Okay, it's 1 o'clock, so I'll call to order the Green Mountain Care Boards hearing of June 28, 2023. We have a pretty stacked agenda today, so we'll have to stay on task. I am going to Vermont Medical Society this evening and have to drive to that. So we're going to have to stay probably get done by 4 o'clock so I can get over there. We have an update on the evolution of Green Mountain Care Boards hospital budget review process. That'll be presented by Tom Reese, who's been working with our office in Sarah Lindberg, our director of health systems finance. We'll have an all pair model update from the agency of human services. And our friend Pat Jones, who is the interim director of healthcare reform at AHS. We'll also have an update on hospital sustainability and global payment model development from our director of health systems policy, Sarah Kinzler. And we'll have a Medicare only budget guidance and potential vote presented by health policy analyst. I'm sorry, advisor Julia Bowles. The ACO budget guidance. I've taken off the agenda for today. At last week's hearing, I think it was last week's there was some board member request for information relating to the benchmarking that one care used for its executive compensation. The staff requested that information and on June 26 one care indicated that they would not provide it to the board. And so we don't have the information that we wanted for consideration of the benchmarking for guidance. I've sent one care letter and we'll soon be issuing a subpoena for the information that we requested. So that is off the agenda. We're going to put it on for July 12. So I'll turn to executive director Barrett for her report. Thank you, Mr. Chair. I have some scheduling announcements, public comment announcements, and then some updates for the board and the public. First, next week, we will not have a board meeting on July 5th. Happy 4th of July, everybody. And as chair Foster said, we will resume the next week on July 12th. We've extended the public comment period for one care of Vermont's FY 24 budget and certification guidance until July 11th at noon. And we're also accepting any public comments on the next Vermont all pair model agreement with a center for Medicare and Medicaid innovation or C. M. M. I. We'll be hearing an update on that from Pat Jones today, but we do share any of those comments with our colleagues at the agency of human services and the governor's office as they are leading those negotiations. You can find more information on any of our public comments on our website at GMC board dot Vermont dot gov. And then I have a couple of announcements. First, I have an update on a recent submission and then I am will be reading out a recent rate decision. So, first, on May 31st UVM HN sent us their proposal for the reinvestment of the $18 million into mental health programs. The board and the staff have reviewed the submission and the finance team are now developing a monitoring plan. I want to thank the Department of Mental Health for their collaboration and guidance to UVM HN on this project. In addition, the Vermont psychiatric survivors and the Vermont chapter of NAMI, which is the National Alliance of Mental Illness, providers provided letters of support for that plan. Any documents and these letters can be found on our website under hospital budgets and the enforcement actions tab. And then lastly, the board on May 11th 2023 issued its decision and order approving modifications to the Blue Cross Blue Shield of Vermont large group rate filing. The decision and order are posted on the GMCB website under what's new and on our rate review website. So with that, I will turn it over to you, Mr. Chair. Thank you. Thank you. We'll take up the minutes from June 21st 2023. Is there a motion to approve the minutes? So moved. Second. And any board discussion. Right. Those in favor, please say aye. Aye. Aye. Aye. And the minutes are approved. I'll turn it over to Director Lindberg. But before I do, I just wanted to thank both you and Mr. Reese for your work on this. This is something that we've spent a lot of time on. And I've had the pleasure of working with both of you as have all the other board members and it's been for new board member extremely informative to understand how we have done it historically. And to get to work with you guys on the new approach, which I think is really great. So thanks for all your diligence and your time educating all of us. And I greatly appreciated it. Director Lindberg. Good afternoon. Our folks able to hear me and see the slideshow. Wonderful. All right. Always the easy stuff that can be the hardest. So I'm joined us. And I'm joined by Director Foster said by Mr. Reese, who will, you'll get to hear from directly a little bit later on in the presentation today. But we wanted to take a little time to update you on how the process for evolving our regulation of hospital budgets is evolving. Which is very much work in progress, but we're here to share some learning with you all. Overview of what we'll go through today. A very brief history about hospital budget regulation in Vermont's past as well as how we're trying to enrich that historical approach with evidence based techniques. And then giving you a demonstration of how this might really be implemented in our regulatory process. So, in 1992, which feels a lot sooner than it actually is to me, I'm getting to be that demographic. The Vermont healthcare authority was formed and what that organization did is merge the health data, the health policy council and the health data councils, as well as the certificate of need review board. Which only lasted a few years before it was coupled with the Department of Baking Insurance and Securities, which became Bishka. So fun fact is when people talk about the HCA like anything in Vermont, you have to be careful which HCA they meant. But this is when the rubber really hit the road for Vermont in terms of the fact that that's when the authority to limit hospital budgets came into effect. So that's when the state not only could collect the data, review it, but actually do something about it. So the Green Mountain Care Board was formed in 2011 and that's the time when Bishka was renamed to the Department of Financial Regulation. And so hospital budget decisions for fiscal year 13 onward have been the responsibility of the Green Mountain Care Board. So why would we bother to regulate hospital budgets? Well, if you look at this tree map, you can see that nearly half of the spending in Vermont is happening at hospitals. So in 2019, there were 6.8 billion dollars spent on healthcare in Vermont and 3.1 billion of that was at our, I'm sorry, million, yeah, 3.1 billion of that was at hospitals. Obviously, there's many other drivers of healthcare expenditures, but it is a big bucket. And because Vermont has such a highly concentrated market, not just for hospital services, but also for health insurance regulation is an essential tool to help help markets that don't have competition to help keep them healthy. And when we say monopoly here, we know that over half of the care is centered at the UVM Medical Center. The network more broadly is up to closer to 60%. So when we say monopoly, it just means a bunch is concentrated in one organization. So it's an important factor in any regulatory process to know what your market looks like. I would also say that some of these buckets, unfortunately, are very vexing for us all such as that drug bucket. That's when I think that the whole country is really grappling with. So hospitals are one where we might be able to exert some leverage. So, to date, most of the regulation in the state of Vermont has used has been based on revenue. The regulatory approach specifically is limited net patient service revenue, which you'll hear me call NPR mostly, but if I remember, I'll say NPSR. And that focus might have some unintended consequences. So NPR changes for lots of reasons that can go up or down from volume, say, we have a global pandemic and people can't go show up, you know, that will have an effect on NPR. And that mix will have an effect. So if you happen to live in a community that serves more folks that have a governmental payer or maybe not a payer at all, that's going to look a lot different than someone who has commercial folks more broadly represented in their payer mix. A service mix can also affect NPR. So if you were to move to a less expensive or a service that had less of a margin or conversely something with a higher margin, that can affect your NPR, such as the intensity of new care might affect your NPR. So that's probably one of the reasons that NPR might change. And then just, you know, just your infrastructure. So if you acquire or get rid of a practice, that's also going to change your net revenue. So it's hard to narrow in, I think, on the things that regulators are most interested in by looking at revenue alone. So that's why, as we think through trying to evolve some of this and add to it, we wanted to think about, well, what's changed since the Green Mountain Care Board was formed and turns out that NPR might change. So that's why, as we think through trying to evolve some of this and add to it, we wanted to think about, well, what's changed since the Green Mountain Care Board was formed and turns out quite a bit. I don't know if you remember the Affordable Care Act or Obamacare as some people know it, but that really did dramatically change the market here in Vermont and nationally. A growth in multi-state networks, as our speaker series talked about, some of these larger programs are potentially using some market power to affect their negotiating power. And in Vermont, we see not only the UVM health network being established with ties to New York, but we also see Dartmouth having some hospitals here in state too. And so the fact that patient care patterns don't respect state lines gets even more complex when the corporations don't either. We also saw the establishment of three accountable care organizations of which only one remains. Again, Vermont-based and then, of course, the global 19 pandemic, COVID-19 global pandemic really has changed our world in a lot of ways, but I think in the healthcare sector it's being felt extremely acutely even today. So, you know, we think that just looking at revenue or that revenue-based regulation really was a part of a different time and very different circumstances than we're facing today. And with the advent of more data availability and our ability to harness that, we think that we have some new capabilities to take advantage of that. And I think one other advantage of looking, you know, more explicitly at the revenue side of things is that there can be cases where there might be a one-time expenditure that affects a budget. And we might, by going budget to budget revenue, we might be losing the thread on some of those expenditures. So just trying to really narrow in on really what is driving these expenses and understanding those better. And so I'm very fortunate to have had the pleasure to work with Mr. Tom Reese, who's had a lot of experience, and I'll let him speak to some of that now and help you hear some of what I've learned from him about his recommendations for our path forward. Thank you, Sarah. Let me preface my comments by extending my deep appreciation to the board for all that they are doing in wrestling with a new approach to their responsibilities and in trusting me with a portion of that responsibility. I think it certainly is a capstone for a long career that I've had, and I think that career serves us pretty well as we look to take a very different approach. I don't want to spend a lot of time on the experience underneath this. I tried to encapsulate a couple of bullet points of specific interest. I was educated at Delaware and have a master's from the program in health and hospital administration from the University of Florida. But I really started my career here. I was born here. I was actually born at the old Fletcher house. That's a long time ago, and started my career at the Medical Center Hospital Vermont under the tutelage of Dan Olson, a career that ended several years ago with a senior management position at Geisinger System. After that career as an executive, I've spent 26 years consulting basically with three different types of healthcare providers, much of the time with academic medical centers. Recently, a lot of time with Ascension Health Hospitals as we have been doing performance improvement projects for them, and spend a lot of time with community medical centers around the country. Over the last 20 years, I've really worked in the space of financial data and its relationship to health outcomes and their relationship to healthcare performance, both as a member of several teams working to alter hospital financial trajectories, but also working with many hospitals on issues of improving both clinical quality and cost effectiveness through the utilization of expense data. Specifically, expense data at two levels. One is the departmental level and the second is at the actual patient level. And all of those things are coming together for us, I think, in a very robust way, and we'd like to talk to you a little bit about the six domains that we think are important for the board to be conscious of, cognizant of, and to measure to, and just briefly walk you through those domains because they will become very important to us into the immediate future. And those domains are really driven by data available to us in Medicare cost reports, which have somewhere in the neighborhood of 45 discrete elements that are much too cumbersome for us to work with. But one of our first efforts at working in partnership with Sarah was to really hone down on six characteristics that we can view as being specific to things that are important to the board. So Sarah, could you give me that next slide, please? So there are really six domains that I think are important to us. One is how patient complexity, how sick are hospitals patients, and by not looking at that, we miss an opportunity to start weighing the value each individual hospital brings to us and to its patients. The foundational standard for measuring the patient complexity in a hospital has been established through the Medicare program, it's called the case mix index, and each MSDRG, of which there are now 996, have its own case weight, and those case weights vary from minimally, a little over one, two more complicated, and I think the most complicated is a heart transplant, which is a 19, still give you a relative range. But when those are all rolled together, they provide an average case rate for each hospital in the country, and they're all driven by the same factors, and thus we have a way