Today we are very happy to have Senior Vice President of Stadium Operations Doug Bihar joining us. Doug joined the organization in 1998. It is his 24th season with us. He oversaw the closing of the original stadium, was involved in the construction and design of the current stadium. He and his group are in charge of implementing the logistics behind all events at Yankee Stadium, from baseball to soccer to other large and small scale business, community and private events. He also oversees stadium security and the overall maintenance of the facility. And one kind of very important point to bring up, Doug has been in the building throughout the pandemic. He and his group have spent a tremendous amount of time and resources looking into the best practices and how we could get to this point today. So this has been a long, long buildup, getting where we are on Thursday. Could you speak a little bit to that before we take some questions? Sure, Michael. Thank you and good morning to everybody on the call and thank you as well. Yes, this journey to get to Thursday, our home opener started more than a year ago. We March of last year when we closed, we still came in. We had a dedicated group of some ops hoax that would work daily here in the building to try to understand what it was and what it is that we are dealing with. We worked with industry experts. We collaborated with anybody that we could. Our owners were intimately involved in the process to make sure that we were approaching this in the most strategic way possible. For us while we were able to open for our summer camp here last year and host a short season, we still wanted to evolve in our operations, in our health and safety program, continue to work with industry experts. We sought to achieve the health safety rating for the International Well Building Institute. We were the first stadium in the world to achieve this rating and it gave us a look and a checklist if you will of all of our health and safety procedures and protocols that we were putting in place to make sure that we were checking the right boxes. Being third party verified was important to us and the process is still continuing. We're still evolving, working very closely with the city and the state and the Department of Health on protocols and most recently, Michael, as you know, we're able to use Yankee Stadium as a vaccination site. We're hopeful that by the opener, we will have given close to 80,000 shots, which we think is remarkable and great work with the state and the city on that effort. Doug, thank you very much. Can you move the microphone a little bit closer? Great. Excellent. One other note about Doug obviously is on the stadium operations side. If you do have questions related specifically to ticketing, we can work with you offline on that. You can just send me or someone in our department an email. But with that, we can take a first question. Please use the raise hand function and we can take a first one from Bob Clappish. Thanks for taking the time. I'm curious how a decent number of fans will be in the ballpark. Will they be allowed to mingle in their concourses, buy food, use the restrooms, and buy the restrooms? But I'm just curious about the foot track in the ballpark, what's there inside? Yes, hi Bob. So this experience, first let me say we're very excited to have our fans back in the stadium and we appreciate their patience and understanding throughout this entire process and recognize that Thursday will be a completely new experience for them at Yankee Stadium. However, we also recognize that New Yorkers and folks all around the world are familiar with the physical distancing and the face covering requirements that exist today in most places that are open. So yes, concession stands will be open, but there is a distancing requirement and we'll have markers and signage all over to help people understand where and how to do that. But it should be a seamless, recognizable experience as they've had in the past. And just to follow up, will all parking garages be functioning as in the past? Most of the parking garages will be open as they have in the past, yes. Okay, thanks. Thanks Bob. We can take a next one from Sweeney Murdy. Good morning Doug, nice to see you. I was wondering if you could spell out some of the procedures for both entry and exit, because I guess they're both unique in their own way, with the entry to the stadium being kind of formal. But the exit to the stadiums is usually a little less structured. Are there certain procedures for both of those? Good morning Sweeney, good to see you. Hope you're well. So the experience, of course, will be a little bit different. We encourage all fans to get here early. As most everyone knows, there is a testing requirement in New York. So fans will have to show up with either a negative COVID test or proof of vaccination. We're working very closely with our security team here at the stadium to try to make that process as seamless as possible. There will be temperature checks as well. We have our queuing lines will look like they have in the past, except they'll be distancing between parties. Once inside the stadium, we've sold tickets in pods. So there'll be pod sizes of varying degrees. But most of them will be pods of twos and fours. And like I said, the look and feel of that flow will feel very, very similar than it has in the past, just with some restrictions. Egress, there's no formal protocol on how fans should leave. But like they have been in any other parts of what they're experiencing now, we just ask them to do it in a safe and as distant way as possible. Thanks, Sweeney. We can take the next one from Bruce Beck. Doug, I hope you're doing well, my friend. Is testing at site for fans a consideration at all, Doug? Hi, Bruce. Good to see you as well. You know, we have been speaking with multiple different groups and believe there are enough facilities within the five boroughs and close by that fans can have the opportunity to get tested fairly quickly. How do you define seating in pods? The guests are separated by empty seats, but do pods necessarily have to be family? Are they a group of friends that commit to being a group of friends? How does that break down? Yeah, so the seats are separated by at least six-footed distance and the seats that are not manifested are tied together so they can't be used. But yes, people that are comfortable to come within a allowed pod size, two, four, three, five, whatever they choose, we are okay with them being in that group together. And my last question, just following up on my five-footed shaft, if you're on the contours, will it be one-way, going sideway, you know, going forward and back? Is that the way it's going to be instead of kind of a mishmash when you're racing for a concession? So we looked at that as a possibility, but as you know, Bruce, the seating, restrooms, concessions be very difficult to control one way of traffic. We believe that with how we have everything set up, whether it's concessions and the seating, that our fans and guests will understand how to flow through that in a very safe and healthy way. Thank you. Good luck, Doug. Thank you. We'll take the next one from Barry Bloom. Thank you. Hi, Doug. How are you? Hi. The question for the future here, as this plays out, and more people get to come into the stadium, how much of what you're basically putting into place now, do you envision staying in place permanently? And then, OK, go ahead. So I think there are, well, certainly, we hope some of the distancing requirements get lessened, right? So we could enjoy a fuller capacity at our venue. But a lot of our health and safety protocols, I would say, are here for the future. How we clean and disinfect is of paramount importance, and that just doesn't speak to COVID. It speaks to any other virus or pathogen that may exist. So our training, we spent a whole lot of time this off season and working towards this season on doing things that fans and guests may not necessarily see. We did an enormous amount of training with our staff on how to use PPE, on the proper hand hygiene. And it may sound silly, but how to wash your hands is of vital importance to us. And our cleaning and disinfection program, we took and are taking biological samples of surfaces throughout our facility and have been doing that since March of last year to understand what, if anything, we're dealing with how our cleaning and disinfection program works. And we're doing that in conjunction with industry experts who work and train and clean hospitals to create the same type of safe environment for our fans and guests. And I'm assuming you're going cashless, right? We're trying to be as frictionless as possible. So yes, cashless is just that. And we'll have cash to card machines in the facility for those folks that come with cash that could, it's kind of like a reverse ATM. Yeah, I've been told by other stadium operators around the country that the cashless thing is kind of here to stay, that it's not something that's gonna change. And one of the things I also noticed during spring training at hockey games I've gone to is that there are no vendors in the stands anymore. Is that something that is a dinosaur and we're not gonna see anymore? It's hard to say, I think at least out of the gate, you're not gonna see that for a lot of reasons. I think when it comes to the health and safety piece of this as far as the distancing, I think avoiding unnecessary interactions with people that we don't know is always gonna be a good thing. Thank you. Thank you. Alyssa, you have the next question. Delay, so you're starting off at 20% capacity, just how many people is that? And what is the rule around mask wearing? Will there be people going around making sure people are wearing that? Yeah, so 20% for us is 10,850 tickets. Face coverings are required unless you are actively eating and drinking. We will have a team of folks who are responsible for ensuring compliance on not just face coverings, but occupancy in spaces. And of course, the foot traffic flow, which Bob and Bruce alluded to earlier is important to us to make sure we're managing that accordingly. The days that there are night games with the vaccination site is still going to be open. Is there any kind of delay when fans are allowed in? Is there any kind of transition period? Any complications or challenges with that? No, we're excited to still be able to continue to do this. And we've been working very closely with the state and city on how to manage through that process. And because we've been doing it for as long as we have seven days a week, and in some instances we did it around the clock, we have it pretty dialed in and don't anticipate any issues between vaccination in the morning and games at night. Thank you. Andrea, you have the next question. Good morning, thanks for taking my question. I appreciate it, Doug. Just a couple of things. The negative COVID test that fans need to have, how far in advance is it a day of test that they need to take? And then separately, I just wanted to confirm the steep separated by six feet. Is that the pods separated by six feet or in the pods, the seats are also separated by six feet? So thank you and good morning. The pods are separated by six feet. So if you're in a pod of four, you're sitting arm in arm with your group. As far as the testing, the requirement is a negative PCR test within 72 hours of the event or a negative antigen test within six hours of the event. Thank you. Thank you. Jack, you have the next question. Hey, Doug, good to see you. Both you and Michael talked about how getting to this point has been more than a year long process. And I'm sure you've thought about everything that could go right and could go wrong. I know you can't predict the future, but what's on your checklist of things that you are saying, we have to make sure we get this right? Good question, Jack, and good to see you as well. We have to get everything right. We've approached this as a kind of a pass-fail situation. We don't look at it as we're gonna get graded with a letter. Everything we've set forth is important. It is tremendously important for us. And it's not just the cleaning and disinfection part. It's the signage we put up. It's the relationships we built, the collaborations