Okay, we are back. This is Senate Health and Welfare and it is March 10th. We are moving on to S-285 and Jen, I know that you've been working hours on incorporating the suggestions that the group that we had in yesterday was working on. So I would just like to thank the group publicly for the work that they've done to improve the bill as we go through. We can make decisions about the language together and then we'll have a little bit of time tomorrow. Do we have you tomorrow with you? I think I think so. Yeah I thought doing some combo with the house depending on what they're up to. Right okay so we'll and so hopefully we'll be able to finalize the bill tomorrow morning but this is an opportunity for us to get some of the language as recommended from various folks and you also have language from Patrick Flood that we can perhaps share and look at. Did that get sent to all of them? No it hasn't yet. We'll talk about that as we go along. Jen I think what you might want to do if you can is as we go through the bill maybe there's some comments from Patrick's short email that would fit in I don't know if that's something you can do on the fly or not. I think I'm gonna have to compare it with the version from. Yeah okay. Just because I think in some places I change. Okay. You change things in ways. Okay I'll keep my I'll try and keep my eyes open as well and then we'll get some maybe two and so that certainly is easy enough to discuss in context. Yeah okay. Turning it over to you. Great good morning Jennifer Carvey office of Legislative Council which chairs is let me sit in her seat at the head of the table today. So we're looking at a new draft of S285 this is draft 3.1 and it has highlighting in blue which is a little easier to see on the screen than I think it is printed but I didn't want to confuse anyone since I have used yellow yesterday and I know the stakeholder group had provided their changes to me at least with both my yellow and their blue and so I thought it would be easier this way. So I had incorporated everything that was in yellow yesterday I have incorporated all of those changes as kind of the baseline for what we're looking at now. So what we're looking at is changes from what we were doing yesterday just for context. And so and I think the chairs spoke some but there was a group of a number of the witnesses that you heard from yesterday and some others who they were working with who put forward these changes so it's not I don't think it's necessarily consensus across all the witnesses you heard from but many of them put forward these changes and that's what they think. So the first section is still unhospital global payment design although we may want to change that name because it's it really talks more about value based payments if you go there. So I will make a note to myself about potentially changing that. So this would still appropriate 1.4 million degree mountain care board to engage consultants. This would say to develop a process still consistent with their their payment reform. Some of their reform duties in the green and care board statutes and then it would add and including the meaningful participation of health care providers payers and other stakeholders in all stages of the development for establishing and distributing value based payments including global payments from all payers to Vermont hospitals. So I'll stop that point and just say this is adding in that concept of meaningful participation by stakeholders in this process as well as in the process in section 2. And also talking about value based payments including global payments but making that a broader concept of value based payments. So then this is of this process is supposed to again establish it come up with a process for establishing and distributing value based payments including global payments from all payers from on hospitals that will and then it keeps the language by helping move the hospitals away from the for service and provide hospitals with predictable sustainable funding that's aligned across multiple payers consistent with the act 48 principles that's codified in the green mountain purple statutes and sufficient to enable the hospitals to deliver high quality affordable health care services to patients and changes to this language and take into consideration the necessary cost of providing services and not be based solely on historical charges. So it's not specifically saying based on the actual and necessary costs but instead taking into consideration the necessary costs and not be based solely on historical charges and there is a suggestion from Patrick floods language here to add this and this was still using that former version of the language but actual and necessary operating costs. So you can think about whether you want to say take into consideration the necessary operating costs of providing services and I don't know which section this is on page 2. H2. H2 lines 3, lines 3 and 4 the necessary operating costs. Would it make sense to have including including operating costs you know I don't want to restrict it but its services and operating costs. I try to I think it's a I don't think the word is necessary. Yeah, I don't know position to determine whether it's an appropriate addition at this point or not it might be helpful to have the other stakeholders weigh in on yeah. Yeah, okay. I mean cost is broader than just specifically same operating cost of just saying costs would include operating costs. Yeah, it says cost of services. And that includes that would for me that's top to bottom on cost of services because you've got environmental supports you have all kinds of supports including you know so that fold into operation. All right. Okay, well we'll I'm not here in significant interest at the moment so maybe we'll keep going. We'll see if others weigh in strongly in favor. All right. The next is so that is all about determining this developing the process for the value based payments. Number two is that this consultant would work at the board to determine how best to incorporate value based payments including hospital global payments. So again introducing this idea of value based payments for broadly into the hospital board hospital budget review, ACO certification and budget review and other regulatory processes. And then they kind of combine this idea from what was number three into this one. So including assessing the impacts of regulatory processes on the financial sustainability of environmental hospitals and identifying potential opportunities to use regulatory processes to approve hospitals financial health. We keep going or do you want to pause there? Keep going. If someone wants to say something, just sort of raise your hand and ask the question. But yeah, let's keep going. I do have a question. Based payments including hospital global payments. So what would some other value based payments be? I'm not a great person. Can I go to friend? I see some other examples of that.  Yeah, I mean the capitate, this is my Fisher healthcare advocate, the capitated like payments that are currently being used by dedicated. Okay. Yes, there are a number of them. And I think, you know, in a back us could probably talk to you about what other ones she is particularly interested in exploring on the spot on that kind of level. Could be bundled payments. Yep, that's another example. Thank you. All right. So then this incorporated that number three that have been recommended by the hospitals in along with number two in a better way than I was able to come up with on my own. So that that's helpful. And then they're taking out number five that I'll speak to a little bit in a moment. So they would then modify what would now be number three to say recommend the methodology for determining the allowable rate of growth in Vermont hospital budgets. And instead of including would be which may include the use of national and regional indicators of growth in the healthcare economy and other appropriate benchmarks. And it provides some examples, such as the hospital producer price index, medical consumer price index, bond rating metrics and labor cost indicators. Oh, that's good. All right. And then five is is structured. This is the idea of looking at ways to use global payments for providers of community based services. And it's my understanding that this concept will be included in some language to be proposed by in a vacus from agency of human services. So not getting rid of this idea entirely but putting it potentially in its own section. I haven't seen the language yet although it may have come in while I was on my way into the office. I'll check. I've already fallen down on the job of trying to incorporate Patrick floods comments. So if you go back to the earlier part of this, where we were looking at the process for establishing and distributing value based payments to hospitals, he would add a D and an E. So where we end with C on page two, lines three and four. So we're going back a little bit back. After taking into consideration necessary costs, not based solely on historical charges, he would add a subdivision D. And I think he mentioned this yesterday in his testimony, develop options for the design and implementation of a standardized system of fees for hospital inpatient and outpatient services across all payers. And E determine how best to secure comprehensive data and analytical services from hospital financial analysts to evaluate hospital fees, revenue sources and financial and operating reporting and metrics. By using the word by using the word fees, what's the implication there? I'm trying to sort that out a little bit. Right. I mean, to me, it does sound like it's it's sticking more closely with the fee for service. Yeah, payment model. Unless it's just considered to be a way of sort of calculating the value based the amount of the value based payments to be provided. But I know there was some discussion yesterday about with concern about standardized costs across hospitals. Given that we wanted to email that to us. I don't know if Aaron can you email that to all of us so we can actually. Here, do you have an Aaron because I can do that? If you don't. Yes, I know it's hard to listen. Yeah, Aaron has it.  