you get into mental health there's also a number of folks there that also provide some of that care. With those many types of providers what we wanted to talk a little bit about is when we think about primary care and well care and screenings and population health and panel management we think do you have a PCP and have you seen them in the last year? It may not be for an annual exam but have you seen them? So preventive care which is annual for most adults but it might be every other year for some includes screenings for hypertension, high blood pressure, diabetes, cancer, mental health, keeping immunizations current. We provide evidence-based care, there's changes in that evidence over time and as other have mentioned it takes time to review those options. It takes time to discuss that with the patient and family and we call it shared decision making so they are part of it and what the plan going forward is is something we agree on and we as providers may not always agree with what the patient chooses but that is their choice. Patients don't always know what preventive and well care is and they see their annual exam as the time to get everything done. Their annual care, their preventive care as well as their three or four chronic illnesses it's not a good use of that time and that's also more than you can get done in that time. Patients will wait until their deductibles are met because they can't afford anything until the deductible is met. They can't afford copays, their medication, taking time off of work to come in. There are times of once they've gone to the emergency room for something and in their case it may have been a legitimate pain legitimate issue and they get one CT scan they've met their deductible. We build relationships as Rick Dooley said. We build trust. We interact with patients and families one on one or in small groups and that's really where the strength of primary care comes in. Fay has a few cases that she would like to run through and then I have one as well, Fay. Thank you. I always think the patient's stories are the most illustrative of what's going on in primary care and I have two stories and the first one I wanna talk about is a young man who was seen in a nearby emergency room with an opiate overdose and he was resuscitated with Narcan and sent out with two friends who had accompanied him. They noticed very quickly that he still wasn't right. He refused to go back to the emergency room. The two friends were enrolled in our clinic's MAT program Suboxone program and they just walked him over to our office. It was very evident immediately that he was in deep trouble. He was brought into the office and was observed for multiple hours with one of our MAT nurses watching vital signs deciding whether he needed more Narcan which we do have in our office. Normally a new patient has to file paperwork and become a new patient. In this case he just arrived looking very poorly and was kind of brought right in. During the many hours that he sat with our MAT nurse talking he acknowledged that this had in fact been an intentional suicide attempt. He had taken much more than his usual dose of opiates and that day in that same visit he was able to meet with one of our behavioral health counselors, establish a relationship with her and start in with counseling within that week with her and within the following week was also enrolled in our own MAT program and met with a psychiatric nurse practitioner in our office. Through that relationship was diagnosed with bipolar which he had never been treated for before. And now about a year later this young man is stable in our Suboxone program on bipolar meds doing well. Has passed a certificate program, has a job. All of this happened. Well, first of all you can talk about getting value for your healthcare dollar. What we could bill for that entire day that he spent in our office was probably somewhere a max around 200 bucks. And you can compare that to the less useful ED visit that he'd had that day. But the other important message is this was healthcare that was in a walkable distance to where he lived. It was a place where his friends had some trust and relationships and knew to bring him there. And it's a success story about primary care that I thought was worth repeating. The other story speaks more to the issue of too much specialty care and not enough primary care. And this was a 14 year old in my practice who fainted at school. And what often, as often happens when people faint there's some muscle twitching that goes along with it. And so there was concern about seizure. She was sent to the emergency room and she was sent from there to pediatric neurology. The neurologist did an extensive workup with the EEG sort of the brainwave study and couldn't find anything wrong with her and sent her to cardiology, pediatric cardiology because in some rare instances fainting in teens it's quite unusual but can have to do with the heart. She had an echocardiogram, a heart monitor that she wore around for a month. Nothing was found. Incidentally in the emergency room she was found to be anemic. So the cardiologist sent her to a pediatric gastroenterologist because occasionally anemia has to do with intestinal problems, not commonly again. And then she received a scoping procedures of her entire GI tract. During this saga, we reached out to the family and said, can you bring her in? Because I knew this girl and I had a theory about what was going on. And they said they were pretty busy with their specialist appointments and they'd come see us when they could. And when she did get to my office about eight weeks later and all of this healthcare later, we really, we got to the bottom of it. She was in the early stages of an eating disorder and a very common reason for a 14-year-old to faint at school and have anemia. And at no point through the whole saga of the specialist was there a strong recommendation to go back and see your primary care provider. In fact, it didn't show up in the follow-up plans from any of those notes. We did pretty well getting to the issue in primary care and better coordination between specialists and primary care. And I may speak a bit more about that later. Would go a long way to keeping cost-down specialists available and patients getting the care they need where they need it. That's all, thank you. And then I have one more case in this particular section that to talk about, this was a wonderful example that came up in another practice. So this is the patient that in late 30s presented for a new patient visit they were supposed to come in in a couple of months but they were really not feeling whilst they came in early. They had headaches, fatigue, their tobacco user and classic symptoms of diabetes. Physical exam was benign, they were thin patient, it was most likely type one diabetes. They had their labs drawn, A1C, which is a measure of your diabetes management. It's supposed to be under 7% was well up into the double digits. So the provider basically knowing this is type one diabetes and the patient has no insurance and is probably not going to follow up elsewhere was able to get a hold of an endocrine fellow and came up with a plan together. So the patient's going to start insulin and they have to start two different insulins. They also need to check their sugars in the morning and at mealtimes. They have to do some follow up. They need more blood work. So at this point we have a new patient with no insurance who needs a glucometer, needs medications, needs injection teaching. Patient was actually connected with a pharmaceutical company to get some of the insulin and supplies through a company program. This patient has access to insurance at work but the premium's too high. The spouse has insurance but is not able to add family members on. It's not allowed. The children are on Dr. Dinosaur but they're just above the cutoff for financial assistance for Medicaid. So the patient was also connected with resources in the state to see what can go, what can happen next for her to get that insurance for her. All of this was done in primary care and like Faye's story of the hours it took to do the work with the patient, this is not necessarily going to get reimbursed as it happened for all of us who've had students whether it's a PA student, an NP student or a physician, there was a good student in the office that day. So they were able to see the next patient, prep the patient for the provider and keep the flow going for the afternoon. And that is just a wonderful thing to have to have a student who can help manage some of that. But that is the issues of the lack of insurance. The next thing I'd like to do is I have a flowchart, Kristen, if you could put that up. And there's a couple of cases I'd like to walk through with you on watching a patient go through the system and what can we do to prevent this in primary care. Some of the issues about insurance premiums and assets versus deductibles was covered in a recent Green Mountain primary care board meeting. There was a presentation by Cooper and that was actually very good and contributes to this discussion. So if you think about a couple of cases of either heart failure or COPD, the patient comes in every three months for their checkups, doing fine, doing stable and a few weeks after their last check, they start developing symptoms. And for those of you who know what COPD is, you can imagine that for those of you who understand heart failure, you can follow along with that. So they call back and in some offices, they would not be able to get in because there just isn't room to get the patient in. In this case, they were in office that could. So the patient has a PCP office, they have a PCP and they can see that PCP for well care, sick visits, chronic illness, nurse visits, triage, there's on call, telehealth. So this patient, the secretary takes a call, recognizing the patient has symptoms and gives the call to the RN, in some cases that may be an LPN. Then an assessment was done. The nurse could either schedule the patient for a visit that day or the next day or they might go and talk to the provider who knows the patient. Sometimes depending upon the situation, you might give medications to treat at home and schedule a follow up. And so it just depends upon the situation that day. If the patient wasn't able to do this, this is what happens next. They might go to the emergency department or urgent care. If they waited long enough because they couldn't get in with their PCP soon enough, they got worse. They might need to be in observation, which is 24 hours. If they really did get sick enough, they might need an admission. They might need to get transferred to a higher level care, a tertiary care. Then when it comes time for discharge, where are they going to go? Well, they maybe could go to the community