we have with industry experts and making sure that the, not just the fan experience, but the players, the media, all of the stakeholders who will be in our building have as seamless as a process as they can. We recognize we're doing this for the first time. This is new for all of us. It'll be new for you. It'll be new for me. So patience and understanding on everybody is certainly gonna be at the forefront, but we've, because we've been looking at this for the past 12, 13 months, we feel we're in a position to execute on those the right way. And then one quick follow-up. The governor's office gave a number for what it thought 20% was, but the Yankees have never given their number. Not gonna hold you to the exact number, but what do you envision the attendance will be on Thursday? How many people are you allowing in the building? The number we actually have approved at 20% is 10,850, and there's a lot of excitement around coming on Thursday. It is opening day, it is Yankee Stadium. There's always something very special about that. And we anticipate a good afternoon. The only thing we can't control is the weather and we're hoping it cooperates. Thanks a lot. Thank you. We'll take the next one from Ronald Blum from the AP. Hey, Doug, how are you? Good morning, how are you? Well, good. Of the tickets, are they all reserved for seasoned ticket holders? How did you decide since you have such small, limited number, what percentage, what, who gets to buy them? And of the 10,850, how many are set aside for players? Ron, I'll be honest with you, the ticketing part of it is a little bit out of my sweet spot and that's something maybe Michael and I could follow up with you after. Sure, Ron, we can take care of that offline. Feel free to reach out to me afterwards. Thank you. Okay, thank you. Thank you. Next one goes to Kevin Reichert from Ballpark Digest. Good morning for taking the time for this. I have two questions. The first one is, have you considered a vaccination only section like other teams are looking at? We did not, we've spoke through that but we wanted to maximize the ability to get folks in and also the ruling from the state is that regardless of vaccination, we still have to have a distancing requirement. Gotcha. And secondly, do you have some sort of timeline in organizationally as to when the capacity can be re-evaluated? I know you guys operate in a lot more complex circumstances than other main teams, given the multiple layers of government but do you have a goal where you wanna say, hey, this is working, let's boost it to 35 or even 50%? So we're obviously working very closely with the city and state and they're guiding us on those efforts and for us it's getting out of the gate and starting, we're excited about the 20% and having the opportunity to show that we could do this in a safe way and we'll let this happen in a very organic way. Thank you. Thank you. Great, we'll take the next one from Christie Kaleshian. Christie, who are you representing today? Christie, I have to hit unmute. Great, thank you. Also, somebody has one shot and they're not fully vaccinated, is there an issue with that? Yeah, so the proof of vaccination being fully vaccinated will suffice in lieu of a negative test but the requirement is 14 days after your second shot of Pfizer or Moderna or 14 days after your first shot of Johnson & Johnson. Great. We will take the next one from Gilmour Avalos from NBC New York. Hi, Doug, sorry for the delay there. Will Yickey Stadium allow guests to use that Excelsior pass app and if so, how would that work? Yes, absolutely and good morning and good question. Absolutely, it's an important piece of our program, the Excelsior app through the state of New York is a great way for our fans to show up and have their proof of vaccination or proof of a negative COVID test on their phones. It'll make it very easy for security to validate that part of their entry, absolutely. And can fans use that as soon as Thursday? Absolutely, yes, it's ready to go and our staff is trained on how to look for it and use it. Thank you, Doug. Thank you. We'll take the next one from Bill Ladson from mlb.com. Yes, will you continue to still have the pomp and circumstance before games, is that allowed? So, that's not allowed, there are restrictions both from not only government restrictions, but league restrictions, but we feel opening day, Yankee Stadium, that in itself will create enough excitement. Thank you, Bill. One thing, Doug, we hadn't hit on just yet was the vaccination site and the fact that it will be continuing through April 30th. Could you speak to that and kind of what your experience was getting that site up and running? Sure, thank you, Michael. Yeah, you know, when we had the opportunity to host a vaccination site here at the stadium, our owners jumped at that opportunity. It was important for us to be and continue to be good community partners. It's always been a mandate from ownership and we started working very closely with the city and state on what would be the best way to function and what would be the best experience for the folks that were coming in to get vaccinated. It's been a very rewarding experience as seeing folks come in and out as excited as they've been to participate in this. It went incredibly well over the course of time and we've been doing it that when the question came, can we pull this off even in season or at least at the start of the season? Again, our owners made it clear if we can make it work, let's make it work. And working again very closely with the city and state on this, we think we could manage both not only non-game days but game nights being able to give shots and do it in the right way.


Turn it over to the executive director. Thank you. Well, welcome, everybody. We have most of our advisory members here. Oh, thank you. I would be talking on mute. This is why Josh was here to remind me of these things. Thank you. OK, welcome, everybody, to today's advisory committee meeting of the Green Mountain Care Board. We were here last in February when it was very much winter out there. It is spring now, and I see there are some buds on the trees, but it's still really cold. So I'm hoping that it'll feel like spring pretty soon. What I thought we would do first before I give you an overview of the agenda and some updates is to go around the room. We have some newer faces. Last time when we met, we talked about everyone introduced themselves and said why they were here and why they wanted to be on the advisory.  That's great, too. I know we have a member here that was not here last time. So when we get over to that side of the table, I'll have her talk a little bit about her background and if she can do that for us today. So I am Susan Barrett, as everyone knows. I am the executive director of the Green Mountain Care Board, and I'm delighted to see all of you today. Sarah Kinsler, I'm a director of strategy and operations at the Green Mountain Care Board. Rick Dooley, clinical network director for Health First, the Independent Practice Association. I'm Sam Liss, I'm chairperson of the Statewide Independent Living Council among other titles. I'm big CEO of the hospital. I'm Jason Garverine, I'm an assistant professor in the Department of Nursing at UVM. Andy Miller, pharmacist with Broadable Pharmacy. David Sickle, private citizen, but I recently retired after 30 years at Vermont League of Cities and Towns, working on health and other insurance programs. Margie Rietmone, I'm a social worker at the AIDS Project of Southern Vermont. I'm Jeff McKay, I'm the VP for community and behavioral health at Wellum Regional Medical Center. I'm Sharon Guttwin, a physical therapist and a business owner of the rehab gym. Jim Gullagher, I'm a family physician and VP at the University of Vermont Medical Group. Alison Ebrahimi-Golden, I'm a registered nurse at Kingdom Internal Medicine. I'm Kirsten Murphy from the Vermont Developmental Disabilities Council. I'm not a member, I'm here to support our member. Who will introduce yourself? I'm Terry Olden, I wear a lot of hats. I'm from Memorial County, which is north of Montmainsville. I have a son with developmental disability and he's also insulin-dependent, diabetic. I have a MMS, so I'm on a road that is going to be dependent on medical care and I'm a farmer with a valid farm and someday I'll have time enough to put it back on its feet and get going again. I'm Micah Demers, I work in Quality Improvement at Blue Cross. Mark Nellist, Family Physician, formerly of White River Family Practice. Josh Claven, Primary Care Physician, CMO at Blue Cross. Gail O'Claire, RN, and CEO of Little River Self-Care and Breakfast. Kevin Mullen from the board. Tom Palland from the board. Joseph Hansen from the board. Robin Lange, also from the board. And Eli on the phone, could you just introduce yourself? Sorry? And Walter, wait Eli, hold on a second in the room. Walter Carpenter of Vermont Health Care for All. Citizen Activist and Green Mountain Care Board Health Care Groupie. Kathy Mone, I'm the associate chief medical officer for Bay State Health in Massachusetts, but I live in, what, low Vermont. And my interests are in quality and patient safety and how those, the intersection of those things directly impact the cost of care that we provide our citizens. And Eli on the phone? Yeah, I'm Eli Lester Goldsmith. I'm a small business owner in South Burlington, Vermont. I'm on the advisory committee. And I'm just looking to be a helpful part of the committee. Thanks. Great. Well, welcome all. Today, we have a very busy agenda, so I will be very brief, but I wanted to walk you through our agenda and I have no idea which way to, ah, to get it out. So after I walk you through the agenda, I'll give you a brief update on the work that the board has been doing since February. So today, we are going to have my updates and then we're going to finalize the draft charter. We incorporated some of the changes that you asked from the last meeting. Then we'll hear an update and an overview on the all-payer model and ACO. We have staff from the Green Mountain Care Board who will give you that overview. Then we're going to break out into different groups. We sent you the information on the three different groups and I'm just going to briefly give you a little bit of background on that. I think it was David who brought up the open meeting law last meeting, thank you. Then our lawyers took that and ran with it. Here we are today. So you all, if you want to communicate outside of a public meeting, you cannot be in a group that's larger than seven. That would be considered a quorum. So in order for you to take a discussion offline or online, you need to be within that group of seven. So what we did is we, it's actually, it works out well because it serves twofold. One, it allows us to abide by the open meeting law, which is very important. And two, for today's meeting, what we're going to do is break you out into those groups. We've given some scenarios and some questions around some topics that I can go over in a minute. But we're going to ask you to give the board advice on those issues. And I think that's the primary goal for you guys is to advise the board. So it's actually a nice way to kill two birds with one stone. The three topics that we're looking at are actually the result of a doodle poll that we performed with the group. And they're also aligned really well with the top three priorities that the board has for this year. So they are the all-parent model and accountable care organization, healthcare workforce, and price transparency. Or actually, let me back up, it's transparency in general, including price transparency. So any questions before I move on to the updates? Great. And everyone got the packet of information beforehand. If you need hard copies, they're on the table behind me. So this is a bit of a busy slide and I don't have a pointer. So I'm actually going to go up here and point to you. So what has the board been up to since we met last and some updates? So this is a slide depicting rural hospitals. As many of you know, we've had some recent troubles here in Vermont, specifically around Springfield Hospital. And what the board has done, I believe it was in April, is among other things. We convened a panel to discuss