here we go. Oh actually I it just came up on on mine so I'll try it and if if we get stuck again I will I'll defer it to you. Sounds good. Okay so thank you everyone for having us today we're here to discuss a lot of work that's been ongoing over the past several months on doing an in-depth analysis of the Vermont essential health benefit benchmark plan. So we're here today to talk about that work and the analysis that we've done on several benefits and what our findings are. So I'll just start today by discussing what what entail what the process entails and what we've been doing over the past few months. So under federal law there's currently an avenue for states to revise their benchmark plan. So as several of you know the essential health benefits are defined in federal law and states were required upon the implementation of the ACA to select a benchmark plan that would be offered within their state. In 2019 the federal government expanded options for states to update their benchmark plan and they laid out several options states could pursue to make those changes. The first being states could select another state's benchmark plan to substitute an existing plan. They could replace one or more categories of their essential health benefits with another state's benefit or they could also just select a benefit that they felt would fit well within their existing benchmark plan. And so what we're going to be talking about today is the third option here looking at benefits which we could add and supplement our to our current benchmark plan. And just to note the Green Mountain Care Board the reason why we're here is the Green Mountain Care Board has jurisdiction to review and approve the benchmark plan to implement it within the state at the recommendation of DBA. This slide just gives the statutory authority for that for what I just talked about. And some background the last time that the Green Mountain Care Board did approve a benchmark plan was in 2015 with the original plan being approved in 2012. Important to note is that in 2015 no changes were made to the existing benchmark plan and it remained and today remains the Blue Cross Blue Shield or the TBHP-CBHP HMO plan. So I reviewed this before again this is just some of the statutory citations if you're interested in learning more about the federal process and what's required under federal law. And another important note is that this work is being funded through a federal grant as well. The Department of Financial Regulation was awarded this grant back in September and that grant the purpose of that grant was to look at the essential health benefit package and see if there are any changes that need to be made to enhance affordability and access for policyholders to better health care in Vermont. In addition to the grant the legislature had also asked us to look at the essential health benefit package and they had pinpointed certain benefits that they wanted the department along with AHS and other stakeholders to consider. Those benefits are hearing aids, dentures, vision care, durable medical equipment and fertility services and two primary care visits with no cost share and we'll be talking about each of those benefits throughout the presentation today. The legislature also asked that when we were looking at these benefits that we assess how each benefit would align with the state's all-payer accountable care organization model agreement as well as the state health improvement plan. Some other additional benefits which we considered were enhanced mental health and substance use disorder benefits, a preventive dental benefit. The legislation had asked us to specifically look at dentures but after further discussion within our working group we also considered adding a preventive dental benefit, tobacco treatment, lactation consult consultations, medically tailored meals, gym membership, nutritional counseling and pre-diabetes self-management tools and all of these benefits were considered either because the group felt that they would improve the plan or align it more consistently with the state health care reform goals as well as a comparison of what other states have done to update their benchmark plans or existing benefits in other Northeast region benchmark plans. So the working group members which the working group convened I believe it was the end of June early July of this past summer consisted of members of DFR, Department of Vermont Health Access, the Green Mountain Care Board, Office of the Director of Health Care Reform. Oh I'm getting some feedback. I don't know if anyone heard that. Okay Blue Cross Blue Shield and MVP and those issuers were included because they are currently the two issuers who offer plans in the Vermont health insurance market. Northeast Delta Dental, the Vermont Hospital Association, Vermont Medical Society and not Legal Aid. So this slide gives the timeline and an overview for where we are in our process of updating the benchmark plan. So I believe it was last week we reported to the legislature on our findings of the actuarial analysis as well as our working group right now and it is obviously not February but it's a little ahead of that. Presenting to the Green Mountain Care Board and we're due to update CMS in March with any findings or suggested benefit updates. There is a required public comment period which will also go into April and then by April we hope to if the Green Mountain Care Board approves submit any benefit changes to CMS and once we do receive CMS approval which will probably be in the fall of 2022 we would then move to implement the new plan designs for January 2024 with the issuers filing with the Department of Financial Regulation in March of 2023. Any questions about the process before I move into the actual analysis of the benefits? Are there any questions from board members? Not saying any Emily. Okay great. Okay so some of you may have received a similar slide deck last week. We have made a few updates and edits to this deck mostly related to the estimates of the allowed costs which Wakeley had calculated so if you're seeing some of the numbers looking a little different that's the reason. So as I mentioned before the federal government has laid out a test or some standards for states to follow when they are updating their benchmark plan. Those states are not currently allowed to add whatever benefits they they have they need to stay within two tests and those are called the typicality test and the generosity test and really for purposes of our discussions today we'll be focusing on the generosity test which many have referred to as the ceiling of the amount of benefits that a state is allowed to add to their plan. The typicality test is a requirement that when the state does have a new benefit package they must find another plan which provides a scope of benefits which is equal to a typical employer plan in our state. But again for today we're really going to be focusing on this generosity test which will give us the room or the actual real value we'll have to work within when we're considering adding new benefits. Wakeley came on board in September. The first step that they took was to review all of our state in stakeholder information input. Like I said we have had several meetings during the summer where we took information and testimony from several experts around each benefit we were considering to make sure that not only were we looking at it from an actuarial perspective but also looking at it from a health policy perspective as well. Wakeley then took our current benchmark plan and compared it against the other benchmark plan options states have to determine which test with or which plan would serve as our our plan to compare for purposes of the generosity test. They then priced all of the benefits we were considering to figure out premium impact as well as how these benefits would be utilized. And right now we're at the point where we are here discussing these benefits and some of the decisions that we have come to. Okay so as I said before Wakeley has identified and gathered plan documents for all of the eligible comparison plans. In this instance it was the state health employee plan which was the most generous plan but Wakeley did do an analysis of other plans to ensure that it was the correct plan to compare against and that was then the state plan was then used as the comparison plan for the generosity test. The way that Wakeley determined that was using V-Cures data as well as some internal information which Wakeley had from their ACA database to formulate the allowed cost and premium impacts for this analysis. An important part or important thing to note here is that the actual impact and premium impact of adding any benefit will probably vary by issuer. The analysis also does not include any downstream potential downstream impacts of adding a benefit. For instance if you're adding here hearing aids and it had improved impact on health care utilization in some way those impacts would not be captured in this analysis. Okay so here is a comparison of the current benchmark plan against the state employer plan again which was determined to be the most generous plan from all the plans that we were able to compare against. The benefits which were found to be more generous in the state employer plan and thus provide the room for the state to consider when adding benefits were the infertility treatment which currently in the state plan is only covered at a diagnostic testing level and if in the state employer plan it includes IVF drugs artificial insemination egg preservation as well as the drugs that are associated with those treatments. The state plan also covers acupuncture, the chiropractic care and rehabilitation benefit in the state employee planner are more generous which then again provides some space within which the state could add benefits as well as a habitative services, massage therapy. So the total allowed cost or room that the state has to work with if it wants to consider adding benefits is 0.8, 0.89 percent to 1.59 percent and the reason why there's the range there is because depending on what plan you are you are looking at for instance a bronze plan obviously the impact of adding a benefit would have a lesser impact as far as the allowed cost because those plans are covering a lesser percentage of the health care benefits in total whereas if you are looking at a premium plan those plans are covering a higher percentage of the total health care cost so you would have more room to add benefits there. Okay and again, weekly evaluator the value of each benefit being considered for inclusion in the plan. The comparison of newly proposed benchmark plan against the generosity test such that the changes do not result in the new EHB plan being richer than the most generous plan included in the generosity test. So again we cannot if the state chooses to add benefits we cannot exceed the generosity of the most generous plan which again is the state health employee plan. So this slide gives some benefits which were looked at and will be changed in the coming year but not under this benchmark process and the reason being is that these changes will address discriminatory benefit designs which are actually existing in the current plan. Under federal law plans are not allowed to have discriminatory provisions in benefit designs so an example of that would be a benefit limit which is associated with the age of an individual or the disease or condition of an individual. So nutritional counseling is the first one which had a limitation based on a policy holder status as having diabetes and so the benefit change there will remove the nutritional counseling limit to be unlimited not only for those who are diabetic but it will move to being unlimited for all policy holders. Currently the benefit has a limit of three nutritional counseling visits for those who are not diabetic and that will be removed. The habilitative treatment benefit currently again has an age limit which will also be removed. Currently it only applies to those under 21 and the state will be removing that to comply with federal law. Foot care is another one which again had a limitation for diabetics or not a limit for limitation for those without diabetes and that will be removed so that any one policy holder may access that benefit without being required to have a certain health condition. And the last one is the prescribed food and nutritional benefit that also has an age limit of five for the 100% amino acid formulas. So the department will be asking the care is to remove that age limit. So all of these benefit adjustments will be able to be made without triggering the benchmark process and requirement for CMS approval because they're currently out of compliance with federal law. Okay so moving on this table summarizes the benefits that we have looked at. So we considered hearing coverage and the benefit designed for that would hearing aid exam or hearing exam pardon me for children and adults and hearing aids for both years every three years. The other benefit we looked at was infertility services. The goal here was to match the state benefit as closely as possible. The current state benefit covers artificial insemination as well as IVF that has a dollar limit in place which are not allowed under the benchmark plan. So while we won't be suggesting a benefit limit or sorry a dollar limit we will be suggesting the benefit be designed to cover three rounds of IVF treatment as well as the artificial insemination. And as I mentioned before diagnostic testing is already a covered benefit in the benchmark plan. So it will just be the addition of the artificial insemination the three rounds of IVF as well as egg preservation. The next benefit we considered is medically tailored meals. This is a benefit while we did a lot of research on it and there was a lot of interest from the working group. It's something that I think we need to do a little bit more research on if it were to actually be suggested as a benefit and I will get into that further down the slides. Nutritional counseling was also a benefit that we had started to look at early on in the process and while it was not priced it was we were able to make that change and enhance the benefit not through this benchmarking process but through a change to make the benefit more accessible and not discriminatory. And we also did look at a wellness and gym benefit but after discussions with issuers as well as the working group it was determined that this benefit is currently available in the market. If an individual wants to buy this their non-standard plans I believe that currently offer this benefit and there were concerns again around if this were to be added as an essential health benefit. Some Vermonters maybe not having a gym close enough to access to actually make this a meaningful benefit for those in our state. Okay so moving on so now I'm going to kind of go into a little bit more depth on each benefit that we considered. This is the both of them so the infertility treatment again is what add about 0.61% to 1.0% of a loud cough while the hearing aid coverage as it's currently designed would add 0.05% to 0.09%. So with if both benefits were added in totaled it would add around 0.65 to 1.09% and then the total room that the state would have to work with where it had benefits is 0.89% to 1.59% so if the state for instance in the future wanted to add additional benefits it would have the ability to do that because adding those two benefits again would not use all of our room or generosity for this purpose. And then to give the board an idea the cost impact of adding both of these benefits would be between $4.20 to $7 per member per month with about on average I'd say 40 cents of that being attributed to the hearing aid coverage and then the rest being attributed