hospital where they came from, but oh, there's no beds. They might need to go to rehab, but maybe there's no beds. They might need to go to a nursing home if there's a bed. And if they can't move, then they stay where they are. At some point they'll transition to home, but can they go home? Are they going with home health services? Do they need other services in there besides just a home health aid? Do they need palliative care or hospice care? So in this case, you can follow either one of these patients along and see that primary care can keep them out of all of that, which then takes the burden off the hospitals and all of the other pieces of that system going forward. The other thing that RNs and LPNs can do, RNs mostly, is they're part of that preventive care, well-care screenings, population health and panel management. RNs can do those Medicare well visits. RNs and some LPNs can educate the patient and family about that new diagnosis of diabetes, about using their medications and about lab follow-up. So if they need complicated lab follow-up, if there's a plan in place, they might be the one who can actually speak with the patient about the labs and what they might need to do next. And I'm gonna give it back to Faye because she had some comments as well about referrals. And then after that, you can go to Mary Kate. Thank you, Eileen. We've edited a little on the fly here, but I did wanna make just a couple of comments in terms of solutions for primary care about some changes that I think could happen in the relationships that we have between specialists in primary care at this point. My story about the fainting teenager was certainly illustrative of that. But as you know, in the last year, so there's been a lot in the news about delays, getting in with specialists. And I can tell you that that's gotten much worse since that was in the news in Vermont. We're having extraordinary delays. And there are a couple of issues here. One is if we had easy phone access to specialists in the moment or at the end of the day when we'd seen someone that we were referring so that we could tell a specialist about a plan A that we had and maybe come up with a plan B, we could talk with them about further testing or imaging that might need doing before they saw them. Then when they arrived in the specialist's office, it would be a very efficient visit. And it's very hard to get phone contact. And some of that, I completely understand, returning calls at the end of the day is very difficult and it's not something that is incentivized in any way for us to do, but it would help with our referrals. But the other thing that's happened really a lot in the last decade or so is that sending people to specialists has become kind of a cyclic thing where they see the patients back frequently for problems that are, in fact, primary care problems. So we have a lot of stable people with blood pressure, heart issues, age of fibrillation who see cardiology multiple times per year. There are financial reasons for that and some of that may be that there are not enough primary care providers out there. But as we look at solutions shifting the culture so that specialist care is truly consultative as it used to be, you went to a consultant, you got a plan and you went back to your primary care provider. And then we can assure that there's less pressure on the specialist, so they're available when we need them as we often do. And you get more coordinated care for the patient and certainly savings in healthcare costs. So I can plus the baton on to Mary Kate now. Just one thing I'd like to add, Fay, that's I think pretty important, both Fay and I wrote a piece on primary care addressing many of these issues and how to address them and solve them. And I sent the article to Susan Barrett earlier today and I'm hoping that it can be posted on the website and that the Green Mat Care Board members will see it as well as people who are participating today as well as our audience. Thank you. All right, thank you. So I believe my portion of this was to talk about sort of a brief overview of the different types of primary care, different settings of primary care, but I will also focus a little bit more on the FQHC setting for primary care. I think you heard a lot from Susan Ridson and Rick Dooley about the independent perspective. I would reiterate their points that they made that their reimbursement is really based solely on a payer with a payer pays in claims to those providers and also the patient and provider relationship is so critical in those settings. I mean, in all primary care settings, it's really important. But I just wanted to echo what I heard Susan and Rick say. I'm also gonna let Dr. King talk a little bit more about the hospital base and what that looks like and the different pressures that they're experiencing. As to the FQHCs, we cover about 30% of primary care in the state. We are present in 53 sites in all 14 counties. We have a different payment structure than any of the other primary care that you will hear from either hospital based or independent. We have for Medicare, we have an encounter rate. Also for Medicaid, we have an encounter rate and for federal law that is supposed to be based on our costs. Commercial, we have the same kind of payment structure as hospital and independence. But I just wanna call it that a lot of what you hear about paying for primary care, at least with the public payers, it's were slightly different. We also, primary care and FQHCs, they also, it's typically beyond what you would often see in a primary care. I think a lot of what Eileen covered is gets to that expansive view. But in an FQHC, you've got the mental health services. That is a critical component of our care. And I believe it will actually be in a required part of our care model after this federal budget cycle. We, all of our FQHCs are spokes and the part of the hub and spoke program. Obviously medical services, physical wellness. There's reproductive services, vision care, gender affirming care, pharmacy services. They often have an on staff pharmacist and dental and oral health services are all and sometimes they are available on the same site. All within the same organization. And then beyond that, there's what we call the enabling services. And this is also a critical part of the FQHC model. There's the nutritional food access. There's housing supports, there's economic empowerment and services. So you might sit down and talk with a financial, not a financial advisor in sort of your retirement planning way, but hey, what benefits do you qualify for? Are you eligible for our sliding fee scale? There's the translation services. There's transportation services, often providing transportation vouchers that allows people get appointments in a much more flexible way than say the Medicaid non-emergent transportation services. There's a lot of focus put on health, education, safety. And then there's generally coordination with community partners. And often we have a large presence in the schools specific to the coordination with partners and the role within the community by federal statute, more than 50% of the board of directors have to be patient. So that the idea is that the model of care, the structure of the care is reflective of the patient population. It also gives a real strong grounding into the community needs. And I wanna kinda give some examples of the different community ways that our providers interact with their community. So for example, Notch, they have a grocery store, which I thought, you know, sort of like that's really cool. They also have a camp that they support, but like a grocery store that they saw their community, they saw was they were losing a grocery store. There was a risk of becoming a food desert. So they brought that grocery store, make sure they maintain it in that community so that they have access to groceries. But also means that if you have a patient sitting down with a nutritionist and they're really trying to like, what do I get? Like, what do I buy? The nutritionist can walk downstairs to the basement and walk through the grocery store and help that person really think through, what foods do I buy? What foods do I bring home? How might I prepare it? And in Southern Vermont and Springfields, they have a PT office. So, and that is very tightly coordinated with their medical staff. So you may have someone going and getting PT, but they're having a shared care plan with the medical provider and potentially the nutritionist. So you're really thinking, okay, so not only are we doing exercise, but how does this correspond with our heart health and other factors that may be contributing to either their mobility issues or other overall health? We have a number of our sites are starting to open up ExpressCare. And this is a really, ExpressCare is often a way that people, that's how they interact with the medical system. But by being part of a broader system, you can start to say, hey, we're seeing you here, but maybe we can do a follow-up and set you up with a more permanent primary care provider going forward. And so you get that more continuity of care, that building of that relationship. The other thing that I, when I first joined Biostat, I did a tour of all of our facilities, all of our organizations. And the one thing that struck me in every single waiting room that I went into, there was always a basket of free diapers and a food shelf. So the patients could come in, just grab something and they got, and that just felt so emblematic of what these organizations do and the services they provide to their communities. So that's, oh, and then I wanted to cover a little bit about the free and referral clinics. These are, I'm blinking on the exact number that we have across the state, but these are clinics, no charge, no cost to the patients going in. They're an important entry point for care. It's often they are a point of care for an individual. That's where they receive care. That's how they're gonna access the healthcare system. But they're also, for other people, a point of entry into the broader health system. Let's connect to you with the primary care provider. So there's a really close relationship between the free clinics and the FQHCs. The other thing I wanna call out with the free and referral clinics is they are seeing more and more people who are insured. They are seeing more people who are underinsured. So those who cannot afford their cost sharing responsibilities or co-pays, they're seeing those who just can't find a primary care. They need to get their kids athletic form filled out. They can't get an appointment with a primary care provider until November. So they go to the free clinic. They're also seeing more Medicare patients because Medicare, people who can't afford that Medicare co-payment or Medicare dental patients. They're