challenges and opportunities for rural hospitals. We had an expert, a national expert, who just did a great presentation. I believe we sent that presentation in the link to you. I know everyone's busy, but if you do have time, take a look at it. It was very dynamic and very informative. Then we also had CEOs from a couple of our hospitals on the panel. And the takeaway from the panel was two things. The national expert said, obviously there are challenges, but what we're doing in Vermont around the all-payer model and moving away from fee-for-service towards population-based payments is the way to go. And that was heartening, but the thing he also said is that it's a really hard time for folks who are trying to do that because you're in the proverbial two canoes or is it the doc in the canoe? I can't remember what it is. And that's really where we are right now. It's a very challenging time. But we've also incorporated into our hospital budget guidance some additional measures related to oversight of hospitals and getting more information on their finances so that we can keep an eye on these hospitals and also find ways to support them. I don't know if board member lunch would like to add anything and put you on the spot, but she was actually integral in putting that panel together. Sure, I'll just chime in briefly. I think what was helpful for me was to really get more of a national perspective because I think it's very easy to be focused on what we're doing here and how's it going and all those sorts of things, but really understanding that the dynamics around payment reform are really national and they're being driven by Medicare. And so that's something that we all have to understand when thinking about moving forward here in Vermont. The other piece I think that's important to notice there is a bill going through the legislature to establish a rural health task force. And I think right now what we're doing is waiting to see kind of how that comes out of the legislature and then that would be the followup to our meeting and kind of the next step in looking at rural hospital issues and what's happening in that area. And it hasn't been signed by the governor but it has passed the chamber. So this is DC, if you can tell. And I'm gonna ask Chair Mullen if he could describe or update the committee on his recent trip to Washington. It really wasn't that recent. Really? Yeah, when you think about it. Time flies. Yeah. But Governor Scott, Secretary Gobay, Ina Bacchus and I traveled to Washington to meet with the new director at the Center for Innovation at the EHHS facility. It was really a fascinating discussion because what you continually hear about is how government is broken. And this was a case where we went to discuss an agreement that was signed under the Schumlitt administration with the Obama administration in Washington. And yet, here we are with the Trump administration and the Scott administration. Everybody's still working towards fulfilling what everyone sees as the future of Madison which is moving away from fee for service. And the good news was we felt home right away when Deputy Director Bowler talked about how we love Vermont and makes frequent ski trips up here. So that was a very good thing. And I think that the governor definitely walked away from there with a much better understanding. And as did our Washington partners. And it's nice to hear when the governor's out making speeches. I know I was in Rutland just two weeks ago for the groundbreaking of the Huebner building which they're calling the Hue. The governor was talking about the move to the Alpera model. So that's a very good thing. So I think that it was refreshing just to see that despite changes and administrations, everybody's still moving forward. Thank you very much for that update. I have a couple of more. The picture in the middle is the picture of a recent report that I believe was also sent to all of you. It is, I don't know how many pages, 180. It's a lot of pages. 600 or something. Oh, it's more than that. Okay, clearly I will say I did not read the whole thing. Executive summaries are wonderful. But this is a document that came out in April and it is a federal evaluation of the state innovation models. So the state innovation models was a program that Vermont participated in, gosh, four or five years ago. It was a $45 million grant that we received from the CMMI which is the Innovation Center of CMS. There are many people in this room who worked on SAM, either worked, like Sarah sitting next to me, I don't mean to embarrass you, Sarah, but she was working on the same team. I know there are others. But then there are many of you who actually worked tirelessly in the stakeholder groups and suffice it to say, and I don't like to read off slides, but I'm just gonna read what they said in this evaluation. They looked at the six round one states. First, Vermont yielded savings of $97 million in Medicaid over the three years in relative to saving in the comparison group. And Vermont had a statistically significant slower increase in total Medicaid expenditures. Vermont showed comparatively lower rates of ED visits and inpatient admissions. And then this is a quote from the report. Overall, Vermont's SIM initiative was a catalyst in terms of advancing alternative payment methods and innovative delivery models focused on paying for value and quality rather than volume. Many especially recognized the importance and influence of the SIM initiative for promoting alignment, coordination and communication across state agencies, delivering payment models, stakeholder communities and other state initiatives. While a solid foundation of health reform initiatives existed in the state, the SIM initiative was a valuable driver of funding major activities that accelerated the models forward. Strong stakeholder engagement and invested providers who were supported through innovation grants and learning collaborators were key to Vermont's success. Although still in its early implementation phase, Vermont's all-payer ACO model, which has developed under and informed by the SIM initiative is expected to continue the momentum of payment and delivery model reform across the state. So it was an excellent evaluation from the federal government. And I want to thank all of you who participated and then the folks also who worked tirelessly on that. The last thing I just want to mention to sum up and Robin talked a little bit about this earlier. We've been at the legislature for the last, since January, so five months, four months. I want to point out to you that this is actually Kevin in the witness chair. I don't know if you can see that on the bar. I am right here, you can see my hair. But we have been working with the legislature throughout the session and fingers crossed, I think they're going home on Saturday. But so there are bills that are still working their course through the legislature, but two bills I wanted to highlight that are pretty much done. Robin alluded to the healthcare task force bill that has not been signed by the governor yet, but the board as well as many other stakeholders will be involved in looking at the rural healthcare in the state of Vermont and then reporting that back to the legislature in January. And then another bill that is quite an accomplishment, I think, and I have a phone a friend here who may have a couple of highlights for you is the primary care spend bill. This is something that the board has been looking at on its own through the all payer model, but the legislature wants some reporting back to it for next year's session. Michelle Degree, I must have called you by your wrong name, Michelle Degree, who is a health policy advisor here at the board will be shepherding the work on this bill. And if you wanna have a high-level overview of the bill, you don't have to get into the weeds, right? Do you wanna sign this? Sure, I'll give it to you. Sorry, it's really bright. I will just, I had my eyes dilated this morning, so I might just put my sunglasses on at some point. So it's in concert with Diva. So it's the Dream on Care Board and the Department of Vermont Health Access. And so it's kind of directing us to report back to the legislature on January 15th of this coming year on a variety of things. Most importantly is sort of developing what we think is an appropriate primary care spend measure. And as Susan alluded to, we already have a few versions of that that the board already uses, but this directs us to kind of work with some more advisory groups and get some feedback on that. And then, so we're gonna look at the proportion that's spent across a variety of sectors and submit that to the legislature and then also determine sort of future implications. So if this, then what might happen? If we were to say all commercial insurers up to X percent, then what might those implications be down the road? So there's a lot of forecasting, but also a lot of current state. And that's what we'll be working on, I'll be working on. That will be Michelle Summer. Over the summer. But I also wanna highlight this too. There may be folks on this committee reach out to as we prepare the report for the legislature. I think there's a few primary care providers in this group. So thank you. Oh, I should, it's also Act 17 now. Oh, right. It has been signed by the governor. So it's Act 17. Thank you. So I am going to turn it over to Melissa Miles, who's a healthcare project director. At the board who came in a little late because she was getting a piece of material for me not because she was late. And then Sarah Kinzler who you met earlier to give you an overview of the all film model. And you know what I just realized? Why don't you guys go and then we'll do the charter afterwards because I didn't see the copy of the charter. So I don't think that makes sense. Sure. All right. Again, I'm Sarah Kinzler for strategy and operations report. Melissa Miles. Health policy project director. Thank you. All right. So just to, before we really dig into the all-care CO model, we want to put that in context. So to do that, I'm going to start with by reading a quote from the board's decision to sign the all-care model agreement in 2016. The rise in cost of healthcare imposes unsustainable financial burdens on Vermonters and their families, imputes equitable access to preventive care and threatens to cripple our state's economy. Left unchecked and uncontrolled, it will prevent Vermont from reaching its goal to ensure that all of its citizens have access to affordable high quality healthcare. So to couple this with data, this slide is really just showing, it's showing data from Vermont's healthcare expenditure analysis, which we've been doing since the mid 1990s to track Vermont's healthcare spending. And in 2017, the most recent year for which data is available, Vermont healthcare spending grew 1.7%. Healthcare is also growing faster than our economy in general. The healthcare share of Vermont's gross state product has risen precipitously over the past 20 years, as has healthcare as a percent of national GDP. So the blue line is Vermont, red line is national. There's actually some visions on that slide, because if you look at the most recent trend, it's the lowest spread between the two lines of recent history, so. Absolutely. And I should say, Kevin has presented similar versions of these slides. Chair Mellon has presented similar versions of these slides over the past few weeks and months. So if anyone's heard Kevin present on the all-pair model recently, you might be getting a little bit of a review. Kevin, you can chime in if you have additions for us. So despite our high-scunding, health outcomes must also improve, even though Vermont's consistently ranked one of the healthiest states in the nation. Chronic disease, suicide, and drug overdose take a huge toll on Vermont and Vermonters. Chronic diseases are the most common cause of death in Vermont. In 2014, the year for which, the most recent year for which data is available, 78% of Vermont deaths were caused by chronic diseases. And Vermont's death rates from suicide and drug overdose are higher than the national average. So to address the issues that Sarah has just laid out, the legislature gave Vermont permission to enter into an agreement with