to the infertility coverage. Okay so as I said the infertility services benefit would cover three cycles of in vitro fertilization including the evaluation counseling, egg preservation, other related services. Important to note it also cover several prescription drugs which are required for these services as well. We did a comparison of other northeast states to see where Vermont stood in relation to our states around the region and found that all states outside of I believe it was Maine oh in Connecticut oh I'm sorry yes outside of Maine had some type of infertility coverage but as you can see from this chart it varies widely. You have Massachusetts which covers which has a very generous benefit covering the artificial insemination in the IVF but then also has some prior authorization restrictions which relate to requirements to conceive during one year with states like New Hampshire not including the artificial insemination in IVF procedures which as I mentioned make up the bulk of the cost here but covering the diagnosis and treatment of infertility. Any questions on this chart before we move on? I have some questions but we typically hold them to the end so that's okay thanks Robin thank you okay and then here we've just mentioned some of the benefit considerations. There can be increased claims costs related to maternity cycles including multiple births but it can also have an improved impact on members well-being included including support for mental health and it can lead to improved support for organic state population growth. In this right down here just gives a more broken out example of what the impact would be were the infertility services to be added. The PMPM as I mentioned before would range from about $3.90 to $6.50 PMPM and would have a pretty low utilization. So the next benefit we looked at were the hearing aids and exams. This benefit would provide an adult and child hearing exam every year and hearing aid one for each one for each year every three years and for this benefit we did try to mirror the current Medicaid benefit which is provided in Vermont and while the Medicaid benefit limitation is medical necessity when we looked a little deeper at the benefit and how Medicaid was determining what was medical necessity for purposes of their benefit we did find that they were limiting hearing aids to every three years and if it was before the three years it required a prior authorization. So adult hearing benefits are actually not as prevalent throughout the United States with only 11 states explicitly requiring hearing aids. What we did find though is several states had an existing benefit for child hearing aids which because of the prohibition on age limitations under the ACA those states have now been required to change their benefit to also include adult hearing aid coverage. And so again we did a cross comparison looking at other Northeast states and found most states did have a hearing aid benefit with the exception of Pennsylvania. And some states again did have the three month limitation some less and then some states also had certain prior off requirements such as New Hampshire having a requirement that it's the prescription changes the the individual could receive hearing aids outside of the 60 month limit that that state has. Potential impacts of adding hearing aids when the group heard testimony or information on the benefits of adding hearing aids there was a lot of information provided on its impact to to individuals mental well-being as well as their health as well as their socioeconomic position. Another caveat to weekly analysis was there while the the cost impact is determined to be pretty low there might be pent up demand which would lead to higher claims utilization within the first years. So while overall increased costs are estimated to be 0.05 to 0.09 the actual impact in the first years might be might be higher. And again like the infertility services this benefit would have a pretty low utilization among this population with 0.1 percent to 0.2 percent of members utilizing this benefit. And the last benefit that the group considered was the medically tailored meals and this benefit was I think chosen because of its alignment with a broad range of the state health care reform goals as well as its potential impact to to help those with chronic conditions in our state such as heart disease and diabetes. So while we're not proposing it or putting it forward today as a benefit I think there was a lot of interest from the group on looking at this further and potentially looking at a pilot program within our state. There aren't currently any states that offer this as an essential health benefit. There are some Medicare Advantage plans that have this as a benefit. But I think overall there was consensus that this could could be meaningful but just more work would need to be done to figure out what what benefit design would make sense for this market. And this slide is just for discussion purposes and gives you an idea of what we did talk about and what a potential benefit could look like. So this chart on this slide gives you an idea of the cost impact of benefits such as one box or one bundle of groceries could have and then depending on the engagement the cost impact. And so a few slides ago when I was talking about the room we would have to add if if the board or the state was interested in looking at this benefit for future for for a future addition we just have to consider leaving enough room within our current plan to add this benefit. So this slide just gives again information on the allowed cost impact for purposes of the generosity test and then a breakdown of what each benefit would have on the premium for plans a high and low estimate and again adding them in what room we would have left for purposes of the generosity test. So I did have several slides on non-EHB considerations but I wasn't sure if the board would like to hear about those or if this would be a good place to stop. Any preferences board members? My preference would be to hear the the considerations. Okay great. So is that should I move on? Yes. Okay great. So the non-EHB considerations so these benefits which I'll be talking about while many of them were aligned with the state health care reform goals and some were benefits with which the legislature had asked us to consider for one reason or another which I'll get into the group either was not allowed to consider them as an essential health benefit or decided that it wasn't a good fit for our current benchmark plan. So those benefits are adult dental adult vision and the free primary care office visits. So the first two that I mentioned adult dental and adult vision those are actually not allowed to be considered as essential health benefits under federal law and the free primary care office visits while you know there there is a lot of interest in offering free part PCP visits at no cost share because the PCP visits or primary care visits are already a covered benefit it wouldn't be an additional benefit for purposes of this analysis. Another important excuse me another important thing to note is that because these benefits are non-EHBs if the state was to add them to the benefit plan the state would be would be on the hooker would be required to defray the cost of adding those benefits. So for the adult dental benefit what we what the legislature had asked us to look at were was coverage for dentures and after discussions in our working group it was determined that especially for the QHP population which is which is made up of individuals usually from children to age 65 a denture benefit maybe wouldn't be the best use of a dental benefit. So the group looked more towards offering a prevent an adult preventive benefit and what that would include is an exam and cleaning every six months. So some considerations when we look at this benefit were the dental health is often related to your physical health it's also very much in alignment with the state health improvement plan and preventive coverage can ensure people get the proper cleaning so that they wouldn't need dentures or or further expensive dental work in the future. When wakely analyzed the cost of this benefit it was it came out between 1.3 percent and 1.7 percent of allowed costs with dentures being a lot smaller cost impact mostly because as I mentioned the age the population age for this group when when you actually looked at the claims weren't using dentures as as much as an older population. Adult vision was the next benefit we looked at and that included an eye exam and eyeglasses or contacts every two years and again as I mentioned before adult vision is not allowed to be included as an essential health benefit so were the state want to want to add that benefit they would be required to to pay for it and obviously adding adult vision would have some serious impacts on quality of life and having an eye exam can work to for the early detection of ocular diseases. So the cost impact of this would vary greatly depending on the cost sharing so wakely estimated that the increase in paid cost would be between 0.6 percent and 1.0 percent for adult coverage. Important to note also is that currently there is a pediatric benefit for both vision and dental services within the benchmark plan so while the children are currently covered for vision and dental services adults are not and the last subject I'll touch on which I won't get into too deeply because the QHP design standard sorry the standard QHP design working group is actually looking at this issue currently of the the impact of adding the two PCP visits to the benchmark plan and this slide just gives you an idea of what the increase in actual value would have depending on where the the cost share was waived for those two visits with obviously the bronze plan having the largest impact were there to be two free PCP and mental health substance abuse disorder visits added and that's it now I can take questions. Okay since we started with member Holmes this morning I'm going to start with member lunch this afternoon and go in alphabetical order Robin. Sure thank you. Emily I was wondering if the group looked at or if it's possible for Wakely to now look at the potential premium impacts of the changes in the benefit adjustments due to the discriminatory rules because while of course that's not as you said relevant to the generosity it is relevant to the premium impacts from the decisions we will make and so be good to kind of have a sense of how much our premiums going to be going up as a result of those changes when considering these other issues. Yes definitely and I I do recall and maybe Wakely could help me with us when we've looked at the nutritional counseling for instance because that was a benefit we were considering before we realized the benefit design might be discriminatory I think it was a point zero to a point two percent impact and Julie maybe you could fill in any detail there for me. Yeah I agree that that one will be pretty small I think the overall cost of that benefit and since it's already being covered at some level I think yeah the impact will be pretty small and then I think the foot care one tends to also be small I don't think any of them are significant but we can definitely go back and Kwan have tried and put a number on those. That would be terrific thank you Julie good to hear your voice. You too. It's been a while and then the other question I had about the discriminatory changes is will those go into effect for the 2023 plan year or the 2024 plan year. Those will go into effect for the 2023 plan year because we don't have to go through this federal process for those changes we'll be able to meet with the issuers you know in the coming months to talk about those changes. I believe one of them has already been discussed and agreed upon so we're hoping that that's not a heavy lift and we'll be able to be put in for next next year. Great. Okay thank you. The other this is just really more a comment for it sounds like medically tailored meals need some more work and one area that I was wondering if you had thought about in your preliminary discussions is whether some some of the individuals who would be purchasing insurance through Vermont Health Connect might also be eligible for food stamps or other sorts of public benefits and whether there's any potential conflict with those other eligibility rules just so that when you're exploring it further to have an understanding of the complete impact that the family might face. Yep okay thanks. Yep and then I did note in your opening slide that you recognize that under the statute the commissioner of DEVA will would make a recommendation to us about what benefits they he or she would in this case she would recommend being added and so I'm hoping that in a future meeting you'll be coming back with those recommendations. Yes that's correct. Okay. That's those are my questions right now. I may have something as I go through my notes but I'll pass it to the next. Thank you. Thank you Robin. Next we'll go to board member Pelham. Tom. Thank you very much and thank you Emily and team for the presentation. My first question isn't about it's kind of like what the mission was here because I was confused and still am a little confused. The specific language in section E 227 charge the named participants of your basically your working your working team quote to review Vermont's benchmark plan establishing the state's essential health benefits to assess whether the benchmark plan is appropriately aligned with Vermont's health care reform goals regarding population health and prevention as set forth in the Vermont all-payer accountable care organization model agreement and the Department of Health state health improvement plan then subsequently the law moves on to the consideration of specific possible new benefits that the legislature was concerned with and that sequencing made sense to me because you know it was kind of an approach to kind of we've had the existing benchmark plan going back a decade and to 2022 it wasn't amended in 2015 I see from your slides and so it's the basis for going forward that is could be may have aged well and maybe hasn't aged well I don't know um but I thought kind of looking I thought what the legislature was saying was go take a look and and another reason why I think that makes sense maybe or maybe I don't understand the law is uh that in the in the um creation of actuarial room you know with the generosity you know being the the ceiling uh and the floor being the base plan if there are things in the base plan that just don't make sense anymore could be changed or modified can could we have create or could we create more actuarial room by uh improving updating modifying modernizing the benchmark plan so my question um and so in your draft report not in the slideshow but in the draft report uh it it stated that quote for the purposes of benchmarking service exercise the group focused on how each benefit would most fully meet the goals of providing services that are available accessible and affordable while also working towards accomplishing improved health and social games so that language kind of focused on each of these uh benefits alignment with the state health plan so my my question this is my question um and I don't have a lot of questions so I'm taking up a lot of time with one question um is so did the working group explore the existing plan relative to its clinical content and utilization and find any existing benefits which could be updated streamlined or diminished in order to create quote actuarial room for replacement benefits which the legislature asked to be considered or which offer higher value higher levels of benefit um because I think in our two by two the other day um I think I asked the question someone asked the