to actually look at the severity of patients in every hospital and compare those to one another. So it is a gold standard of patient severity. The next slide, which is a similar Medicare based standard, which I have always used as the gold standard for hospital financial efficiency, which is, in fact, the Medicare cost per case risk adjusted. And many hospitals that had the pleasure of working with actually have for a number of years managed their costs to Medicare costs, and relying on other payers to provide them some level of satisfactory profit. Spent a lot of time, as I said, with Ascension Health Leadership, who actually now use managing to Medicare as one of the performance standards for their CEOs in their 21 hospitals around the country. A third standard that we have created ourselves, which is interestingly the ratio of administrative and general service salaries to clinical salaries. It's a field from the Medicare cost reports that are available to us. When we started to evaluate these, we saw a considerable variation in what these relationships look like. So we've decided that it's an important indicator of discretionary investment in services that are and purchase of human resources that each hospital administrative team takes under their advisement. So it is a means for us to look at how hospitals are spending and what their priorities are in their spending patterns. Next slide is EBITDA, which is a very clear measure of financial operating performance. But it's pretty clean definition of financial operating performance because there are variables taken out of the normal evaluation of performance, which, and this just focuses on pure operations without extraneous accounting manipulation of those operations. And that gives us another way to compare across hospitals in a pretty consistent fashion. The fifth factor is cash for operations. Critically important to the board as you look at sustainability and we certainly have some pressure points in our system relative to sustainability and thus we are recommending bringing to you a gold standard of cash available for operations. And that's all cash available for operations as opposed to simply days cash on hand. There are two very different things and we can extract those from Medicare pass reports. And finally, one of the most complicated, you might think it's simple, but it's not a simple at all is how do we measure quality. There are dozens and dozens of measures of hospital processes that are indicative of quality, but they're very, very hard to compare. And in actuality, many years ago, I had the deep pleasure of looking and working with Uwe Reinhardt, who is probably now passed away, but the dean of medical economists in the world. And we had these discussions relative to looking at the performance of efficient physicians from a cost perspective versus physicians who spent more money on patient care. And the conversations with Uwe settled on the fact that the quality, the absolute quality of a hospital is did the patient survive and go home or did the patient pass away during their hospital stay. The standard measure, it's available out of Medicare. It's a pretty very high level. A lot of factors go into that measure, but it's a high level cage for the level of quality a hospital provider is delivering. So those are the six standards that we think are important. They're going to use those standards to compare, promote hospitals with peers. As you may remember, we have structured four peer groups, one of critical access hospitals, one of small rural hospitals, one of mid sized rural hospitals, and then one of academic medical centers with the academic medical center. We have used several cuts of profiles so that we understand more the dynamics of the university compared to other types of peer peer groups. So given all that, we wanted to bring back to you a little example of what power we believe these statistics bring to the board as they deliberate their actions into the future. I've got to thank Tom Walsh for driving us to this example. It was Tom's brainchild and we worked together to profile the brainchild, but his request was give me two similar hospitals with different structures so that we could demonstrate what happens with additional information. So here we have two hospitals that are about the same size. They certainly are the same as close as I could come up with. They seem to like to stay occupancy about the same. As you will see, they have very different mixes of in and out patient revenue. One is very concentrated on an outpatient side. The other is kind of split between in and out patients. It's not unusual to see an active medical center with the split of the hospital on the left, but there are others that are very concentrated within patient services. And there is, of course, if we go to the next slide, there is a substantial difference in the outcomes that these hospitals are producing. So one has a has a negative bottom line and driven by an operating high operating loss. It also is now in a position where it's really low on cash. And but they seem to be collecting money at the same rate as their as their counterpart, who is actually generated some net income. These are 2021 data, by the way. Much of that was supported by COVID monies generated a really good EBITDA and has a lot of cash on hand. So the question becomes if if these two hospitals approach the board and ask for a 5% rate increase. The tendency, I think, based on my observations of the board now and in the past was it's likely that the board would be concerned about the sustainability of the hospital one. And probably give them the benefit of the doubt and help offset that by approving a larger rate increase than hospital hospital two. If we look at some additional factors and the gold standard factors, we see suddenly see that hospital one is taking care of patients who are a little less ill. They are costing a lot more. They are using discretionary costs to spend on administration versus clinical affairs. As we have shown them are very different and the cash on hand is very different. And their Medicare deaths are also different so that that perhaps hospital one is taking care of less sick patients with not as good results as hospital two. And how would that affect our decision in investing into their future by granting them rate increases and thus we have a different decision. We now have a decision of wow hospital two really needs to be encouraged to keep driving that performance forward versus hospital one which we need to have asked some questions about. Well, what are you doing with your discretionary spending and and why aren't you achieving the results that your peer hospitals are able to achieve. So, in summary, I think this is a rhetorical question for me, but I do believe evidence based expense analysis. We'll change the way we think about rate increases, because we'll have much richer and information to deal with and much richer conversations to discuss with our hospital leaders. I guess I would close by saying using an expense base establishes a new language for us to communicate with hospitals and for hospitals to communicate with their medical communities and amongst themselves. It's a common language there. It's it's created by Medicare to create an offer Medicare cost reports. And so we can. There are very nuanced pieces to the language, but the language is standard and I think it will allow us to communicate in a much more finite way with with the hospitals into the future. So, last slide, Sarah, and we can move to questions. Sure. Yeah, I'll just wrap my piece by saying that, you know, these are the metrics that we'll be looking at as part of the hospital budget review process this this summer. And this bridge year I see as an opportunity for us to really be curious, learn no data are perfect. There's going to be a lot to learn we want to be really responsible with this information. And figure out how we can effectively and efficiently try to incorporate these types of measures into a standard predictable evidence based regulatory practice. So, you know, I think it's important to say that these in and of themselves are information it's not measures that are designed for regulatory decision making in and of themselves, but it can help round out the picture. And it's, you know, cost reports are far from perfect, but they're the best thing that we have to really put ourselves into context. And now we have kind of some more acumen to really just take a closer look at how we're doing compared to similar hospitals. So, with that, what can we address for you this afternoon. Thank you both very much. I'll open it up for board member question or comment. Members London homes have anything. I do have a couple of questions. So I'll go ahead and jump in on slide. Can we go back to slide 11 please. You can see slide numbers. Oh, it's this one ratio of admin. Gotcha. Thanks. Sorry. I had a question. I'm not even there. That's okay. So I had a question about this metric. As I think most folks know most of our hospitals are the fiscal intermediaries for the blueprint for health community health team so those dollars run through the hospitals budget. And we have over time seen some increased investment around care management delivery system transformation. And I'm just curious how that fits in like where this that falls in this metric. And that's coming from knowing that in the medical loss ratio world in the insurance world. Part of what the feds did when they looked at the federal medical loss ratio was ensure that they were carving out care management expenses because otherwise that's typically in the admin. So, and I think if we want hospitals to transform and we're thinking about those kinds of dollars as a good thing. But they're in the admin part that would increase the, you know, the admin component compared to clinical. How do we think about that? And how do we make sure that we don't have an unintended unintended consequence of creating a disincentive to invest in those types of clinical transformation dollars, which technically are admin. Wonderful comment. And thank you for that, Robin. My response is we're talking a new language and that new language I think will allow us to communicate more effectively and efficiently with hospitals. So all of these standards are simply standards, measurement standards and and provide the board with an opportunity to have conversations above and beyond those standards. So if if a hospital has a has in this particular ratio, something that seems to be a little different, I think the board will want to ask them about what that difference is. The hospital and its board comes back and says, yeah, but we're investing in care management or investing in some additional patient service investments. Then that makes changes the argument and we all get educated by that. But it's not a standard that we're going to say, well, you're out of control and we're just going to walk away from that. But on the other hand, if we find through this standard that there's some really strange investments being made in one area or another, then likewise we can have those conversations. Yeah, I'll just add another factor in this bucket. That's top of mind for me is that this will also be really sensitive to the corporate structure of the hospital. So if a hospital has stuff in like a shared service organization or something, that's really going to distort this. So that's exactly the type of learning that I'm trying to do and evolve our data models so that we're wrapping our arms around the full labor expenses as those, you know, due to accounting and reporting differences that we're not able to do as successfully as I'd like. So, you know, I agree, but that there's, you know, anytime you kind of get new data, it seems like you also have new questions. So it'll be a process. But yeah, very excellent point. As we move past that, and I think it's very important for the board to understand how we view this as a shared process, we are extending to hospitals once they see their comparator hospital groups, which they will within the next month. We are extending to each CEO the opportunity to come back to us and say, oh, I'd like to see these other five hospitals included in that comparative group. And we're very open to that. We haven't got this perfect. So we want it to be a collaborative process as we start evolving it. Great. Thank you. That's, that's super helpful. I just wanted to think through, you know, people tend to hear admin as bad, right? But some admin is care transformation and the direction that we hope to move in. Then on the Medicare deaths as a percentage of discharge, I was just wondering a little bit about this just because I'm thinking about our current quality metrics and the all pair model agreement and that quality framework. I don't think and I did not go back. I did not have time to check. So I could be wrong. This was one of our metrics. So I was just curious about choosing a metric outside of our current measure set. And whether this is a measure we should think about moving forward. As, you know, as you know, we're working on the global budget methodology and whether we should be thinking of this as a possible metric in that context or not. You know, measures don't always have to be exactly the same, but they're at least in this state has been a lot of work statewide on ensuring that there's a robust conversation around metrics and making sure that we're not constantly just adding and that we're cognizant of the administrative burden that that brings when folks are trying to focus their work on their based on what they're being measured on. Thank you for that question and part of it harkens back to conversations a long, long time ago with UVA. But in essence, there also are important process measures that that we are all working on and and certainly Medicare is working on them and they end up for for non critical access hospitals. They are ending up with a broader distribution of quality process scores. And so the decision on whether to use this particular standard, Robin is, I think, up to people who are thinking collaboratively with hospitals about these metrics. This metric can be pulled right out of Medicare very, very easily doesn't no requirement to put additional resources into this from a hospital perspective. And it just gives us just gives us a bit of insight. It doesn't give us great insight. And if there's a quality issue that we think exists, we probably would want to explore other other quality measurements from a process perspective with those hospitals to see what we can do to help them improve. Yeah, and I'll just add that we're fortunate to have experts here at the board collaborating with the Vermont program