the federal government back in 2015, as long as it met specific terms, which were outlined by under the Golden Dome over there by House Health Care and Senate Health and Welfare. And the act is called Act 113. So the criteria that the legislature wanted in the agreement and can be found in the agreement includes things like predictable population-based payments and alignment of payer programs and population health outcome measures, utilization of local community collaborates. These were all priorities for both the community and the legislature at the time. So the all-pair model was signed in 2016, went into effect in 2017, and our performance period is 2018 to 2022, so we're in performance year one. But basically, the premise of the all-pair model as it's outlined up there is, if we move away from fee-for-service to value-based payments that are tied to quality and also increase investments in primary care, will we be able to accelerate the care delivery transformation and improve health outcomes while also slowing the growth of healthcare costs in Vermont? So that is our logic model that we are touched on that we go back to. So basically, how are we doing this? What is the all-pair model? It was built on the chassis of an accountable care organization, which was a program started by Medicare, Centers for Medicare and Medicaid Innovation, which provided a way for providers to contract with each other to work together to increase quality while decreasing the cost of care. So Medicare has grown their ACO model into something called the Next Generation Program, which over time, Medicare is looking for providers to take on more risk and be more accountable for the total cost of care for their patients. So the all-pair model uses the ACO to, it's given us the flexibility to design our own Next Generation ACO model and with Vermont-specific modifications that reflect our population and our healthcare delivery system. And it's also allowed closer alignment of commercial and Medicaid programs that are risk-based that the ACO has. It's also allowed us to continue funding from the federal government that was otherwise going to go away for community innovations like the blueprint per member per month payments for Medicare patients and also the SASH dollars. So this slide really gives you a high-level overview of Vermont's responsibilities under the all-pair model agreement. In the box on the left, you'll see that the agreement includes cost and quality targets. The cost targets require Vermont to limit spending growth for certain services, both for Medicare patients and then a separate target for all-pair beneficiaries and quotes there, which really includes most Vermonters. With respect to quality, the state is responsible for meeting targets 20 different quality measures, including three statewide population health goals, and we'll talk about that quite a bit more in the next slide. Moving to the box on the right, the state's also responsible for ensuring that ACO programs in Vermont are aligned on some key areas, including attribution, so how we know who is a member of the ACO, the services for which the ACO is held financially accountable, quality measures, and then the payment mechanisms and risk arrangements that are part of the ACO's financial arrangements. Finally, the all-pair model signatories are responsible for steadily increasing the scale of the model, so how many people in Vermont are ACO members, and that is something that will happen as more payers and providers decide to contract with the ACO. Both the scale and alignment pieces are aiming to maximize the benefits of the multi-pair aspects of this model, so by aligning Medicare, Medicaid, and commercial payers, and then ensuring that their programs are similar enough, we give providers some strong common incentives that are moving in one direction. You've been muted. Unmute yourself, Chris. Darn. Sick. The phone is not. You're no longer muted. The phone is, again, interested in this presentation. So multi-pair alignment on things like quality measurement also supports decreased provider burden, which is a significant increase with the Board of the Legislature in Act 113. So now, if there are questions on the quality framework, I'm hoping to pitch them over to Michelle DeGray, who's our quality queen, and getting a lot of shout-outs today, and I'm actually gonna start from the bottom of the pyramid here and work our way up. So as I briefly mentioned before, the all-pair model agreement is tied to these three population health outcome goals that were selected way back as the agreement was being negotiated based on Vermont's state health improvement plan. So these are statewide measures and targets related to the health of the population regardless of whether individuals seek care or not. The population generally includes all Vermonters, and these measures are part of what makes Vermont's all-pair model unique. Around the time that this agreement was being signed, we were not seeing other states sign on to improve chronic disease measures. For example, to reduce the prevalence of diabetes in their state. And here in our all-pair model, those are really not just part of the quality framework, but they provide the structure for the whole quality framework. So as we move kind of up the pyramid, I'll give examples of measures. Well, and I'll focus specifically on reducing deaths related to drug overdose. So healthcare delivery system quality measures and targets are measures and targets evaluating ACO performance and quality of care. And for these measures, the population is the ACO population. Measures can either be across payers or payer-specific. And an example here is initiation of alcohol and other drug dependence treatment. And then for the process milestones at the top of the pyramid, those are measures that ensure that the state and the ACO are striving to improve quality and population health. And an example there would be the rate of adults in Vermont who are accessing medication-assisted treatment for drug abuse. So now Melissa's gonna switch over to talking a little bit about the board's specific responsibilities under the model. You are no longer using it. I'm interested in that question. Okay, so this slide has the Greenmont Care Board's two main goals to reduce the rate of growth in healthcare expenditures and ensure and improve the quality of and access to care. As you'll see under that, there are a variety of regulatory levers that the board is able to use and is working toward integrating to meet these goals and to achieve the goals of the all-pair model. So I'm gonna do a deep dive into the regulatory duties under Act 113 of the ACO certification, ACO budget review, and I'll touch on the ACO program design. But as you also see, we have the hospital budget review, the health insurance rate review, and the certificate of need. In absence of time, I will keep moving on to stay on ACO-specific staff. So the ACO certification in Act 113 of 2016, there were about 10 areas of focus for the board to look at. And so they are all listed on the left-hand side there. So composition of governing body, leadership and management, solvency, the provider network. And so in the beginning of 2018, the board did a very detailed review of this to examine the areas of the ACO. We looked at their governance structure, their population health management and care coordination program, their patient protections, performance evaluation, and so on. It was quite a detailed review. And so within each area, then we looked for additional criteria. And I thought an example might be helpful here. ACOs have a large focus on care coordination and enhancing community provider communication to ensure that patients are getting the right care in the right place. So we looked to see how this is being performed in collaboration with the Blueprint for Health, as was required by Act 113, and the local community collaboratives and community health teams. So this is a vehicle that the legislature has thus far used to add additional certification requirements. And so in 2018, the legislature added the review of mental health programs and childhood adversity and how the ACO is addressing those and wanted us to take an additional look at provider payments. So we reviewed those at the end of 2018. So we had quite a bit of certification review in 2018. And now we're receiving and reviewing on an ongoing basis any updated policies and procedures that OneCare has. And do that through a quarterly monitoring process. So secondly, Act 113 gave us the authority to review the ACO's budget. And this is an annual budget review. And it includes a look at their budget and their planned revenue. We also look at their payer contracts. We look at how they're mitigating risk among the different programs and how their different payer programs with commercial Medicare and Medicaid align according to the requirements of the agreement. We also look at scale and if the ACO is growing and in what lines of business or what areas of the state they're growing in. And so as it says up there, so for the 2019 performance year, the ACO provided the board with an estimated budget of about $850 million with a projection of 196,000 lives. Those are still being settled and they're coming in to present to us in June to give us the final numbers because attribution takes a while to run. But it should also be recognized that a majority of those dollars are passed through from the ACO to the providers and they're turning them into prospective payments for our population health programs and care coordination payments. So the board writes a budget order every year with conditions that the ACO needs to meet and those can be found on our website from 2018 and 2019. I think I do the next one too. I think you do. So this is where we have the flexibility with Medicare to design our own next generation ACO program and simply put it allows us to set the financial target for the ACO for their Medicare attributed lives and also allows us to make any operational changes that would align the Medicare program closely to the state and the state's priorities for Medicaid and commercial. So for example, the board worked last year to set the 2019 quality framework for Medicare in the Medicare program. So I'm gonna give you a quick overview and it doesn't look that quick I guess. I think to staff at least on the reporting that we're required to do under the all panel. So that in signing the agreement, CMMI did not just say and we trust you to improve quality and control costs. We're doing a very significant amount of reporting to help them understand what we're doing and how we're performing over the course of the model. So you'll notice that year two, which we're early in year two right now, it's a big year for our reporting and particularly for the recurring reports and analytics that we're starting to produce. So we've only listed those once but the recurring reports include our quarterly total cost of care reporting which began earlier this year and we'll continue quarterly for the duration of the agreement. So these reports come out about nine months after the quarter during which an individual might receive care. So our first report, including a full year of data won't be produced until September for the 2018 performance here I should say. In addition, we did our first annual payer differential report which measures the percent of ACO benchmarks, or sorry, the percent ACO benchmarks increased by payer and we'll be doing that annually as well. And then we'll also report annually on scale and alignment, so the number of Vermonters participating in the model and how the different payers models are different or similar to one another annually and doing annual quality reporting. In addition to this, Vermont's gonna produce a handful of more one-off reports on particular topics including additional reports on various aspects of the payer differential, a public health system accountability framework which will be led by the Agency of Human Services and a plan to integrate Medicaid and mental health substance use disorder and home community-based services within the all-payer financial targets that are included in the model and again, that will be led by the Agency of Human Services. So we have a lot of