question was there any benefit that was uh um uh terminated or amended and and and the answer and the answer was no and further that if there was one um rate payer out there or one member of of the qhp population that used a benefit that that benefit would be retained so that's that's kind of my broad question yeah so to answer your question we didn't look at every single benefit and how it was currently being utilized um and the cost it was adding to the system when we when we did start to talk about okay which benefits would make sense to maybe take away and we posed that question to our working group uh the feedback we received was that there was no interest in in taking a benefit away um that's currently offered in the plan I think I think some an exercise that could be done that might more get to um utilization how the plan's being used could be looking at cost share and because cost share and um for instance prior authorization other utilization management tools I think are really what can drive um individuals to use a certain benefit more than others for instance when we're talking about the pcp visits and adding those as no cost share that would obviously open up that benefit but those conversations are that that type of analysis isn't necessarily relevant to the the benchmarking exercise in a certain extent because we we're not looking to change the cost share we're really looking to as you said add take away um or supplement a benefit and just going back I think the feedback that we received was that there was really no desire to take away a current benefit and there wasn't really any benefit when we were looking at the certificate of coverage that we thought would be even a candidate for exploring to take away so that's why we really focused on looking at benefits that could be added to the plan but then would maybe have um a downward pressure on utilization of other benefits that are currently offered in the plan and the one again that we went back to and that we were looking at was the the medically tailored meals or food prescription where if you were to add that benefit to the plan you could put um you know some downward pressure on um those needing insulin or really expensive prescription drugs which as we all know have been driving um cost increases over the years to to uh premium so we were really trying to to focus on what benefits could we add while not taking away a benefit could maybe decrease utilization across the health care system and then overall improve policy holders health health so does that does that answer your question I get it I just wonder and I don't know but I just wonder if we had a team of clinicians you know that are into evidence-based medicine and they went through our existing plan and they and and they they'd look at and say well why are you doing this or why are you doing that and I I just feel that that opportunity after 10 years might uh yield some some more capacity to do other things that the legislature might want to do or that other reasonable people might do I I understand a working committee you know you look at the working committee and it's it's a group of people it's a bunch of stakeholders and I understand that um but I I but there's a part of me that says that after 10 years this is existing plan it's got to have some inefficiencies um that that that we could capitalize on but yeah something else I just want to add to that too is that while we've been talking about the generosity test because that's when you're adding benefits you don't want to go over that that ceiling but we also have to consider that there's this typicality test so if we were to remove benefits um and again going back to 2013 when we when the state analyzed other plans that were in the market and chose the benchmark plan while it didn't choose the richest plan at that time which I believe was the state health employee plan but it did choose a plan that was comparable in a lot of ways to other plans so I would always also caution that if you did decide to take away benefits while maybe utilization there wasn't you know maybe the benefit itself didn't have a high uh benefit or as high as some other benefits that could be added I think that you'd also have to be careful if you were removing something that you wouldn't be able to pass um the test that the the federal government has laid out and then my last point on this is that the essential health benefit categories um are essential so um and and defined in federal law so if we were taking something out let's say we wanted to remove something that was adding to our rehabilitative benefit we would have to then make sure that we were putting something back in um so again when we looked across northeast states and we're doing a comparison we we saw that we were pretty well matched up um with with our states uh in the region and so we wouldn't want to also fall below in any of the categories that we're looking at and and again I just go back to saying I I do think that the benchmark plan we have um you know provides provides a robust set of benefits when you compare it to other northeast states as well so this was trying to make sure that not only were we matching what other uh states were doing but trying to see if there were any holes um that we could fill where there was a need I I get it I I mean it's a it's a difficult task Robin yeah explained to me I guess she was involved in this effort way back when and and I won't say uh you know on the zoom here of what her description of it but uh it was it was you know it's it's a it's a tough task and I don't end end the any of you but my next question area is um and this may not be significant but in an earlier slide I think it was some somewhere around slide 20 um there was just this reference to impact on premiums um having to do with different design plans and different carriers and um uh the phrase was I wrote down the two words some significantly could be different than kind of like the the averages that you were showing and so I just want to kind of I wanted to ask what significantly might mean because there's a part of me that says um we've from a premium point of view we've gotten to a sweet spot which you know I had hoped that we would get through a state effort but thankfully no one listened to me because the federal government did it in terms of um you know you know subsidies up to 500 percent of poverty um but I'm just wondering so there's there's folks out there um yeah potentially significantly in the bottom in 2024 premiums by issues may vary potentially significantly and I'm just worried that that Vermonters out there have experienced the these new subsidies and that's a good thing um but then here comes some plan redesigns that eats into those subsidies uh you know through premiums and I just worry do we have any sense at all as to what potentially significantly means yeah so just to give you an example um I think especially for the infertility services being added uh while we've only analyzed the the benefit itself you could then have other costs that are associated associated with adding that benefit same goes for if you add a benefit that can then have like I mentioned before um have you know a downward pressure on utilization of other health care services so it can go both ways but I think what we just want to make sure is very clear is that if you were to add um the hearing aids or the infertility services there could be uh for instance more uh multiple bursts um with with the addition of the infertility services there could be more maternity care so um if you're looking for an exact percent I don't have that but I just think it's it was important to be aware that it might not just be a minor um a minor addition uh to the to these costs it could be substantial so and Julie I don't is there anything you can add to that and not I mean yeah it's really up to the the issuer and there are actuaries in terms of what they do um you know I think and it'll be important that you know the Green Mountain Care Board and DFR review um you know the rate filings with that perspective um the Oliver Wyman report that was done a bit ago on infertility did have some estimates um on the impact of maternity costs so that would be kind of a guideline there um in terms of what those impacts would be and and I can say this as an actuary that I think we do tend to to think about what the additional costs might be and for where there might be savings I'll kind of say oh well we'll wait for those to come in to see if they're real so um that's just kind of a bit of caution as well as that I think actuaries tend to be more concerned about the the risk of increased costs um as opposed to being optimistic about savings um also I know as we when we went through the hearing aid um we did actually some work on the hearing aid analysis um about a year ago and one of uh at least one of the issuers commented that they thought our estimates were low um so we but we actually we've looked at the data we actually have done hearing analysis in a couple of other states and also referenced a report that was done by a different actual company um our actual firm I believe it was for Maine um and all the estimates are coming in around the same amount so um so I think for hearing aids hopefully that one's in the ballpark and fertility is one that um you know may vary significantly based on what kind of downstream impacts they include what's the age of their population so that's also going to be it's going to be you know what what does our online population look like if no one's in the you know general age of of needing um infertility treatment that will impact the costs that they add as well so yeah it's kind of hard to put a number on that um you know we can try um but uh but it really is up to the individual um actuary for each of the companies and what their assumptions are well that that answer uh answers my next question which was I noticed that the reference on hearing aids in the report was at the a typical cost of there was a study done that a typical cost of approximately 2400 per single hearing aid was the reference point and I'm thinking given technology in time since 25th uh 2015 probably a lot has changed but it sounds like you've been out there in the marketplace uh yeah yeah and one important caveat actually is that we did not incorporate that you know there's been some this you know the hearing aid the over the counter hearing aids you know may significantly lower the costs so to the extent that those become more prevalent again we haven't assumed that was the case because we don't want to underestimate the impact for premiums but it is possible that that is one area where costs may come down over time but we're we're trying to think through kind of how what the cost is um today and so my my last I is it my last question maybe maybe no more than two um so one benefit and it was mentioned earlier on a slide and I didn't see it pop back up again which was uh pre-diabetes workshops or the uh self-management program so I saw it at the beginning but then there was nothing in the slide so let me read you my spiel here so that you'll see where I'm coming from um one benefit that would be fully in accord with both the state health improvement plan and population health goals of the APM would be the inclusion of the CDCs well regarded in established national diabetes prevention program as a benefit diabetes is an expensive killer um and according to the department of health it is one of four chronic diseases that are the cause of more than 50 percent of the deaths in vermont each year nine percent of remoders suffer from diabetes and it's expensive according to this year's according to blue cross two shield silver plan profile joe's type two diabetes cost the health care system $5,600 annually and $2,290 out of pocket in addition to premiums engagement in a CDC prevention program would be far more or more cost effective my understanding is the blueprint self-management program offers CDC program but on a very thin budget given that nutrition counseling may become more accessible due to fixing a discriminatory benefit design and likely thus not be considered as a change in in essential health benefits plan isn't it the opportune time to maintain mainstream mainstream the cds diabetes prevention program by embedding such as a covered benefit in the benchmark plan so i i mean this i mean i mean here we have a killer i mean it's it's uh um and the wind you know uh you know an 89 percent of remoders already suffer from diabetes doesn't it make sense to to put wind in the sail of of of you know by having as a direct benefit um in the benchmark plan and yes there would be some reorganizing you know maybe physical therapists and nutrition people you know what we'll need to get together to kind of spots of these but but but let's grow in vermont let's grow the number of people the number of entities the number of providers that are providing this um CDC plan which is well established and everybody says you know it it it cuts um you know diabetes rates by people who participate in it in in in mid double digits so it works and i this is one thing i just well i just don't get it i i i i don't um i don't see why um well i've given you my spiel i i don't get this is a big miss miss to me well and i want to apologize uh for i actually want to return to that slide um and thank you for for bringing that up but i think i'll um now pass it to enabocas to respond to your question thank you uh board member pelham as you pointed out the blueprint for health program is required to provide education for patients on how to manage conditions or diseases including the prevention of disease and um that the blueprint is also required to provide programs to modify patient behavior and methods of ensuring compliance with uh patient behavior change and these offerings have been available through the blueprint program um for many years the blueprint supports chronic disease self management workshops and these self management programs have also been supported by the vermont department of health the department of health supports the training of program leaders and marketing to potential participants in these workshops the workshops are available to any vermonter regardless of their insurance coverage regardless of the payer uh and that creates a low barrier to access for providers who might want to prescribe or suggest participation in these workshops uh it creates it creates fewer barriers for the providers fewer barriers for the vermonters who might want to register for these workshops the blueprint for health program um has looked at the efficacy of these workshops and how to improve them in collaboration with stakeholders and recently in the fall um late september um after that stakeholder input determined that the agency of human services um department of health uh collaborating with the blueprint uh should take on the management um of these self management programs so the blueprint for health has endeavored in the mo u with the department of health um to uh provide for the self management programs the department of health um consistent with its obligation uh per the cdc and also consistent with its uh mission is providing more resources for this programming you can go to the healthy vermont um webs or my healthy vermont excuse me uh web page and you can find a number of self management programs to include the federally approved pre diabetes self management program available the programs in particular now are available statewide they have moved online in the era of COVID-19 and vermonters statewide can um participate in this programming again at no cost the um programming um we will be monitoring uh this transition evaluating the administration of these programs and particularly um looking to see how these programs are