Yeah, I think there's a language later that or maybe it got taken out. I don't know that sort of gets. Yeah, let's let's let's continue on. Let's continue on, Jen. And then we've highlighted where this might be. And then we'll look at it. Yeah, keep going. Alright, so then we're back to page three and we still have these reports coming in November 1st would be an update on the from the board on its use of funds to the Health Performer Oversight Committee. And then by January 15th, a report on the use of the funds appropriate in this in this section and taking out language about the status of the efforts to get Medicare participation. We're going to see Medicare participation come up in a new section a few down. But it doesn't no longer fits in this because we've moved the money and the duty somewhere else. So this is just a report on the use of the funds appropriate in this section and it's to this committee, the finance committee and hospital care. Are you ready to move on to section two? Yes. Alright, section two is the delivery system transformation and community engagement. So this would retain that 2.5 million you saw in the last draft, although I will note that I think in the version that was sent to me, the Green Mountain Care Board still believes they need the full three million, but this would do 2.5 million from the general fund to the Green Mountain Care Board and FY 23 to engage one or more consultants and then this language has changed a bit with expertise and community engagement, preferably with experience in working with a diverse rural population and one or more consultants with expertise and health system design to assist the board in consultation with the director of health care reform and AHS to build on successful health care delivery reform efforts by and then our verb tennis changes. So we have facilitating a patient focused community inclusive plan for they just had Vermont's health care. I put delivery potentially for my child care delivery system to reduce inefficiencies, lower costs, improve population health outcomes, increase access to essential services, including both providing the analytics to support delivery system transformation and leading the broad based community engagement process and providing support and technical assistance to hospitals and communities to facilitate and then changing the terminology planning for delivery system reform and transformation initiatives. Talks about the community engagement process and some language has changed throughout here. Can I stop? Yeah. So back on this is a lot to endorse. Back on page three, why did they change it to preferably with experience and working with I mean, we made a whole point yesterday that we really wanted to consult with that could work with. Yeah, I can't speak to the right. I don't. I think we should say with experience and working with a diverse world population not preferred. Well, I the only the only thing I can think of and we'll have to ask maybe we can ask Robin is that maybe there's someone that has experience but not not as much in the rural parts of the country as we would like when the person that has the rural experience might not appear to be as effective. I don't know what the reason for that is, but I think that there are multiple consultants that they would be hiring so sure it's really important that they don't have a if they right now think that they know somebody and they're trying to write this to hire that person that makes me uncomfortable. I don't I probably I don't think that and I think we really want to make sure that the consultants is experienced working with not just an urban population because it's right. The crisis in health care is we've got it. We got it. So Jen, can we reach out to Robin and ask that question? Why that word is there? That's important to us. Okay, anything else in this chart before we look at the details on the community engagement process? And I did do some I don't think they will matter to anyone other than my spacing here. I did do a little bit of just changing of the different levels so that the lead in language from the subsection a I didn't even change it. It's probably more in the weeks and you care about I just noticed when we were looking for this yesterday that the community engagement process language led came sort of was was put in like it came after the meeting language from a and that didn't fit. So I made it in its own subsection B. That's all. So the community engagement process shall and now instead of informed communities about what's going on, it would include hearing from and sharing information trends and insights with communities about the current state of the healthcare providers in their hospital service area. It moves trends into that earlier part. Oh, I'm sorry, in their hospital service area and then it leads into it continues on unmet healthcare needs in their community and opportunities to address those needs. So it collapses what was two separate provisions into one. So include hearing the community engagement process shall include hearing from and sharing information trends and insights with communities about the current state of the healthcare providers in their hospital service area, unmet healthcare needs in their community and opportunities to address those needs. And so that's number one. And number two is provide opportunities at all stages of the process for meaningful participation by employers, consumers, health care professionals and health care providers, including those providing primary care services for volunteers who have direct experience with all aspects of Vermont's health care system and for moderates who are diverse with respect to race, income, age and disability status. So it's taking I think really most or all of the same elements but package them packaging them a little bit differently. Ready for C? Yes. All right. C is that the agreement care board shall use a portion of the funds appropriated in subsection A and this takes out the language about collaborating with the blueprint for health. So they would use a portion of those funds to contract with a current current or recently retired primary care provider to assist the board in assessing and strengthening the role of primary care in its regulatory processes and to inform the board's efforts in payment reform and delivery system transformation from a primary care of perspective. So Senator Lyons, you said I brought up that primary care advisory group yesterday and you said that you had something to say about that. Do you not think that that's an effective group or I think it's a great group advisory but this person or in this consultant would have a different authority and that is could weigh in independently and collect data independently. An advisory group would be a group that's asked on behalf of the Green Mountain Care Board and this would be something a little different. I think we also heard from Patrick Flood that having the independent voice was something important rather than simply advisory. So I think this is an important addition. And would this be the way it's written, Jen? Is this a permanent day or attempted? No, they would be contracting with someone using a portion of those same funds. Okay. All right. And then no changes in subsection D. Those are the two reports, the update in November to the Health Reform Oversight Committee and the report in January to this committee and other legislative committees of jurisdiction. Section three is a new section and it may actually be largely replaced by what Dina is here. Erin just hopefully bring it out for me. Dina's proposed language. Oh, and I do see no one has his hand up. So I don't know if you want to stop. Yes, for that. Yes. I didn't see your hand up. So go ahead now you're right next to me. Sorry, I'm a little slow. I have a hard time finding my hands sometimes. I was just thinking about that primary care piece. I might one suggestion might be to end or someone with primary care experience. So a lot of times you get people who aren't retired, but aren't practicing anymore, and do a lot of this type of work.  So I don't know if you want to say or has primary care experience, just trying to think about ways to broaden that pool because of people who have the experience you're looking for. I don't know that I mean, I'm not sure if somebody was not currently practicing, but hadn't retired, that they would necessarily be unable to fulfill this role the way with current retired. I think the intent is clear that it's somebody who has practiced fairly recently. Okay. Just as someone who's been doing a lot of RFPs and contracting lately, I've learned that as soon as we get caught up or the language can hinder more than help. So I'm just trying to make sure. No, I think I think Jen is right. Yeah. Thank you. Okay. Okay. Did you, Jen, did you want me to just double check and see whether they're going to go ahead? Never mind. I'm just I'll do it myself. Go ahead. Okay. So the next section is new. It's a proposal. It's a proposal from the group about including Medicare and payment reform and delivery system transformation. I'm not quite sure how it relates to this language that I also have from Ena that's the same 600,000. So I'm not sure and I don't believe there's necessarily consensus on the language that Ena provided. So I'm not sure how you want it. I'm not sure how you want to approach that. We'll look at the language that's in the bill for now, maybe, and we can figure out how this other proposal fits. Do you have, do you have Ena's language? I do have Ena's language. Aaron printed it out for me. I came in this morning while I was in the middle of Yeah, that's what I was just going to look for. And then why don't we go through the language that's there and then we'll come back and look at Ena's language. And we can talk about that. Great. So as written right now in the bill, the 600,000 would be appropriated to the Green Mountain Care Board in FY 23 to support the board and the director of health care reform in AHS in the design and development of a proposed agreement with CMMI, which may include engaging, consulting and analytic support in order to include Medicare and Vermont's payment reform and delivery system transformation initiatives. And it would maintain this language saying the board would ensure any services it procures with the funds are supplemental to and not duplicative of analytics and other support available through AHS. And it would have a report due on January by January 15th on the use of the funds and the status of efforts to get Medicare participation in Vermont's payment reform and delivery system transformation initiatives. So what was section three is now section four, but it's a totally different section four. So this was the language that had been looking at updating the statewide HIT plan to recommend ways to connect clinical and claims data through an enterprise master patient index and work with other systems that are already in place in Vermont and include social determine of health data and potentially integrate with other unique person identifiers in other state agencies and departments. Have you heard about this about Eunice proposal on this yesterday? So this is believe her language, but also came from the stakeholder group. So I think that was general agreement on this from the stakeholders. And this would instead direct the health information exchange steering committee to continue its work to create one health record for each person that integrates data types to include health care claims data, clinical mental health and substance use disorder services data and social determinants of health data. And for the rest of these goals, the HIE steering committee would include a data integration strategy in its 2023 health information exchange strategic plan to merge and consolidate claims data and be here with the clinical data in the health information exchange. And it would continue to appropriate 500,000 to the agency human services for this work. I don't know if that funding is necessary. That's the right amount. But this is the other 500,000 that came from the original. What was a three three million dollar appropriation and now a 2.5 million appropriations degree master for the deliberation. It kind of doesn't I guess the the amount is going to depend on the extent to which they're they work with a variety of organizations and practices. So I don't I don't know whether this is accurate or not. That's all I wanted to flag is a legacy number from the prior version. Right. We could. Yeah, I see. I suspect it might be less than that. But if there is any if there are any capital expenditures that go out to various organizations or clinics, it could be more than that. If there is software that provides linkages with various organizations, it could be more than that. I don't know. Nolan, do you have a thought on that? I was going to suggest I would reach out to the Green Mountain Care Board to see what they think the number should be. Since they're the experts on this and then maybe leave it blank. Yeah, I like Jen's term legacy appropriation. Jen Nolan, do you want to reach out to Robin? Or I'll reach out there and I'll see you then. Thank you more. Inna, this is her proposal and it's all right. Inna, OK. She heads up to make a exchange during Kate. Got it. I'll do it right now. OK, terrific. This basically sounds like this language is just keep doing what you're doing. Language, it's not anything new. The first sentence directs them to continue their work. The second sentence does direct them to include a data