seeing a lot of those, an increase of those. So it's in all, I think my point that I would make about this is it's really, they're a key safety net providers in the state. They are struggling to keep afloat. We're seeing funding sources going down not only with our reimbursement but also the grants have stayed stable. Those are the grants that are intended to support the uninsured and the underinsured and frankly the Medicare co-pays and dental and then other sources are just drying up. So there's a real struggle in trying to keep the balanced budgets for those organizations. And I will turn it over to Dr. King to talk about the hospital-based. Oh yeah, thank you, Mary-Kate. I might just add a couple of things before I talk about the hospital-based practice. I really appreciate the cases that Rick and Faye presented and I'll just comment. The patient that Kay spoke about that ended up getting hooked into her opioid treatment program. I haven't, since I do practice at the medical center in the hospital, the hospitals are just getting, for every patient like that, there's probably five or 10 that don't have the access and they end up with horrible complications from their substance use patients with needing heart valve replacements, needing to be having infections in their spine that require a lot of antibiotics. And then you have to spend thousands and hundreds of thousands, I'm sure, of curation theories to treat the ongoing problem that ended up getting them there in the first place. So that's just another piece of that story. And I would give, the other thing that was encouraging in hearing Rick's and Faye's story is this. I have a... John, let me interrupt you just for one second because I think you're... I have exactly the same pace in my practice and Milton, the patient, enough for us to end up seeing three or four different firms a month.  Yeah, okay, all right. Hey, John, I think, John, you're kind of coming. Is my audience not good or... Yeah, it's coming in and out.  Can you hear me now? Yeah, it is working, but you're kind of coming in and out a little bit. Why don't you try again?  Oh, is it?  That might help with your bandwidth. Okay, I'll try that. Here we go. Yeah. Yeah, I apologize. Okay, yeah, I mean, I'm good. Yeah, the, in terms of the... Like my connection's a little soft here, sorry. I think in terms of the hospital-based practice, I think we're fortunate in that we are connected to the big institution, which can be paid for all those wonderful procedures and admissions and all those things that they do. But the only thing that gets them to invest in primary care is the value-based payment contracts. So I guess the main thing I think that I wouldn't, which, and we've seen that over the past few years, more investment in primary care because the contracts are going more to paying for value rather than just paying for more procedures. And I think that's kind of a key thing that would encourage in terms of the payment system, we sort of get what we pay for and if we're paying for all these procedures and specialists, then that's what we get. But if we can have contracts that are based on keeping the population healthy, that really causes them to invest in us. I think that the examples of improvements recently is an investment in our medical homes, the integration of mental health. We've just started doing e-consults with our specialists so we don't have to send them 20 miles down the road to see somebody that can just look at their chart and give us advice like Faye was talking about so we can take care of it in the office. So those are the comments that I have. Thanks for having me. Great, thank you very much. And thank you very much for you came in on short notice. So thank you very much for doing so. Why don't we take a quick four minute break and we'll come back at 2.25 and we'll go to our last topic which is the regulatory solutions and policy solutions and ideas that folks have which I'm really looking forward to. So we'll come back at 2.25, thank you. Okay, it looks like everyone is back so we'll resume. We're gonna have Mark Hage, Patrick Flood, Julie Wasserman, Jessa, Mary Kate and others join in here to share their views of possible solutions to some of the challenges we have. This should be interesting. I've told everyone if you had a magic wand to make the care board do whatever you wanted, tell us what it is. Typically people are not shy about taking that magic wand and I hope that you're not either. So I'll turn it over to you all. Who should start?  Yeah, we're ready. I just wanna say up front, thank you very much for the opportunity. Mark Hage, Julie Wasserman and I are gonna participate together in this portion of the presentation. I'll say quickly, I'm having trouble with my internet. If it goes out, they're just gonna pick it up. And furthermore to say thank you to the Green Mountain Care Board for having this roundtable. This is the most comprehensive look at primary care that I can recall in years. And I think it's long overdue. I would say that the neglect of primary care has been going on simply too long. As an example, there's a bill in the legislature right now to establish universal primary care sponsored by 60 representatives and it's never even had a hearing. I think that's symptomatic or emblematic of the part of the problem we're facing here. Now, Julie and Mark and I have been working with and talking with numerous people literally for years about the nature of this problem and what the solution should be. Some of those people are on this call today. We've talked to doctors, nurses, mental health professionals, home health professionals and others about what really needs to be done here. We believe that the solution actually has to be a comprehensive one. You can't fix primary care by itself. And we've heard a little bit of that today from some of the presenters about how intertwined their care is with community services. So when we talk about, when we make the recommendations we're gonna make, you'll see that they also include dealing with issues like mental health, home health and hospital financing. Also wanna acknowledge that while we're gonna focus a lot on primary care physicians in our remarks, we fully understand that the same issues around pay and working conditions and loan repayment have to be dealt with for nurses, for mental health professionals and for the other professionals in primary care, like nurse practitioners and physicians assistants. We acknowledge that all the recommendations were about to do not fall under the jurisdiction of the Green Mountain Care Board, but we think the Green Mountain Care Board is well-positioned and in fact has a responsibility, I think to come up with a comprehensive plan to deal with this problem in it. I pretty much think I heard that from the chair in his opening remarks. So we welcome that. The recommendations that we're gonna make, some of them are or will be considered controversial. I think you just invited us to do that, Chair Foster. And they need to be controversial because they need to be big and they need to be substantive or we're not gonna solve this problem, we've let it go for too long. The first comment I wanna make is not really in the form of a recommendation, but more an observation that I think is fundamental to everything we're gonna deal with here. And that is that we believe there's actually plenty of money in the Vermont healthcare system. We believe that unfortunately, we're not spending it all very wisely or very efficiently. And one example, an important example, the Green Mountain Care Board has received reports from Mathematica and from the Berkeley Research Group.  In the case of inpatient care, the number that was cited was between 10 and 34% of Vermont hospital care could be described as avoidable. And in terms of the emergency room, 26 to 41% of spending was considered unnecessary emergency room care. It doesn't take very long to figure out that that is a lot of money. A lot of money that's being paid for avoidable care in hospitals that should be provided in other settings. And we believe that there can be put in place a process to over time reduce the amount of avoidable care, deliver the care where it should be delivered, save money and continue to reinvest that money in building up the rest of the prevention, primary care and community services system. And that's really important because by the time we're done talking about our recommendations, people are gonna be saying, where's the money gonna come from? I think the money is already here. We just need to plan for how we can reinvest it. So onto the recommendations. Recommendation number one is actually that Green Mountain Care Board come up with the process during the hospital budget process. To deal with this very issue of avoidable care. As part of the hospital budgeting process, the Green Mountain Care Board could require hospitals to identify where in their organizations there is avoidable care and come up with a plan for how to deal with it and how to reduce it. And in fact, that plan should be done in partnership with other key providers such as primary care physicians, home health agencies, mental health agencies and others. And so that in fact we come up because in fact you probably can't reduce a lot of the avoidable care unless you're strengthening home health, mental health and primary care. So that's recommendation number one. As with all our recommendations, we're gonna move quickly here because we don't have a lot of time but we would be happy to go into more detail at some other time to explain how we think this can actually be done and what it would look like. And at this point I'm gonna turn it over to Julie Wasserman to talk about a couple of other recommendations. Are you there Julie? Thank you. People have been very articulate today about the neglect of primary care and our attention often is diverted to hospitals or other entities but we know that many Vermonters do not have access to primary care. But we really don't know much more than that. We need empirical data to better understand and know the lay of the land with regard to primary care. So we are suggesting that the Greenman Care Board do an in-depth analysis of primary care. We would look at primary care expenditures and resources and you could do this by hospital service or health service area. And then use that data to identify gaps in provider resources, service delivery and of course most importantly access to care. So this empirical data and this sort of assessment of what resources and expenditures are currently in existence I think is a foundational step. Now if we had that valuable information one idea to consider would be the establishment of a primary care budget for health service areas. And that's a thought and a possibility but fundamentally we really need