for quality and other partners to come up with a broader framework for assessing quality in our healthcare delivery system, as well as narrowing on kind of which might make sense for an accountability standpoint, particularly as it might relate to any sort of budget exercise so this is certainly not meant to be exhaustive nor to ignore that that critical body of work so I'm duly noted. Thank you both. Thank you. I just have one question for you. And I really just want to say I really appreciate the expense based approach that we're going in and the addition of some of these new metrics I think they'll enhance our ability to analyze budgets and I think they're going to shine some interesting lights on on the submissions this year. I think my my only question really is, are there data? Is there a data source available that would allow us to compare cost per adjusted case for commercial patients, not just Medicare. You know, I think there's a fairly extensive literature pointing to price as a driver of expenditure growth. And since hospitals don't really have a leverage over Medicare prices or reimbursement, but they do have leverage over commercial prices, I think there could be hospitals that could be low on cost per Medicare case and actually high on cost per commercial case. Depending upon their, you know, the market concentration bargaining leverage other factors. So I think that would be an additional metric that would be really helpful to have and I wondered if there was a data source availability of that information. And what your thoughts on the list of yeah, the cost reports are perfect, but it does allow us to back out the federal program. So Medicare and Medicaid costs and expenditures. So, or utilization on the impatient side so we'll have some ways to start getting at that but I think that's, you know, the type of work we're still working to extend for fiscal year 25 and beyond but yeah. Tom, unless I'm not remembering any data sources that could solve this problem magically. Well, I hope you I'm glad you had an answer because I didn't really have an answer to that. Because I am not as familiar with that dynamic within the cost report that as you are. And I will come back, Jessica to you and and say that through all my work with Ascension who drives to Medicare as their management objective. And they drive that so that they can set their costs, commercial costs to generate their margin. That's it's pretty simple technique for them. They execute it pretty well actually. Yeah, I think that's why we want understanding of what's happening than that in that drive. Okay, that's my only question. Thank you so much, both of you. I really appreciate member homes is question if we can somehow sound get a direction on that because we are such an outlier nationally on our Medicare costs. That could be a little bit deceiving and of course doesn't take into effect market power by various places. I don't know if there's a way to do it based on the reimbursement data we have for commercial as by reference to Medicare and sort of at least roughly in a sense maybe. So I'll put a plug for member homes a suggestion and the other question I had was for the care transformation dollars that may be in administrative costs for our hospitals. Do we have that quantified now or can we get that is that something we have. Yeah, we have that revenue broken out separately in our current data model. Yep. We have the blueprint revenue, but if there's other investments that they've made, I don't know if do we have that too. So we have what comes into the hospital as revenue related to other types of revenue that aren't NPR. What we don't have much granularity on is the expenditures that are supporting the communities and I think that's an essential point and hopefully we can get a better sense of infrastructure. Our hospitals are supporting that might be more of a dotted line in terms of kind of corporate structure. I love this conversation because we're talking the language. We now are talking the language. Thank you very much. Thank you, Tom. Then the other question I had, you know, in those hospital one versus hospital two, I think, you know, just by how you analyze that you do come to a different conclusion. I mean, I went through this and sat and said, okay, we got to give hospital one more money. And then the way we do it now, it's like, well, hospital two is performing really well. We want them to have more money to be continuing to do such a great job for Vermont. So I thought it was really interesting just to see the way we look at it and come to very different conclusions. And some of I wonder, so what happens to hospital one if you say, okay, just in this hypothetical and realizing it might not be reality and there might be nuance. If you say to hospital one, no, you're not performing at the level you want and we are going to give the money to hospital to what happens to hospital one. My off to cuff response to that and I have a short sleeve shirt shirt on so it's not a big cuff. My off to cuff response to that is you say to hospital one. We're really concerned and we have we share your concern. We're going to have to talk about what operational improvements you're going to make over the next 12 months. In order for us to support increased in your in your funding. I think there's a quid pro quo to do to take with that hospital in this case. Yeah, great. Okay, I'll turn it to the health care and get for any questions or comment they may have. Chair faster. This is Susan Barrett. I forgot to tell you that the health care advocate is unable to make the meeting today they had a scheduling conflict. I'm sorry about that. That's fine. I probably should know I figured that out. I think that there might have been an email and maybe I missed part of it or didn't read it closely enough. I'll turn it to public comment via the raise the hand function. Mr Davis, how are you please go ahead. Mr chair. Mr chair. Thank you very much. I have a comment and a question. I've been involved in this for a long time. The 1991. My, my bill was the first hospital control bill that existed in Vermont past the house, but not the Senate, but it had picked up in 1995. We saw that. That's where that would fit on Sarah's. In Sarah's slides. I believe that based on that background I watching at this time I think this movement this project whatever you want to call it is one of the single most important one that we want to single most important ones that we've ever had. It's the, and I think if it's it's absolutely essential, I think to really get get this problem solved is to is to make this make this work. I think it's just we we we've got to we've got to make this work. That's my comment. My question is this with Tom. I'm curious, whether in you for based on your judgment, I know you may not have a full answer yet, but I'm very interested in your experience here. If you shift from EBITDA to if you shift from days cash on hand to EBITDA, do you expect to see should we expect to see of a significantly different way to look at what's going on now. So how important in your judgment is that shift because if you look at, for example, the 60% of the system, which is the UVM health network, their days cash on hand is terrible. And, and, and so, and so that's that's that's my question, can you, I know I mean, you may not have the data yet but I'd be interested in your experience here. Thank you. The relationship between EBITDA and cash, of course, is is is close, but not exact. And I think it's, it's important that for the board, we look at all sources of cash. We don't look at just days cash on hand, which is one metric, but, but there are a lot of hospitals that have a lot more cash than they have dedicated to days and cash and, and many of those are reserve funds that the board has reserved for for the future but are actually available for for operation so. So, while there's a relationship, it's not a dollar for dollar relationship and, and we, I think need more time to evaluate those relationships over the over the spectrum of hospitals we're working with. Thank you, sir. Public comment. I saw you come on off camera if you can. No, I thank you, chair Foster. I've been having a problem raising my hand. Just showing up. It's okay too. Thanks. Thanks. So, Sarah and group and Tom, I am good to see you again. I appreciate the simplicity of this. My thinking was somewhat aligned with board member lunges around the quality piece. You know, we've always in Vermont been a little bit concerned about a mortality rate because of the small end. I'm not saying that's right or wrong, but that's been a little bit of the thinking in the past. So, as we evaluate that will be important to sort of figure that out a bit. I think the Medicare cost report. I don't, I don't know if. How many have filled it out. I filled it out with a pen and paper and did step down by hand. Understand lines through 1 through 20, whatever they are. You know, administration to Robin's point is an interesting concept. Because the Medicare cost report is structured. A worksheet a, which includes all of your expense activity. Are we talking before free free reclass is. Post aid adjustments. What lines are we including in administration and, you know, maybe even a bigger point is electronic medical records. A huge hog. That's considered administration in general. There is 1 line item that is tagged to line 5, which is called administrative in general. The other line items that are called administrative in general, you could almost does it does an interesting line in the in that slide. It's called direct. There's pharmacy. When pharmacy dispenses. Meds to a patient that's administrative in general is it indirect or direct Medicare calls it indirect. So there are these nuances that we need to sort of evaluate and figure out what's included what's not included. And I'm particularly interested in the comparison piece because that's. That's critically important, especially when you consider. The makeup of employed physicians in Vermont. That do sit on our Medicare costs reports where many of these other external systems have. Employment arrangements that sit in separate corporations. So what do we compare to? How do we understand those expenses? We're, you know, a whole sort of set of nuances. So that leads me to the, I guess, the surprise moment for me that this is the 2024 sort of process or part of that. So I think we need to be have some awareness around that. And then, and then the other thing is what year of cost report are we using an audited cost report, a filed cost report. You know, the last audited cost report is probably 2021 maybe ish. So those are some interesting things that I think about cost reports certainly as I think you've said more than once there are interesting tools. Sometimes right sometimes not right. And we get into all this. Intentional confusion. And again, I appreciate the simplicity. Just want to be aware of some of the moving parts. Thank you. Thank you for the comment, Mr. Del Treco and I good points. I think that that's something that. Director Lindberg is very aware of. So I'm glad that you've cited those and that will definitely work to make sure we get them right. Thank you. Yeah, of course. Any other public comment. Great. Okay. Well, Mr. recent director Lindberg. Thanks so much for all your work on this. It's been impressive and a joy to work with you both on this. So thank you. Thank you. Thank you. Good luck, Pat. She used to have this job. Next we'll be hearing from Pat Jones is the interim director of health care reform at AHS on the all pair model update. For those of you who don't know, Miss Jones, she did used to work here. She's a dear friend to many of us and one of the most enjoyable people to work with in government. And I really value the friendship and collaboration she's given all of us and taught us taught me a lot. So, Pat, thank you for being here and take it away. Great. Thank you for those kind words and especially thank you for the chance to come and present an update on the all pair model work to the board and to the public. So, as chair Foster said, I'm in a new role as interim director of health care reform for the agency of human services. Excellent. So, what I'd like to do today is provide a brief overview of the current all pair model agreement go into a little detail on where we are. And then talk about what we can share in terms of the future potential multi payer model with the center for Medicare and Medicaid innovation and CMS. The current model is, I think most people know has three signatories, the governor, the H S secretary, and the Green Mountain care board chair, and a full GMC be vote was required in order for the chair to sign this agreement. The original period was from 2018 to 2022 so encompassing five performance years, we are currently in the first year of a two year extension period. I think partly precipitated by the COVID-19 pandemic. This extension was suggested by CMMI and the board and the other signatories approved that in late 2022. And the intent was for the extension to act as a bridge for a future federal state model that would allow Medicare to continue to participate in advanced payment reform. And at the time that was expected to occur in 2025. So that, so the extension is currently set to end at the end of 2024. And I just want to thank members of the board and the staff at the Green Mountain care board, because this is a heavy lift in terms of implementation. And the close collaboration that we've enjoyed has really been an asset. Next slide. So this this just provides a little more detail about the current model and I want to emphasize, you know, the header here actually says it all. But what we really, you know, what this agreement allows us to do is it allows us to have and sustain Medicare participation in multi payer alternative payment models in Vermont, and that type of participation and alignment is really important for the goals that we're trying to achieve. So again, the original agreement, well, five performance years, six year agreement 2017 was considered a ramp up here. It's a it's an arrangement serving its most basic sense the all payer ACO model agreement is an arrangement between Vermont and CMS the federal government that allows Medicare Medicaid and commercial insurers to pay for health care in a different way. What we're trying to do is shift from paying for each service on a fee for service basis and shift toward paying for high performance and good outcomes. So value based model. The changing how we pay for services the intent there is really to achieve what is called the triple aim which is reducing the growth in health care costs to maintain and improve quality of care and improve the overall