The first item on the agenda is the executive director's report. Susan Barrett. Good morning. Can everyone hear me? Again. Excellent. I'm sorry. All of a sudden my my video camera just lined out again and I'm having a little bit of trouble. I'm in my main system but I'm not hearing everybody really clearly. I don't know what it is. It says I'm a guest and maybe that means I can't use video. No, I think most people are guests. Okay. I mean, I've done this a thousand times on Zoom but I'm going to try and log in one more time. Okay. Yeah, the state insists that we use teams. Sometimes do not to make it more complicated, Bill, but you can also log in on the computer and use your phone for audio but you just have to be careful with background noise. Why don't you just try to log in and see what happens. Okay, Susan, why don't you proceed with the executive director's report while Bill is trying to figure that out because we have a jam-packed day with the two board meetings this morning and afternoon with CON deliberations in between. So let's try to get the ball rolling and start your executive director's report. Thank you, Mr. Chair. I have a few announcements on public comment. I'm sorry, I just logged in again and at this point I guess I have to give up. I don't know why I'm on video one minute and then I'm not on video the next. Bill, we're just going to try to proceed and if you could just do it by audio. There you are. Now we see you. So, but we're just going to proceed and right now we're doing the executive director's report and then I'll turn it over to Patrick. Okay. Great. Thank you, Mr. Chair. So I have a couple of announcements on ongoing special public comment periods and then an announcement on some physician transfers and then I will give you the board an update on the wait times working group for the FY23 budget guidance. So first this afternoon we'll hear from One Care Vermont on their revised budget to the board. The staff analysis will be on May 11th and a potential vote is scheduled for May 11th or May 18th. The revised materials can be found on our website and that we would ask that public comments be submitted by Friday May 6th in order to be considered ahead of the GMCB staff analysis presentation on May 11th. Comments submitted after May 6th will still be shared with the board. We also have an ongoing public comment period regarding a next all-payer model. We have accepted comments on this for over the last year. We encourage the general public to provide any public comments regarding the next model to us. We will then share those comments with our partners at AHS and the governor's office as they are leading the negotiations on the potential next model. I also wanted to announce that there has been some physician and practice transfers. This information is sent to the board per statute and we have an official GMCB transfer policy and I wanted to let folks know that effective dates of these transfers. So the first one is for Copley Hospital where they added a .8 FTE to Mansfield orthopedics and then the next one and that was effective for 1-20-20-22. The next two are actually from Northwest Medical Center. Here on 5-22, Northwest Primary Care in Georgia Health Center was divested from Northwest Medical Center and then earlier this year on 1-1-22, the Northwest Pediatrics was divested from Northwest Medical Center. So now I will switch over to an update and just to back up, there's more detailed information on those transfers on our website under our hospital budget tab. So now I'll just transfer over to wait times unless there are any questions from the board. Okay, seeing none. Just pop up my slides here. Kara offered to do that graciously. Thank you, Kara. Okay, so as the board knows and for an update for the public as part of this year's FY23 Hospital Budget Guidance Language, we had a wait times working group formed and I will summarize the language in the in the Hospital Budget Guidance. The board staff and up to two board members will establish a working group that will include the hospitals, laws, the Vermont Department of Financial Regulation, the Office of the Healthcare Advocate and any other interested parties to determine by May 2, 2022 appropriate wait times metrics that hospitals shall submit as part of the FY23 budget process. If the work group could not determine appropriate metrics, the default would be the following. For each hospital-owned practice, for each primary care and specialty care, as well as the top five most frequent imaging procedures, specifically please report for each practice and imaging procedure, one referral lab, the percentage of appointment scheduled within two days of referral, and two visit lab, the percentage of new patients seen within two weeks, one month, three months and six months of their scheduling date. In each case, hospitals are asked to align steps to resolve wait times. Well, I am here to report that the working group did determine metrics and I will review those for you now. So as I said, the stakeholder group was very broad and as I just mentioned, it included DFR, the HCA, VAWS and hospital CMOs. I want to point out here... And if you could just stay away from the acronyms, we have a lot of people that aren't normally at the meetings... Thank you, Kevin. The Department of Financial Regulation, the Healthcare Advocate, the Vermont Association of Hospitals and Health Systems and Vermont Hospital CMOs. The Department of Financial Regulations involvement in this process was very meaningful for us at the board and also for the stakeholders. As a reminder earlier this year, there was a wait times report issued and as part of that report, there was a recommendation that the Department of Financial Regulation would take on the reporting of wait times with a much broader view across the health system to include independent