to know what the situation is first. And we have data on all sorts of aspects of our healthcare system but I think there's a real lack of data on primary care and access. Patrick. You're muted Patrick. But for some reason it's safe forever. Okay we heard you there. Can you hear me now? Yeah, yeah we can. Okay. All right, so I wanna in the next few recommendations address the acute shortage of primary care physicians through some measures related to salary, loan repayment and working conditions. We believe that Vermont can become a destination state or a magnet state for primary care physicians. We have a lot going for us outside the healthcare arena. I would know that people have been moving into Vermont at a very interesting rate over the past few years because of politics, partially because of climate change. But I think we should piggyback on that and make our primary care system so attractive that it will include more and more physicians who wanna move here. What we propose to do is A, raise wages and eliminate the gap between or at least shrink the gap between specialists and primary care physicians and shrink the gap even within primary care between different physicians in different settings. So what we would propose is raise the primary care physician salaries by $10,000 per year for five years. When you get into the details of that, you might make some exceptions here or there based on who already gets paid what. You may wanna think about a threshold that you wanna reach, that's all details. But I think in terms of really making progress, we should be prepared to raise salaries for our primary care physicians by that kind of money. B, in terms of loan repayment, we believe that we could and should provide $50,000 per year in loan repayment for five years for any physician who comes to Vermont wants to stay and is willing to practice here for up to 10 years. It sounds like a lot of money, but if you think about maybe 10 physicians a year would take advantage of it. That's really and truly not a lot of money. It's just over a million dollars a year to run such a program for 10 years and attract 50 new physicians. We also believe that to address the inequity between independent practices and other primary care settings that the state should initiate per member per month of something between $16 and $100 to provide to the independent primary care physicians to help cover the administrative costs that their rates simply do not cover. And you heard Rick talk about that burden for which they are really not compensated. And having run an FQAC, I always appreciated the special payments that we got from the federal government and from Medicaid to help us cover those kinds of things. But the independent practices don't get that. And we think that should be appropriated and provided to them so that we get closer anyway to leveling that playing field. There are ways to do this. We could do it through Medicaid. We could do it through the blueprint. And now I'm gonna turn it over to Mark H to talk about a couple more recommendations. Thank you, Patrick. Good afternoon again. We were told recently that in this year's UVM medical school graduating class, there were just eight students who were committed to practicing family medicine and that at Dartmouth, that number was five. That is shockingly low and it should be unacceptable to us as a state. So we're calling for an increase in the number of future physicians in each graduating class at the University of Vermont Medical School. And we're gonna borrow an idea that was launched back in 2018. It's called the 25 by 30 campaign, meaning that by the year 2030, 25% of each UVM medical school graduating class will be a future physician committed to family medicine or primary care generally. I will add as point of personal privilege that my union is now leading an effort with the Agency of Education, with Castleton College, the Vermont Rural Education Association and several school districts in the first year of this project to keep 170 people licensed. They're provisionally licensed now. They need full-time licenses in order to keep teaching and we're helping paraeducators with college degrees transition to teaching to address the acute shortage in those areas. If we can accomplish that for 170 people in the first year, in a collaborative vein, it should be possible for the University of Vermont Medical School to figure out how to put 25 people into each graduating class who are committed to primary care. And if the medical school is unable to lead on its own volition boldly, dramatically, then the legislature should compel the University to take this step or something akin to it. This has been touched on already. We think it's necessary to establish a primary care physician task force and empower it to identify low priority or burdensome administrative tasks for elimination and that the state of Vermont and our insurers should adopt those recommendations that that task force designs. And whatever permissions or procedural requirements are necessary from CMS to facilitate this, then we would ask that be negotiated as part of the APM 2.0 agreement. At the top of our list for eliminations and Dr. Holman has already touched on this as others have, we believe that prior authorizations for primary care physicians should be eliminated and we would also eliminate quotas, patient quotas on daily visits for primary care doctors. I'm gonna return to a theme I've discussed in other occasions with GMCB and in other venues as we move toward a future of global budgeting for hospitals and in order to correct the imbalance in funding between hospitals and community-based care practices, we would ask that these global budgets incorporate reference-based payments, benchmark to Medicare. We know this has worked in other states. It is working today in Montana when they undertook their RBP initiative and it was successful. The savings were so significant that fundings went to other projects outside of lowering insurance costs in that state. So I could imagine if we were successful here with reference-based pricing, we could take those savings and redirect them to primary care and other community-based practices. Also in Montana, they were able to be so successful with RBP, they could keep funding for primary care centers, five of them that served state employees. So I think there's a model there that we should look to. Thank you. I think Julie, you're muted, Julie. And lastly, I'd like to comment on the all-payer model 2.0, the upcoming all-payer model agreement with CMS. We understand and appreciate CMS's focus on value-based care and quality. However, as Michael Johnson, a physician at Evergreen stated in his Digger commentary, there is no evidence of a primary care quality problem. There is no evidence of a value-based crisis in Vermont. In fact, Vermont's pressing issues, in our view, are affordability and access to care. And if we don't address these issues head-on, I feel our efforts will be in vain. So we would like to suggest that our recommendations that we have just described be incorporated into Vermont's APM 2.0 agreement, but with special emphasis on three things. And those three things are, number one, ensuring adequate access to primary care, adequate access to primary care. Secondly, addressing the affordability crisis through specific proposals. And we need specific proposals to address affordability. And lastly, expanding community mental health and home health services, as we've all described, we need an integrated system in order to coordinate and integrate care and have successful outcomes. So this concludes our comments. We will be submitting these recommendations in writing for your review, and we're happy to provide additional detail. Thank you. Thank you. Thank you. We also have Mary-Kate and Jessa, and I think anyone else on these issues. You know, Mary-Kate has a hard stop at three, so I'd be happy to let her go ahead if that works for the board schedule. Perfect, yeah, thank you. Sure. I think I would point to, so I would point to some of the work that we are doing as a primary care association with other primary care associations around the state and thinking through what does value-based care look like in an FQHC setting? And as part of that work, we've reached out to the Maryland PCA, the Pennsylvania PCA, the Washington PCA, some of these other states that Vermont's working with around the APM 2.0. And one of the things that we really wanted to talk to Maryland's PCA and try and understand how their FQHC systems are fitting into that system, that all-payor model, or now it's the total cost-of-care model. And it was funny, the first thing she said, the CEO of that PCA was, don't do what Maryland did. And I think the point here was not that what Maryland did is and what their current model is bad. In fact, she subsequently said that the payment's going to primary care under the total cost-of-care model are actually really beneficial and they're really helpful in implementing coordinated care. But where they struggled in Maryland by starting with such a hospital-centric system when they started bringing in the other sectors of the healthcare system, the other primary care and other, whether it's home health or other, they really struggled in trying to figure out how do you then redistribute these resources across the system. So I think the biggest take home, and I think we see that with CMS's call out for their seven principles with what they're looking for in the next model, which is really starting with primary care, starting with safety net providers from the beginning, making sure that they are part of the total cost, there's a real focus on the total cost-of-care, not just what hospital spending is. And I think one of the things, another and cocked in with the Pennsylvania model, the Pennsylvania PCA, they were very only tangentially involved in their hospital all-payer model. So I think that there's a real opportunity to think about how do we get primary care more involved in the flow of funding, the flow of patients. If you're talking about a global budget, you really need to think about, if you're talking about a global budget for a hospital, you really need to think about the patient flow because the only way that that global budget is gonna be really successful is if you do what you can to reduce potentially avoidable hospitalization. And once people get into the hospital that they have a clear path once they're ready to be discharged.  