further modernized I think there was a lot of appetite for these this programming to um move online and when that happened due to COVID-19 I believe that was welcome for many individuals and increased access to the programming however there are folks who um prefer the in-person workshops and those are planned to return in combination with the online programming so as we um are new in this relationship with the department of health to improve the the programming and offerings and to refresh and modernize again we'll be monitoring throughout the year and we may be making further recommendations in how these programs are supported and continue to be expanded in their access and the my healthy vermon web page you can um you can see that there are numerous um pre diabetes uh self management offerings currently open for sign up the program takes uh the program is available and is a year long program with 12 sessions for a person to enroll and participate in as one as one example well you know I I understand that I just um um I I just you know I just think it's a more powerful relationship when a benefit is part of an insurance plan and a doctor primary care physician can say to their um patient um you're pre diabetic and uh you should you know enroll in this program whether it's sponsored by the department of health or privately uh but you should enroll in in in someone certified to provide this cdc program you know to to cut your chances of getting your diabetic I fully understand what you're saying I just think by by by embedding embedding um um access to this plan both financially but substantively it's a much more direct and powerful relationship for a chronic disease that's at the top that's at the top of the list so I understand what you're saying I I just I just think that it's you know it's it's still kind of buried in the in the bureaucracy I've been to the website that you talked it's very nice website but you kind of got to find your way there whereas opposed to being sent there by your primary care here or sent to a program by the primary care physician so I'll I'll leave it at that I have one last quick question um this had to do with gen membership and nothing to do with with uh uh the uh with diabetes but I just caught my eye a um in the report it says quote a gen membership benefit was also considered and not recommended at this time due to concerns around geographic equity I can kind of understand that one cost maybe as well as the benefit currently being offered under some non-standard plans and I just wondered why would a benefit being offered under some non-standard plans be a limitation uh whether it's good or not be a limitation to a benefit being in the standard plan yeah that's a good question so I I don't really view it as a limitation but a concern we heard from the issuers when some of the benefits that we looked at was that part of the non-standard plans as you know is to offer a plan design that might be different from their competitors and so that can maybe draw people who for instance really value a gen membership that might draw them to one carrier or the other so I think they liked having the flexibility to design that benefit in a way that would make them more competitive in the market and because the benefit was available we thought and with the other concerns that we mentioned we thought that it is available and if if someone really wants that benefit they can now purchase a plan that has it or they might want to buy a plan for instance one of the plans we looked at had more of like a wellness amount like an amount of money that maybe you didn't have to spend at a gym but you could put it towards like a yoga class or a different type of of wellness activity like you wanted to buy a ski pass or something like that so you could put money towards different healthy activities so we just thought that the the benefit was being served in some ways already in the market and because of those those equity concerns I can even speak to myself not having a gym close by or accessible to me that we thought that because it was available and our other concerns that it was best not to consider it for now. Well I understand what you're saying I just think that that generally is a you know the kind of public folks should be blind to the competitive interests of some of the carriers and that phrase caught me that you know there might be people in a whole bunch of other different plans and and people out there that don't want to you know go buy a plan specifically for that a gym membership you know this I don't think people are making their decisions about the insurance plan that they engage based on a gym membership but if but I don't think we should be making decisions based on one plan offering a gym membership and another plan not so thank you very much for your patience thank you okay next we'll move to board member Walsh Tom thank you chair I think you've well thanks for all the work that you've done it's been very enlightening and I think some of the questions that Tom just had previously I was thinking along the same lines the existing plan is a decade old and I was wondering if you had kind of comb through that with some greater understanding of ways of utilization management I think is what you called it but with the behavioral economics behind it with nudges and you know loss aversion type of things have you gone through that exercise to see if it's possible to free up more for newer additions and it sounded like in your response to Tom's question that you had and if that's the case I think it would be beneficial to just show that kind of show the work behind that about how you came to the base model for this exercise that might be it might help in understanding the work that you've done to arrive at the base and to see what's available to kind of play with yeah and I so I if I understand what you're saying I we have not done kind of a claim by claim analysis to see where what benefit is being utilized by how many people and the cost we have not done that but I think overall the consensus of the group was that there wasn't necessarily a benefit that even if it was maybe not utilized as heavy as other benefits didn't have some value as being included in the plan so we didn't really go down the road of saying okay what what how is this benefit being utilized we didn't do that in-depth analysis of and what are the what are the health outcomes for all of the benefits and again that is something we can go back in and look at but for purposes of this exercise and then also to stay within within the grant specifications because again this money has to be used for certain purposes so we also kept we're keeping that in mind when we were doing this analysis and tried to kind of meld the legislative mandate as well as we could with also the federal requirements that we were being subjected to for for for this analysis but again I think I think that work that you're talking about would be really would be really great to do not only in the context of how the benefits are being used but then as you said where where where are the utilization management tools being used and could those shift whether that's prior authorization requirements um cost share uh all of those things I think need to be looked at together whereas we were just really looking at the benefits so so I think definitely like a great idea but needed would need to be done in in a in a larger context of looking at other issues that were kind of outside of our our scope here if that if that makes sense yeah and I'm you know I'm new so I'm just kind of coming to yeah about all of these things and and what's your purview and I don't want to send you on a on a on a wild goose chase but it just seems like with something that's a decade old is it tweakable to to then free up or to make available funds for something something else where there's a big impact tom's example with diabetes is spot on and with that freeing up it kind of leads into my second question comment it's in in looking at what we what could be available to modernize the new plan I imagine you've done this and I just I think it would be really helpful to show but kind of looking through those possibilities with a little through an equity lens right that that are we helping Vermonters who need the most help the most right when we think of something like a dental benefit and I know there are federal limitations around that I'm coming to learn there are federal limitations around that but if we're looking at that compared to infertility treatments for example being able to describe why we're making the decisions we are after we've looked for ways to improve upon the base and looking through the process through an equity lens I think that would be helpful yeah and I didn't outline it in these slides but if you refer to the report that member Pelham brought up there are there is some discussion in there about equity and we definitely that was pretty forward in a lot of our discussions especially with the hearing aid benefit and bringing equity equity to people who who have a disability and some of who aren't able to get hearing aids to to put them kind of on an even footing with with others in the market currently so it was definitely something we considered and looked at the tried to look at the benefits through that through that equity lens as you said good thank you okay next we'll go to board member Holmes Jessica thank you so much thank you Emily and team big team this year for coming in I just have a couple of comments I don't really have questions one is I really just want to echo my fellow board members there on the equity lens I think it's really important to think about those benefits and and if they are disproportionately going to impact our lowest income most vulnerable for monitors that probably has to have more weight and so I think about that when I think about dental and when I think about that with vision and when I think about that with hearing in terms of I just want to make two quick comments one is on actually the geographic equity around the gym membership I'll just this is just a side comment but if more insurance plans subsidize gyms you'd probably see more gyms being built and you actually might be able to reduce the inequities of gym availability so I'll just say it can actually work in the same kind of you know equity and access and the second comment I will make is just that and it relates to the infertility and you alluded to this and you talked about it a little bit but you know for us to really think about whether that should be added to the benchmark plan I would really as one more member I'm speaking as one more member now I'd really need to understand the full cost of that infertility treatment and I mean that beyond yes there's the the three rounds of IVF and then there's the artificial insemination but what are the downstream costs and I recognize you know Julie you mentioned that there's an Oliver Wyman report and that that calculation hadn't been made but there's multiple childbirths there's complications associated often with multiple childbirths there are downstream costs and I think just to be fair we're truly trying to the cost and benefits of adding this to the benchmark plan we have to have a full accounting of those costs so I know Emily you're coming back and I appreciate that you're coming back with recommendations maybe in those recommendations you can include some of the Oliver Wyman estimates of what the full downstream costs might be you can make a really informed decision about that those are my two I can do that thank you okay at this point I'm going to open it up for public comment on the I have a quick follow-up sorry sure go ahead Robin yeah you know this is related to the blueprint programs I wonder if when you are thinking about the refresh of these programs getting more additional information to Tom's point about just a sec Robin Tom P can you mute yourself there's some feedback coming through your line go ahead Robin sure the power of the referral from the primary care physician at one point certainly the blueprint self-management programs you would see the posters related to those in your primary care doctor's office so I'm wondering if that relationship piece is something that could be bolstered to Tom's point which I think you know to me it's that referral in that relationship which has the power and the availability and making sure that the funding is sufficient more than the embedded necessarily in the insurance plan the embedding in the insurance plan is potentially a funding source but currently the blueprint does get funding from insurers so there may be an alternative way to provide additional funding should that be needed for that program so I just wanted to that's not really questions just a comment and to think about how we can ensure that the the programs really get embedded in the primary care office thank you Robin at this point we're going to go to public comment does any member of the public wish to offer a comment on the essential health benefits discussion Walter carpenter good afternoon Walter hey Kevin how you doing hanging in there thank you I suppose as usual I think I I agree with Tom Pelham's comments and some of the board members and Jessica as well so especially about the gym memberships and I think one of the things about the gym memberships is that the biggest hurdle to that is simple poverty in Vermont it's not just building more gym shimmer is that nobody can afford it to begin with I don't belong to a gym but I happen to work at a ski area and because a gym you know is too expensive for it's 60 a hundred bucks a month some are 160 bucks a month so no Vermont or living paycheck to paycheck which is what most promoters are doing can possibly afford that but in any case that's another story I think another I just wanted to comment after this is that from about 10,000 feet as I listen to all this benefit stuff the irony here is that we think of health care as a benefit and not as a need and as I listen to all these added benefits and stuff that's the general observation I got and that's how perverted this system really is and it's I know it's difficult to work in it but I wish we could get over that benefit versus need health care is not a benefit that's all I got sorry that's okay thanks Walter next I'll go to Theo Kennedy well thank you very much and good afternoon everyone I'm just a brief public comment slash question on the typicality test I really appreciate the work of the working group and just for context I'm here as the chair of the statewide independent living council today as part of the here-here-for-mont coalition and we appreciate all the hard work of everybody you know I find this excruciatingly hard to understand I'm sorry between the CFR and the CMS guidance so I'm just very quickly I'm relying on a CMS or looking at a CMS guidance and we don't have to answer us today perhaps it'll come up later dated August 8th 2019 specifically around the new state flexibilities and at the very end of that memo there there there's an attachment a with q and a's at CMS is issued and the last one speaks to it's number five sorry no gotta go further down the memo it's number three at the bottom it's saying compare the expected value of covering all the benefits at a hundred percent actuarial value in each EHB category the typical employer plan or the comparison plan so rather than belabor reading that text um are you going to have a subsequent session on how the typicality plan will be applied here and is there any risk that the generosity test will not be applied and this is the magic language it says quote from CMS in the case of the generosity standard we would not consider the state's proposed EHB benchmark to satisfy the requirement if the expected value for each applicable EHB