integration strategy in their next strategic plan. So that may be something that they were not necessarily planning to do, but I don't know. Yeah, that's a good question. Are they, is the money actually being utilized to take a step forward? A plan is a plan, but action is action. Well, and if this 500,000 is base funding, that's already they already have, or if this thing. Yeah, I don't know if it's unclear. And then in the next you haven't gotten to the next session, but section is to consolidate the data of individuals. Right. The idea being, and this is one of the recommendations I think from Donna Kinzer and and from the consultant to the affordable accessible healthcare task force about really trying to take more steps to get integrated records so that you have so that so that providers can be looking at more information about their patients than just the services that that provider has delivered and they can get information on their social determinants of health and and services they've received from other providers around the state or around the region so that they're getting a full picture of the patient when the patient is in their office. I'm not. And to set up this question, whether it's new funding or well, this would be new funding and I think the question is, is there work that's going to be done as a result of this language that requires an additional 500,000 or is that work that they're already doing, they would be continuing to do and we have since that additional funding, in which case you might use it elsewhere. All right, are we ready for section five? Section five is a new section. It's not it's not new statute. I mean, it's an existing statutory section and it's this is the statute actually on the cures so we don't use the we're not sure we use the term in here, but this is the all care clients database for Vermont and I can't recall if you have had testimony on this or not, but the House Health Care Committee has because the same section was in the Green Mountain Care Board's bill that they put forward this year, H-498 and this would, so this language, the change in the language is on page 10, there's a lot of existing language that is here for context and this proposal would delete language in the current v-cure statute that prohibits information from being provided to the board in a way that discloses the identity of patient and so this is important if they're going to do if they're going to be able to do the work that was being described in the previous section about really being able to combine all of the information about a person they're going to need to know who the person is even if after that information is made available from the cures to others as it currently is for research purposes and otherwise it would need to be de-identified again and that's what a lot of the HIPAA language includes about and so that's why you're seeing so much extra language because there was interest among the from the board in making sure that members were aware that they're still all of the same HIPAA protections in there that would still be in there it would just allow the information to be provided to the board in a way that does disclose the identity of the patient so that they can it can be used for the exactly for matching. Yeah I think we talked a little bit about this with the Donna Kinzer report when we were talking to APMI so yeah okay. Right so the idea being if you're going to have some kind of a master patient index which is the MBI card of the MBI then you need to be able to to identify the patient in all of the settings that they're getting you services from which sort of necessarily requires that they that the information not be de-identified so be identified when it comes in. Yep. Madam Chair. So I guess I totally understand why they're asking for this but just scrolling through this current law language I just want to make sure that that I mean it says compliant with HIPAA but then it also not withstands something about HIPAA the current language the current law language in D. But I think you'll like that notwithstanding HIPAA I don't know really why notwithstanding HIPAA particularly but it says the comprehensive health care information system shall not publicly disclose any data that contains direct personal identifiers. Okay that seems contradictory because it's notwithstanding. Well they're not. I'm not sure why not with this existing law and I don't think I wrote this one um I'm not sure why notwithstanding HIPAA other than perhaps there are circumstances under HIPAA where they could disclose that and they're saying even though we could we won't. Okay um where they or even though they could they they can't even though they could under constantly under HIPAA. Is there another part of statute that you know of that requires them to use certain data security processes or whatever because if they're going to have I mean I know that a lot of this already happened so this is right it happens already out of this bag but understanding they currently get Medicare data that is not de-identified. Right. That's what I've heard in testimony from the board. But does the board have any higher level of data security requirements or does the state just in general um just given how much data they would have with people to actually. Right I mean yes there is actually this issue came up as the chair may recall in Elkhart um couple best context of V-Cures um yes there are some existing requirements and the board has this information so I might I know Robin's been watching so I might ask Robin to follow up with the committee um with the the data security information that they provided to Elkhart because yes there is a fair amount of and a lot of that goes into who they contract with to maintain V-Cures and how that data is secured. Right and how they how they have to write their contracts so the end contractor who sees all this data is exactly so there's so some of that I think is in here with the way that they are able to provide um so for like on page 11 where it talks about um collaboration for creation of or development of limited use data sets the criteria and procedures to ensure that HIPAA compliant limited use data sets are accessible there's also to the extent allowed under HIPAA the data is available as a resource for various various parties to continuously review utilization and then there's also I get you to this all sort of running through HIPAA and that's my understanding of where they end up and would continue to have to de-identify the data um so so you might be able to tell that it's the same individual person who is getting various services but not who they not in any way to determine who they are. Yeah I I guess just um in finance um we have had this where we've where we've asked the tax department you know about sharing data and using it for analysis or where you know whether somebody could be eligible for a certain program based on their income level at center the tax is extremely tight with their data it doesn't share it with most people even for even de-identify or you know or it has really so I guess I want to make sure that maybe there's not I want to make sure that I understand the level of data security that's happening. Yep and I really touchy data. Very much with the path that Elphar was on a couple months ago and I would encourage either you to reach out to the board or the board to reach out to you to describe. So Jen let me suggest Erin that you uh can you communicate with Robin who is probably watching and ask her if she would I I think you could probably hear the jets right now uh but if you don't mind Erin communicating with Robin and sending her a zoom and she may want to join us uh for a little bit of discussion after we've gone through the bill and Nolan you have your hand up. Yeah um as someone who recently had to go through a DUI process to get de-cured. A DUI. Oh Nolan. Can we go back and fix the record? I don't know what you're talking about. Anyway is someone who just uh beat a DUI? No um just went through a DUI I will say that the board was very very very rigorous. It was a DUI. To be able to have Joshua Slend's group use data we had it took us almost two weeks to negotiate the DUI and to fill out all the paperwork that they needed so I would I can vouch for the how rigorous and protective the board has been and is on their data. Okay thank you. Good luck with that ticket. Any good lawyers? Okay so uh why don't we go ahead I'm going to mute myself when the playing goes over. Okay great um so section what is now section six is the blueprint this language itself has not changed it's adding to the blueprint specifically uh an initiative on the use of quality improvement facilitators and other means to support quality improvement activities including using clinical and claims data to evaluate patient outcomes and promoting best practices regarding patient referrals and care distribution between primary and specialty care. Section seven what's now seven is um just just uh I know Patrick Fudd sent something on blueprint you want to go through it now or hold later. I think it's the next section. Okay yep okay because of the way things moved so yes I was tracking that I think it's this this section we're about to start. So what is now section seven blueprint community health teams and quality improvement facilitators this would continue to require by September 1st the director of health care reform and the agency payment services to recommend to the health reform oversight committee the amounts by which health insurers and Medicaid should increase the amount of the per person per month payments they make toward the shared costs of operating the blueprint community health teams and quality improvement facilitators with a goal of increasing each plans or pay or spending on primary care until primary care comprises at least 12% of the plans or payers overall annual health care spending using the calculations determined by the board in accordance with the 2019 act. This language here in blue was suggested by the Vermont Medical Society and it would say such increases shall be reflected in health insurers plan year 24 rate 2024 rate filings if the increases cannot be implemented in a rate neutral manner. It would require the agency also to provide an estimate of the state funding that would be needed to support the increase for Medicaid both with and without federal financial participation and then Patrick flood recommends adding funding for the blueprint shall be sufficient to cover the actual costs of primary care practices implementing these provisions. That'll give her applications to appropriations. I sure will but you know what it's important it's a it's an important statement to be made but we're losing primary care practices I understand. I got it. I'm sure we'll come back to it senator. Yeah it's a good job. I gotta mute myself.  