So I think thinking through the flow of funds, the flow of patients really needs to be critical as we're talking with CMS and CMMI around what this next iteration of a model will be. And the other thing I think is also looking at what Vermont has learned and what they've done really well. I think our community health teams, they've been a real example for the country around how to really start to bridge those medical social divides. I think you're starting to see other states pick that up. I think another thing that Vermont did really well with the rollout of the Blueprint for Health was transformation, facilitation. And I think we can do more of that when we're talking about how do we get primary care into a value-based payment system, having someone there to say, hey, this is maybe how you wanna restructure your staffing. This is how you maybe wanna restructure your workflow. This is, these are the quality efforts that you need to be focused on. And this is what I've worked in this practice. You may wanna try that here, this didn't work, but it may be tweak it this way work. So having that facilitated support, I think is really critical for helping the system transform and then all payer alignment. Practices don't want to have their commercial payer cohort, their Medicaid cohort, their Medicare panel. They wanna have a panel where they can focus on people with complex conditions and that involve diabetes or hypertension or COPD. So they wanna focus on the patient and the needs of the patient, not what specific payer they're linked to. So if I had my wands, those are sort of the things that I would call out. And I know we're getting close to time. So I'll turn it over to Jessa. Thank you, Mary Kate. That was great. I can certainly say ditto to everything Mary Kate said. So thank you for putting all those points on the table. We really support those comments. The Medical Society working with the Vermont Academy of Family Practice in American Academy of Pediatrics in Vermont came up with a white paper to support primary care in 2001. I have not submitted it yet because there are some things we've actually accomplished from that white paper. So it's a little bit out of some of the things are outdated, but some are not. So I'm building off of that. First, we believe we need sustainable government payers for primary care. I know not all of this is within the Green Mountain Care Board's purview or not much of this is, but I'm going to mention it, especially cause I know some of our federal partners are listening, but it starts with Medicare. We've had in the professional fees schedules for medical services. There has been a Medicare cut for 2023 and a proposed cut for 2024. And so not only is that a problem in and of itself, but Vermont's Medicaid fee schedule is built off of that Medicare fee schedule. So when one payer, one of those payers reduces the other does. And until we have a, you know, I don't think we can build a future and alternative payments for primary care if we are in the interim are losing primary care practices and providers in the meantime. So we need immediate stability and support for primary care as we're trying to build longer term goals and more creative funding models. Part of that hand in hand with that goes for flexibility of modalities for payment. So thinking of what we've learned from the pandemic about telehealth and audio only telehealth services, we continue to struggle for fair reimbursement for audio only telehealth services when those may be a very patient centered and way to increase access to care, especially folks who don't have transportation. So that is a continued item we are working on as well. We think there is a real value in looking at primary care spend. So not just for our government payers, but commercial payers. And so there is a bill pending in the legislature H220 that would require an increase in spending from commercial payers and all payers actually up to at least 12%. So in 2020 I wanna sort of add to the comment earlier about data. We actually have quite some good data about primary care. It could be updated, but it is out there a 2020 report by the Green Mountain Care Board and Diva looking at the percent of spending on primary care services in Vermont. So this is for based on 2018 data. It was about 10.2% overall between payers. This is claims-based and non-claims-based payments ranging from 24% for Medicaid to 9% for commercial and about 6.5% for Medicare. So here's one place where I think our all-payer model agreement could play a role is that Medicare needs to be a partner in that as well. So not only, you know, while H220 addresses the payers that Vermont's and the legislature can address, the all-payer model could play a role in asking Medicare to increase its investment in primary care services as well. 12% is the rate that has been modeled in Rhode Island or used in Rhode Island and Oregon and it seems to be successful though that may not be a magic number. Certainly look forward to a conversation around that. And interestingly, there's been some mention about a sort of a czar of primary care or coordination for primary care. Oregon's model was coupled with the creation of a primary care transformation office in state government. And we do really echo the ask that there really be leadership in this area. You know, it's dispersed right now. There's amazing work being done, but it's in a number of different places and not one centralized voice.  So there are many areas that are focused on primary care, but it's not all coming together into one vision and model for primary care for the state. In terms of payment reform, more specifically, I want to echo what Mary Kate said about let's not build a hospital only model that doesn't really look at primary care and community services at the same time and how that's going to work. Our concern is backsliding from where we are with our ACO and support for the comprehensive payment reform program that is a model, a successful model of multi-payer investment in primary care, especially, you know, independent and smaller practices. And we are concerned about, you know, creating a whole sale new program that is not building off of the successes we're having and what's already in place to support primary care, the blueprint as well, you know, another successful multi-payer model. Let's look at what's been working and build off of that. And also make sure we're supporting primary care in moving to new payment models. You know, it's not so easy just to flip a switch and go from a fee for service to alternative payments. So we would hope that there would be upfront financial support, either per member per month or one-time investments if we're really asking practices to be doing care differently. And I will, you know, there's been a lot of conversation around workforce, the Green Mountain Care Board actually had a fantastic panel about workforce a couple of years ago now. And I think it would be certainly valuable to hear from Ahac and the others doing actually, right after us, I know you're hearing a workforce update. There have actually been some really positive developments. There's the new Medical Student Incentive Scholarship at the Larner College of Medicine, which is very exciting, paying full in-state tuition for 10 primary care graduates a year. There's been a significant increase, a federal increase in loan forgiveness programs. And then you heard about the resident, the new building, ideally, hopefully a new residency program. So we would just certainly support continuing all of those important investments in workforce. And then my last topic, I know we're coming to time here, but I do really need to mention administrative burden and prior authorization. I just need to mention a statistic that I think is shocking in terms of how we could use our primary care clinicians better that a fairly recent study showed that during the course of an office day, physicians spend 27% of their time on direct clinical care and 49% of their time on EHR, desk work, other paperwork. So these highly trained clinical professionals are spending only less than a third of their time actually seeing patients. So if we can make any progress, and this is a hard one, we know this is coming from multifaceted federal regulation, state regulation, multiple quality measures, multiple prior authorizations from different payers.  One step in the right direction, we are asking for from the Vermont legislature is also in age 220. This is building off of actually another bill Act 140 that passed in 2020 requires all commercial payers in Vermont to have pilot projects for what's called gold carding. So an exemption from prior authorization if you have a high percent of your prior authorizations approved. This, the proposal in age 220 would build off of that and require that payers exempt for any procedure or medication that they get their prior authorizations approved 90% of the time. They would then continue to be exempt from prior authorization for those medical procedures or medications. So it's a small step. We know we can't solve this one all at once but we believe strongly we have to keep making progress on the administrative program. Thank you. Thank you all. That was really, really, a lot of really great ideas. I wrote down 18, but I think I missed four or five. So we have no excuse for not having ample material to work with and think about. I wanted to open up to the other panels. We do have a bit more time. I know Mary-Kate's gotta go and Mary-Kate, you can go whenever you're ready but thank you so much for- Sorry, thank you for hosting this. I know you're very busy. Thank you. If any other panelists have anything else they want to chime in on this topic, please go ahead. Mike Fisher. Yeah, I just want to chime in right after Jess's comment about the Rhode Island approach. Seeing as how Rhode Island is just down the road and they've been at it for a while. I think it was in 2010, they instructed their insurance carriers to raise by one percent the amount going towards primary care each year. I thought it was until they reached 11% Chesa but 11, 12%. They've been doing it for a while. I think they show some real increased amount of money flowing to primary care. But that's sort of the extent of my knowledge. I think it would be interesting to hear from them about whether that's, how that's translated to improvements and the sustainability of primary care there. Susan. I just wanted to say that I agree with many of the points that were brought up. I want to echo the emphasis on we don't necessarily have a value problem here. We have an affordability and access problem and I do think that that needs to be front and center of anything that we do. The other thing that I just want to point out is there's fee-for-service has been villainized and we've been moving toward these capitated payments. But I honestly think that the solution needs to be a hybrid of some capitated payments or upfront investment payments, administrative payments to the practices as well as some fee-for-service so that you're not disincentivizing the primary care clinicians from doing all that they can do in the office and referring