health of Vermonters. And I think as most people know the current model relies on an accountable care organization that's one care of Vermont to develop a voluntary network of health care providers and those providers agree to be accountable for the care and cost for the patients that are attributed to them. Next slide. So, as I mentioned 2023 to 2024 represents an extension of the original agreement. We executed that extension it was signed in late 2022 the agreement terms are very similar to the original model. The extension is in place for this year and the state has accepted the option to extend the agreement through 2024. One of the really important things that continuing this agreement does is it allows us to continue to take advantage of Medicare investments in Vermont. And a good example is the innovations that have been developed under the blueprint for health to support primary care practices. So Medicare contributes to per member per month payments for participating primary care practices that have become recognized as patient centered medical homes. And Medicare continues to provide support for community health teams in each region of the state that provide additional services for people with complex needs without this agreement that we would not have that Medicare investment in the blueprint for health. And similarly one care has developed a program called comprehensive payment reform that supports independent primary care practices. And again our participation in this model and Medicare's participation in this model has allowed support for that program to continue as well. Next slide. So as we think about a future Medicare multi payer agreement and I'll have more to say about that in a few slides starting in 2025. What we know is that the federal government is developing a multi state multi payer model for the future. The model that we currently have is Vermont specific where the only state that has this model and the federal government is really looking for the future to have a multi state model and not a specific Vermont model. And so to the extent possible we are trying to provide feedback on model design. It's challenging because you know CMS hasn't hasn't issued much information about the model. And so we're doing the best we can to try and articulate Vermont's priorities. When that model does get released we will then want to take a very careful look at it with the stakeholder engagement to see if it beats the state's needs. Next slide. This is a rough timeline of you know how we look to engage with the center for Medicare and Medicaid innovation which is the part of CMS is developing this model. In sort of late last year we really you know tried to convene some some groups to see if we could provide some initial preliminary feedback to see MMI on its priorities that it was sharing and our priorities as well. A lot of that work during that time also really focused on how to support short term stability for our health care system as we were coming out of the out of the pandemic. And then this year from January you know through the rest of the year we're continuing to meet with CMMI as we can to provide what feedback we can. We're seeking to gather feedback we've developed some technical work groups which we'll say more about in a minute. We're looking to obtain broad stakeholder engagement we've begun that work as well. But really for the rest of the year trying to get the feedback that we can to then try and use to communicate with CMMI and to develop a response to a model offering should Vermont decide to proceed with some of the such a response. And then again you know sort of looking at the later half of this year it looks like we will be provided with a formal opportunity to participate in a multi state multi payer model from CMMI at some point in 2023 it's looking like that's going to be later in the year possibly sometime in the fall. Once that is released we will then need to decide whether we want to participate and if so that's when we'll be developing a proposal in response to the model offering. Next slide. So just wanted to spend a minute talking about what you know what you know why do we want to do this what are the benefits of continuing to include Medicare in Vermont's reform efforts and there are several. One is that we want we would like to get continued recognition of Vermont as being a you know pretty long time low cost state for Medicare. If we were to let participation in a in a multi payer model that includes Medicare to lapse. It's possible that a new baseline of with savings targets and spending trend could be calculated and if it doesn't sort of give us credit or look at our history of being a low cost state. That could end up being detrimental to Vermont's to providers and to our ability to meet targets and retain savings. Similarly we you know are we want to make sure that when we look at financial targets and baseline financial calculations that we recognize that there are some Vermont reforms that have been demonstrated to save money for Medicare and we tend to call this accrued savings but a really good example of that is the blueprint for health and the support and services at home program sash where we've been participating now for over a decade. Medicare has been supporting that participation. They've been paying their share as I mentioned earlier and having you know we want to make sure that when we're looking at what has Vermont provided to Medicare that those savings over time are recognized and that they're part of the financial calculations. Obviously including Medicare and Vermont's health care reform efforts does give us the ability to potentially influence what reimbursement is looked like looks like what the payment model looks like and so forth. Again we continue as long as there's Medicare participation to get that support for the blueprint that's about 10 million dollars annually. Next slide. A couple of other benefits in our existing model we have some waivers of Medicare regulations that have been beneficial to Vermont and one example is that there is a regulation that there be a three day stay in patients before a person with Medicare can be discharged to a skilled nursing facility. We have a waiver for that regulation in our current model and it also gives us the ability to propose new waivers if there are Medicare rules that we think make it make sense to have a waiver of those. And then fundamentally what Medicare's participation really does is it gives them the flexibility to pay in a way that works with Vermont. So what we see is alignment and priorities, alignment and payment models, alignment in quality measures and reporting and all of that is supportive of our health care system partners who are trying to juggle a lot and it sends a stronger signal in terms of what not only our priorities are as a state but it brings the federal government on board as well with those priorities. One sort of detail that I want to make sure we mention is that our current model is what's considered an advanced alternative payment model by the federal government and as such it means that our primary care and specialty care providers don't have to meet federal it's called a merit based incentive payment system requirements. They get the benefits of that simply because our model is considered an advanced alternative payment model. Any sort of a break in that would mean that our providers would have to revert to the what's called the MIPS system. Next slide. So just this is just a graphic description of Vermont as a low cost state for Medicare. This is a per capita or per beneficiary spending growth. And our spending is the dashed line. The US as a whole is a solid line. And our spending has been below the national average, as you can see for quite some time, harkening back to the, you know, to the early 90s. You know, growth sometimes our growth maybe has been a little higher than the national average. Sometimes it's been lower across the years. It's it's run fairly comparable to national averages. But you can see in 2017 that's the year that we entered into the all pair model agreement with CMI 2018 was the first performance year. You can see, you know, for the years that we have data the cost growth that's dropped pretty sharply compared to national spending. So it looks like, you know, there has been a bending of the cost curve in Vermont for Medicare spending. It compounds annually so that leads to an even greater divergence. So just wanted to provide some specific information on Vermont as a low cost state. Next slide. This is this is a pretty important slide. What's the focus and timing of the future multi state multi payer model with CMI and we have gotten some very recent clarification from CMI on particularly the timing of the future model. Again, as I said, CMI is moving in the direction of offering only multi state models. They are not planning to offer state specific models. They've outlined seven priorities that will be central to the model and I'll share that in a moment. They are planning to provide more detail as I previously mentioned in the fall and that's when we'll really have a sense of where things are going with this model. If they are able to release the what's called a notice of funding opportunity, it'll you'll hear the term no foe for short. If they are able to release that in the fall. It's likely that they'll be looking to states to outline their proposals in early 2024. CMI has recently informed Vermont that full implementation of a new multi payer multi state payment model will occur in 2026. I did previously anticipated that it would be 2025, although I will say that we knew it was a very tight timeframe, but we have just learned that it will now be 2026. So what what that means is that we are now negotiating with CMI what 2025 will look like here in Vermont. I think it's a mutual goal with us and CMI is to ensure that we can provide a smooth transition to a new multi payer model with Medicare in 2026. So that is very recent news that I wanted to share. At the same time that we're now talking about what will 2025 look like, we are continuing to discuss the future model. And so we're continuing to discuss that potential 2026 model as well. Next slide. This is a tentative timeline. I'm going to emphasize the word tentative because again it's very dependent on when that model when those model details are released. But fall 2023 we expect to see more details will want to engage in a broader stakeholder engagement process. I'll say that that's really already begun. Early 2024 is when we expect those applications to be do we would be working very closely with GMCB staff to prepare that application for consideration. There will be a time when there will be, you know, more public presentations to this group, public comment periods. We already have opportunity for public comment but there'll be a good deal more to comment on. And then a vote of this of the green map care board would be required before submission. Later in 2024 if we decide to submit a proposal. If we are selected that it would be later in 2024 that detailed negotiations would occur with CMMI and some examples of some of the areas that we might negotiate would be savings targets. What the Medicare payment model looks like and so forth. 2025 as I mentioned on the previous slide we're looking for a bridge from the current all payer model agreement to CMMI is multi state model. And what that will look like is dependent on our discussions and then according to the new timeframe 2026 would be that multi state model launch. Next slide. So what do we know at this point about the new payment model that CMMI is is developing. So they have signaled that they're, you know, that they're looking to produce a design that addresses seven priorities, and they're listed here. The first four I think we can call payment design priorities. The last three we can call core principles. So the first is that the CMMI model is expected to include as as a payment mechanism, global budgets for hospitals. So that's why we've been spending a lot of time thinking about global budgets. So include a total cost of care target and approach so looking at services that are included in the total cost of care, and then setting a target there for what the expectations are in terms of cost growth. You know, the goal is for it to be all payer so to include Medicare, Medicaid, commercial insurance. And the desire is that there be a goal for minimum investment in primary care, meaning that there needs to be a minimum level of support for primary care. Those core principles, they want to include safety net providers from the start and that would include federally qualified health centers. There is a strong principle around the model addressing mental health, substance use disorder, and social determinants of health. And there is the model will be, you know, have as a core principle health equity. CMMI issued a blog post a little while ago and they actually asked that we provide this excerpt from that blog post in this presentation. And you'll see that a key area here is that it's really that last sentence, the future state based total cost of care models under consideration will amplify Medicaid led advanced primary care efforts by aligning Medicare fee for service and other payers to these efforts. So, a big focus on advanced primary care. Next slide. This is, I hope folks can see this this is a rather busy slide but it's a really important one and I want to spend a little bit of time on it. This is our best effort at depicting our vision for a statewide approach to health care reform. And, you know, a lot of the work that's depicted in this slide is ongoing. But, you know, what we have, I think what we've learned over the years is that no one payment mechanism is going to do everything that we're looking to do in health care reform, and certainly not will not necessarily speak to the broader health care system. And so the way that we're looking at this is that, yes, it is important in that top box to have statewide total cost of care and quality targets. But having those types of targets really helps set a course. It helps make sure that we're all rowing in the same direction. It helps focus efforts it helps support alignment, but it is removed from individual providers and payment mechanisms that are more direct in terms of helping to support care transformation. So while it's an important part of any model, it is not the only part. So, you know, we're calling that sort of the broad structure that it supports efficiency it supports quality across the system, and it's important as a really in that middle box. We believe there's an opportunity to support providers working together and that's actually some feedback that