category benefits in the proposed state's EHB benchmark plan exceeds 100 of expected value for those same EHB categories in the most generous comparison plan so if that feels confusing to you join the club but I just want to understand is that is that something that's going to be a part of the report that wakley issues and and will that report be available to we members of the public yeah so the answer is yes um we were not planning on coming back to talk about the typicality test here because again as I as I mentioned really because we're not taking away benefits substituting benefits we're really just looking at the generosity test because we already have a we already have a comparison plan really for that sets the typicality test if we were to add if we were to add these benefits we would then have to find another plan which is a little bit richer than our current benchmark plan at least this is how I understand the typicality test I'm not an actuary so we would have to then find a plan that was a little bit more generous than the plan that we currently have let's say if we added hearing aids you would then have to find a plan that was slightly a little less a little more generous than our current plan match that plan and then also show the federal government that you weren't exceeding the state employee health plan which we had determined is our generosity so it's kind of the way I had been looking at it is a floor and a ceiling and the plan is in the middle but what at least the new guidance from CMS has kind of said is that it's really when you when you raise your plan up you have to make sure there's another plan that's kind of equal in value and I think the reason being is that they they want to make sure that there are other plans that are compared comparable in the market and there's not this kind of outstanding very rich plan that exceeds all the others so I think it's an effort by CMS to find some balance with the changes that aren't necessarily so generous that they're not going to be in line with other plans that are available in the market but then not drop below any type of floor for instance if you were taking away benefits or substituting benefits where your plan would then not be equal to a typical employer plan in your state. That's wicked helpful if I could just have a follow-up so it's really we're talking about actual value it's not given benefit and because we're not taking out in this instance okay thank you I'm sorry if everyone else knew that already I just it's a little bit confusing to me thank you. Thank you. Thanks Theo. Is there other public comment? Is there other public comment? Hearing none I wish to thank Emily and company for great presentation this afternoon and we're going to next move to a discussion hospital budget regulatory process and preliminary guidance but does any board member need a break for five minutes? I see a shaking head so we'll take a five-minute break and we'll be back at 236. Thank you. So it looks like all the board members are back I see Patrick is here so I guess we'll call this meeting back to order and we'll get started with our discussion on the hospital budget regulatory process and preliminary guidance and at this point I'm going to turn the meeting over to Patrick Rooney the head of the finance team Patrick. Great thank you Mr. Chair can you hear me? We can. All right super and right now you should be able to see the title page for the slide deck up and Lori's going to be driving that today and so good afternoon board members stakeholders and members of the public as the chair alluded to we are here today to discuss and provide some updates and progress on the fiscal year 23 hospital budget guidance and also what the future may hold for the hospital budget process as we've discussed internally here at the Green Mountain Care Board and I say we are here because we have an integrated team participating in this work this year that you can see from that title page includes members of our legal team our analytics and data team ACO all-payer model team and quality contingent of that ACO all-payer model portion of our regulatory responsibility so we have folks on the call today to assist with questions and provide feedback when we get to the discussion portion of the presentation because there are some components of this that are new and there are people in this organization who can speak more intelligently about some of the finer points than I can so I will defer to them on those specific areas during the discussion portion but I will provide an overview and do most of the talking so Lori if we can go to the next slide please thank you so this is kind of the order of battle today we're going to cover how we got to this point we'll talk about where we are presently as I alluded to will discuss the future of where we think hospital budget guidance may be going and also then open it up for a board discussion in which we hope to have a robust dialogue to get some of your feedback so a couple of items to address here Lori I'll throw an instruction to change slides a couple of items here to address before we get going is that regarding the 23 process we're still very early in this work about three weeks or so working as a team so the presentation today is simply meant to provide a kind of a check in on that and the plans for the future as well as the dialogue that I mentioned so the talking points being presented are those that have reached a level of maturity where their discussion and potential feedback is prudent but those listening should know that there are other pieces in discussion internally to help round out some of the guidance for public consumption in March of of this year and so I'm sure there's there's thoughts from the board too that aren't going to be in here but that this team is also thinking about and that we'll have that come out in the discussion piece next slide please lord so to kind of recap in and level setting us to how we got here this is our high level timeline of how the hospital budget process works for those following along at home this is the relative time frame that we've followed for many years now with the one exception of the fiscal year 21 process that occurred at the beginning of the pandemic and the board under emergency power shifted around some of the dates to accommodate the public health crisis that our hospitals were combating other than that though we pretty much stick to this timeline which is set out in rule and statute for the most part and as far as specific dates go around presentations for the hospitals and meetings for deliberations and decisioning whatnot that will be discussed in more detail when we get to that March presentation and those dates have been established however on this the one date that we can take away from this is the preliminary budget presentation that we've scheduled for the 27th which gives the board an overview of what has been submitted for our state's 14 community hospitals next slide please Laurie so continuing with that level set here is a familiar look to many it's the history of net patient revenue increases year to year you can see the most recent decisions that were made provided for a 6.2 percent increase in budget 22 over budget 21 that is the highest during the Green Mountain care boards time of regulation however much of that is the result of the environment that we have found ourselves in over the last couple of years and difficulty in accurate budgeting is a major component of that and so there is quite an increase there over the prior year and on the 31st of January this year I'll remind everyone the hospital audited financial results are due and we should be able to update that 2.7 percent with real npr growth over the coming month or so as we receive those submissions next slide please Laurie so continuing with that npr trend in the last budget cycle you will note that charge increases are are higher here the weighted average being based on the size of the organization and their approved and submitted request so you can see that we've had several several years of low submitted charges and low approved charges and given the environment that we're in we've started to see an uptick over the last couple of years both in requests and board approvals and so as we think about that for this year's process and Laura you can go to the next slide we put some items here for themes that may surface this year and this is something we've done over the last several iterations of the budget process and some of these we've heard directly from hospitals some of these are continuations on themes from last year and the year prior to that and some of these are also areas that are beginning to percolate nationally and so as we migrate into that 2023 discussion that level set is important because we have an evolving situation in our society and in health care in which we find ourselves relating to that public health crisis and it's having a lot of impact on the day to day existence that we have and so we want to take the opportunity to talk about some of those items and if we if we go back 365 days most of us were very excited to be in line to get vaccinated and that was two variants ago and Delta was something that was in the whispers in far off locations and hadn't quite descended upon us yet so just to show how quickly things have changed for us and some of these items are going to continue to be have to be on our radar in future iterations of the hospital budget guidance process and our regulatory authority and we can probably expect to live in this this uncertain space for the immediate future in a couple years ahead in the aftermath of the pandemic so talking about some of those points and their consideration moving through this process as we begin to outline guidance is going to be essential to us creating a successful framework for this budget process so some of those high level items as you can see on the screen is the ongoing pandemic impact that we've been living with the potential transition to an endemic situation ER and ED volumes continue to be volatile at these hospitals overall real uh unreliable utilization assumptions because of the ebb and flow of severity of the pandemic and the impact that that's had inclusive of the staffing challenges and burnout socioeconomic challenges that come with trying to effectively recruit child care accessible child care accessible education opportunities for the families of folks who would like to move here and traveling staff which has been a significant issue and grown more significant over the last several months we're seeing a growth in both number of traveling staff and in the price of those staff and the cost pressures that that is having on operating expenses and the bottom lines of our hospitals included in that are inflation pressures that continue and that's occurring with travelers and supplies and really all elements of health care in general and in our daily lives just to illustrate that I was talking to a good friend of mine a couple of weeks ago who traveled to Los Angeles for a business trip about a month ago and for those who know LA the airport is in kind of the northern part of the city near Englewood and the port of Los Angeles one of the largest ports in the world is in the southern part of the city and his aircraft came in between those two geographic locations and he said he looked out the window and as far as as I could see there are container ships that are probably taller than most buildings in Vermont and it looked like more of an invasion fleet than a global supply chain so the logistics and costs are starting there and they're being incurred as that supply chain struggles to bring those goods to to consumer markets in the internal part of this country and that is not going to subside with Omicron or any other variant it's going to take time to see those through we're also having hospitals who are notifying us of capital plans and then having to put those on cessation for a period of time until things calm down and they can return their energies to that work we have the ongoing risk of 340b revenue and we know the importance of that to hospital revenues as well as other operating revenues and some of the covid relief that's still trickling in and we also have hospitals specifically last year citing renewed strategic plans and budgets based on the activity that's occurring so not a comprehensive list but some of those items that have popped up on our radar over the last year or so and recent and more recently in the last several months with the rise of Omicron next slide please Laurie so some updates as we move into the 2023 discussion again we have this wonderful integrated team that's been working to populate some of these ideas and these work products that's part of an internal work process that the Green Bank care board is undertaking with regulatory integration we began to work on that in the ACO process this this last go around and we're building that out further here in the hospital budget process and looking to take that a step further with the future of hospital budget guidance and many folks who have contributed to the guidance discussion currently are also contributing to thoughts and RFP for the future of hospital budget guidance as well so collectively a solid group of people to to work with to bring some of these ideas to fruition and what you're going to see here again I'll reiterate is not prescriptive we have various stages at which we're at in this process and some of the concurrent work products that we'll talk about so there are going to be items that aren't on here that are important to us also important to the board that will begin to mature as our discussions on guidance go on internally and and with some of our stakeholders that participate in this process next slide please Laurie thank you so first up is work products from the data team that we're proposing for this year and these additions especially around the cost coverage piece are a direct result of the sustainability planning work that's gone on the data migration census work that I'll highlight here quickly are being incorporated to help inform the board of any potential changes at the population level we heard the university of Vermont health network stressed some of that century census information around Chittenden County over the past hospital budget process last year and for anyone who is listening to the ambulatory surgery center discussions this morning they also mentioned changes in census at the Chittenden County level for their organization the impact and necessity of accessible health care based on those fluctuations so trying to fold this in to the overall discussion on appropriateness of budgets is an important step that we support the data team on and the work that they've done here so looking at these specifically with summarized cost and cost coverage by service line again using that burns data for the 23 process and adapting that for uniform reporting in the 24 process and onward and building that into our regular work product here the report on shifts in Vermont hospital patient characteristics using the buds and vcures data such as changes in MPR by patient residents payer and service line changes in paid amounts by patients payer hospital choice etc and then some of the census information to summarize changes in community characteristics and converting that to the HSA level so changes in overall population as distribution changes in socioeconomic status and its distribution and the possibility to incorporate out of state demographics as well in that work and I will have I will divert to Sarah and Jeff Batista who I think are on the line for any questions you may have on that because as I discussed this is not my forte so relying on those sound data mines I will definitely defer to them next