work to do on analytics and reporting over the next few years. So this is progress to date. Where are we? As we head into performance year two of the model. So the ACO is one care of Vermont. We have one ACO operating in Vermont and they have contracts with Medicare, Medicaid, Laplace, Lucio, the Vermont QHP program and they have a contract for their self-insured employees at UVMMC. So we have found that these contracts are largely aligned and this intention once again is to reduce burden for providers and just hopefully streamline things. In these risk-based programs. So I will say that we're starting to see and hear that the payment changes are providing some flexibility for providers to develop local transformations in their clinics or in their communities. We had reports from the field presentation board meeting back in February and providers were saying, yeah, I was able to hire more care coordinators or I was able to embed a mental health clinicians in my practice with some of this increased funding and flexibility. So that is a hopeful sign toward progress in my plan. So we have 12 of Vermont's 14 hospitals participating in at least one payer program and we're still, as I said, settling out the final attribution for 2019. These maps just show performance year zero. One care had a contract with Medicaid for a next generation program and they were in four communities in Vermont. So then performance year one was 2018 and that included an addition of Medicare contract and Blue Cross and Blue Shield, Vermont contract and the UVMMC contract. And then performance year two shows where there is at least one, where the community is participating in at least one risk-based program. Medicaid has been the leader for communities to jump into that's what we've seen this far. And then at the bottom are all the different types of participating providers. That's it, great. So I'm looking at the time. It's 2.40 and I just wanna make sure we have enough time to do our breakout groups and we wanna finalize the charter, which should be, but I can open it up to questions either Melissa or Sarah or for the board. Does anyone have questions? That's great. Maybe, I think that's a good sign, I hope. Is there a strategy towards achieving the scale model targets? Oh, that's a good question. Well, I've got a little, a little cheat sheet with who in terms of then self-funded of course is the area we chip away at. Yes, we are working on that. We have a scale report due at the end of June to the federal government. I don't know if the board members wanna add anything else? One of the things I would add is in the ACO budget process, one of the areas that we often explore with them is their strategy for scale. And so that we can kind of get a sense of how they're looking at it, because there's a number of different ways that reasonable people could approach it, of course. You could do a payer approach, you could do a provider approach. Probably wanna do a little mix of both. And as you mentioned for self-insured employers where we have no regulatory levers, that really has to be a private sector approach. So we certainly, that's a question that we've been asking and promoting as well as certainly doing our own internal thinking about. And I don't know if you have anything to add to that? I guess I would just say that there's a small group of us trying to think about strategy in respect to a lot of these folks who may or may not be already in the model on how do we change attribution methodologies, how do we reach some of the self-insured populations. So I think it's an ongoing process and I think we're trying, and we welcome feedback from anybody here who can help us think through what are some of the mechanisms and levers and ways that we can encourage people who wanna be a part of this model. So. What has been successful has been the Medicaid population. It's the other two populations that are a little bit more elusive. That's the commercial and the Medicare. And so we definitely, the good news is it doesn't seem to be any panic from Washington at this point because the take up between performance year one and two is very good. But we're still behind. That's because we started way behind. Yeah, and Medicaid got a year start on the other head start on the other programs. Was there a question? Can you just add a quick question about the number? As you had mentioned the self-insured population, what percentage of Vermonters would that apply to? Oh, a big percentage actually. It's the majority of the commercially insured or consured population. It's about a third of Vermonters, maybe a little bit more. And we don't have authority over them. Sam? How closely aligned is our, the strategy that targets with the Medicaid pathway project and sort of dissipated, but like the mental health and the substance abuse targets and strategies. So how closely aligned is what's rolling out now with that dissolved Medicaid pathway project? I'll start and I think there are folks who can add. As I understand it, that is not dissolved. It just has a new name which escapes me at this point. But I do know that our partners at AHS are working. As Sarah mentioned in 2021, 2020, there needs to be a plan for integration of those other services. So the goal of this program is to have alignment. So I think that they are just, they're starting that plan right now. You'll hear more, I believe in the legislature, they're asking for some reports out at the beginning of next year. So you'll hear more from them, but I don't know. Do you wanna add? What I would add about that is there was a, from the, as one of the people who negotiated the agreement with the federal government, we've made a conscious decision to push, to not include certain services in the financial target because the financial target is meant to be a cost containment device. And we thought that these are the types of services that we may need to invest more money in to improve outcomes and populations. And so if it's an area where investing more money is desirable, you actually don't want it to be under the financial cap. You want the efforts to be aligned programmatically. The federal government, however, they are obviously very far away from people delivering care on the ground in Vermont. And so one of their major tools in their federal programs are these financial targets as a way of basically getting people to play ball on the ground. But it's a pretty blunt instrument to be frank. And I haven't been involved obviously in the AHS work since I moved over to the board. But I think that's something that I'm sure that they're really thinking hard about is how to balance those two interests. And we are, we will be working, the board will be working in consultation with AHS on this. Any other questions? As you think about the, one of the two primary charges reducing the total cost of care for remote areas. Is there a sense that there is any low hanging fruit places to start? I have a turn. The analytics is just now starting to be produced because as Sarah mentioned, it's nine months of claims and so the analytics team is going to be able to start to dig into that and do some decomposition analysis. So I think, I can't speak to anything specifically right now, but I know the ACO is looking at their data and identifying clinical priorities where they do feel like there could be areas of low hanging fruit to reduce the total cost of care. But in general, we are a very low cost date. In general, New England, healthcare is lower cost than in other parts of the country, so. And I think really this model is, it's a dispersed model because it's built off of the blueprint for health. So the decision making on which areas to tackle is really pushed down to the community level. The concept being like people in Montpelier who sit on a regulatory board don't necessarily know the right clinical priority for a particular local area and really putting that decision making in the data and information in the hands of that local group of people will result in better outcomes and just better thinking around the clinical piece. Now there are challenges to that of course because a dispersed model means that you'll have different priorities in different areas. You'll have different talents in different areas. And so you could get some, I think as we've seen in the blueprint, there are some very strong blueprint communities and there's some others that are less strong. So that's kind of the downside of that approach, but I think because we as a stated, proceeded that way with the blueprint, the legislature basically said, we don't wanna undo that. So ACO, you need to go work with the blueprint. You can use your analytics and your data and your tools to pass on, but you need to be able to work through the communities and through the blueprint as well. So I think it's hard for us to answer that question because it is this kind of dispersed model, but we did hear some good stuff at our panel on lessons from the field and some of the examples people were talking about were reducing emergency room utilization and getting people more closely tied into their primary care and looking at ways to support people with mental health needs by embedding either primary care in mental health or primary care. So I think there's a lot of good stuff happening and we certainly heard some of that. Yeah, I was just gonna answer that. I think in some ways the benefit of having it be dispersed is that you can actually, it's like every little community is almost like a little Petri dish and there's some experimentation happening to the extent that we learn from those across communities, which has the best ROI or return for investments as communities are varying those healthcare reform investments, I would say there's a lot to be learned. I think that we're also trying to understand the variation in cost of care across communities and understanding is it the delivery system, is it underlying health of that community, is it, you know, so how do we start to unpack some of that is what we're starting to do in our data analytics team is doing and I know that the ACO is doing as well. So, and to your point about our lessons from the field, I don't know if folks are able to, you can go back in time, any of our board meetings are actually archived on our website and that's fun to listen to if you're really curious to see how this is actually manifesting, how some changes are manifesting themselves throughout Vermont. I mean, I was struck by, you can start to see how the services are changing in hospitals as the payment system is changing. You're starting to see hospitals, here's an example that I often use and think about palliative care. When I was on the board at Porter Hospital five or six years ago, palliative care was a service area that we were, the board was being challenged with thinking about whether it's something we should keep, right?  