What do they do with still flying over the house? Get there a lot of time. The only the only thing I can say is it's I'm glad it's not three o'clock in the morning as it was a bit ago. I thought those clients went to Poland. What are they? They went to Germany and I guess I don't know where they are now. Yeah they were from Utah that you're still here. I thought ours what? Ours are right over my head. Over your head okay. Let's hope there are senator over your head. Oh where are we? There is my hand tube. It's confusing um and you can't use the whole hand. Exactly both hands um I still remain just a little uncomfortable with this 12 number. I know it was in some study in Rhode Island and I know that we have repeated it in our work here but it's not based on Vermont and it seems pretty arbitrary. Um I'm at page 13 um line eight. It's not not blue. It's yeah it's the it was already there. I mentioned this a couple times. I just don't like using date like numbers that are not based on anything. Yeah I I'm you know spending on primary care until primary care comprises at least 12 percent. We're just spending money on primary care doesn't mean we're doing more or better primary care. It might just mean that everybody's raising their rates. I mean I well it also depends on what codes you include and some people include different codes. So but but we're also talking about value based payment so we're getting away for fees for service. We'll be eliminating a lot of codes or bundling them together the way the blueprint does. So I you know there has to be a way that we that we put money into primary care. One of the problems is that as primary care is prevention it's the upstream activity and it is lower reimbursement and lower payment and people are having to put out a pocket and other expenses so we're trying to offset that. Based on repayment rate Medicaid it would go a long way. I get that Senator Lyons and I want to do that. I just don't think that naming this random or semi-random I know it was based on percentage well do it and I think that you know there's a lot of ways you can you know make the data get to 12 percent without actually increasing spending on primary care. Okay so let's I think right you had asked that question yesterday how far away from 12 percent are we in the state? Well it depends as we heard in testimony it depends on the payer so one payer might be 15 percent and another one might be eight or nine percent so trying to get everyone at a level that will ensure some sustainability of prime for primary care. So what I'm going to suggest is we also have Patrick Flood's language and let's go through let's complete going through the bill we flag this one because I know it's been something of concern and then we've invited Robin to come in and others who worked on the language to be here with us so if they come in during this meeting we'll be able to get their thoughts as well. Hey. Alright so Erin and just to just to Erin I did send the email out that the folks who wanted to be on Zoom and it's perfectly fine to invite them in they can sit and listen with us and then we can call on that on them as needed. Robin is here you want me to let her in? Sure and we'll we'll call on her at some point to go through some of the questions that we have. So do you want to continue walking through the bill for now? Let's keep going yes Jen please. Okay so the next section is the moderate needs supports and this would continue to require Dales to convene a working group with representatives of older Vermonters, community-based service providers, the office of the long-term care office, many agencies, human services and other interested stakeholders to consider extending access to long-term home and community-based services and supports to a broader cohort of Vermonters who would benefit from them and their family caregivers including the types of services and I don't know I've not made any changes since yesterday I don't know if you want me to go through all of the language here. No I think unless somebody has a question we've been through it a couple times. In the category so they would be looking at the types of services that many Vermonters need older Vermonters need but may not be eligible for or aren't covered, most promising opportunities to extend those supports, how to set the criteria for the extended supports, how to fund the extended supports, how to proactively identify Vermonters for the greatest need for these supports, how best to support family caregivers and the feasibility of extending this access to the impact on existing services. And that's Patrick Flood recommends adding a new subsection be here that would say that the working group shall make recommendations for changes to service delivery for persons duly eligible for Medicaid and Medicare to improve pair expand options and reduce unnecessary cost shifting and duplication and shall request from CMS any necessary waivers to implement the proposed changes. Not sure I'll put it there but anyway and then existing subsection B says the department must collaborate with others in AHS as needed to incorporate the working group's recommendations into the agency proposals and negotiations with CMS for the iteration of Vermont's global commitment demonstration that will take effect following the expiration of the demonstration currently under negotiation. Doesn't look quite as bad without all those strategies. Yeah so is there any let's give us a clearer time for if you have a negotiate one at last a set number of years but then there's options to extend or we end up extending so putting a date certain and it seems a little yes dangerous question here does anyone disagree with adding the dual the dual folks Medicare Medicaid folks recommended by Patrick Flood I think that makes a lot of sense you have the language I don't know if you're you have it okay so you know I think there's there's a lot embedded in this one sentence because it not only requires them to make recommendations but also to request any necessary waivers to from CMS to implement those changes yeah and you may want to hear about them before they proceed I agree we should take that out and there is already a thing about that reporting back to us right yes yes that's the next piece yes yeah you see all right so so I only put add Patrick's the dual eligible but taking out the right going ahead make the recommendations first and then yeah add to report all right so I'll make the changes I'll add in this concept of looking at the dual's issues but not the reference to pursuing waivers I will add a reference to them in the report as well so they'll look at them and they'll talk about them in their report all right almost to the end here second what is now section nine is to agreement on your board reports and the requirement that they summarize and synthesize the key findings and recommendations from reports for what prepared by and for the board and that all reports and summaries prepared by the board must be available to and understandable by so I want to read this and this question to that the public and posted on board for that okay that's great hey Jenny yes Ena's available if you want to her to join oh yes please I have her join Aaron did does Ena have the zoom okay good that's good and when they when when Ena comes in please put her right in the room with us okay and because this will help we can get into a more of a conversation mode the the question I have is we have language from Patrick Fludge and maybe at this point could we go through that language I missed one which one I missed one piece of it because it was not in section order so I didn't notice until we're after after okay so the other piece of language from Patrick Fludge is it would be in section two and he recommends adding any new subsection C I don't know if we put it somewhere if you wanted to that was directly agency human services to identify the funding necessary for so this is in the delivery system transformation out there this is in the delivery system transformation community engagement process this would direct so so far the money is all going to the agency of I mean sorry to the green mountain care board to this working consultation with the director of health care reform and agency human services I'm not sure this is exactly the spot for but he his language would direct the agency human services to identify the funding necessary for community agencies to effectively implement the redesign is the redesign here and provide the proper level of services to consumers community agencies shall include a minimum of federally qualified health centers designated agencies home health agencies area agencies on aging adult day providers residential care homes nursing homes homelessness service providers and agencies so you know it's you know we'll be here and then I think we should hear from you know and also Robin this may have been discussed yesterday with the group but I know that ahs will have something to say about this it does it does provide for some discussion of continuity of care between and among our various types of provider types so I think it's an important issue to address some way at least a conversation at this point go ahead Ruth Senator Hardy thanks I'm wondering I don't disagree with this language but I'm wondering if it do you know Jen if this is similar to what's in S1 or H153 no that's really looking at increasing their Medicaid payment rates and creating a methodology for you know for for ongoing inflationary investing oh okay this is about redesign I see this is about redesigning what it was cost to implement the redesign so yeah I mean think care management you think referrals think keeping people from acute care moving into chronic care and how that happens in a seamless way that's kind of the way I've been thinking about it I know I don't know the extent to which we need to have a total and complete analysis of every little detail that's there but rather how do we move people from one care type to another so from the hospital acute setting into a long-term care facility with supports they need or into a place for ongoing counseling some of those issues Senator Cummings go ahead yeah I'm just wondering if that's what he's asking or if he's asking us because we've sat in this room and we've done healthcare reform before and then the total cost of that comes in and sticker shock sets in and it dies and I'm wondering you know while we're going through this I think he's saying and we need to be cognizant of what what it would cost to do it I keep telling people that are emailing me about healthcare reform you know and other countries have done it please remember those other countries pay a tax rate about 50 percent it's not you know it's it's not that you're going to get more and pay less necessarily it will just be more fairly distributed yeah yeah this is the rock in the hard place it's expensive yeah we should all die earlier it would be cheap oh no don't do that we're going to get out of the pandemic I don't like that solution anymore long time fast so I think it may also be going to see if the sort of goal effect of the transfer delivery system transformation is to move more care into the communities looking at whether the community settings are are well placed to be able to provide additional services to more Vermonters who will be coming in that in that door it's nice so we're going to do it make sure they find it right which I think is is kind of the idea that you had in the or there was conveyed to you in the moderate needs group expansion is you know we we can't expand the services that we provide to older Vermonters we don't have the workforce available to do it so I wonder if if we added this I'm just trying to make sure I understand what he's asked for to identify the funding and capacity because it's not just about funding it's also workforce it's about facilities right and it may be so I mean I think it may be helpful if if Patrick is wondering to um to have him clarify what he is proposing maybe not in legislative order but in just a description and then also to see what it is that you all want to do with language yeah regardless of what he's proposing you may decide what you want to find out about this is about capacity and workforce as well and FQHC's do we even have any oversight over them I think they would want to be participating in this they participate in a lot they I think voluntarily participate in a lot of the reform activities but I think that again some of this might I think they may be concerned about what may be coming their way as far as this domain for services if more cares transitions with community side let's let me ask this question I have two questions uh one Erin I just sent you Ena's language and I don't remember whether I already sent it to you or not for the share with the committee to print out for the committee yeah do you have Ena's okay I've sent