them out. So just something to keep in mind. We are more supportive of a hybrid option generally. Thank you. Rick. And I just want to touch briefly on the CPR program that Justin mentioned. Our practice is a CPR practice. So for those on the call who don't know, so the CPR is conference of payment reform and it's a capitated plan where one care of the ACO in the state essentially pays a per member per month fee for all of the covered patients. So right now it's for all Medicare, Medicaid and MVP patients. We use that money as we see fit. So it's not fee-for-service, it's a capitated payment. And that is probably the first thing that we've seen and like I said, I've been in practice for 30 years, where it's really shifting fairly significant amounts of money into primary cares. That program is working. It's still as a long ways to go. There's still some flaws with it. But they have continually increased the amount of money that's approaching to primary care. And one care is releasing a new initiative this week on mental health and transitioning some money. Again, in the per member per month sort of category where for each of you who are a member, you get X dollars for doing some mental health screening and suicide prevention. So those are very tangible ways that the system is shifting money into primary care. Primary care does its job. If primary care providers do their job, they just need to be paid. The number of times that I've heard people on this call say, this was unreimbursed or the example from a fair Eileen, but one of them said that they did all this care and they get reimbursed 200 bucks for the cost and everything else is just unpaid. All the forms we fill out, all the paperwork we do, all the prior office we do, all the phone calls, all this stuff is just unreimbursed, unpaid. That model doesn't work. You gotta pay a whole ton of money for each office visit or you pay for the value-based care with here's a sizable amount that covers all that administrative and other work that you're doing. So it's shift money to primary care and let us do what we're best at. Thank you. And Susan, I can't tell if your hand is still up or if you have another comment. Okay, great. Okay. Thank you all. That was really, go ahead Eileen. I was hoping I wouldn't have to be the one to say that I'm hoping the focus will not just be on supporting medical students and physicians and even with the last comment that Rick made about reimbursement that reimbursements would be similar across the board if you're doing the same work, which is not currently the case. So I'm hoping this will be an inclusive project going forward. Thank you. Thank you. I agree. Yeah. Okay, well, I think we'll wrap it up there for time and we'll just turn to board questions and comments. Are there any board members with any questions or comments? I just have a quick one and I thank you so much for this very comprehensive presentation. Really helpful, really interesting. I'm just wondering, again, there was some discussion, a lot of discussion about prior auths and I'm wondering and I don't, I haven't followed what's been happening too much other than I believe at the beginning of the year there was some CMS proposed rule about streamlining and reducing some of the administrative burden around prior auths and I'm just wondering if any of the folks on the call have analyzed that to see whether that would have significant impact here in Vermont and reduce the burden. This is Jessa with the medical side. Are you happy to address that briefly? As far as I am aware, the proposals that I've seen coming out of CMS are specific to the Medicare Advantage Program and so certainly do stand to make a difference in those with those specific pairs but they are not as far as I know, generalized to other federally regulated or RISA plans which is where we see a lot of the, well, Medicare Advantage is certainly a problem as far as I'm certainly, I'll let the practitioners weigh in if I see some nodding heads but also some of the larger employer sponsored plans or RISA plans are also a challenge as well as, frankly, one of the biggest challenges is just the misalignment between all of the different payers. So even if you see improvements in one pair, if all of the others have a different set of procedures that have prior authorizations, it's still a huge administrative burden. So, but yes, CMS, we are very pleased and at the national level, the American Medical Association has been involved advocating for reforms in that arena. Thank you. I have a few comments. I have pages and pages of notes and so I probably could make a lot of comments and questions but one thing I just wanted to talk about briefly, I think Rick, your introduction about your work day, I think speaks to the complexity, speaks to a lot of the issues which is that you're talking about eight to seven grinding through every day, being incredibly present, you have to be emotionally receptive and you have to be cognitively on your game with every patient you see and then finishing with the burdensome burnout work at the end of the day. And I think when we wonder why there's only a few people who are graduating from medical school going into primary care is it doesn't look great. I mean, my field in emergency medicine had a huge decline this year for similar reasons. It doesn't look great. There's violence, the hospitals are filled, you're taking care of patients that are admitted for days, like people are just not choosing to go into that field right now. Thankfully psychiatry for some reason had a major bump this year, so hopefully we'll have a bunch of young psychiatrists but I think that it speaks to the, if we design our workforce around people who are incredibly passionate and super dedicated going beyond all the time, it's just gonna burn out because people have things in their lives that they have to do. They've got families, they've got kids, they've got spouses or parents that they're caring for, community engagement that they wanna do in addition to their work. So I appreciate your dedication and hard work and so many people who are here but I think it speaks to the challenge of actually having a sustainable workforce. I guess that's my, there's so much that was brought up here and so much that I think about and resonates with my work as an emergency physician but that was one of the biggest things. So thank you, thank you for all the work you do and all the ideas to look through and try to reconcile. I will just say that my students routinely, because I preset PA and MD students and they routinely are sort of incredulous at the amount of work that we do. The ones we sell on primary care are the ones who are like, I love the relationship you have with your patients. I love that you know their grandparents and their parents and their kids. I love that you've left to go to their father's week today. Like people appreciate that. And so there's that, you're selecting out that select group of people who say, yes, that's what I wanna do. I don't care if I make enough money and if I have to miss dinner a few nights a week, that's okay. And that's not what it should be. That's not what it always should be. And there's other people with hands up but I just wanna sort of go back on that which is another comment I was thinking of making is in my field, we see patients who come to the emergency department because they call their PCP and they don't know their PCP, their PCP left. They had a resident as a PCP and that person's changed or a PCP was here for two years and they left and now they have another PCP and they don't know them and then they have another PCP and that someone, I wrote down the words as I was thinking about this trust in relationships and someone else they think it was that I leaned that brought up trust in relationships as well. So I think that if we structure a workforce around a powerful deep dedication to the work, it's not gonna, people are gonna, you were not gonna get that sustainable workforce that I think that Patrick was talking about like how do we get a sustainable workforce? And my feeling is yes, you can pay more but almost even more important than that. I think even more important than that is to make the job really good. And so prior authorizations, all that kind of stuff to me is just super important in order to create a sustainable workforce that wants to be here because I agree with Patrick that this is like a place where Vermont is a place where a lot of people wanna do primary care. People would move here to do primary care. I moved here to be a clinician here. It's attractive in so many ways. But it has to be a good job to keep people here. Sorry, thank you. Ms. Morris, why don't you go and then Faye, will we go after Ann Morris, please? Hello, you serve you Faye. So my name is Ann Morris. I'm a family physician. I happen to be the current president of the Vermont Academy of Family Physicians. I am also the current program director for the UVM family medicine residency. And I just wanted, I was hoping that Dave was going to say exactly what he just said because there are two things. As Academy president, I am seeing physicians go from model to model to model because all of these burdens, all of these administrative burdens are in every single one of these models. And anywhere you go, you're working a full-time FTE is not a 40 hour week, gets a 50 or 60 hour week. And so I think we are vastly underestimating what we need to grow our workforce in. And I say that specifically as the residency program director that I am graduating residents who need to work 1.0 FTE in order to pay off their loans but are choosing to work half-time, part-time, 80% time because that means they're going to be working 40 hours or plus and not 50 or 60 hours plus. And when that comes to access, you're still not creating access where you have a physician or a AVP or the whole team in the office every day to create that access. So I think as you talk about that, you have to recognize I think that we are underestimating the growth in the workforce that we need to do. And I think we're forgetting possibly that Vermont is an aging population where chronic disease is only increasing. And so the need and the complexity of the patients is increasing so they're going to need even more access. So we definitely have our work cut out for us. I just wanted to add a comment or to what Dr. Merman was saying about how it doesn't look like that greatest specialty. I find something different in my practice, which is that the students come to us, medical students come to us in one of two ways. One group loves primary care, wants to do primary care, has $400,000 in medical school debt and simply can't choose it. Those students break my heart. But the other large group has no idea what family medicine is. They come to me in their third year of med school and don't know that family physicians can work in hospitals. They don't know they do hospital admissions. They've never been told what a great career it is, the meaning of long relationships with patients. They haven't heard that message. I personally can't imagine a practice where you do one procedure all day, which many physicians do. Why go through all this training and do the same thing all day long?  