we've gotten from some of our engagement efforts is that how can we and we're calling these shared quality payments but how can we reward and support providers who are working together and there's some measures a few measures that really speak to that I've given an example of one, which is follow up after hospitalization for mental illness. There's a measure that speaks to both the hospital and to the end of the community providers working together to make sure that that follow up care occurs when someone is discharged from a hospital. There are other examples of measures but that's one. And then when you get to that lower set of boxes for the different provider types. That's where you get to those more direct payment mechanisms and provider supports that hopefully can encourage the best possible care. And these can be multi payer. They can be payer specific ideally we'd like to see as much multi payer work as possible. So, there's some efforts that are already underway in Vermont because of our historical approach to health care reform and I'll provide a couple of those for primary care. The example that we're giving is enhanced payments and population based payments. An example of an enhanced payment is the blueprint for health. For member per month payments that primary care receives an example of a population based payment is the work that one cares done with independent primary care practices through their comprehensive pain reform program. So those are a couple of examples. Hospitals again the signals we're getting from CMMI is that hospital global budgets or health system global budgets will be part of the model so that's an example of a payment more directly to hospital providers. Specialists we have you know some work in place but you know that's definitely an area where we would want to continue to focus and focus more effort. Mental health and substance use disorder treatment providers. There, we have several payments in place now for adult and children's mental health through Medicaid and the Department of Mental Health there's a case rate program in place. We have enhanced payments through the hub and spoke model through the blueprint for health and the Vermont Department of Health and then we do have an episodic payment model for residential substance use disorder providers. Those are some examples of really direct to provider mechanisms with the intent of trans transforming care delivery. Long term care providers we have some efforts underway but you know some work to be done there as well and other provider types including home health. So that's the vision the overarching targets important for alignment and rowing in the same direction. Those shared quality payments for work that providers do together across the continuum of care and then those more direct provider payments and supports that are dependent on the provider type. So I hope again it's a busy slide. But it really does depict the vision that we're trying to hew to as we do our work. Next slide. This this talks about how we look to obtain input from Vermonters. Again summer 2022 we are really focused on short term stability for the system that was important given where we are at. In that in the fall we began to gather input on the multi state multi payer model really started some very technical discussions on a potential global budget model for hospitals and potentially other services and the Medicare waivers that we might want to look at. And then later in 2023 we're looking to you know continue to broaden that stakeholder engagement that will include you know public input. There's places on our website net on both of our websites now for that updates at these meetings discussions of existing forms and other opportunities. Next slide. This is our current work group structure. It's you know these are advisory groups. We have a health care reform work group. Then we've got a global budget technical advisory group Medicare waiver technical advisory group and a payer advisory group. We're contemplating a care transformation advisory group as well. Next slide. And these are the organizations that are participating in our health care reform work group. You know lots of provider organizations from across the continuum of care. Next slide. This shows our mechanisms for public input. Next slide. And this summarizes our feedback to see MMI and you know these are themes that I think most people here have heard before but we'll you know we're repeating them as much as we can. One is that we want to see support for rural provider stability and sustainability with workforce and inflation being important concerns. It's important to increase predictability of payments we are able to see during the pandemic how helpful predictable payments were. We want to make sure that the model assures the right amount of revenue with recognition that we're a low cost state for Medicare. Support for investments in preventive and community care is really important. Making sure that to the extent possible those payment models and quality measures are aligned across payers. And then really allowing Vermont to keep moving forward on the health care reform efforts that we've achieved today that includes care for people with complex health and social needs. Support for primary care. Again blueprint and comprehensive payment reform being two examples and support for community based services. Critical elements of a model going forward. Next slide. And next steps will continue to meet with CMMI as we can. We'll continue to gather input however we can. And we will carefully review that model when it's released by CMMI to ensure that it's good for Vermont. And we'll continue to and really step up gathering of input and formulating our response. I think that's the end of my slides. Thank you very much Miss Jones. I'm trying to board members for any comments or questions they may have. I don't have any at this time Pat but that was really thorough and really helpful. I really appreciate it and I'm looking forward to the updates that we're going to you know as as this process unfolds. Learning more. So I really appreciate the catching up on where we are and where we're going. Thank you. And I also don't really have anything. The only other point maybe that I wanted to throw in the mix around the MIPS implementation is MIPS came came into effect while we were in the all peer model as you said so while we talk about reverting to it we have never actually had to implement it as a state so I think. I know we're working to try and get a better understanding of what that might mean for providers so that we understand if you know maybe that's a good thing I don't know I think I've heard it's complicated and there's some administrative burden so I look forward to understanding that better in the future. Thanks Pat. Thank you. I don't have anything either. Well I was distracted by your background making sure there's no gondola at the top of that. It looks like we're okay. I'll turn it to any public comment. Mr. Del Treco please go ahead. Thank you chair Foster Pat you always do such a great job so really appreciate it. I forget what slide it was maybe 13 I think that you call it the busy slide or the one with a lot of information on it. You know one of the challenges we've had in the all pair model is is getting all pairs into the fold. We have largely we have two commercial carriers in Vermont I know that there's others that come in in a transient way through Orissa plans but I mean maybe this is too big of a question for right now do you think the things are going to get easier or harder under this delay and time period and and and I'm specifically thinking about the new relationship with Blue Cross Blue Shield and the blues of Michigan like it what does that look like and you know part of my mindset was maybe maybe a deal couldn't have happened at that time frame when when there was negotiations happening because because there was a deal trying to be made between two organizations so it's kind of like when you go for a mortgage and they say don't buy anything until sign sign off so maybe it's something along those lines but how do we see you know that going forward and interestingly enough on the MIPS piece is there any way to get a sort of a you know the speed pass around MIPS as we wait for this postponement be you know this isn't you know we've always participated in reform we've been huge advocates and to you know to be penalized because of a delay seems a little bit like a backhanded compliment so I'll stop there thanks. I think some of those might be a little beyond today's presentation they're good questions but we might try and get back to you on those Mr. Del Treco I think although I saw Miss Teach Out's hand go up so Walter I'll pass you your next but I'll go to Miss Teach Out first that's okay. Thank you very much. I just wanted to be very clear and say that our decisions about participation in health care reform here in the state of Vermont have nothing to do with the proposed affiliation. All of those decisions are made independently by our executive team. Great thank you for the public comment and Mr. Carpenter Walter please go ahead. So and can you hear me. I can but I can't see you usually I get to see you. Yeah the video camera doesn't work isn't working right now I don't know what's going on with it. I just wanted to ask Pat exactly what a multi payer Medicare is so what does that constitute. Yeah perhaps I wasn't clear so let me take a run at Medicare is a you know is a payer Medicaid commercial Medicare is you know developing this model but there one of their principles is that it be a multi payer model so that they not be the only payer participating in this model. They'd like to see Medicaid participate as well and they'd like to see commercial insurers participate as well. So Medicare itself isn't multi payer but they are trying to design a model that will entail participation by multiple payers. Does that help clarify Walter. More it confuses more. I guess that's clarification in the health care world. Okay. Thank you Walter for the question any other public comment. Okay great Miss Jones thank you very much. Nice to see you and we appreciate the update. Thank you. All right have a good day. So before we turn to Miss Kinsler why don't we take a nine minute break and we'll just come back at a 250. Thank you. Hey it looks like everyone's back so we can resume and I'll turn to Miss Kinsler. Thank you so much Mr. Chair. One moment while I get screen sharing going. Great can folks see what they need to see. Excellent. Chair Foster you should know that we can't actually see you at the moment or at least it looks that way to me. Oh there you are okay. All right well thank you so much for having me at the board meeting today. I'm going to provide an update on the board's work around hospital sustainability which is update maybe is a little bit of a misnomer really it'll be kind of a historical look back as well as a bit of an update and then an update on our work to develop a global payment model as required in act 267. For the record I should state this is Sarah Kinsler director of health systems policy at the board. And I'll actually be joined by an old friend from our last agenda item Pat Jones interim director of health care reform for the agency of human services who co-chairs our global budget technical advisory group and we'll be speaking to a little bit of that content. So thank you Pat for sticking around for the remainder of the board meeting today or much of the remainder. So I'm going to give us a little bit of legislative history to contextualize this work and remind folks kind of how we landed in the position of pursuing global payments in particular. So big picture. It's the board's work to regulate hospitals that has brought this to the forefront for us and I think all the presentations that you've heard today. Sarah and Tom to start Pat just now and then this presentation tied together really nicely in thinking about how this work can evolve and support the state's goals. A little bit of background on this work. It's been building for quite a few years now both in the work of the GMCB and in the legislature. So I'll I'll be as brief as humanly possible when I walk through this timeline. But in 2019 the legislature required the board to convene the rural health services task force with the purpose of evaluating the current state of rural health care in Vermont and identifying ways to sustain the system and ensure it provides access to affordable high quality health care services. So I think those goals still resonate and will sound very familiar to many of us in the work that has that has come since 2019. There were 14 members designated in statute and they met throughout the second half of 2019 really brought brought together a lot of people to think hard about the the future of Vermont's rural health care system and how to ensure that all Vermonters can access high quality affordable care. That same year GMCB required a subset of hospitals to develop sustainability plans due to persistently low and declining margins and the news that Springfield hospital would enter bankruptcy. In 2020 obviously the pandemic hit requirements for hospitals to develop sustainability sustainability plans were expanded and then in part building on the rural health services task force work the legislature passed Act 159 which required work on two major reports. I think most saliently here the hospital sustainability report but also report on options for regulating provider reimbursement which is going to come up a couple of times here and those reports are linked here on the page. A lot of work in 2021 went into developing that hospital sustainability report, including a lot of analysis and stakeholder engagement, noting that a lot of our provider partners were really focused on COVID response at that time. And then finally in 2020 to the hospital sustainability report was released with hospital global payments is one major recommendation and in part growing out of the legislative discussion around findings and recommendations in that report. The legislature passed Act 167 which really we've discussed, you know, kind of three quarters of the first two sections of that in our in our three presentations this afternoon. These recommendations were also echoed by two legislative consultants who recommended person global payments as well. So the board ended up with 4.1 million and dedicated funding for these activities across work on the all pair model. Global hospital global payment model regulatory evolution work, you know, in in the vein of what Sarah was discussing earlier, and then some work to engage communities and providers to inform hospital transformation. There are a lot of