it twice that doesn't begin with the sum of six hundred thousand yeah okay okay you have it then so then my other question my other suggestion is that maybe we could ask Robin to join us and we can have a ask questions of Robin thank you for being here so what the Ena language this is new language to what we currently have in front of us and Robin have you seen that I have seen it thank you okay all right good and then so I'm I'm interested then Jen we've identified some places where we have questions for Robin I think you've also been listening in so we we'd like to get a sense of the what the group was thinking and then why don't you give us your thoughts at this point after hearing our uh discussion sure um thank you Robin Lunge I am a member of the Green Mountain Care Board so the group yesterday that met um but you've Jen has walked through the the suggestions I think what we were trying to do is work towards some common ground around issues that various people raised one area and I certainly don't want to speak for Ena but I will say that one area that did come up that was of interest of the community providers was having this new section around broader reform that AHS is leading to be clear about the role of community providers I think uh and again I don't want to put words in anybody's mouth but based on the discussion my takeaway was that there was some concern about having the language embedded in the Green Mountain Care Board sections because we typically don't regulate those providers um and so I think this general concept of adding this new section was um supported generally I don't know that people have necessarily seen the language so um you know there may be language issues I don't know that so so here's my suggestion I think before you continue unless you were gonna I would I think let's have Jen go through the language with us that Ena has sent so that we can get a sense of where it would be and then obviously the question that we have had we've had is about the $500,000 for HIE and then the $600,000 that's here and the distinction between those two so Jen why don't we go through Ena's language and then we'll get to the funding piece great and can I just clarify and Robin I don't know if you know the answer to this is this would this potentially go in instead of the section three that is in the bill to $600,000 I think that's Ena's proposal but again I don't want to speak for her what I included in section three was the existing appropriation to the board and the reporting associated with that from the underlying amendment and we I do want to be clear the board does feel that it needs those dollars to support it's part of the work in the all pair model agreement as an independent board we need to make sure that we have our own resources separate from the administration and can appropriately participate given our role as the regulator and you know we have been very clear that we welcome AHS's leadership in healthcare reform I don't know their resource situation so I don't want to speak to that but I'm not so I'm not sure exactly what you know was intending I but my impression was that it would be a substitute thank you sorry for section three for section three yes okay okay so let's briefly look at section three so the existing section three is that language okay six that would appropriate six hundred thousand for the board and the director of health care reform to develop design and develop post-agreement with cmmi to include medicare and vermont's payment performance delivery system transformation initiatives okay and then keep keep going go right through do you want me to do enos proposal or yes please yes please enos proposal instead I think instead would be to appropriate six hundred thousand to the agency of human services in f y 23 to support the director of health care reform in consultation with the green line care board to develop and design a proposal for subsequent agreement with medicare for medicare's continued participation in multi-payer value based payment models in vermont the proposal will be informed by the community and provider process which I assume is the process in section two which I confirm to reduce inefficiencies lower costs improve population health outcomes and increase access through essential services maybe it's sections one and two the design and development of a proposal shall include consideration of alternative payment and delivery system approaches for hospital services and community based providers such as primary care mental health substance use disorder services skilled nursing facilities home health care and long-term services and supports says at a minimum the alternative payment models explored shall include global payments for hospitals geographically or regionally based global budgets for health care services existing federal value based payment models and broader total cost of care and risk sharing models to address patient migration patterns across systems of care the alternative payment and total cost of care models shall include appropriate mechanisms to convert fee for service reimbursements to predictable payments for multiple categories of health care providers as specified above not sure what that's specific to the models shall also include a process to ensure reasonable and adequate rates of payment and a reasonable and predictable schedule for rate updates any potential models must also meaningfully impact health equity and address inequities in terms of access quality and health outcomes okay so thank you that's great i agree with you about that as specified above maybe that so ina is here ina do you want to say a couple of words about this language that you shared with us yes happy to thank you ina beckis director of health care reform at the agency of human services we did work on this language to propose to the committee related to our testimony as we shared yesterday where we feel that if we are looking towards potential future agreements with our federal partners and certainly if we are carrying forward our health care reform objectives which are are to be inclusive of of the health care continuum that we need to be considering total cost of care models certainly in companion with other models that are considered as we explore and develop a next a next potential a proposal excuse me for a next potential agreement with medicare we want i think it's a principle that we share that we all want to see medicare continue to participate in alternative payment models in vermont and consistent in a multi-payer model and to do that we need to go forward with a proposal to cmmi for how medicare would be participating in the state specifically okay thank you and so the question i have then we're hearing all of this and then we're seeing a six hundred thousand dollar sort of appropriation and then later on we're seeing five hundred thousand dollars can we talk about that distribution a little bit and i would like to hear you know both from inna and robin on this uh because the i think the five hundred thousand goes back to section a um can we just talk about what funds are required for the work that is in the bill as proposed right now so who are you i guess i'm not there i mean i can show you where the money is in the bill yeah let's do that okay so there is 1.4 million in section one for the green mass care board for the value-based payments designed for hospitals there is 2.5 million in section two to the board for the delivery system transformation both the community engagement consultants and the health system design consultants and there is six hundred thousand in in both in section three in the bill right now it just in the draft we've been looking at to support the board and the director of health care reform in this proposed agreement with cmmi and also inna has the proposed i think the same six hundred thousand to the agency human services to support the director in consultation with the board to develop a proposal with the basically with cmmi and then there is five hundred thousand in section four to the agency human services for the health information exchange steering committee work on creating one health record for each person okay let's i think inna nullan may have reached out to you about the cost of doing the work on the hie uh previously and it would be helpful to us to know the the work that's there is really continuation of the steering committee work and then planning and so the question is it doesn't look like there's anything different from what would be in the current budget for the steering committee so what how is the five hundred thousand dollars going to facilitate that work that's currently going on thank you for the question um it is and does build on the work that the steering committee has laid out um as you saw or as you can read in the language um we're looking uh to inform the 2023 strategic plan with us you know a specific uh task in terms of the integration of the claims and clinical data and a data strategy to support that very specifically uh we do have work um that has been it will be initiated uh to support a data strategy for the next hie plan update but with regard to this particular project i think that the scope um would be expanded for that work and we would we would like to see some resources to focus very specifically on that task related to v carers and the hie so the question is because the five hundred thousand dollars to be quite honest was like a placeholder that i suggested to gen a long time ago but we don't have any backup information to demonstrate what the actual need is from your perspective yes and i as i was communicating a little bit offline with with no one i was working uh with my team to get a little bit more of information there um as as we um you know we certainly contemplate a a piece of this work but we would be accelerating it um with this planning process okay so it would be helpful for you i think to continue to work with no one and get us a more concrete estimate of what's needed there that would help so then we'll then we'll set that one aside for now and then move back to the language that you have and with the recommendation the a hs take the lead and consultation with green mountain care board and we hear exactly the opposite from the green mountain care board so uh there they're neat i know that in the past you folks have worked collaboratively on this so is it just is it a matter of language here and who's i'm just trying to sort out how we can resolve the differences because i think it's really what what's in the language in terms of uh including community resources and services is uh going to be critical in the design and transformation process so what is it here that we can how can we build some language that will satisfy all of us thank you um so i will just speak to the board's piece which is um as you know as part of the hospital sustainability work uh we included an estimate of the funding that we believe the board would need to support including that type of work in the all-pair model agreement as you know the prior agreement what it's co-signed by the governor's office the governor himself in fact the hs secretary and the chair of the board as an independent body it the board's regulatory role in the all-pair model is currently setting the medicare ACO rate and we are the entity that provides total cost of care and quality reporting to the federal government under the current agreement so i would depending on how the new model evolves our role we think will continue in terms of hospital regulation that that will be a piece of it in the hospital space and since we have the staffing expertise currently on statewide total cost of care um i think we we wanted to make sure that we had resources to support um proposals for the next agreement around those areas that are currently in our wheelhouse so um you know when we did that estimate we did