slide please ACO and policy changes this is one that I will highlight as an area where we still have several discussions to have but as far as what we have discussed this is what's mature enough to kind of bring here to the discussion today and it's a result of discussions that I've had with Michelle Sawyer and Marissa and Sarah around the fact that we've asked a lot of questions in hospital budgets in the past related to ACO and Michelle Sawyer was kind enough to do a crosswalk of the responses and it was very disparate in nature and not super helpful in adding value to the discussion so some of these are not just to inform but to begin to tie the ACO and hospitals together more closely and so data point number one and I'll defer to Sarah Kinzler on specifics of this in the discussion session of this presentation but there's HCP LAN alternative payment model framework and the importance of that and you heard about it last week in Alina Parube's presentation is that we're working towards catarising these various types of reform revenues so we can do a better job understanding that that funds flow between the ACO and the participating hospitals and again this is a work in progress for the AVM policy team and we're going to meet on this in the coming weeks to discuss further what the timeline would be on that deliverable but being a new concept to me I can't go into a lot of detail so I'll defer to Sarah if you have questions on that. Furthermore querying the hospitals to discuss ACO population health dollars received in reinvestments and improvements to quality and population health initiatives this is a theme that percolated in the ACO budget process this past November and December and we want to understand what's going on kind of in that boots on the ground end user situation that the hospitals are in especially as it relates to the pandemic are have these efforts been stalled in any way are you having a difficult time moving some of these initiatives forward because your attention is being drawn elsewhere or are you having successes in continuing to do this and that's feedback that we really want to hear. We also want to know overall hospital population health initiatives within the organization their goals their outcomes things like progress that they're making as I discussed and also another element that percolated in the ACO discussion is the FY 20 settlement and the planned investment of those dollars in furthering hospitals health care reform goals so again bringing that hospital and ACO piece a little closer together there for this process to understand and get kind of a health check on how those those health care reform efforts are proceeding. Next slide please Lori. Thank you. Access quality and health equity we've heard a lot about all of these lately and it's very important that we continue to have the discussion and provide a check in on where these are headed so regarding access this is an area of opportunity for us again this is something that came out of some of the pressures that the hospitals have been facing we have this state wait times task force they're preparing the recommendations for February of this year and our proposal here would be that we adopt the appropriate recommendations from that task force for this guidance. Now whenever you have a group like this getting together with recommendations there could be offshoots of work that come out of this that are the sole focus of subgroups so when we get these recommendations we want to digest what's being put for like what can we take action on for this year and what do we have to kind of defer on and wait but should become part of the narrative and the work that we're going to do for the future of the hospital budget process and I plugged in here also the alternative which is to collect the third next available wait time which we've done in the past we did last year it's the current IHI measure it does have its drawbacks but where we could go with that if the recommendations that come out of the wait times task force are not something that we can take a lot of action on we would like to see something so that we can compare where they were last year at budget time versus where they're going to be this year so that's an area that we see a lot of opportunity in with that wait times task force and being able to find ways to get feedback from hospitals and measure across hospitals in a relative way some of the wait times that are being experienced that the board can be better informed on that specific area of interest next we have a VPQHC quality framework work group this kicked off yesterday it is a I was in and out of that meeting but it is a broad array of stakeholders and we have some here by us some of the hospitals Grimount care board membership HHS by state the HCA from my department of health and diva and recommendations for that are due out in august it doesn't do us a whole lot of good for this process and again taking those recommendations and looking at the appropriateness of them maybe perhaps we could build something out to request that data later on in the fall we've done that with some items before in the hospital budget process to get a feel for what's occurring there but we put a lot of chips in the sustainability pot and this is a direct offshoot of that so this is where the best investment is right now and being able to get recommendations and hopefully effective measurables across the hospitals and that's something that's really eluded us in the quality space for some time I don't think that's a secret but this work group is really setting out to hopefully find some positive changes in that space so that we can begin to measure quality across our various hospitals in a relative way so moving on here we also have health equity and this is a new and very important concept in this process this year I think our intent here is to get some questions out there so we understand what hospitals are doing and hopefully some of the feedback at that can drive some questions from our counterparts at the HCA who probably have a bit of a leg up on us on this specific area but they are a necessary and appreciated component of this process so we'd like to start wading into that space and bringing that awareness to the board and hopefully they can help kind of take some of the feedback from there and drive some questions that they may have for the hospitals come the time for presentations and the Q&A that occurs out of that process so this is us trying to get an understanding for example here what are you doing as a hospital to recognize and correct inequities in your community and prepare for the development of health equity measures and Michelle Degree was great at finding a report commissioned by CMS as a result of congressional action and Rand put together a report around the coming health equity measures and approach and their definition is there on the screen and so we want to understand what hospitals are doing to prepare for that what are they doing in their community and we're not here to head hunt so if they are not taking any steps in that arena that's fine but we want to understand better about where they're proceeding on that plane of discussion so something for evolution will probably build out more to that part as we continue through our hospital guidance process before we get to the March presentations and any feedback that perhaps the HCA would like to give to us is going to be very welcome once we start engaging with them as well on the guidance process next slide please Laurie so kind of rounding out the FY23 discussion I don't think we could talk about it without addressing some of the challenges and opportunities that come with this year and there's a lot of moving pieces out there that are in play at various stages I've already discussed the sustainability some of the sustainability offshoots that are already happening happening and we also have a pandemic related changes that are occurring as well and part of that is that the state legislature is moving to help the Greenmount Care Board continue with flexibility in its regulatory role and we also have the health health reform oversight committee accepting recommendations from a consultant around the future of health care regulation in the state of Vermont so there's a lot moving parts right now this feels very much like a transition year for health care regulation in this state both internally here at the board and and from areas we might consider outside from state government and so addressing some of those challenges in this process this year is certainly a piece of that but there's some more specific components that we should weigh into as well so COVID being one of the major one the strain on hospital resources but that constantly changing pandemic environments also poses challenges to this regulatory processes we've come to know it and have experienced over the last couple of cycles and so being flexible and accepting the ability to be flexible is something that's important we've come to learn that being too prescriptive in our work can cause issues down the road because things change and they change rapidly we've seen over several cycles will be in this guidance process and things will be very very dire and then over the course of the summer when we get to those august presentations we're looking at a very different world as it relates to health care in the pandemic and then you know a couple months after that we have slid back into some of the dark days of fall and winter as we all retreat inside so it's been very challenging to regulate in that space and unfortunately the data that is coming out has been all over the map which the consistency we've relied on has posed challenges as well so getting more specifically specific on some of the challenges the cost outliers information from burns and there's a component to this later on that we'll discuss around wanting some feedback from you all the data from 2022 is not generalizable in that effectively 25 percent of their year that year they went without elective procedures and so that's a major chunk of revenue that and and cost that was not borne by the hospitals as as we've seen from the audited financial results and in 2019 this was used in the sustainability work that's the most reliable that we currently have but admittedly it is it is aging out we're in 2022 and we're looking one year ahead of that so the discussion piece on that will come to that in a couple of slides here quality data alike has the potential to be skewed by the challenges hospitals have faced since march of 2020 that situation has arguably gotten worse in that time and again we have that VPQHC stakeholder collaboration that is occurring that we've really put a lot of emphasis on so looking towards the future perhaps and not so much this next year but out from that and building that part out and taking those recommendations for the future of discussing quality data in an intelligible and measurable way I believe is a priority for the group that's put together these these components today and so we have to ask ourselves what resources do we want to put into quality if any this year no we may not use them again so where's the value we have to ask ourselves that and we've put quality on hiatus for the last couple of years to alleviate administrative burden and with this opportunity with VPQHC it might be best to continue with that that effort of delaying the quality piece for another year as we explore that collaboration and the recommendations that are going to come out of that next slide please Laurie so despite those challenges this is a great time to pilot some of the proposed and potential additions and changes for future use cost coverage being one of them some of the census and market census and data patient migration information as well as the wait times information as well again it does feel like a transition year for this process and that's okay as we look towards the next several slides that integrated GMCB team working on the RFP is considering all of that for a contractor or consultant to have to consider as part of their review of our process any recommendations they may bring out of that so this is a good time to start doing some of this stuff there are going to be a lot of lessons learned from the pandemic and that trickles through to our regulatory processes as well and what's useful to us and making our decisions so it's a good time to start exploring some of those those new data points and we'll take those back once we get through this cycle and we'll review them and we'll analyze them and we'll begin to refine those for future iterations of this process next slide please Laurie thank you so as I alluded to there's some discussion points here that this is not an exhaustive list as you can see at the bottom there we did some areas that will really help guide our work towards that public discussion in March and allow us to set expectations and timeline deliverables for work products and helping understand especially with some of these newer points around the cost outlier market shift you know what year do you want to use and how do you want to use this information because that will dictate timelines for deliverables and who we deliver it to so if it's something you want the hospitals to react to in their narrative great we know to deliver it to them and to put that in the outline for guidance do you want it for informative information only informative purposes only or do you want to use it for budget here hearing questioning so we should send to the hospitals and tell them to prepare for discussions on those various data points that are our a team is going to deliver for this process should you choose to want to move forward with that and again this is just kind of making sure we cover ourselves here the access quality equity piece the recommendations from the wait times task force and I admit I'm not on the inside of the discussions there so what I I want to temper what I say here that there may be components of that that are very well rounded and we could drive forward with in this guidance process but I always like to be prepared for the fact that they may not be the case and I don't want to over speak my place so would the GMCB want us to revert to third next available appointment as the alternative although an imperfect one for this process so that we can have some sort of update on wait times or at least a snapshot of wait times that we can compare to a relative period last year so that is really just covering our behinds there to make sure that we're we're doing our diligence even though it may be an imperfect way to do so so a couple points to consider there as we move into the discussion piece later on all right now we're moving into the future 20 2024 and beyond and as I stated the many of the folks who are on this call to support this discussion had been working on this RFP we published it yesterday so if there are any contractors or consultants listening to this dialogue here this about this afternoon there is a ease of access link there by which you can access the RFP and some of the high level goals and items for consideration here are two that we want a contractor consultant to do is to assess the current process really take in where what we collect and the decisions that we make identify areas that we can enhance or modify GMCB statutory authority and regulatory decisions and provide greater alignment with payment delivery system reform efforts those are some of the high level goals there's certainly more specifics as you can see in that RFP to some of that that requested activity there and items for consideration again high level facilitate a stakeholder engagement an example of that would be what do we want how do we want to measure the growth of the system or buy hospital npr has been