Now, under the all-parent model and fixed payments, it's actually exactly what you want. You want, you know, palliative care keeps, in some sense, care out of the hospital, but it keeps people patients healthier and their quality of care higher at lower cost. And so, now that that hospital is expanding their palliative care. So that was an example of, you know, care delivery system reform changes and as Robin was saying, we're also seeing hospitals change the folks that they're hiring. So more social workers embedded in emergency rooms, more integration across community services, your integration with the hospital and the community care providers. Psych nurse practitioners now embedded in primary care practices. Really fascinating ways and the different ways in which each community is tackling. Some of the challenges in the community using the resources they have at their disposal differently and we can learn a lot from all that. So I think it was a good presentation and folks want to go back and look at it. We'll make sure we send it out to the group. Yeah, interesting. I know we sent the rural panel out to the group, but we'll actually send both of them and shout out to Orca Media, who is the volunteers and tapes our program. So, okay, I am going to transition to the charter. Did everyone receive the April 2019 charter in their email? And if you, I'm seeing some nodding heads, I'm seeing some not nodding heads. You know what we can do is I'm gonna have this sent out to you again and in the interest of time, I think we'll put this to the next meeting because I want to make sure that everyone sees it and is okay with it before we finalize it. We just, what we did is we took some of the comments that we heard from the last meeting and we incorporated it into this new draft. So, does that work for everyone instead of trying to rush through that and see some folks haven't had a chance to look at it so I'd rather do that. And this way we have enough time to do our breakout sessions. So, you all should have received in your packet a chart with the three groups. So we have group A, group B, and group C. Group A is going to have a question about the all-care model and the ACO. Group B has work on questions on healthcare workforce and group C on price transparency. Does anyone need a copy of this or does everyone have their questions? No, I had the question. My question is for group C, that is sort of the title is price transparency, which is a hot topic everyone's interested in. The question is about the amount of care for transparency, which I think is not as robust a conversation or something like this. It's not a hot topic. It's not a hot topic. I guess we're really curious here. So, how wedded are you just really discussing? Could you stop something outside? That's great. We're about wedded on price transparency. Yeah, no, please expand and provide your input. We're very much open to that. That's a great clarifying question. So what I'm going to do is everyone's clear of their groups. So, Sarah's on her way back. She just had to take a bathroom break. Michelle, can I just name that Michelle? Michelle is going to be helping out with group B, the healthcare workforce group. And this room is not great for right now. How are we doing this? I was actually going to, do you think we'd be too loud in the hallway probably? Maybe we'll have one group, Michelle's group over here in this kind of entrance area. So that's group B, healthcare workforce. James O'Lager, Eli, who's on the phone, will be participating. Terry Golden, Jason, Gabriela Nino, Allison, everything, Gold, Trey, who's not here today and Bob Beck. So that's workforce. And then group A, group C is Sarah Kinsler. So, Sarah, why don't you take your group over in that corner? Marguerite Monet, Andrew Miller, Kathy Mahoney, Samless, Sharon Gutland, Rick Dooley, and Walter Campenter. And while you're out, just so you know, there was a question on whether the topic could be if it expanded a bit to talk about high transparency. And then for the all pair model with Melissa Miles, I'm trying to think, I just don't like to be so loud. Why doesn't that group go over there where the chair and Tom are? Did you say we were going to take a quick break? Yeah, yeah, if you want to take a quick break, please do. So we'll meet back, convene back at 3.30. Work that you did today, like this is not the transparency group. This is group, I think it was C. And group A is not always the all pair model group. I want to clarify that because I think it was a little confusing. So we'll have different topics for each meeting. And certainly, please send me a note or folks, let us know if there's something in particular you would like to bring up. As a breakout group, we are all ears. We're very transparent. The second clarification piece related to these groups is I had a consultation with our associate general counsel, Ann Marin, and she just wanted to stress to everybody two things that when you're communicating within your group, you have to understand that you can't, whatever, say you come up with an idea that you want the board to hear, you need to bring the idea here to a full board meeting and have and talk about it here as opposed to emailing the board. Is that, did I get that right? And then the second part of the groups, the subgroups, is that just be aware that any communication that you have is open to being FOIAed or it is open to open meeting law. So if you have any questions regarding that, just let me know. But I wanted to clarify those two points. So can I just ask, so just logistically, so someone in our group of seven has this issue that they're, oh, this is really a burning issue. They, it shouldn't be something that the seven of us are talking about, something that goes to you presumably for the next advisory committee to become a group about. Yeah, sure, if you have a burning, like you're like, can we talk about this? You could send it to me and I could talk with the chair and the board to see if we want to talk about it in another meeting. But if there's something, you know, say you talked about, you had a great idea on transparency, you want to continue that conversation on your own within those seven people. You can do that, or any other topic. Does that make sense? Yeah. Okay, great. So I'm going to give you each six minutes to report out. I just want to make sure we get everybody in for the last time of 20 minutes we have left. So why don't I start with group A the all pair model ACO. Okay. And do you want to meet the question just so folks know? Well, do you want me to just distill it? Yeah, distill it would be great. We're charged with determining the ideal state of health care and who the partnerships and stakeholders should be asking for that. So, and please the rest of the group jump in because I'm quite sure I missed a lot of it. Distilling it down to in terms of the elements of the ideal state would be basically accessible health care for all regardless of without any barriers at all which would include, you know, in addition to transportation and cost, things like social determinants of health, behavioral health issues, mental health issues. So access to care without barriers, patient engagement, community involvement, aligned incentives for all participants, not just the payers or the providers. Infrastructure that supports the health care system and stable funding. So, and then in terms of the second question about who the partnerships and stakeholders should be, we look to the larger community even going as far as state and national but in addition to provide care, which obviously those are stakeholders, municipalities, schools, employers and the patients themselves. And one comment that Dr. Nunlust made was in terms of getting those stakeholders to number one, see themselves as stakeholders and then participate is the fundamental piece to that is to get people to commit to a goal larger than themselves because they're, for short term, if we were always looking at short term return or very narrow line item returns, we're not going to get there. We need to look at the longer view and much bigger picture in terms of looking towards safer communities, savings in terms of special ed and corrections, looking way beyond the health care narrow budget. I left out a lot of details. You have about four minutes left, so you have time? Oh, okay. Just to focus on the people who are the value that's derived by patients from honors is one of the focus and particularly outcomes that are important to them rather than important to the payer and the provider. So that was one kind of theme that I think I heard. I mean, one of the ways, a sort of shorthand way to think about what the health care ought to be like is how many of us feel that we get the care we want and need exactly when to how we want to need it. And that seems like an unattainable goal, but it's not really if you break it down and start to work away at the edges. And that's really what would seem to be a superb health care system. And if we achieve that, I think the total cost of care would go down. And along the lines of access, we also talked about things, not only hours of availability and cost and transportation, but also some people just psychologically can't leave the home or Vermont roads and home visits. Sometimes it might take something like that, keeping in touch with patients in between visits and always having that lifeline and accessibility that way. So we had also talked about the need to have a defined mechanism for transferring dollars into to adjust the social determinants of health and just general community wellness that we talk about this dollar shift from inpatient expensive care, back into the community and the savings that will accrue in other parts of our AHS system, for example. But we haven't really defined any ways to move those dollars from one place where they currently exist, where people have ownership of them back into the community into these other types of investment opportunities. So we need to do more work on that. That speaks to Dr. Nummel's comment about that common goal and bigger than ourselves. And then, I'm sorry. Dave, we also talked a little bit about wellness and the fact that the benefits of that really are far broader than just the health care system. Yet it's the health care system that is associated with my insurance or whatever when a lot of the benefits from the, for example, for an employer are having productive employees being a desirable place to work, retaining employees. Those all have great value to employers, but it's the health system that's doing it, which often isn't very good at recognizing those things or even letting employers know that that's a value in this ad. I think that, I'm not sure about data and predict events. Oh, data and savings and just being a way of getting toward those goals. I'm also going to let folks know that we are taking notes on this and then we'll send this out to all of you. And there might be other interested parties like the ACO who might want to read the notes. And of course, our board is here listening to us, so. Okay. Am I allowed to contribute just an idea? Sure, please. As a consumer, twice over, myself and my classically autistic is one thing that we desperately, desperately need to navigate the maze of healthcare and developmental services. We need a social worker to talk about quality of life, just to help us connect the dots so we don't waste so much time running down the wrong path in the maze, only to find out it wasn't the right thing to do, the right place to end up. And I don't know any other profession that could do that, other than the social worker who connects the family to the community, to the health and keeps the community. Hallelujah, as a social worker, I have to admit I have a huge bias there. And no, I think that there's studies that have proven over and over and over again. If you have case management, you have social workers connecting the people in the community to all the different to the primary care, to specialty care and looking at things like insurance, housing, nutrition and all of those things. You get a much better outcome picture overall for a lot cheaper too, by the way. Did everybody have a chance to take a look at the video link that was sent out? The one on the car? The analogy to getting your car fixed? So those, I thought that was wonderful. And I look at many people, which are about social work, but they're one of those folks that coordinates the care. And so what we need is to make sure all of those folks are represented, right? Exactly, but we really need to see social wear and case management services embedded into the healthcare system across the board. Great, thank you so much. Thank you all for your honorable ACO discussion. So now I'm going to turn it over to the workforce. Oh, yes, all the workforce is up here, okay. Great, so I'm going to echo your comments that group members, please chime in for the pieces that I forget. Our task was to talk about workforce shortages in Vermont. We focused a lot about nursing with the current workforce. We're going to be short about 3,900 nurses in the next few years. That said, and I don't want to forget, we also had some conversation about other professions. Howard Center included that's really struggling with getting the staff to fill their vacancies. So some of the problems we talked about that we think lead or cause the problem of nurse shortage, our reentry program could see some improvement. We only have one reentry program in the state. And when I speak of reentry, I'm referring to professional nurses who leave the field, who leave the profession and