it for uh the work that we were anticipating would need to be done and as parallel work to the hospital sustainability so we do feel that um and absolutely we need to work together we do work together we work together actually quite well um i do think though the board is an independent board and we do need resources to support our part of the partnership because we're going to have to vote on it in public after a public discussion so um you know certainly that doesn't diminish necessarily a hs's need for additional funding and we would if they need additional funding i certainly they should speak to that and and we wouldn't we wouldn't we were not we're we're supportive of that but i think that doesn't diminish our separate independent need for resources so the question i have of you is as we're looking at the language that ena has brought to us and just simply um just move down to the second and third paragraphs uh that is is it the intent of the board to also to include this uh evaluation and this info work within the within the um appropriation that's in the bill so we had not uh the 600 000 that we included we were looking at the work we thought we would need to do so um but no the question is yeah does that include the regionally based global budgets for health care services existing federal value based payment models and broader total cost of care risk sharing models to address patient migration patterns etc etc and then in the in the previous paragraph the the alternative payment delivery approaches for hospital and community based providers such as primary care mental health so on and so forth it certainly be it would be inclusive of some but not all of this work so for example uh alternative payment and delivery system a system approaches for hospitals is in our wheelhouse uh we currently do the total cost of care uh reporting to the federal government as well as the quality reporting in the prior agreement the board brought stakeholders together on the quality um framework and uh we currently look at risk sharing models uh in the aco program as part of our regulatory process so i think we would need to work out with a hs the work plan of exactly who was doing what i do think some of what's included in the languages in our wheelhouse and i think some of it is not some of that is squarely a hs is uh expertise and and that's exactly i think what a hs is saying here and so for us i think there is a compelling reason to move forward on the evaluation and the work the a hs is presented i think it's something that we care about in our committee so to for full integration uh for a consistent system of care so so how can we how can gen modify the language so that we so that the work is getting done uh in a collaborative fashion so that i think that's the issue and then the funding piece of course is key i know that the green mountain care has presented one one proposal to us we've also looked at other consultant reports and we've heard from a hs and each of those are critically important in the decision-making process so i'm pushing back a little here because i think we'd like to we'd like to move forward uh with the work that is suggested here so listen listen to robin and then i see you senator hardy thank you sure so i think what i would do is i would separate out the appropriation from the work so that uh you can have collaborative language um directing the parties to work together collaboratively on the work and then the committee will have to decide who gets how much money for each of us separately to support that work okay so that would be my drafting recommendation or suggestion i'm happy to think more about it or work with gen on coming up with other ideas if that okay let's work okay that's helpful senator hardy let's go to sheila livingston and then we'll come back everyone sheilding stand policy director for the agency of human services for the record thanks for let me hop on um i i hear robin's point senator um but i think that it is really important when we're talking about policy and work and input there is not i don't believe there's a way to separate out the money in this case because that is that is what's going to fund what actually happens um so i just i want to just put that out there it's an uncomfortable truth it's the truth um and then just the question of you know collaboration that the green mountain care board is asking for a substantial sum of money to do a lot of this work um for hospitals specifically and this piece is much broader and i agree with robin that we work with them very well and i don't know um that i feel sort of the i hear that you need to vote on that the board needs to vote on it publicly i i can understand that but i think that the work that needs to be done is this evaluation and that that information can then be presented to the board by hs and we can take their input and work with them on the design again collaboratively and since they are getting the vast majority of the funds in this bill to do work specific to global hospital payments and we will work with them on that well well they direct that funding and i'm a little confused with how that doesn't then go the other way for the specific part of the bill and that would be my argument for why a hs would would receive that funding okay thank you um senator hardy yeah i guess that my understanding when this 600 000 was first proposed by the green mountain care board and and hs didn't get any of the funding was that hs already has a budget to do this work that this is this is the renegotiation of the agreement with cmmi and that that um it now seems like this proposal that we just got from hs significantly expands this to be something that's beyond negotiating the agreement with cmmi which i'm not opposed to but it seems to have drifted into something different and and that's confusing to me and i also think that the 500 000 for the work that they're already doing for the hie is excessive so i'm wondering if we could just take the the 600 000 and the 500 000 that together and then split them in half and a hs gets 550 000 to do both of those things and the green mountain care board gets 550 000 to do the the work on the cmmi because i believe there's already funding in the budget for this work for a hs and no one might know more than about it but this proposal came to us as a proposal from the green mountain care board and now it seems to have so senator you've made some good comments here and that's why we asked knoll and the work to identify how much money is needed so that maybe some of that can be shifted a line item shift over to a hs for this other work um i know and the suggestion that you made about splitting it down the middle is um a good one something that we we certainly can consider uh i'm interested in ensuring that we have language that it saw that builds collaboration and addresses the work that is um in there for our community services because you know as we said this will continue to be an important part of the coordinated system of care so let's hold let's keep that on the table uh in terms of splitting the total amount the 1.1 and splitting it in half and we need to know what is through knoll and what's currently in the budget and then what the actual request might be so other questions or comments senator hooker i robin mentioned that there was an overlap so some of the responsibilities between a hs and the board and i wonder if you know we could find out what that overlap is so that there's no duplication of effort when this money is appropriated good question sir i can jump in if that would be helpful sure okay um so the board the board's current currently i would say there's not overlap in the roles um our role is as the regulator of hospitals and uh accountable care organizations and as uh the entity that does reporting to the federal government in relationship to the all-pair model metrics which are statewide total cost of care quality um and the scale of the aco program so how many people are participating in that uh i think that for the work moving forward we would necessarily work collaboratively in our spheres um to move forward with a proposal to the federal government because the board is a public body um no one or two board members can bind the board so in order for the board to sign on to a proposal it does need to come through the public meeting process and we would need to take a vote that does mean that we do need some independent analysis and ability to analyze the proposal that comes before the board so i don't think it's so much that there's overlap um it is collaborative i do think there's kind of these two pieces that work together um to make a whole picture i don't know if that helps senator yes thank you questions or comments so we are going to drive for solutions i think that senator hardy has offered one that might be very helpful um nullan you just appeared yeah well go ahead no no just um i um i've been reaching out to i've asked ena and i'm going to reach out to hs folks just to find out what they do have in the budget um specific for the negotiations and how this differs um so i i don't have an answer right now but we'll try and i don't know that ena may not know either at the moment uh if she does i'll let her weigh in uh i just didn't want to go around her now thank you and the thing is that as i look at this in the context of healthcare um system design and transformation there there are certainly can be additional costs associated with the work that has to be done so i don't want to diminish the need for funding for the work that ahs may may have to do would have to do so i think that is still important and i think uh we'll keep that money there that's some of it somehow go ahead senator hardy i'm sorry can we let ena weigh in i think she was trying to answer the question okay i didn't see a hand but go ahead yep i um into you know i so ahs um does have um contract support at this time with um some planning around the all-payer agreement um that contract supporting is also relative to our 1115 waiver and as you know the 1115 waiver does need to work in companion to a all-payer agreement um but i wanted to echo and reiterate the comments around the collaboration that is necessary to move towards a proposal for our next agreement um there are three signatories on that agreement with the governor the secretary of the agency and the chair of the green mountain care board each being one and we do have particular roles um in um the work that happens and the design and um proposals that go forward i think it's really as the director of health care reform i think that there is a particular role in terms of those of the innovation um the the design and the board has its role as robin described in terms of regulating and and uh regulating in any future agreement as well um but that is uh that is different than where the director of health care reform has a particular role and in envisioning and supporting the work um to move towards a collective vision for a future proposal i think that that's where the innovation and design work may fall more with the with the director of health care reform in that position um and the agency of human services as well again we have to work with and we do work very regularly and well together um but i think when we uh are looking at the bill and wanting to be sure certainly that the hospital global payments are accompanied by some overarching um payment and delivery system reform design that we we need we need additional funds to be sure that we are um looking at a model looking at hospital global payments among other strategies and being sure that we have um a design that envelops those potential hospital global payments in some other frameworks that would it really encourage and and maintain um the innovation that we we do see with providers uh working across the continuum Senator Hardy go ahead yeah so i mean