I'm using my brain constantly. I don't think we do a very good job at messaging in medical schools about what a great specialty this is. And that's, I guess, that's all I need to say. Yeah, go ahead, Eileen. Not that the physicians need my help and support because they don't, but I will say that that was actually a discussion when I was at Dartmouth Family Medicine and involved in a lot of this, that family medicine programs are closing and that universities aren't necessarily supporting them. So I think in New England, it's a little harder to connect with folks going to medical school who might be interested in that. So it may also be reaching a bit farther afield to medical schools that actually support and encourage family medicine. Great, any other board member questions or comments? Yeah, if it's okay, Chair. I'd like to thank the panelists. It was very informative. Like my other board members, I've got a lot of notes. I particularly liked the blend of stories and data. The patient stories took me back to my first career for over 20 years. I helped care for patients with chronic spinal pain. A pretty tough patient group, but one that I came to appreciate learning from and working with. One of the things that we learned and got me interested in outcome research and then policy were the roles that anxiety and depression, particularly undiagnosed or under-treated anxiety and depression have on the overall outcomes for patients. Their outcomes are poor.  And so Rick's story in the beginning really struck me because the patient he was caring for, he was managing her anxiety. And so we had a presenter a couple of weeks ago who talked about the affordability crisis. And he noted that out-of-pocket expenses, premiums, deductibles, co-payments are approaching $30,000 a year for a family. That's like buying a new car every year. I imagine the stress of that. Now I just imagine the stress of buying that new car in January and then wanting the keys to it and being told you can't get the keys until September. We have an access crisis. People are waiting six to nine months to be seen.  And most of us on this call have quite a few things going for us. Some of us are in a home. We have access to the internet. We have abilities to get transportation. So these stories were really powerful. And so I appreciated you all sharing them. The data part was also powerful. And Ms. Wasserman's point about needing more data, there's a specific piece of data that I'd find really helpful. It sounds, it's a convincing presentation about the shortage of primary care. It's not clear to me if it's getting worse or if it's always been in Vermont. So I wonder if there was a time when we had enough. And to understand that I need to know how many primary care providers there are per 10,000 or 100,000 Vermonters. We need a rate. And I'd like to be able to compare that rate to other states. I know Vermont's unique, but I believe there's a lot that can be learned from comparisons. That number would also help us understand the gap between what we have and what we might need. When would we know if we have enough? So that piece of data would be really helpful. Finally, I think people have pointed out that a lot of the magic wand ideas that our chair asked for, the board doesn't specifically regulate. But I put on a clinician's hat when I say this, that as a board, we need to make sure that how we do regulate does no harm. I worry that sometimes it may, unless we can increase our knowledge of what's going on outside of the places that we do regulate. So you coming to us today helps us understand that. It helps expand our lens and our view. And so I just wanna thank you for it. Chair Foster, I had another question, but if Robin or you also have questions, I realize that I'll wait till the end. No, go ahead, Jess. And then if Robin has anything, I'll go last. Okay. I just actually wanted to circle back and do a pulse check on, there was some wait time inquiry. And I think Dr. Homan, you mentioned that it's gotten worse. And my ears perked up about that. I had hoped it would be getting better. And I wondered if any folks on the call could share a couple of things, which specialties are facing the biggest pain points where you're still seeing access issues in your referrals, but also there was something that came up in the wait times inquiry around communication between specialty practices and primary care practices in terms of not learning about when an appointment was scheduled, not getting visit notes back. And as we think about care coordination and the importance of that, I'm wondering if there's been any improvement on that. So these were sort of related questions that I meant to ask if there was any insight into that from your perspectives as really important primary care providers facing these issues. I could, I'll volunteer that we're having much more trouble with wait times getting into specialists now than ever before in my career. The big ones for us, neurology is eight to 10 months out sometimes. Rheumatology, now our referral center is mostly to Dartmouth because of my geography. Rheumatology is almost impossible. We basically get told, no, we don't have anyone here who can see this patient frequently. One of the other crazy things is a very specific treatment in ophthalmology for macular degeneration, a common form of blindness in seniors where Dartmouth is simply not taking referrals for that anymore. So patients from here, from Wells River, are driving to Burlington to get that procedure done. Those, I would say rheumatology, neurology are the biggies then no, not any better at all recently. Communication is really poor, not a day goes by in my office when I'm not trying to track down referral notes from providers. I don't know if that's true for the other providers on this call. It might have to do with our own IT and our own system, but I would say at least one in four times that someone of my patients sees a provider. I don't get the notes back. And then if they are being seen in a followup of that specialty referral, I also don't get notes back. So usually I'll get them the first time the patient goes but when it's a repeat visit, I rarely do. Communication is pretty grim right now. And I was like, I work in Willisons, so it's a realm second area. And I would echo what they said, it's still neurology, urology is impossible, rheumatology is impossible.  I would say that communication is exactly as it was before. I don't think there has been improvement, you know, they're very good. The hospital has a good system for discharge summary. So when someone gets discharged from an inpatient admission now, I definitely get that notification. That's definitely an improvement that you know, over a couple of years ago and sometimes I didn't realize my patients had been in. You know, now I get the discharge summaries, but the consult notes seldom, not definitely not regularly. And I will echo, and I forget it was fairly, but someone said some of the specialists holding onto patients and that I see very routinely. For urology, for example, it's people with history of prostate cancer who are seeing urology yearly for literally just a PSA check, but they're going in for an office visit that could be used for any of the folks who have been waiting to get in. And instead they're going in for literally just have a blood drop PSA, saying, being okay, great, okay, have a good day, see you next year. So we need to find a way to get those folks back into primary care. I appreciate that. Thank you for that update. Paul Rice, I see you have your hand up. If you'd like to go ahead, you can. Well, thank you. I didn't know if I was allowed, but I appreciate it. Thank you all. Yeah, I just to echo what Rick was saying, ENT is a real backup as well, very frequently. And the other one that I didn't realize was such a problem is cardiology now. Out of patient was discharged with a cardiology problem from the hospital and was told to call cardiology for a follow-up. And this was last week. And their first appointment was November to follow up from a hospitalization for a cardiology problem. So that's the kind of thing that we experienced routinely. And just to add to that, and thank you. You muted yourself, Dr. Yeah, I think you stepped on the mute. So Jessica, I was saying thanks for bringing up because that's another reason for burnout is really us having to manage, not just go through the hoops of finding care for these patients, but having to manage them ourselves until they can get in. And that's especially true for psychiatry, as we all know. But for these other specialties too, it's like, what do we do with these patients? We have to sort of shepherd them along until they can get into a specialist way down the road. Thanks. Thank you.  Thanks. I'm gonna do the same. I'll let them to express, and I'm sure Robin would as well, our immense gratitude for your work and for doing this, trying to help us do our jobs as well as we can while you're all busy with your own hectic job. So thank you all very, very, very much. I'll give you a applause. I appreciate it. So I'll move to our next agenda item, which is a presentation from our AHS partners on the Healthcare Workforce Development Strategic Update to the plan. Ms. Traffton, are you here as well? Yes, I am. Thank you. Great. How are you guys? Good to see you both. Good to see you. All right. I'll turn it over. Please go ahead. Thank you. I'm sorry for the slight delay today, but it was hopefully an enjoyable conversation for you as well. Thank you. Hello. So I am Laura Rushing. I'm a health services researcher with the agency of human services. I'll kind of try to zoom through some slides. So let me try to share my screen. Can people see a slideshow? Looks great. Perfect. Okay. So what we're hoping to provide today is a quick update on the recommendations that were in the strategic plan that was presented to the Green Mountain Care Board in 2021. And I'll just go over the background briefly, but Act 155 of 2020 really charged the director of healthcare reform with maintaining a current healthcare workforce development strategic plan. And that plan was developed along with representatives from the following organizations. And so it included individuals from really across the spectrum of healthcare in Vermont, as well as subject matter experts from state government, including the Blueprint for Health, the Department of Labor, a