then want to rejoin the nursing profession and have to do some things to get their licensure up in place again. And that can be a struggle for nurses in our state. We find that there is not a lot of nursing nurses in the state. We have a lot of our nursing workforce entering retirement and we don't have a young nursing workforce to replace those nurses. We recently had a closure of one of our nursing programs in the state in Southern Vermont. Fortunately, there's efforts to get the current students in place. I know at UVM where I teach, we're taking some of their students to help them finish their final years, but that's certainly a driver of getting some nurses in the Southern part of our state available for employment. We find that not just nurses, but all healthcare professionals who move to the state, their spouses or their partners who maybe aren't in healthcare. And correct me if I'm wrong in what you were saying. This is how I understood it, that their spouses are having trouble finding jobs. So there might be a nurse job or a physician job, but there's not jobs for their spouses in other fields. We had some conversation about paid disparity, a lot of nurses find that they will make more money going out of state. A lot of my nursing students are interested in large metropolitan areas for a variety of reasons, but paid disparity is certainly one that's hard to fix, but is real. I mentioned the topic of mentorship. In my years as a nurse, the patient's census and acuity is just staggeringly going up, so nurses are experiencing burnout. Young nurses are experiencing burnout, and we have to come up with some solutions to help them work through that. We talked about work environment, kind of goes along with that, but physical injuries, mental health concerns of nurses and other healthcare professionals needs to be addressed. Nursing has the advantage of having a traveler system where we can get travelers in place, but many of our travelers don't have buy-in to the facilities and the organizations they work for, so that's one of the main drawbacks that we've talked about with travelers, along with the cost. We mentioned it can be two to three times more expensive to have a traveler than to have a staff nurse. So some of the solutions that we talked about, we talked about increasing educational opportunities for nurses, that could be degree programs, that could also be continuing education. We talked about how the all-payer model might help with that. New facilities in the state, the UVM Medical Center's opening in Miller Building, we think that could have some positive implications towards nursing environment and practice. We also talked about shared governance of nurses, so getting them involved in making key decisions for institutions I think is really important. And I think the final thing I have written here is we talked about the advantages of programs like AHEC that can provide loan reimbursement for healthcare providers to work in rural areas and areas where it's hard to recruit nurses, such as mental health nursing, so yeah. Awesome. Great, so there's two minutes 18 seconds left of your clock questions or comments or thank you for that input. Yeah, it's a bit peripheral, but it isn't, isn't, because not only is there a nursing issue in the state, but I know, I hear all the time, there's a terrible shortage of psychiatrists in the state, and it's not only Vermont, it tends to be in all rural states, but nevertheless, and this is what I teach and I hear all the time, one possible way to alleviate at least some aspects of that and there've been bills in the last two sessions in the legislature is to follow a few states which have already done it, but bestow prescriptive privileges upon psychologists and it's just something to think about to alleviate because in some cases, there are year-long waits for psychiatrists and so this might, is it a perfect solution? No, but it does give prescriptive privileges to only doctoral level psychologists with considerable advanced training in psychopharmacology. So that might be something to consider to alleviate which is a very real issue. Thank you for that and I know Brattleboro Retreat has had success with telemedicine and recruiting psychiatrists who live in Brooklyn and work at Brattleboro, so that's pretty cool stuff. I think in my area, I know one of the concerns for the nurses is a lack of support staff, like LNAs, because the pay is so low and we're on the border, I mean it can mean a difference of four or $5 an hour. So they just go to Greenfield or wherever and they work there and so the stress that that puts on the nursing staff is extreme and so you lose nurses. So we're in a big hole with that. Absolutely, it's been my experience with them. Thank you, thank you for that great feedback and so, yes. Sir, I was gonna add that the other group is primary care providers in terms of trying to get workforce issues, trying to get people to go into primary care, which is routinely under-reimbursed and with high workload. But hopefully with the primary care study, that shows how much money goes on the primary care if it's actually a target that makes sense after that, that will hopefully improve reimbursement and improve, hopefully, recruitment. Great, thank you. Okay, so last but not least, we have our Group C and they are given the topic of transparency, but I think you may have expanded it a bit, so go ahead. We originally decided we spent the first couple of minutes saying how much we didn't need to talk about transparency of the Green Mountain Care Board, but then actually we did talk a lot about it and we did expand a little bit from that to messaging and then we did very briefly in the end touch on price transparency. And I think the latter topic is gonna need a lot more conversation, but I can sum up what we did. We spent a while talking about perception of the Green Mountain Care Board, both from the outward-facing image to physicians, other provider groups, hospitals, and most importantly to the Vermont public really, was we talked about how there is a disconnect between what we think the Board wants to be doing and what maybe it's messaging and what the average person, and we struggled a couple of times to describe what's the average person. I think a better term is probably the citizens of Vermont. And so what is the image that the Board projects and how is that projected? There was pretty strong agreement that as far as transparency is concerned, most of us felt that the website was actually excellent and I liked your comment about the boards, every board is always told they need to be more transparent. And so maybe the reason that that perception exists is because maybe folks aren't accessing the website, maybe that's not the medium that they use to be educated, oh, I'm looking for you, yes. Maybe that's not the medium they use, maybe they're used to something else and in-person visit or television or maybe a website and reading documents isn't the way that they would learn. We also talked about what's the message of the Green Mountain Care Board, is it cost, is it quality, is it improvement, is it safety, is it, you know, what is it, is it targeting, is it clear, is the message clear? And we had a lot of input on that conversation. We didn't really come up with a strong answer except we all realized that most of us really want to see as you articulated care to ourselves and to our families and that really is what would resonate with most folks rather than targeting cost. Although we are all in this room because we understand that cost is important as well but how do we message that this is about improvement of life for all Vermonters as opposed to a cost initiative? We talked about the appearance of the Green Mountain Care Board as being a big government and maybe it doesn't trickle down to the folks at the front line of healthcare and patients and their families. We talked about the historical development of the Green Mountain Care Board and how there's been some angst over it does the board actually represent the populations that are stakeholders in the conversations and is what is said at the meetings or expressed in various forums. Does that actually get to the board and then get acted upon? We talked about that for quite a while actually. We realized that this group is a stepping stone to closing some of those gaps, particularly around the lack of healthcare participants and patients and families informing the conversation. We talked also about social services, preventive therapy and pharmacy and behavioral health as participants in that. We talked a little bit about cost and what does that mean? Does cost create better, when you look at cost, does that negatively or positively impact care? I think that it's tough to message that accurately and we struggled with that as well. Reducing cost, we know we need to because it's not sustainable and ultimately high cost will negatively impact access to care. We talked about that and so we have to be careful about how it's message that if the board is about reducing cost, most of us if we put our individual hat on would wonder how is that going to impact my own personal care or the care of a sick loved one or you mentioned someone, your family member with autism of yourself. So there's a complexity of healthcare that is difficult to weave through. We talked about some of the advocacy groups. I thought you made great points about certain populations. You mentioned HIV when it comes to transparency. How transparent do we really want to be and are there confidentiality concerns when we're transparent about sensitive topics? One of the things that's the goals is to reduce suicide and substance abuse issues and how I thought of those populations as you were talking about HIV, how do we manage that? How transparent should we be and where's the line between confidentiality and transparency? The other thing that we talked about was the board's role as far as does the board perceive it has less power than it needs? Does the public and do the healthcare members perceive that they have the right power, not enough too much that we talked about every different iteration of that conversation? Lastly, we talked a little bit about price transparency and we didn't get very far in the conversation because we only spent about two minutes doing that, honestly, but I think the general thing that I can sum that up was that there is some need for consumers, whether that's prescribers or users of healthcare to understand what the costs or prices are, of what they might pay, but how to operationalize that is very difficult. There are some legal barriers. Sharing of price information is not encouraged. In fact, it's prohibited in certain contracts and maybe there'll need to be some legislative ways around that. Did I miss anything? You got it, yeah. No, I think you did a great job. The one thing in talking about getting the general public interested and involved was language. I think we all forget when we're in our little professional worlds how specialized our language often is and that we're already at a level where we've been working in our particular field for many years and have a much greater understanding than the people that we're trying to talk to and transmit information to and that we really need to take language and how we use it very seriously in our communications with the public. That's a good reminder. There's a lot of acronyms we use. Thank you. Well, that was wonderful. Thank you very much. I'm looking at the time. So I have one, we should open it up to public comment. I don't know if there's any members from the public who would like to comment. I don't, I see a couple, okay. We will send these notes to you. I also realized we wanna share the emails of the groups with you. So you just expect those so that you can have a follow up conversation within your group. And our next meeting of the general advisory group is September 9th. So that is already, should be already on your calendars and it's on our website as well. We will be here in this room again. And please follow up if you have any questions, comments, thoughts, please direct them right to me. And I believe we can adjourn, Mr. Chair, if you are ready. All in favor? Hi. Hi. Thank you all. Thank you all. Thanks.