one of the the ones that we've used in the past but we heard from UVM health network last year they'd like to see us move to a per capita measurement so as part of the hospital stakeholder group should that be a narrative that the health network continues to want to address than that that would be their opportunity to do so but you can see here that there are some examples of folks that we hope to engage in that stakeholder engagement to create a better regulatory decision-making process and a more well-rounded one to help us address the the health care system and those areas that we want to impact next slide please sorry so continuing on that items for consideration one of the things we would ask is that they review related work streams and deliverables provide recommendations on enhancing regulatory alignment and alignment health care reform efforts for example sustainability planning this is going to be a major component of what we'd like them to consider regulatory alignment from the white papers that we produced internally h-rap and c-o-n as well as a co and rate review to kind of fold all of that in where possible to this process and if not also let that be known as well integrate that stakeholder input with the current process identify data gaps how we can ease administrative burden increase efficiency in our work etc that should always be components of any good process and operation recommend alternative methodologies here we go hospital budget regulation with the goal of cost containment while improving access quality of care for example alternative to npr per capita measurement payment reform incentives and data sources to support new methodologies and so on and finally consider current gmcb work around equity access quality and value-based care and affordability there are as we've discussed throughout this there are components of that that are moving forward at various stages and we want that to be folded into this process as well next slide please all right thank you so to kind of bookend the discussion on this we did publish the contract yesterday or the rfp yesterday excuse me and not to get into the minutia of between then and what i have here on the screen but we hope to have a contractor or contractors if there are subcontractors uh on by late july early august of this year for observance of the 23 hospital budget process that's a pretty quick turnaround but it's definitely going to be to our benefit that we give them some kind of a live fire exercise in how we go about this current process and we'll update the board with further timeline specifics on uh that that contractor or contractors work it's probably going to be a multi-year process to encapsulate all of this and get much of this work and the recommendations and advice from them into place so we should be ready for that as well next slide please lori so that brings us to the end of the slide deck and the team is on here for board thoughts feedback or questions that we can answer i turn it back to you mr chair would help if i took myself off mute thank you patrick um i'll turn it over to uh board members for comments or questions hi this is robin i'll jump in with a couple things um on the vpq this is more of a comment um the in really in terms of the vpq quality group that's um moving it with the expected suggestions in august 22 it might also be a good idea for uh the staff who are attending that group to communicate that um to be thinking about that in terms of a potential next federal agreement where we will also have a quality framework it may or may not make sense uh robin somehow you got muted i think she froze hopefully she doesn't keep talking you made a hop and chat for a bit and then robin can come back on kevin or do you want to wait a minute she might log off and log back on yeah let's just see for give her a couple seconds and then we'll okay she doesn't seem to be leaving to come back on so jess why don't you go ahead okay no worries um so i want to thank you patrick and everybody else who was clearly involved in a lot of thoughtful consideration about how we move forward um i want to say that i'm really excited about the rfp and the work streams that are outlined for a consultant to do so i'm anxious and excited about that process um a couple of thoughts i have um i very much appreciate the incorporation in this year's analysis of the burns type data to understand cost and price variation um i specifically think we should be looking at differences between inpatient outpatient professional services uh separately you know and maybe looking at that in our regulatory letters separately but having that data and having that incorporated in our decision making will be helpful one of your questions was you know which year should we choose you know how do we do that and i guess i would say why do we have to choose a year um if if we can if our team can you know access that data for 2020 we can look at it in the eye of what happened in 2020 but look at all the data that we possibly have um recognizing that 2020 is an anomaly so you know looking at 19 and then carrying it forward as much as we can with data i think will be helpful so i'm not sure we have to choose a year i guess is what i'm saying um i really appreciated the the attempt to integrate the aco and the hospital budget process so there's stronger ties between the two i think that's going to be really helpful um i also really appreciated and i think we've seen how important it is to understand community demographics population changes all of that in our hospital budget process so really a very great that we're kind of bringing that in a little bit more substantively potentially in this hospital budget process um i think if we're going to use npr as a lever lever even in this upcoming year i recognize we have an rfp we may dismiss completely with npr in the future but um depending upon what the consultants say in a better process we might endeavor but i think at the very least for this year's upcoming budget we need to incorporate data as you've said i think patrick on patient migration population size that census information i would also say adding to that this concept of rural bypass or where patients are receiving care so we have some of the data on that so it's not only who's in your community but where those community members seeking care um and then i think also we have to understand pair mix more deeply as it relates to cost coverage and even case mix in the acuity so i think you know if we're thinking about npr we should be looking at npr but through the lens of patient migration population size rural bypass pair mix cost coverage case mix all of that has to kind of be part of it i think that will allow us a more nuanced approach to our hospital budget process rather than just a straight one-size-fits-all npr target uh with respect to quality i also very excited about the vpq gmcb collaboration stakeholder engagement to try and figure out quality i think um one of the things i would ask that that committee to think about is volume standards how do we think about volume because we know and i've talked about this at a lot of hospital budget hearings but volume quality relationships so should there be volume standards minimum value standards and i do think and i think i mentioned this last week in the meeting at the very least i think we should be tracking data on mortality rates for things like heart attack strokes gi bleeds readmissions surgical complications and revision surgeries and i think we need to be able to get that data even in small numbers we can look over a longer period of time three years or five years to sort of smooth out outliers but we need to be looking at that data uh for even our smallest hospitals where sometimes as i said last week the hospital medicare reports will just say not applicable because the sample size is too small well let's look over a longer time period but we can't not look um with respect to wait times as i think most people know i actually am on that task force looking at wait times and i guess what i would just say is the inquiry is well underway there are going to be some recommendations and i think our method of tracking wait times will probably need some adjustment but i think if we hold out for a couple of weeks uh more information soon on that and what was my last thing oh my last point here sorry lots of sticky notes want to make sure i catch everything i do think perhaps this year it might be helpful to have a separate module or a series of questions around workforce we know the workforce shortage is just is just killing us right and so i think asking some questions and again i haven't thought specifically about these questions but maybe the various teams can help us think through these but you know what have the recruitment efforts been what are the costs associated with that the travelers costs you know what are turnover rates at hospitals what are some of the efforts that are being done to help reduce those shortages right so you know what what what creative solutions have hospitals undertaken because there could be learning you know there could be some incentives that maybe the board could create through the hospital budget process um you know one of the things we hear about is that there's not enough residency sites and internship sites and things like that so you know could there be but there's costs associated that you know for practices so how do we you know ease that burden um how many preceptors are currently taking students at each hospital you know how do we start to think about ways in which the board might be able to help through the hospital budget process to ease some of the costs associated with building up our our pipeline so i'm not sure exactly what the questions are patrick and team but i feel like this is a year where we we should ask and better understand some of the costs and some of the successes so that we can learn from it and and if there's ways that we can incentivize or help defray costs of improving our workforce shortage situation that would be helpful to know it and might be incorporated in hospital budget guidance oh my last point sorry i do have one more point and it's just thinking about you know so the sustainability planning report as you all know is due to the legislature february 1st and but i think obviously and you alluded to this you know the work has to continue um and so our work isn't done just because the work is you know the report is being submitted to the legislature so and nor is the hospital's work being done so i guess i would just ask you know the policy team and the data team and the hospital budget teams to think about how are we going to continue to incorporate that that planning effort and the learnings into the hospital budget guidance going forward and i recognize that's part of the rfp but what do we do it for for march upcoming march those are all my thoughts and comments robin are you back she is all right i was pinching for you thank you wish i had heard all of you so i would know if i'm being redundant but unfortunately the internet went down so i missed a little bit before i could call in and get the internet back going so mr chair should i jump back in absolutely robin okay so what i was trying to say when i got dropped was um in thinking the vpq quality framework should be thinking forward as well to the out pair model 2.0 agreement which hospital level metrics may or may not be appropriate for but it would be good to just have that in the back of the mind during the conversation so that we can ensure that we're aligning quality metrics as much as possible as we always attempt to do so that was the end of that thought um in terms of the other discussion items that patrick had on his slide 13 um and i think i heard the tail end of just talking about this um it does make i think the data issues are going to be quite a challenge this year and so it does make sense to me to do something similar to what we did last year where we look over multiple years so that when the bottom's out in 2020 and then we're looking at actuals in 2021 with the pent up demand we can kind of see maybe um what that ebb and flow looks like so that makes sense to me but certainly i would appreciate more thinking from staff on that and the other areas i don't know um i guess i'm not quite decided yet in terms of the use of the market shift and demographic datas and whether it makes sense to you know kind of pilot that to to figure out the right use of it this year um or exactly how to do that i think it's a little bit tough not knowing where we're going to be in the covid ups and downs um so i think wherever we land in march we'll we may need to just be mindful as we get closer to the budget submission time that there could be another covid surge and we may need to adjust um so i love more thoughts or advice from staff on what they think makes sense in terms of particularly this year but also how that that information gets incorporated in a way that's useful um the other area i just want this is really a question for i think for sarah linberg um although she can tell me if it's not um and i know that in the past when um when we uvm and uvm health network had brought up the per capita measure um we had talked about trying to think about that and i know that sarah had done some preliminary thinking about the data availability for that type of a look um and i'm excited that that might be something we can delve into deeper once we the rfp process is completed but if sarah could just talk a little bit about some of the work that she's done on that i think it might be helpful in the discussion around um moving forward hey sure um i will answer quickly and then i have to pick up my kids from daycare um but uh yeah so the challenge that we have with any sort of thinking about per capita is just that you know we really are a state that has two major hospital referral regions and so that is complex when you think about it geographically and so coming up with the denominator can be tricky we also have the challenge of some of our hospitals serve um quite a number of patients from out of state and we don't have a lot of insight um about that information so um thinking through both on a service line and on a data perspective the way to um come up with something like actionable is um gonna require quite a bit of thought and i think stakeholder input um in terms of you know what what we can reasonably and practically do um to measure the signal there but you know overall i i also want to echo that i think that my advice is as we start to build this stuff out that you know thinking about systemic monitoring and kind of piloting tools is a really good way to think about it in my opinion thanks i'm all set okay do other board members have comments or questions i don't have much to say i unfortunately and regrettably haven't thought about it as much as i should have um but um my my my basic sense is that 2023 for the hospitals is still going to be a tough year it's not going to be um stable it's not going to be steady state they're still going to be you know kind of recovering from this this mass of assault and so that um so that we've got to be very conscious about that um which i i'm sure we are but um so my feeling is that you know if there are that we should be aware as we go through our budget process of what can we jettison i mean that that is something that we basically said we're going to go the data analytical route and uh you know managed by uh kind of more top side indicators than the grunt and grind of a you know a line item budget and i i think that that that we should um you know kind of i'm not saying appease but do whatever we can to show that we we understand what their situation is i think that um we need to be uh very aware of what goes on in the legislature um