number of different people gave their input. And what ultimately resulted was a very wide-ranging strategic plan that developed recommendations in the following areas. So coordination, data and monitoring, financial incentives, education and training, regulation, practice changes, recruitment and retention and federal policy. So we have been needing as a group over the last few years to try and track these recommendations and chart whether they've been implemented and what sorts of barriers we've seen. And I just wanted to thank a number of the people who presented earlier on the primary care room table. A number of people have overlap between this committee and that presentation. And I know that a number of the issues they raised are issues that we think a lot about in their meetings. So first we're gonna focus on those recommendations that we have updates for. So I'm gonna start with the coordination aspect. And so one of the recommendations was that we integrate with the State Workforce Development Board. And by we, I mean the Agency of Human Services Office of Health Care Reform. And we view that as being accomplished. And we currently partner with the State Workforce Development Board in our healthcare workforce strategic plan meetings. And we work to ensure that there's discussions across the different agencies and with the State Workforce Development Board on pertinent workforce topics. Data and monitoring is also an area where we have some recommendations that are in progress or accomplished. And one of those recommendations from the plan was identify a lead state entity as the healthcare workforce data hub because we know that there is a huge demand for data that can really quantify the shortages that people are experiencing. And so in Act 183 of 2022, which is an act that will come up frequently in this discussion, there was funding that was provided to develop an AHS central office workforce data center and to hire a data center manager. And so recruitment for that position is currently in progress. And we anticipate having that role hired very soon. Another aspect of the recommendations that is in progress is the employee supply and demand modeling. And this once again comes back to that really being able to quantify and forecast the demand and supply for healthcare workers. And this is something where the action was initially required by the healthcare workforce data hub in the plan. But Act 183 actually charged the department of labor with really exploring how to develop the supply and demand modeling. And this is something that they're currently working on and they anticipate having some reporting available fairly quickly. So this is an area where there's definitely progress being made. Moving on to financial incentives, this is an area where there's quite a few recommendations and there is quite a lot that's in progress and sometimes it can be a little bit confusing because there's so many opportunities that overlap. So one of the recommendations is broadening loan repayment to more professional types. And once again, Act 183 of 2022 really broadened loan repayment opportunities for physician assistants, medical technicians, child psychiatrists, a number of other providers. And it also continued funding for the Vermont Nursing Forgivable Loan Incentive Program. It created the nurse faculty for the Forgivable Loan Incentive Program and it created the mental health professional Forgivable Loan Incentive Program. And so some of these programs are currently in the very final stages of being implemented. And so this recommendation, there has been definite progress on. Another recommendation that is in progress is making these financial assistant options more transparent and easy to find for healthcare workers who might be interested in taking advantage of them. And so the Department of Health has created a website that lists loan repayment scholarship programs and they're currently working to make it easier to access this webpage and also to add some additional programs, many of which were created in Act 183 to the site. And so hopefully that should be done fairly quickly. Another area where there's some progress is identifying the financial barriers to recruitment and retention of the non-licensed workforce. And so there's a number of reports that have been and will be generated that we think will speak to this. And so there's reporting required for the AHS premium pay for workforce recruitment and retention program, which we will review to identify financial barriers. In addition, the great studies were completed by D events and into the legislature. So that's another area that can be used to identify these financial barriers. And finally on this side, recommend one-time funds for employers to attract permanent employees. Act 83 of 2022 created the recruitment and retention program and there's now been two rounds of funding. And so these funds have been, these one-time funds have been distributed. Moving on to education, there have been recommendations that about increasing enrollment in nursing programs. And so the Act 183 of 2022 created emergency interim grants to Vermont's nursing schools and hope that these would increase compensation for faculty and staff to support recruitment and retention and thereby increase enrollment because we know that one of the huge barriers to enrollment in these programs is really capacity issues. And those are in progress. Another area in education is strengthening incentives for preceptors for all professions. And this is an area where Act 183 of 2022 really developed two different programs and one was the incentive grants to nurses employed by healthcare employers in Vermont for serving as preceptors to nursing students. And these incentive grants are in the final stages of development and should be open to applicants just coming up in order two. The Act also created a mandate for the director of healthcare reform to convene a nurse preceptor working group to really identify ways to increase clinical placement opportunities, establish sustainable funding models and look for just ways to further incentivize nurses to become preceptors. And that action plan was presented to the legislature in January of 2020. More educational recommendations included exploring opportunities to expand family practice residency programs. And as we heard earlier on this call, Lamoille Health Partners is doing some work from the teaching health center planning and development grant that they received to establish a statewide residency program specializing in primary care. We also have heard that SBMC continues to pursue family medicine residency opportunities with Dartmouth Health and Cheshire Medical Center and they're hoping to begin placements in Bennington in 2026. There have also been some initiatives to modify the curriculum to introduce primary care earlier in medical school. And so the UVM College of Medicine has curricular and extracurricular programming that exposes students to career opportunities in primary care and also careers that are serving underserved populations. Another recommendation was advertising and recruiting for existing apprenticeship opportunities supported by the Department of Labor. So the Department of Labor is currently working with a number of state colleges in Vermont High Tech on developing apprenticeship opportunities in healthcare occupations. And so while they don't directly promote and advertise these opportunities, they really help support those employers and help train providers through funding and offering career pathway support. So they are definitely working on that recommendation. The final slide for education. So it's developing and identifying strategies to streamline advancement through the nursing career ladder and the skill-existing staff. So this is an area where there's a lot of work being done on different nursing pipeline programs. So the Healthcare Employer Nursing Pipeline Apprenticeship Program created by Act 183 provides grants to healthcare employers to establish or expand partnerships with Vermont Nursing Schools to create nursing pipeline or apprenticeship programs or both to train members of healthcare employer staff to become higher level nursing professionals. So this program is currently in the very, very final stages of development and should be open to applicants very soon. In addition, and we are trying to coordinate efforts between these different programs, the Vermont Business Roundtable Foundation is also working on rolling out a nursing apprenticeship pipeline model. And their model focuses on employer-led apprenticeships. It utilizes the LNA LPN RN apprenticeship training via CCB and VTSU and it builds a sustainable financial loan repayment tool via PSAC which encourages retention, seeks to scale and expand clinical education through cooperative joint appointments and provides significant wraparound supports for participants. So there is a lot of work being done on trying to strengthen that pipeline for nurses. When it comes to recruitment retention, one of the recommendations actually overlaps in many ways with one of the previous recommendations and that's inventorying and highlighting state programs that support recruitment and retention. So that's another area where the website that I previously mentioned, the Vermont Department of Health that has created will be another resource for individuals to identify resources and Advanced Vermont and AIAC also have resources as well. There's also efforts underway to modify or expand programs that support working and living in Vermont. The worker relocation program was expanded include all types of healthcare professionals. The state of Vermont in collaboration with the University of Vermont and the Vermont Student Assistance Cooperation is also offering a $5,000 loan repayment program to incentivize and retain new graduates from Vermont colleges and universities. So there is work being done in that area to try and incentivize people to stay in Vermont and continue their careers here. There's also efforts to create a marketing campaign to promote healthcare careers in Vermont. And this is the work that individuals can do in Vermont. Information about healthcare careers and information for healthcare professionals has been highlighted on think Vermont. There was a recommendation that advised AHS to develop a cross-system strategy to utilize section 9817 of the American Rescue Plan Act. So that is very much in progress. AHS is utilizing the funding from 9817 to implement initiatives that are designed to support the Medicaid home and community-based services, mental health and substance use disorder workforce. So one of these is the premium pay for workforce and recruitment and retention program. AHS anticipates providing a total of $25 million in grant funding for home and community-based serv