just i'm trying to look at the the sort of package of the bill just in general and the first section is hospital global global payments or value-based payments so that funding goes to Green Mountain Care Board because that's kind of their bailiwick right so then the second section is the healthcare system transformation the way it is right now the one 2.5 would go to the Green Mountain Care Board but it sounds like some of the things that Ina is proposing in this new section actually go in this section that it's about healthcare system transformation and that that it's not about the renegotiation of the current agreement it's about bigger picture longer term transformation so i'm wondering um about sort of that section and how it's relevant and then the next section is the 600 000 for the renegotiation the Green Mountain Care Board's portion of the renegotiation which is really about renegotiating the next agreement not about not about as broad of system transformation necessarily right now and then the next section is the 500 000 for the HIE for the technology stuff and that seems like that's work that AHS is doing so it and I understand that there needs to be collaboration on the agreement part of it but I think that there's sort of this uh blurring of the lines here in a way that is not that is uh getting confusing or is unhelpful and I just um wonder I mean what we've heard clearly from the Green Mountain Care Board is they need their own separate funding in order to be at the table for the negotiation portion of that and what I've heard from Ina is that she she needs to be at the table for for the healthcare reform transformation process and the renegotiation but that AHS already has some kind of funding stream for that so I'm wondering if if really some of the stuff that that's being proposed in this new section acts Ina that you sent us really belongs in section two and if there's there's a way to look at that sort of mix of funding there and divvy it up a little bit more I I don't know I'm just but I'm hearing like the senator this is a these are good questions to ask and why don't we give Ina a minute to to respond I do agree that there's some blurring of the lines because there there is overlap of these different activities and and so I think that is causing confusion the different activities each of them have a piece that do inform the proposal for a next potential agreement and I really am talking about the work that needs to happen to inform the proposal for the next agreement and to be sure that we have a framework that is maintaining a total cost of care accountability structure and for instance and that we have the opportunity to explore the various alternative payment models that could best promote integration across the service continuum and the you know total cost of care today in in our current agreement is not exclusive to hospital services it is broader already today and it includes services delivered and paid for in settings that are not hospitals and so that's why it's very important that we continue and look to a future potential Medicare proposal that's also building on that and is working from that current inclusion of hospital and non-hospital services in our payment reform models so my our interest is really in informing that next agreement through the process that we proposed in the language and bringing that forward into a proposal and that language does acknowledge that the community-based process that the board has proposed will have also information that comes from it that I believe will inform a proposal as well and I think that that is the board's thinking also in that regard I don't they should Robin should should agree or disagree but so I do I don't think that what I've the language we put forward is about the community-based process it's about the process of information gathering and exploration that drives a proposal for a future agreement with Medicare okay this is very helpful and a good question senator hardy this is very helpful to us I think so this is what I'm thinking we can we can dialogue this through but I'm going to suggest Jen do you have enough information that might help us and you work with Ena and Robin to put together some language and what is it that you might what is it that you're thinking at this point and I know that we're going to have to make some decisions on this but just what is it that Jen you're thinking is that I don't know that I can draft it I mean if you're looking for me to draft some consensus version that comes from Ena and Robin I can try if they're able to not hear yet I think but I think otherwise it's really up to the committee to decide where you want to go okay but the various proposals we've heard yes I completely agree the the the issue is for us is that Green Mountain Care Board has put together its proposal we have heard from consultants we have heard from AHS so it isn't one it's it's trying to bring these things together so that moving forward the transformation includes both after hospital global budgeting is analyzed and done we also have an opportunity for transformation that is included within the budgeting and in that in that area in the transformation area there are significance concerns within AHS and then that we have also heard from our consultants making recommendations that we could include and should include our community services so that that's where I think we are at this point so Shaila go ahead oh thank you again yeah no I don't want to repeat what you just said it was basically to make that point I think we do have some funding I want to be clear the committee in the BAA for work to to work on both the 1115 waiver negotiations and the APM it is less than the 600,000 which is only a fraction of what that total budget the Green Mountain Care Board is requesting I'm not trying to be difficult here with Robin I respect that they did their budgeting process none of this is in the governor's budget regardless and the work that the Green Mountain Care Board will be doing will impact the amount of work that AHS has to do because when we see these this type of reform happened the hospital system exactly what you're saying Senator Alliance it affects all the services in the community and so with that change we also need to do this this work again in collaboration with them and I think Senator Hardy to your point the question is where does the committee want to see that work done and how is it is it led and once more we work together very well but there is something about funding and who controls that that is important there we have it go ahead this is a conversation time and we're trying to get to some understanding of where we'd like to be so go ahead yeah so I'm a budget person and and so this is really frustrating to me because what we've all we've just had these sort of big numbers kind of thrown around into various categories I've never seen a budget so I know we're not the appropriations committee but we're talking about the budget so the two options are we either get a budget for both AHS and the remount care board like a real budget not I mean the remount care board forces hospitals to do this so I want them to do this if we're going to talk about their money and same with AHS come to us with a budget so that's one option we could do or we could just put the language in say there's five million dollars and send it down the hall and have appropriations do this for them because I think we I'm not I'm not hearing any good justifications for the numbers right now I'm just saying we I'm just hearing we need money which obviously I know you need money to do this work but there's no detail on why you need you know 500,000 or 600,000 or 1.4 million or 2.5 million so that's I like the details if we're going to make this decision otherwise let's ship it down the hall and have appropriations make this decision and we just focus on the language so a good point I don't think we are making decisions about the the total money I think we want to get some kind of a differential differential at this point our goal here is to have the policy in place that would allow for AHS and Green Mountain Care Board to do their work independently and collaboratively so there is money involved in that so the independent work money's needed collaborative work money's needed the policy is who's driving the bus I think the first sentence in the in Enos proposal is kind of the is is the one that is of concern who has all the money so I think what we need to say is that Green Mountain Care Board needs money AHS needs resources and they also need something to help the collaborative process so we we need to define who's doing the work on what and and then Nolan is working with Enos to get a better assessment of the HIE and perhaps we can get a better assessment of the AHS Community Service work that has to go on so I think our job is policy here we we very much care about the transformation piece and we very much care that as we go forward with any changes to our agreement with the federal government that we are including in that transfer transformation it changes that affect not just hospitals but also community services so language might be different from that first line so there are there is an appropriation that goes to the Green Mountain Care Board for its work and there is an appropriation that goes to AHS for its work and I don't know if we can say there's money that goes to both of them working collaboratively I don't know what you have done in the past with funding for your CMS agreement. Sure I can speak to that if you'd like or I can follow up later. Can I make a comment? I'd like Nolan to comment first Robin and then we'll come back. I think that we're going to go around and round. Oh yeah. And my suggestion if you think it's a good idea would be have Robin and Ina go into a back room and hash out a compromise and then come back with a proposal to the committee so because they're the experts. Sounds good to it sounds good to us I think for that to happen I know you've worked hard together on this but you're hearing you're hearing a level of frustration on the funding piece and we aren't the appropriations committee but you're also hearing a level of frustration on the work that's getting done and the goals that we have so go ahead and then. Sure happy to do that of course and also happy to provide a budget we have some additional budget materials we had provided to the house health care committee and the house appropriations committee about the budget ask and we can send in resend in Jessica Holmes this testimony which outlined in detail how we were thinking about the potential contractual support. That's fine but I do think there is an additional conversation that needs to happen between you and Ina that so we can get to some closure on this. Sure of course happy to do that. So we what was the other was there other language oh Jessica Barnard has sent some language in on the section is that so committee does this make sense to you the to have Ina and Robin disappear for a little bit and I don't know whether you can do that in the time that we have this morning but if you can get us something and get it to us that would be awesome. We have other bills to get to Madam Chair. I know don't worry about us I'm worried about them right now. I'm worried about us they can they need to go my question is my question of Ina and Robin is can you go off right now you're welcome to come back on Zoom if you find something but at least to communicate with Jen on some proposal that you might have. Sure I'm happy to give Ina a call I need to actually I haven't something I need to do at 11 that is difficult for me to change but I can talk to Ina while I do that. Okay all right so we will we will let you go and we look forward to any agreement that you make. Thank you. I think that that'd be great so let's go to the email that Jessica Barnard sent and I think Erin has printed out for folks and we can look at that section it's also the section that Patrick Flood commented on on primary care reimbursement issues. Do you have a chance to do so? Okay I think it's good. And I do know we will I think we'll be able to stop pretty soon we have two other bills to look at but I'm not really concerned about the the timing on that we'll be fine. Just to reassure you. I think Jess's language is fine. Yeah I like it too. Okay that was easy. It takes off the percentage but it does yeah it keeps it it keeps the intent and it does take out that percentage that's been bothersome. Where does that go Jen we have that you have a spot for that then? Yeah I would go and say what is now section seven on page 13 it would replace some of the language that is currently in there and may look for a different way to say a goal of contributing to increasing but Okay good. Did somebody want to say something? I just said thank you Jess. She's obviously watching. She is watching. Everyone who's been engaged in this is watching and it's extremely helpful. So Jen. We have sufficient information for are there any other areas of question that we haven't looked at as we went through the bill earlier? I think we've done it. We just have that area of for Green Mountain Care Board and AHS to resolve their differences. Well did we show to all Patrick's and Decide Make Decisions? Is there any one that we didn't include? I thought we We didn't make decisions on some things yet Jen.  