kind of long running themes that go across this work. And since it's been quite some time since we've discussed the hospital sustainability report in particular, I thought it would be helpful to provide a brief overview of kind of that the path of the logic that goes through that report of why this work is so important. And some of the findings that came out of the analysis there and the recommendations as well. So I do want to note that I haven't updated the slides in it in every case. So in some cases this this comes from a report that's a few years old now, but they're they're largely illustrative to kind of walk you through the past that got us here today. So to take a step back, we talked about what spurred the initial requirements for hospitals to do sustainability plans in 2019. But I wanted to take a moment to look at the role of hospitals in our healthcare system. I don't think anyone on this call today would question the fact that hospitals are a vital part of Vermont's healthcare system. But when we look at the numbers, how much of the system is hospitals. So when we look at healthcare expenditures associated with Vermont healthcare providers, hospitals are just under half the system that is a huge that is a huge piece of our healthcare system. Again, this, this isn't news to anyone but I wanted to drive home that if we're when we regulate healthcare it's really critical for us to be thinking about hospitals and their role in the system. And when we think about reform on current and future reform, we really can't do that without thinking about the role of hospitals. And so, you know, we've talked a lot over the past few years about hospital cost coverage and, you know, what is what are the factors that are feeding into hospitals margins. And so when we look at cost coverage, I've included a small chart here that really is that really is illustrative. This is not real hospital data. It's kind of sample data to show us, you know, the basic concept, which is that hospital cost coverage hospital paid amounts vary across payers they vary by service and they vary by hospital. So, you know, in general, paid amounts and cost coverage or higher in commercial pairs than Medicare and usually Medicaid, the lowest for most services. And why does cost coverage vary? So one reason for this is revenue, you know, higher bargaining power and the ability to negotiate prices. A second reason is potentially preferential reimbursement rates to ensure access in certain communities like the critical access hospital, Medicare reimbursement methodology. On the cost side, we know that a hospital smaller size could limit economies of scale. In general, efficiency, what Sarah and Tom were discussing earlier today, you know, potentially plays a big part as well as human capital and labor expenses. Those are just, you know, examples of things on the cost side that could impact cost coverage. And then finally, some hospitals prioritize investing in low margin services that are necessary for communities, things like mental health and primary care, which tend to be low margin. Others may prioritize higher margin services either to fund low margin services and kind of cross subsidize within their business or to, you know, make a higher margin. So what does all this mean? This data is updated from the past few years. We're looking at hospital charge growth, noting that charges are pay or agnostic from 2016 to 2023. You know, folks can see a pretty significant upward trend since 2017. So how does this play out? When we look at our QHP premium increases, we see that within the cost of healthcare, medical services are the biggest chunk of the overall trend. Primary driver there is unit costs, also known as price, non-utilization trends. Nonetheless, we see declining operating margins for our hospitals and this is really a system-wide issue. So, you know, both the, as we look across all Vermont hospitals, we see some pretty low numbers there in margin. But we also see it when we look at critical access hospitals broken out at PPS hospitals broken out. This really is impacting our entire healthcare system. And finally, what does this mean for Vermonters? So we know that hospital financial distress has been a potential for big negative impacts on Vermonters, their impacts on affordability for Vermonters. You know, when hospitals increase charges to try to cover costs or make a margin, you know, this shows up particularly in commercial insurance rates. Their potential impacts on quality hospitals and financial distress struggle to maintain quality and patient safety. And finally, there's potentially big impacts on access. So financial distress is a key predictor in determining likelihood of hospital closure. And that would really impact communities access to care, particularly we think that the most vulnerable communities, those who are least able to kind of travel to a further hospital. So this slide shows the recommendations that GMCB brought to the legislature in 2022 coming out of that report. So the, and these are just two among many recommendations. Again, the findings of this report were really robust. A ton of analysis went into this report. As a side note, we have had discussion of some of the analyses that have that fed into the sustainability report quite frequently over the past few years. We recently, in fact, just this morning, updated the Green Mountain Care Boards website to make those more accessible in one place. So if folks visit the Green Mountain Care Boards website and go to the hospital sustainability and Act 167 page. All of the kind of analyses that fit into this, the board presentations that the board received from contractors and experts are all now more easily accessible there. So these are just two of the recommendations or really one recommendation with two parts that came out of this report. But I wanted to highlight it because it kind of ties the room together of everything we've talked about today. So the first recommendation is hospital payment reform and really the hospital payment reform that we focused on in this report and in discussions with the legislature. We're hospital, global budgets are hospital, global payments. And secondly, noting that this work really has to go hand in hand with work to engage communities and envisioning a sustainable future for their health care systems in thinking about the needs and resources that they have locally. And then thinking about, you know, how can we create a system that that provides accessible high quality care to Vermonters at an affordable price. Simultaneously, as I mentioned a little bit earlier, legislative consultants were making very similar recommendations. So things kind of coalesced around the idea of a new hospital payment model or at least developing and modeling a new hospital payment model. And all of this comes together in Act 167. So the Act 167 has many sections. This is kind of the first chunk of Act 167. This is where we're focused today and really I think we'll hit just about this whole little rainbow line of boxes here today. You know, Pat, it all, there could be arrows flowing back and forth, you know, throughout all of these really. I do want to note that Green Mountain Care Boards current hospital budget review process, which Sarah Lynn Berg and Tom Reese spoke about spoke with you about earlier already in some ways function like a hospital global budget in some ways providing an overall cap on revenue revenue. There's there's so much interaction here and so we'll talk about that concept a little bit more as we go forward. Now I'm going to hand the mic over to Pat Jones for a couple of minutes. Pat is one of the co-chairs of our hospital global budget technical advisory group, along with Green Mountain Care Board member Robin Lunge. And so Pat will talk about some of the conceptual issues related to hospital global payments, what they are, why we've kind of gone down this path and I'll then I'll talk about the work of the tag a little bit more. Thank you, Sarah. Thank you for letting me come back today. Again, for the record, my name is Pat Jones. I'm Interim Director of Healthcare Reform for the Agency of Human Services. Next slide. So, I want to start by just being clear about what we mean by hospital global payments. And so we've adapted a definition from the Urban Institute. Hospital global payments are fixed, often prepaid amounts of funding for a certain period of time for a specified population, rather than fixed rates for individual services or cases. So clearly a distinction between hospital global payments and fee for service payments. One of the reasons, you know, why folks are really interested in looking at hospital global payments as a potential payment model is that they can really support hospitals and payers and they can help the state advance our goals in healthcare reform to control costs and improve quality. So what they can do that is through, first of all, ensuring steady predictable financing. You know, we saw again how predictability was a really important during the beginning of the COVID-19 public health emergency when revenues would otherwise have been falling rapidly. And provide flexibility. You know, when we do payment reform, a lot of what we hear is even, you know, even when, you know, more money can't necessarily be generated, predictability and flexibility are key assets in doing healthcare and payment reform. So in the case of hospital global payments, it provides that flexibility for hospitals to change their service offerings based on what community needs are. So it can, these payments can move financial incentives away from volume and really support more efficient care that reduces some, you know, avoidable or low value care and result in positive health outcomes and then controlling the growth in hospital spending at a global level is another potential benefit of hospital global payments. Next slide. So there are, you know, there are, there can be risks with hospital global payments and we want to make sure that we're clear about that. That can include over incentivizing reductions in care provided. You know, if there's a fixed amount of funding coming in, then care would be reduced in a way that's not appropriate. That's a potential risk. On the other hand, there is also a potential risk that there wouldn't be enough funds to cover the true cost of provided care. So both are risks. If we can mitigate those risks, the result can really be a win-win alignment where hospitals, payers, consumers and the state see their needs met. We need to really be careful and ensure that we're balancing the concerns and the priorities of all parties. You know, one really, I think Sarah really alluded to this in her prior presentation, but ensuring that we have robust community engagement where community needs are identified. We understand the population of a particular community. We understand how care is delivered. What are those care patterns? All of that is important when we're looking to design a global payment model that works for us as a state and for all Vermonters. Next slide. This depicts in a graphic format what that value proposition can be for global payments. So the goal improved affordability, better health. What patients can see is that they're able to receive care that's matched to their needs. The result can be better health and more affordable care. For providers, that predictable revenue, the flexibility and then support for care delivery transformation as well can be an outcome of global payments. Then for payers, predictable cost growth is a potential outcome and then better value as well as care becomes more efficiently delivered. Next slide. So we, you know, there are some states three in particular around the country that have attempted implementation of hospital global budgets or global payment programs. One is the New York hospital experimental payment program that was in place from 1980 to 1987. Maryland has the longest tenure in working with hospital global budgets. They have an all payer model and a total cost of care model that's really predicated on hospital global budgets. And that's been in place from 2010 to the present and it's evolved over time. And then Pennsylvania more recently starting in 2019 has implemented a rural health model that has hospital global budgets or budget or global payments as well.  They certainly reflect what's happening in the state in terms of policies and their market dynamics, but there's a lot that can be learned. And so Vermont really is looking to these examples to see if we can gain insight as we move forward and considering hospital global payments. Next slide. So this is our, you know, this shows the membership of our hospital global budget technical advisory group, a number of organizations currently participating. And as Sarah said, Board Member Lunge and myself are co facilitating this group for folks who are on the phone who participate in this group. I want to offer our thanks. It's very detailed and technical information and discussion. Very important discussion just to understand the current landscape and what some of the pressures that the system is facing are including I would add affordability as well as, you know, financial challenges. We have representation from the Office of Healthcare Advocate and from the Vermont NEA and that's been very helpful. Next slide. So the purpose and meeting structure. The charge to the group really has been to make recommendations for conceptual and technical specifications for a hospital global budget or global payment program. You want to try and, you know, gather that input so that we're ready when CMMI introduces the multi state model that I referenced during my prior presentation. We, you know, we think there's going to be some ability for the state, maybe to tailor its methodology a little bit, but there's also likely to be some limitations and guardrails as to, you know, how it looks compared to the model design features that are put out. So again, the deliverable, we want those, you know, we want to have detailed specifications if possible that are informed by input from this group. The group is meeting, start meeting in January is likely to meet into November. We have two hour meetings and they occur about every three weeks. So, you know, quite a lot of work and again, I want to thank those who have participated. Next slide. I believe Sarah will take the mic back at this point. So thank you again for the opportunity to be here. Thanks so much, Pat. Can you hear me? Excellent. Okay. So I'll walk us through a little bit of what the tag has discussed so far and some of the preliminary recommendations that are coming out of that group. And then I'll highlight some areas where we think the board will perhaps have particular interest and will be explicitly seeking feedback, noting that of course we're seeking your feedback on all of this work. And finally, we'll highlight some opportunities for board and public input as well. So between now and the end of 2023, we'll be working fairly methodically through the series of issues that are listed on the slide. They're here at a pretty high level.  