Hello and welcome to Amusement Insiders' first ever ride history video. My name is Jazim and I'll be your host today. If you're not familiar with who I am and what I've been doing here on YouTube, I used to actually do ride history videos on my own channel as well as Wonderland vlogs and that was before I moved to a far far away land where there are no theme parks. So Brendan and I are partnering together to bring the remainder of that series onto this channel since my channel is in a bit of a different direction these days and see if that was something you guys would be interested in seeing and hearing more of. So without further ado, let's dive right into this ride history video. Now if you did watch the series on my channel about the first four roller coasters that opened when Canada's Wonderland first opened in 1981, then you will know that at the very end I hinted that there was a secret additional coaster that even Canada's Wonderland's website doesn't include as a traditional roller coaster. But this ride did open when the park opened in 1981 and it has been operating in Canada's Wonderland ever since and is still operating to this day. I'm sure many of you already know what this ride is and you're probably commenting down below and that's fine, please do so. But today we are talking about Thunder Run. Everybody's favorite mine ride going through Canada's Wonderland's Wonder Mountain. Now Thunder Run first opened on May 23rd 1981 as Blower and Zian. I don't know if I'm pronouncing that right, not even going to try. It was originally located outside of Wonder Mountain, sort of in the spot where the fly currently is, kind of near Jokey's Jalopees and not too far from the rainbow bridge that was to at the time Hanabar, Maryland. Now for five years it stayed in that location and operated as a typical Ma Blower and Zian roller coaster model. In 1986, however, the ride was relocated, extended and basically transformed into the ride that we know and love today, half engulfed by Wonder Mountain. Thunder Run in its current state uses 1,080 feet of track and reaches 40 miles per hour or 64 kilometers an hour, thanks to the power of its electric motors. This ride actually has individual motors underneath each car. And thanks to this motor, the ride actually picks up speed as it begins its ascent into its first upwards helix. As all 40 riders sitting in rows of two on the ride's only train twist and turn inside the depths of Wonder Mountain, they encounter a number of lighting effects and even get to see Wonder Mountain's dragon, Herman. From darkness to light as the ride weaves in and out of the mountain, riders will whizz by the station as their train powers into a second lap around the track. Overall, Thunder Run is a really fun little ride and even though it's designed for younger guests with the minimum height restriction of 102 centimeters or three foot four inches, it's a ride that I always try to get on during every visit that I make to Canada's Wonderland. It's one of my personal favorites. I feel like I've said that about every ride that I've done a ride history video on. But they're classics. There's a lot of fun. Now, the theming and experience of the ride hasn't changed too much in recent years. The recent Halloween haunt seasons have breathed new life into the ride, transforming it for the Halloween season into the haunted Thunder Run. And basically they add new lighting, sound and fog effects during this experience to sort of transform the ride just a little bit for the Halloween season. Now as with many older coasters, there has been talk in recent seasons of what lies ahead for Thunder Run and what potentially its future looks like. It is an older ride and Wonderland has started to branch out with how they're using the space within Wonder Mountain. So is it possible that we can see Thunder Run's removal in upcoming years? I personally hope not and I don't think so. This ride still has consistent lines and a super fun signature experience within the park that people who've been going for years know all about and look forward to an enjoy on every visit. But let me know what you think. Do you think that Wonderland's management wants to see this classical ride preserved? And do you want to see rides like this preserved? As always, I would love your thoughts and opinions in the comments below. And with that I'd like to wrap up this short little video with just a couple of fun facts about that secret fifth original coaster that opened with Canada's Wonderland back in 1981. Did you know that this ride was that old or that it was originally in a different spot? Are there any other fun facts you know about Thunder Run that you'd like to share down below? And what other rides would you guys like to see history videos on here on YouTube and specifically here on Amusement Insiders? Let me know down below and I look forward to seeing you next time. Bye!


The encounter with God is so amazingly present at the Avila Institute. It's that universal quality of holiness. I just couldn't not be here. It was so fulfilling. I'm going to come away from this weekend feeling invigorated. An entirely positive experience. Upbuilding, encouraging, formative and informative. Well, the speakers are very engaging, very joyful and just speak with the words of the Father. And I just, yeah, I like experience God through listening to them speak. What I get out of this is really something that's quite deep because it's something that you take home with you. The Institute challenges me. It stretches me. It pulls me in several different directions that I would not go on my own. And it's really increased my spiritual growth. I knew that the kind of people that I would meet here would have the same sort of heart that I was developing and that I would learn from everyone I met here.  Avila has done a great job in fostering online education that also has real-time engagement. They're really plugged into the best that the Church offers in terms of spiritual formation and spiritual theology and are clearly fostering a community of people that are really healthy and wholesome and desiring holiness and desiring ways to grow in that and to share that with other people. This is an opportunity to be with other faithful Catholics who have such a love for the Lord and want to grow in faith. When I look at the audience here and I see the great diversity of it all, I see the whole face of the Church, young, old, black, white, Latino, Asian, religious, priest, lay, everybody, everybody coming together. I'd say the Avila Institute, just by virtue of what it is, is beneficial to the Church and to the members of the Church because of the depth of its teaching, the quality of it. The talks were excellent, the material was excellent, but the best part is being with this community which I found to be very spiritually engaging, very warm, loving, wonderful people to be with, a whole variety of experiences and ways to apply the material and ways that they're living out their own spiritual life in their own corners of the world and that encounter to actually be here with them was really a very blessed experience and something that I would look forward to again. The summit is an opportunity for us to have those friendships be face to face. The Lord wants to equip us and this is a place that is ready. I would definitely recommend it. It's a pretty special thing that the Avila Institute have done and so I would definitely recommend it to my friends. It's an incredible experience. It's heart changing, not life changing, heart changing.


The colors serve as such a symbol to all United States Army units. The change of command is a military tradition that is rich with symbolism and heritage, heading back to medieval times. In more recent times, the colors represent not only the heritage and history of the unit, but also the unity and loyalty of its soldiers. The key to the change of command is the passing of the unit's colors. The colors of the commander's symbol of authority, representing their responsibility to the organization. The passing of the unit colors represents the transfer of authority from one commander to another. Command Sergeant Major Agnion representing the backbone of the unit passes the colors to Colonel Estrada, signifying his last act of allegiance to him as the commander. Colonel Estrada passes the colors to Brigadier General Reagan, signifying the return of the responsibility of which he was entrusted and to ensure the unit is never without officer leadership. Brigadier General Reagan passes the colors to Colonel Alexander, signifying his trust in him and charging him with the responsibility of the unit and its soldiers. In accordance with Army Regulation 600-20, Paragraph 2-5 Alpha, the underside assumes command of the 16th Sustainable Brigade, effective 15 June 2023, signed Matthew H. Alexander, Colonel, United States Army, commanding. Colonel Alexander passes the colors to Command Sergeant Major Agnion to secure the colors in completing the exchange of the change of command.


In Europe, around 37 million women have used an illicit drug at least once in their lifetime. Around 100,000 women enter drug treatment every year. Nearly 2,000 die from drug overdose. Over the last decade, the gender gap has been narrowing among young school students who use drugs. Women represent only a fifth of clients in specialized drug treatment, but their problems are often more complex than for men. They tend to progress faster towards addiction, a phenomenon known as telescoping. They go through more severe withdrawal symptoms and report higher levels of depression and anxiety. Women often start using drugs through a drug-using male partner, and are more likely to share needles and other equipment with their partner. In general, women are likely to have fewer socioeconomic resources. This is even more the case for women who use drugs. They experience most stigma because they may be perceived as contravening their roles as mother and caregiver. Some groups of women have specific needs, such as pregnant and parenting women, women from ethnic minorities, women in prison and those involved in sex work. A specific drug-related issue for women is intimate violence and drug-facilitated sexual assaults, which has serious psychological and social consequences. Services for women with drug use problems need to address these unique concerns. They need to be welcoming, non-judgmental, supportive and physically and emotionally safe. To achieve this, women who use drugs need to be fully involved in the planning and development of policies and services. The staff recruited in drug services need to have appropriate attitudes, knowledge and skills. Services need to be well coordinated and integrated to address different issues, such as mental health, pregnancy and childcare. And monitoring and research needs to consider this gender dimension to optimise effective responses for women with drug-related problems.


The researchers developed a new method to automatically generate neural network architectures for EG-based sleep stage classification. This method uses a bi-level optimization approach to approximate the original optimization problem which reduces the computational complexity while maintaining high accuracy. The resulting models achieved an average accuracy of 82.7%, 80% and 81.9% on three different datasets. This article was authored by Gang Wei Kong, Chang Li, Hu Peng and others.