Okay so his which one Jen? So his the first page first section under global budgets D and E about this is about assisting the board develop a process for value based payments including global payments from all payers from our hospitals that will and then this would be that will develop options for the design and implementation of a standardized system of fees for hospital education and outreach of all payers. I guess I understand why he's proposing this and I I'm wondering if it might just take them down a rabbit hole looking at fees while they're also trying to do global payments so I would be a little concerned about adding that as an additional thing for that to do. Yeah that's the next step except yeah I agree you need to know maybe what the fees are when you're talking about global budgets and if they're all over the place then how do you determine? Well but this is the part about where they didn't see they will be taking into consideration the necessary cost of providing services so they're sort of moving away from historical charges and looking at the necessary cost of providing services. I mean what if we added in some language to the current C that says something like taking to consideration necessary costs of providing services and the differential fees could currently charge by hospitals or something like that so it gets at that they're going to look at what the fees are that are charged not ignore them but at that time. So that was the that's a good point. I mean the language that we had previously that I think the group has taken out was related to the Green Mountain Care Board dashboard member they were working on the dashboard for hospital. That was in the data collection in the yeah so we could put that I don't know I'm not sure it's necessary I know I'm not sure this is necessary it's a really good idea but I I can't imagine that it won't be in the process so Ruth what was your suggestion there. Take into consideration the necessary cost of providing services and the current differential fees. I'm not quite there yet. Well I guess I'm trying to understand how that then relates to that and not be based solely on historical charges. Yeah I think I think the historical charges really fit. Covers it. Yeah it does. I think it's covered. Yeah yeah as long as it's as long as it's covered because it is a huge issue. Yeah I mean the hospitals are charging all different kinds of fees for the same services and we don't want to bake that into the new potentially new level payments. So and maybe this is necessary. Yeah I know I think I think let's let's let's keep our historical and we might hear some something further but I agree it seems like it's covered. Maybe we take out solely because not be based on historical charges because if you leave the word solely in there that assumes that that it will be partially based on them. Yeah. So take out solely and then say necessary cost of providing services and not be based on historical. Well but yeah here's the here's the issue okay I'm going to forgive me Senator Hardy I'm going to the waiting study where we have different types of students. We might have different types of hospitals you know so solely might be important to the some of the hospitals. Well I think that your point and there's a lot of overlap Jenny I thought about this a lot in terms of policy and health care policy believe me so but take into consideration the necessary cost of providing services. So that would take into consideration the differences of hospitals and the differences of patients. So okay a patient in the northeast kingdom at the tiny little hospital up there that would be a more expensive place just like it's a more expensive place to serve children in schools. Gotcha okay I'm with you. Okay this is good so Jen will take that out then that's solely out we'll see what kind of response we get if we get a response on that one word. Unless anybody else is concerned about it. Okay what else have you got what that what else was that the second one in that section that he proposed is that these that the process for establishing and distributing global payments from all pairs to Vermont hospitals that will and then determine how best to secure comprehensive data and analytical services from hospital financial analysts evaluate hospital fees revenue sources and financial and operating reporting in metrics. If you like the idea I wouldn't put it where he's suggesting it because I don't think it follows developing a process for establishing and distributing global payments that will determine how best to secure this data if it doesn't. Where would you put that where would that go but as a stand alone as a standalone requirement okay that's like a maybe a is it can I ask is this already done by Green Mountain Care Board? That's what I was just going to ask I mean isn't this already part of the Green Mountain Care Board authority and work? Yes this is exactly what they do they look at data on the services and they have financial analysts they look at fees revenue financial and operating reporting in metrics they do all this. But is there something to be said for how best to secure the comprehensive data because there's been a question about transparency in some sectors that maybe I'm sure maybe I think all of the Green Mountain Care Board stuff is public information from hospitals from hospitals and other organizations that may or may not I mean I guess I'm just no they get it directly from hospitals during the hospital budget review. Yeah and they don't yeah they don't have authority. Hello. I just wanted to insert they don't have authority over some places like our DA's. Okay so this is just hospital it's just data is available to them so that you know I don't know yeah I I don't know unless we hear differently this we can consider already a part of what the Green Mountain Care Board is capable of looking at. So so not those and okay so then that his next proposal is our blueprint that I think Jessa has incorporated into her yeah on blueprint you wanted to add something about the funding for community providers but I'm not sure it doesn't really fit under the appropriation to the program we could just put it as a as an E if you wanted to. Well if it's for transformation it's probably important but this is something we will consider as we're going through our budget process with the Appropriations Committee but this is more this is for redesign and future looking is this right included in is this included in Ina's language that we were just looking at do you think. I don't have her language in front of me so I'm it may not. Right her language is is really focused on on the subsequent agreement with the feds to include Medicare's continued participation so she does talk about the design and development of the proposal including consideration of alternative payment and delivery system approaches for hospitals and community-based providers but I think what Patrick's point is really looking at is what what is the funding need for the community agencies to be able to carry out the results of the transformation plan. Okay well it makes sense then to have it somewhere. People are interested in it I can put it I think I would put it as an E at the end of the section everything else is about the board and then it would direct AHS to do this work and I I think you probably want to report on what they have identified or something. Yeah and this was this is to my point of like a lot of what yeah it's all mixed up. It's all mixed up huh. All right so I'm going to add Patrick's number three here. Okay that's on page five. That is on page five right and then I think you already decided you were interested in adding something about the duals yes to the to that working group the moderate needs working groups but again a little bit separate from what they're doing that's focused in one part on including those provisions in the next the next next global commitment demonstration but I think there's a way to put it in there. Okay all right so then at that point the only other things that I think are outstanding this one of them is the whether amount to use preferably describing the expertise of your experience of the community engagement consultants in working with a diverse rural population and I think the chair and I did get a response from Robin on that one that they were the preferably language in there was to cast a wider net not knowing who they were going to get in response to an RFP so they did not have somebody in mind so right so she said they want someone with experience in rurality but they don't know who they will get for bids in response to the RFP in the unlikely event they get no bids from someone with rural experience or the bit they do get is otherwise unqualified they want flexibility in the RFP process in order to still move forward otherwise they'd have to go out to re-bid or come back next session ask for a change she says re-bidding is nothing in the world and if they only got bids it didn't seem like the right people they do that but it would delay the process and she does say they definitely do not have someone in mind at this point and they're actually interested to see what's up okay all right i i'm finally taking putting the preferably back in everyone else's i just want to share our very good that's good that was a tough that was a tough one no no one has his hand up here oh i was just going to say it's better to put your intent and what you want but don't require the exact reason okay thank you because you're you're so you work so hard on a number of these grants so it's important to have that input thank you and then uh and then the only other issue i think is really the money pieces and who does what yeah so here's my suggestion we're good for now and then we'll hear back so my suggestion is jen don't leave us but i think that we all need a little break okay so i am i mean i was sort of supposed to be upstairs at 10 30 uh i have been communicating with them and asking if they needed me now or if i could stay here because you were doing markup so um but i at some point may get called to go upstairs let let's take a five minute let's take a five minute break we'll come back to 239 and 204 and i i honestly think we'll be able to move with alacrity alacrity i i wanted to inject some new language calculary


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