So topics covered to date. I want to, I guess, hedge a little bit. There's not consensus on all of these points. They're all subject to, you know, the state's consideration to make sure that there's policy alignment and operational feasibility, potentially alignment with a federal model. But these are, you know, the topics where we've had input to date from the tag meeting participants. So I'll start with services included in the hospital global payments. The tag proposed that all hospital inpatient and outpatient services be included with the possible exception of infrequent and high cost hospital services. That is an issue that the tag is going to continue to come back to informed by data to help us get a sense of what exactly that would mean and what that would look like. Secondly, to include both employed and non-employed professional services built under the hospital's tax ID, that's a tin, but not non-employed professionals not built under the hospital's tin. Third, the tag recommended that at least some hospital-owned facility-based services be included with phased inclusion of additional services over time. And lastly, corporate parent-owned entities on a case-by-case basis. So, and I think the theme here is having a budget that's fairly inclusive and having a budget that will capture enough of a hospital's business to get the benefits and the benefits of the incentives of a global payment model. Secondly, we discussed the populations included in a hospital global budget or hospital global payment model. The tag recommended to include Vermont Medicaid members, not out-of-state Medicaid program members. All Medicare fee-for-service beneficiaries who receive Vermont care at Vermont hospitals and as many commercially insured individuals as possible, including both Vermont and non-Vermont residents who receive care at Vermont hospitals. Again, the theme here is capturing your critical mass with a similar logic as kind of the scale targets in our current agreement, which is that if you want an incentive to work, you've got to get enough of the population in or enough of the dollars in to kind of see that benefit and change the way the business operates. I do want to know that there still will be people and dollars outside of this payment methodology, so we don't really see a universe in which a hospital's entire revenue would potentially be captured. There are still going to be instances where it really makes sense for things to be outside that model, and that was something that the tag recognized as well. So third, and this is where we start to get a little bit more technical, I would say, calculating the baseline budget payments. We're using that patient revenue for Medicaid, Medicare, and participating commercial as the primary data source. We're calculating it at a facility level, not system level, so we're not thinking of creating a budget for all of Vermont and then breaking it up, nor are we thinking of creating a budget for a healthcare, a health system and then breaking it up among member organizations. We're really thinking about each facility individually. And then finally, the tag discussed potential one-time adjustments to the baseline budget to account for hospital financial condition, inflation trends, demographics, and policy changes. When we talk about inflation trends and demographic changes, we're really talking about how to get from a baseline, so the most recent year of data, to the first performance year. And then finally, I think the kind of mediest area of our discussion so far, here it's on one slide, but this has been like, you know, probably eight hours of meetings is annual and ad hoc adjustments. So once you've got your baseline budget, how do you trend forward? So here's some of the things that we've discussed are making annual adjustments to the global budget for things like inflation trends, and there we're talking about how to balance hospital cost inflation with affordability for consumers. How to take into account demographic changes that have happened over the course of the year. We're also going to have in our future meetings discussion about adjustments for things like efficiency or potentially avoidable utilization and how to reward for high value care. Secondly, making annual and potentially mid-year adjustments for changes in utilization. There are two potential approaches to this that we've discussed really at length. And we've kind of had mixed tag feedback, so I'd say stay tuned on that. Third, we want to ensure that there's two-sided accountability for total cost of care. Going back to the slide that Pat presented in her earlier slides with the portfolio model, that's kind of, you know, those overarching incentives that link what's happening in a particular provider organization, or in a payment model designed for a particular provider type, and thinking about how that links to the continuum of care and really promotes, you know, pursuing aligned goals for the full population we think is very important still. And then finally, the tag is discussing considering adjustments for mitigating provider risk, provider financial risk in extreme circumstances. So that might mean things like monitoring for changes in utilization or monitoring for negative margins beyond a certain threshold that could trigger a more in-depth look and potentially an ad hoc adjustment to ensure that this model isn't so risky that would endanger hospitals. So as we look ahead, we're currently working to develop a straw model based on the tag recommendations to date. That straw model development process has required state staff and contractors to really face the, face up to some serious data and operational challenges in kind of meeting the tags recommendations. For example, we're really struggling with inclusion of professional services because of kind of the limited number of professional claims that are linked to a hospital, which we don't think quite lines up with the number of professional services that are actually delivered at hospitals. So we're dealing with some data challenges and operational challenges that may prevent us from achieving all of the tags recommendations or kind of all of the state's goals in the initial years of any program that we implement. So we're thinking about how to, we're thinking about how to set a solid foundation if this is something that the state pursues and then think about how to grow or add on to that solid foundation over time. In the meantime, we're continuing to tackle key issues. So strategies to support care transformation, the terms of payer and hospital participation, how we deal with budget calculation and payment operations. And I would add to that kind of the intersections with existing regulatory structures in the state, as well as monitoring and evaluation, which we think is a particularly critical area to be focused on in light of kind of the pros and drawbacks of a global payment model. As Pat mentioned, materials are posted online and I've linked here to where those live on the board's website. So what are the key areas where we where we think the board might particularly want to give input, noting that we would love your input on any of these areas? Firstly, the baseline budget and setting the baseline. So how should we trend baseline claims to current day? What adjustments if any should be made to the base budget? Secondly, annual trends and adjustment. So are we looking at the right adjustments? How should we balance keeping up with inflation and hospital costs with affordability? How can we incentivize efficiency, reduce waste and reward the kinds of behavior and the kinds of care that we want to see?  Obviously, this one's close to our heart at GMCB. How could Vermont administer global payments? What are the regulatory authorities and mechanisms that we could consider using? I've listed here the board has provided a rate setting authority that we haven't exercised in the past. We've also got payer regulatory levers. Other levers exist across state government and we'd want to kind of think about that. You know, it related, as I mentioned earlier, our current hospital budget review process already works like a global budget in some ways, setting a cap on total revenue and controlling for charge growth. So when we talk about developing global payments, we're really talking about, you know, how could we add a floor to complement that cap? So we're kind of trying to envision how this would nest underneath our hospital regulatory approach that we already have. And that's Sarah and her team are working to, you know, explore how to grow. And then finally, as we look at quality and monitoring and evaluation, what quality measures should be part of a global payment model? And second, and probably more expansively, what measures need to be part of our monitoring framework so that we can be really attentive to any unintended consequences so that we can make sure that we're watching and making sure that the benefits of this model are coming through and that we're not seeing potential drawbacks. So this slide kind of goes beyond just our global payment model development work, which is kind of the things under the orange box and also includes the subsequent all-pair model agreement. And I wanted to include both of these here, both thinking about when board members will have a chance to have input and when the public and stakeholders will have a chance to have input. Pat covered some of this already, so I apologize where this is repetitive. On the all-pair model, board members will have an opportunity to weigh in on that state application. Our staff will support development of any application. And the board would also, you know, vote prior to submission and vote prior to signature of any final agreement. On the public side, you know, we're receiving input on kind of a potential high-level Medicare methodology from the global budget tag. AHS also has the stakeholder engagement process that Pat described. And the board, you know, will continue to receive public comment on this, you know, both through our all-the-time public comment process and through special public comment periods when we've got particular issues before the board. On the global payment model side, you know, implementation might require use of one or more of our regulatory authorities. And if so, and if we were to need to undertake rulemaking, I just want to note how much granular detail about payment methodologies would be required for that process and how much engagement of board members, public presentation engagement of stakeholders and the public would be required to kind of move through that process. So I'm going to go ahead at a long road of stakeholder engagement and board engagement on both of these processes and want to make sure that we are taking time along the way to understand where board members are at, understand where the public and our stakeholders are at, and be able to learn from kind of all parties involved so that we can, you know, design something that makes sense for Vermont and for Vermonters. And that is all I have today. I will note that I included a couple of appendix slides here so folks are looking for more information on the literature behind global budgets and global payments or an overview of the state models that Pat mentioned earlier. Those are both in the appendix as well as a little bit of an update on the Act 167 Section 2 community and provider engagement work as well. All right, thank you. Word member question or comment. Yeah, I'll just, I had a couple but I know, Chair Foster, I know you have a hard stop at four and I want to, we have another agenda item. So I just, maybe I'll just ask one question and I'll save the other ones for future conversations around this topic. I think we'll be talking about it quite a bit, but I'm just wondering how will the community engagement work that's outlined in Act 167 both inform and be informed by this global budget design work. It seems like it's really integrated and just wondering how that's going to, how it's going to work out. That's an excellent question. Thank you. So I think when we think about the payment model work and the community engagement work, one of the things that I think we've recognized in our current all payer model agreement. And I think it was Pat or perhaps Sarah Lindbergh who said this earlier, you know, a payment model, a payment model alone may not be sufficient to transform our healthcare system. So I think of the payment model as one piece of the puzzle and the work that we would do with providers in their communities to think about, you know, what does healthcare need to look like to serve that community sufficiently. And to provide, you know, high quality access to affordable care as really dovetailing together and kind of making each other possible. I will also note that, you know, I didn't specifically mention this, but when we think about those adjustments, those annual adjustments, you know, to the extent that there were, you know. That there were transformation initiatives that come out of that community and provide provider engagement work, which I think we hope we definitely hope that there will be. You know, to the extent that there are service line changes or things like that or new investments or shift of resources, that's something that we would that we would want to be considering in the global payment and global budget setting. So they're, you know, both technical links, but I think more importantly, thinking about them conceptually as activities that will complement each other. Yeah, I think it'll be helpful to also understand what are the, what are the resources that are going to be needed to actually support that hospital transformation and their estimates of the funding that's going to be required. And that will depend in part on how much transformation is happening in each community. So it's all going to, I can see it all intertwined. It's a really important work. Thanks for all the work you're doing. Thank you. I don't have any questions at this time, but thank you both very much and you're doing great work. I know this is a massive lift. So, thank you. I'll turn it to public comment. Mr. Hoffman, I see your hands raised. Please go ahead. I think you're muted. Thank you, Chair Foster. I think it's worth pointing out that in Cherno's evaluation of the model. I don't have anything to