during this time because the legislature still has a lot of money to burn and i just get worried that um that it begins to set up 24 maybe not 23 but 24 to a period where you know there just isn't enough fuel to keep doing um um what the kind of initiatives that the legislature might be supporting and i don't know that there's anything specific i just that's an instinct of mine that that this kind of topside cost shift could occur that you know the legislature it's an election year they want they want to be nice to the hospitals and and they put things in place that just aren't affordable over the long run and uh you know i think we have to be aware of where those uh you know those those problems might exist i think behind the scenes we should be setting ourselves up for 2024 you know obviously the all-pair model was referenced so that's kind of infrastructure it's the infrastructure in place uses 23 to get the infrastructure in place that allows us to you know become more aggressive um in 2024 so things like this fpp rule that we're working on you know you know we don't have to do that front and center we can do it behind the scenes um you know uh so so that it's in play you know when we're at a point where the hospitals can kind of take on more of a participation you know in thing in change um i i just don't think that um you know that they're going to be ready for much change except leave leave me alone kind of change you know in 2023 and so we should use that space to set ourselves up structurally um for 2024 and there's there's a lot we can do when i'm listening to jess and and robin and and and you know all of that is good stuff but i i i think the target should be 24 as opposed to 23 i i think burnout um they're still going to have staff shortages they're still going to have workforce shortages and so it's not like we're going to be entering the 2023 process with hey we're back to normal we're going to be far from normal and um and um that that that's just my general top side thought is to play defense with the legislature you know be aware of what they're doing and and have a an eye toward it that is this thing rolls out in 24 25 we put it back in the box um or are we going to be stuck with it um and uh that do all this kind of infrastructure stuff that we can kind of off the screen trying not to burden the hospitals with it but getting it in place you know maybe with this consultant help as well um and then be very conscious about identifying stuff that we can jettison you know that word we could just say to them you know we're going down this path and it's going to require this effort but we're not doing this stuff anymore and uh because i i i agree with managing by you some of the top top side analytics it's a nice competitive way to uh kind of move move move down the court where there's a lot of peer pressure is in terms of uh you know the relative standing of hospitals and funding and case mix and population and all those kinds of things so that's my very crude uh that that that crude uh observation at this point and i i promise next time i'll be a little bit more specific thanks tom are there other comments or questions from the board yeah just uh just a couple and and um realizing that i'm new and and not fully informed with all that's gone on before but um taking a look at what you've mentioned today patrick um it's causing me to reflect on what i've seen in other large organizations and other places um and there are some great things that you're talking about right like um integrating more utilization and quality data that's that's a key thing but to um in a value based environment we want to kind of move away from an assessment of charges reimbursement only right when we look through just that lens it creates views about cost shifting and work forcing workforce issues that can be roadblocks to further change using a different assessment methodology that's more service line cost based and per capita reimbursement types kind of freeze up our thinking about some of those issues and we find more flexibility and more ways of going forward um i think small number wise a comment there um statistical significance is not the same as clinically meaningful so don't be afraid of the small numbers all right we'll still learn from them we're not trying to find statistical significance all the time we're trying to find meaningful things that help us think about the future and we can remember these are small numbers but it's that's don't be afraid of the small numbers i guess is a is something that i wrote down i think um integrating the census data is important um because of what it helps us to do with equity measurement right um i'll i'll use an example from the meeting that we had just a few moments ago um i wanted to ask i i tried i think i did it poorly and then i thought about a better way to do it later but one of the questions for the group for the presenters in the last group i would have liked to say um what proportion of vermonters have difficulty with their teeth to the point that it requires more than two preventative visits a year what proportion of vermonters require or want IVF treatment and of those two groups which of the two groups contains more poor vermonters and are we doing everything that we can to to from an equity standpoint provide more for the poor vermonters right and you get that information from pop you you need denominators and populations in order to be able to do that um just looking at my list and one thing um one thing that the last couple years has really pushed my thinking on i've spoken a lot and written a lot about quality measurement and patient perspective and patient reported outcomes um while our healthcare system is really on fire and there are people providing care to patients and it reminds me of time that i've spent with the search and rescue unit and fighting uh wildland fire fighting in california if i'm in the middle of a fire looking for lost people or shoveling dirt and somebody comes up to me and says you know if you hold the shovel a little bit different you could go faster they i'd want to hit them with the shovel right and so we've got to realize that they're in a fire and sometimes we need to think about how do we change the overall structure of the environment to have less fires right and and and so i just want to the my point with that little story is to think about workplace um quality and and wellness like are we putting pressures on workplaces that encourage burnout or are telling people um hold the shovel faster and different and go faster like are there quality of employment measurements that we could be looking at as as well so that's all thanks for all the work that you've done and um thanks for all that you're doing to try to integrate these different measurement streams kevin you're on mute if you're talking no wonder why nobody ever answers me yeah i just asked if there was any uh follow up uh comments or questions from other board members if not i'm going to move to public comment members of the public commenting on the hospital budget guidance walter thanks kevin um i want to thank tommy walsh for his comments especially about the fire uh and the shovel he was going to bing somebody with if they told him to hold the shovel differently uh as a guy who has held many shovels and dug many holes and been told that many times i almost did that once um as someone as tommy's phrase about the or tom's phrase about the dental about what percentage i think a good thing to do would just go into like a normal walmart store and just roam around the walmart store and watch all the people with terrible teeth and bad health conditions and the conditions of poverty that are there um and there's more places where you can do that um i have most of my mouth is dentures in fact i just got bad genes in my teeth just brought it out and i had no insurance because dental insurance in vermont in america is just ludicrous um back to tom's um about workforce i think tom did hit the hit part of the problem and you can go to any number of quotes from uvm for example nurses being on strike um burnout they're they're about to they're about to strike again um the traveling nurses versus the regular nurses and see how this american sort of business model where employees are treated is nothing but resources um plays out and what it's doing and this is the problem with treating healthcare as a factory you know we talk about payer mixes that i listen to this and i often think what are we running an auto dealership here and tom's points are valid in that regard too because that's a great deal of what's going on and it's that it goes back to that shovel metaphor that tom talked about so i'll i'll let others go now but that you know that's that's kind of what's it thanks walter next i'm going to turn to mike del treco um can you see me and hear me we can perfect uh thank you so first i just want to start out by saying thanks to the board and the budget team or i guess teams working on the guidance this year i found the presentation to be refreshing and the questions um discussed are certainly important i have a i guess i have several points to make um first i just kind of want to take a moment to recognize some accomplishments uh that has that have happened as as pointed out in slide four and five we have as measured by net patient service revenue bent the cost curve and we've actually bent this quite significantly i say that because net patient revenues certainly have a direct impact on premium inflation depending on how you measure this um you come up with billions of dollars from where we would have what we would have spent to where what we are spending today um premium certainly are part of hospitals net patient revenue i clearly know our work's not done but again i wanted to recognize that accomplishment um i like i you know i want to also say i enjoy working with patrick and the team and i know we have certainly certainly have many challenges ahead of us um and i have seven more additional points to make um they're short um and they're just uh informative and maybe we have some opportunities here um let's keep this process as simple as possible carefully determined how new requests would be used before adding it to the budget guidance and we must understand what could be eliminated from the process as well let's remain consistent especially as we move year by year if we continually change what we're looking at it's very difficult to measure success let's create a clear understanding of how budget decisions will be made let's recognize costs outside of hospitals control specifically workforce expenses such as travelers and other inflationary pressures such as pharmacy costs let's not forget about how important it is for hospitals to have operating margins not just to cover the extraordinary pressures they faced today but it's equally necessary for investing in technology workforce other staff healthcare reform in infrastructure uh you name it as always we need to balance affordability with the appropriate growth necessary that to afford from the high quality and equitable access to care they deserve and finally as mentioned we need to continue to be flexible as we never know whether it's pandemic might take us or what we might face down the road again i really appreciate the board's work patrick's and the team's work here and look forward to continued working on this with the group thank you thanks mike mike do you have any specifics as far as what you in your mind what you're thinking of is unnecessary collection um you know i like like let's take a take a moment we we had a discussion here about sort of i have a echo so it's a little bit difficult and top column it's coming through your mind if you could mute go ahead mike we talked about important things like measuring workforce and measuring statistics around workforce is that a is that a budget process or is that a workforce uh task force process i don't know but but what are we trying to accomplish in the budget versus what are we trying to accomplish in um in it outside of the budget process i just think it's important to to recognize those those things i'm not and i'm actually not pointing that out as a problem or or a good purpose i just it's an example okay and i'll just throw back at you that um your hospitals may want to be talking about the workforce as they justify their budget so it's a it's a circular thing here about yeah careful careful how we talk about that what i was talking about the the interesting statistics um you know we could look at all of the interesting statistics um or we could look at the new cost associated to travelers really simple questions um but ones looking at new statistics and how they impact things is much more difficult for hospitals to gather and report in a budget cycle as opposed to saying i have 20 new travelers and the cost associated with those travelers has increased x y or z and so i'm not minimizing your point but like what are we trying to accomplish through the statistics or data gathering and how will it be used is really my my message and again it's not meant to say it's right or wrong it's it's meant to say let's be thoughtful of how we add or even take away things okay next i'm going to turn to kathy falton kathy uh good afternoon chair mullen and thank you so much can you hear me okay we can terrific thank you um i just wanted to follow up on patrick's presentation i think um in slide 10 where he mentioned um the vp qhc's uh work group for the quality framework as he said uh we kicked off yesterday we're very excited about this work um we've had uh very well attended uh we invited over 40 partners and had um 34 attendees with a few folks um just not able to participate due to schedule conflicts but in addition to the partners that patrick mentioned um i'd include the medical society insurers and um hospital representatives from uvm copley and north country and and others other um you know key stakeholders and i believe um from alaina's presentation last friday uh i think it might have been robin mentioned uh doctors dupuy and dr macy from copley both were in attendance yesterday so we're very very pleased with the expertise around the table and very excited to to be starting this work we'll be adding the health equity office and um community members from uh the folks we serve as well uh we we're ensuring there's a very diverse set of interested parties for sure um our qi specialist ali johnson is the project lead for this work and we just like to encourage everyone to you know don't hesitate to reach out to either ali myself or hillary if you have thoughts or um suggestions for us we'll be providing all of our working documents um on um for the for the work group we'll be working on shared documents in a secured portal but our final documents will be posted on a public facing website um i don't believe i can post that into the chat for this meeting but we can get that link um over to carah and hopefully carah could share that link of the information but make sure that happens okay terrific thank you um but we yesterday got into an overview of our process and timeline um the intentions of everything we expect to accomplish over the next five months and um you know as as always we're very happy at any time to present our progress to the board as you would see fit throughout throughout this work additionally on um slide 10 of patrick's presentation we have a separate project um the vermont hospital health equity project that will be starting um later in the year uh starting kicking off in the fall unfortunately we've had to postpone that work because of the current situation we found ourselves in you know the hospital the crunch at the hospitals and um certainly the impacts to staffing and and surge capacity but we'll be um supporting hospitals with a