suggest that the application of global budgets led to change in delivery. Similarly, we're finding beyond capping growth here in the application of global budget hasn't succeeded as much else. There's still quite a bit of debate here about what the value has been. So that's a comment. Since the presentation was teed up as the emphasis being placed on advancing value based care as the real goal in this next model. And I think despite many attempts to pointedly ask both AHS and this board about what they conceive of as a rather vague term and icon they placed on some of their slides called Total Cost of Care Accountability Framework which typically appears as an umbrella at the top of their slide. Will anyone please definitively today respond to the public's request to understand is that the current ACO comments have been made by both regulators in the past that the new model would be ACO agnostic. And yet there's been no enumeration of how the Total Cost of Care Accountability Framework would be executed absent something that would replace the current ACO framework. And I think the public would really like to know at this point given the contracts literally would need to start being inked in less than a year really in starting in the new year. Is this going in the direction of the current ACO continuing to be the auspices beneath which that accountability framework will be executed. I think it's late enough in the day that someone, anyone should let the public know if that's where this is happening. And I think that an absence of a response is also a sufficient answer for many of us. And in light of the letter that was sent to the ACO today using words like recalcitrant, unacceptable, and enumerating many failures of this ACO. I think it's pretty unthinkable for the public to suspend this belief that there's no other plan if it is the case that this is your intended vehicle for reform in the next iteration of the old care model. And then lastly, this act that promulgated the workgroup and there is a lot of work that was done specified that the public would be part of a robust engagement, which to date it's not been. And this board generously permits the public to attend the PCAG meetings and the general advisory meetings meetings. Could you please tell us why you would refuse the public to similarly attend these meetings and to permit public comment. Is there, is there discussion or information related in these meetings that are too confidential so as to preclude robust public engagement as was established in statute. And again, our response would be lovely, but in the absence of same, I think we'll all infer the reluctance of this board to answer some of those questions that have been pretty forward. Mr. Hoffman, I was having a hard time with some of that is breaking up on my end. So I'll try and respond to the pieces that I got if you'd like to send an email or a letter with any of it that might be beneficial after this. I heard a question about whether or not the ACO would be the component going forward. And I think Miss Jones addressed that earlier in the presentation. I think the answer was that this information is fairly new as to the delay and that will be working on all possible options and evaluating them and that that's being worked on right now with CMMI. And I think the other question was about transparency into the global budget process. It's something that we're conscious of and thinking of. I think that what we're doing is having public comment being submitted and we're having hearings and updates about what we're seeing and what we're doing and the public can comment and participate there as they can in all of our hearings. Perhaps that changes as we go forward. There is pretty robust participation from a diverse group of people in those meetings including the health care advocate, payers, hospitals, non-hospitals. So I hope that answered your question but I didn't quite catch all of it. But if it's okay, it was meant in statute to be robust community engagement. I see robust executive engagement and I don't see the synopsis of those meetings as in any way offering the public a comprehensive view of 120 minutes of dialogue. It's not possible that these are capturing that. And I would just suggest to you that it's a violation of statute. If this board can permit the public to engage in PCAG and the general advisory committee through attending virtually and asking questions what compelling reason can you offer us today to understand why the community has been foreclosed from similarly being engaged. It's in statute. It's supposed to be robust community engagement. Not robust insurance executives, hospital executives. The health care advocate had the fight to elbow its way into that room. And so not even they were permitted early on into that room. Why is the community being prevented from being at that table? Ms. Jones, member one, Ms. Kinzer, do you have any additional information we should share at this time? You know, I just know that the group that we put together our advisory at this point in time are taking their input. You know, we're at a stage in this process where we really don't have a lot of information to share from CMMI. When we do I think that will provide a better opportunity for more public engagement. We've shared what we have today. We'll continue to share that. I will say that we've started to engage with advisory groups that include a broad range of participants, people with lived experience, providers we've engaged with the Department of Disabilities, Aging and Independent Living's advisory board. We will be meeting with the Mental Health Integration Council moving forward and we're really gearing up on that more public engagement process as we have information to share. Unfortunately at this point there's not a lot we can share but when we can we absolutely will and would welcome feedback on how best to ensure that we get broad participation and feedback. Thank you. Walter, I see your hand is raised. My camera is still unconscious. I can't wake it up. I just wanted to build on the previous commentary around the time of 2015.  My question here based on that is when we design all these models which we always seem to be doing, will a patient be on the panels or member of the public a patient someone who has to go through this, someone who is uninsured because they can't afford insurance or what not be on one of these panels. Blend it there. That's a good question. Is there any information we have on Mr. Carpenter's question at this time? I would again reiterate that we are beginning to engage with advisory groups that include people with lived experience and patients and will continue to do so and would welcome input on how best to do that. Thank you. Mr. Davis. Thank you, Mr. Chair. This is really a question I've never understood about global budgets. The real engine of cost increases is essentially decisions by physicians to overuse or to underuse or whatever. What I'm curious about is does global budgets somehow integrate what happens to the individual doctor, especially in smaller hospitals especially orthopedic surgeons? Is the global budget aimed at controlling the hospital side of the cost or does it include the doctor side of the cost? That's my question. I think we can address. Member Lunge, do you have anything on that? Sure. Happy to unless Sarah prefers to. I think, Ham, you've hit on the reason that the TAG was very interested in seeing professional services included in the payment methodology to align those interests for at least hospital employed physicians and others in both primary care and specialty care who order the services. So I think that's that wasn't a feature in the other states global budget models in the past, but the way that CMMI tackled that in Maryland was to include a primary care model and a total cost of care overlay. So I think from looking at existing models in the past, there's a couple different ways that you could approach that. You can learn from them and think about adding in more services if we can figure out how to operationalize that, or you think about combining the global budget with other payment methodologies and the total cost of care like Pat was describing in the portfolio approach. Thanks, Rob. I didn't fully understand that. Are we now talking, when we're talking about a global budget, are we talking about a global budget for the hospital or are we talking about the cost of the hospital plus the doctor? What does that mean to you now? You're talking about global budgets. I don't know what global budgets mean. How global are they? That's the purpose of the work group is to work through that on a very detail oriented code specific level. So we can model it. So that's really the work that's happening now, when you look at other Medicare models in existence today, it's been inpatient and outpatient facility claims. I think there's been high interest in Vermont to broaden it to include the professional services claims, but nobody's operationalized that. So that's the work that has to happen. Thank you very much for that. Just a comment. If you want to control the cost the hospitals can't raise the money unless the doctors do the service and the doctors do the service based on a whole bunch of things like their professional skills, how much money they want to make and so forth. Because the reality is, if you look at Vermont today, you have X and 2X in the amount of money that gets paid to orthopedic surgeons across the system. Check it out. Trust me it's there. Thank you. Okay. Move for next topic because we got to get through this agenda item. Miss Bowles, are you here? Great. And thank you, Miss Jones and Director Kinsley. I appreciate your work on this. Miss Bowles, take it away. We'll do. Can folks see my screen? Great. Okay. Last item of the day, I'm hoping this can be pretty quick, but we are back here to talk about the Medicare only ACO guidance. In terms of a very quick agenda for today, I will briefly review the performance data section question that we discussed last week and then hand it back to the board for questions and discussion, public comment and the official vote. So this slide just has the questions that we discussed last week. As a reminder, we were adding some benchmark performance measures and asking in question seven here, a holdover from last year asking whether the ACO benchmarks are performance against similar entities and then the new question, which is whether the GMCB expects or saying that the GMCB expects to require FY24 reporting of Vermont performance data from the ACO as part of their FY24 budget approval. The reporting requirements will be finalized in the ACO's budget approval and again, that would be in the fall and the ACO should review the metrics listed in appendix tab D performance data and justify any proposed deletions or additions to this metric. Again, this is just a repeat slide from last week, but as a reminder, the way that this question or statement in the guidance is worded leads the opportunity for the final metrics to be reviewed and approved by the board as part of the reporting requirements that are set for these Medicare only ACOs in the fall. And that also allows opportunity for us to take into account responses from the ACOs or other public comments on these metric lists. So between last week and today, we wanted to allow, we delayed voting last week to allow initial public comment from anyone who wanted to submit to us. We did, we didn't get any other public comments besides the blurb I have here from AHS because we wanted to check in with them about kind of how these measures connected to other statewide measures. So the initial comment that we got back from AHS I'll just read it here says, their initial comment noted that these measures are different from the current state measure sets, but they seem consistent with standard utilization and ambulatory care sensitive condition admission measures. The measures also overlap with areas of interest like diabetes, hypertension, COPD and access to primary care. And that more methodology details would be needed to be able to comment on potential data collection burden for providers. So again with the current guidance, the way that question is written GMCB can receive input from ACOs in the form of their budget submissions with that question, as well as allowing opportunity for other stakeholder consideration or comments prior to finalizing any of performance metrics in the fall. So with that we have suggested motion language here for when we get to that point in the meeting if folks are ready to vote, but for now I will hand it back to you Chair Foster for any board discussion. Thank you very much. Do you have any questions or comments and I'd also be curious if you feel like you're ready to vote. Yeah, thank you. I'll go ahead and jump in because I raised the issue last week. Thank you for allowing for a public comment period and thank you to HHS for weighing in. I'm comfortable voting today. I am as well. Thank you. I am as well. So Ms. Bowles, I don't have any other questions. I'll turn it to any public comment before we take up emotion. It's throwing people off today because we have two fewer board members and no healthcare advocate. All right, Ms. Bowles, would you mind putting the motion language back up? All right, I will move to approve the fiscal year 24 Medicare only ACO budget guidance as presented by staff to the Green Mountain Care Board. I'll second. All those in favor please say aye. Aye. Aye. Aye. And the motion and the guidance is approved. Ms. Bowles, thanks for your great work on this. Thank you. I know we have on the agenda today so is there any old business to come before the board? I have some old business that I will just briefly bring up and this will be quick. So I am considering doing a proposal related to the fiscal year 24 one care ACO guidance related to ACO performance and the payment methodologies tied to cost and quality but I have don't have that available today. So what I was going to propose is that after I've done a little more homework and make a decision that if I'm going to offer something I will write it up and ask staff to post it by next Wednesday on the ACO budget page so that the public will have an opportunity to see it and provide some input and feedback and public comment as well as of course that my colleagues will have time to react to it and think about it. So I just wanted to mention that so that anyone who's interested will be looking at our website for it next week potentially. So no promises but I just wanted to announce that. Great, thank you. Anything else? Okay. Is there a motion to adjourn? So moved. Second. All in favor please say aye. Aye. Thank you everyone and have a good day.