providers and others in addition to hospitals. So they will be working on that process over the next year or so. The working group met several times, actually I think it was four times during the month of April to discuss wait times metrics and determine metrics and questions for inclusion in the hospital budget process. Thank you, Kara, for the next slide. So here we go. I will review these metrics with you. We've asked the hospitals, we will ask the hospitals to please report the following metrics in response to Part A, below if possible, and if not possible, then in response to Part B for each hospital-owned practice, for each primary care and specialty care, as well as the top five most frequent imaging procedures, A, for hospitals that can please report for each practice and imaging procedure, referral lag, and these are back to the default metrics. Referral lag, the percentage of appointments scheduled within three business days of referral and then visit lag, the percentage of new patients seen within two weeks, one month, three months, and six months of their scheduling date. And then B, for hospitals that cannot provide the lag times above, please report for each practice and imaging procedure, the third next available appointment. Additionally, we're asking them to state why the hospital cannot report the referral and visit lag times. So this, to provide context, there are hospitals in our state that can easily collect the referral and visit lags from their electronic systems, their electronic health records. Other hospitals, smaller hospitals have a much harder time and do not have the capability within their electronic health records. Thank you, Kevin, for reminding me of acronyms to report out to these metrics. So we deferred to the third next available appointment. So in addition to these metrics, we have some qualitative information that we're going to be asking as part of this process. And this also, the qualitative information will help inform the Department of Financial Regulation upcoming process. So I'll just summarize here. The current state, we're asking how they currently measure the benchmark wait times, what efforts in their organization they're making to improve wait times, particularly in areas where their organization records wait times longer than available benchmarks. We're asking what EHR systems they're currently using and how that impacts their ability to measure wait times. In terms of processes, we're asking that the hospitals to please overview their clinic scheduling process, including centralized scheduling, if possible, if applicable. And then also how referrals enter referrals into their system and how their staff triages these referrals, including how they schedule and prevent the loss of these referrals. Next slide, Kara. And then the last two areas were one, we want recommendations from the hospitals on how, what qualitative and quantitative metrics they suggest using and tracking to report wait times. And then in their opinion, how should state regulators best account for and measure the intricacies, which include acuity and uniform reporting of wait times. And then lastly, in terms of data, we're asking that they submit a sample of recent anonymized patient feedback concerning wait times, if available. And then if available, any aggregate reports based on patient satisfaction surveys regarding wait times produced by the hospital health system. So the next steps, we will be sending a letter this afternoon to the hospital leadership detailing these metrics. We're going to ask the hospitals to submit these quantitative metrics and qualitative information and responses to us by August 5th. And then we've also asked them to be prepared to discuss this information at their hospital budget hearings. And then the next slide. We have a motion that if you would like to vote and I would defer to you, Mr. Chair, and I think Russ, our attorney is on the line. I put this out as a motion for you. And then I can also open it up to questions if you have any. Thank you, Susan. After referring with legal, there isn't truly a requirement to have a vote. But I have at least a request from one board member to memorialize this in a motion. So I think it's the appropriate thing to do and it's belts and suspenders. As you recall, we voted on the guidance motion and that allowed for this group to come forward with this. But just to put the belts and suspenders on it, would a board member like to make a motion? So moved. It's been moved by Tom Walsh and seconded by? Seconded. And seconded by Jessica Holmes. Is there any discussion on the motion? Oh, no. I think Robin, your audio is off again. Oh, good catch, Susan. Were you trying to say something, Robin, if you could shake your head? I think she's calling back in. Okay. How's that? Better. Better, yep. Great. Sorry. And were you trying to say something, Robin? No. I had tried to second the motion, so I thought my audio wasn't working. It wasn't, let's say you came back in. Okay, hearing no further discussion, all those in favor of the motion, please signify by saying aye. Aye. Can you oppose? Please signify by saying nay. Let the record show that the motion carried unanimously. Great. Thank you, Susan, for having other information to report. No, that is it. Just wanted to thank the members of the working group for their effort. Great. Thank you. So next are the minutes of Wednesday, 4 27. Is there a motion? So moved. Second. It's been moved to approve the minutes of Wednesday, April 27, without any additions, deletions, or corrections. Is there any discussion? Hearing none, all those in favor of the motion, please signify by saying aye. Aye. Any opposed, please signify by saying nay. Let the record show that the motion carried unanimously. With that, we're going to move to the business of this morning's meeting, which is about health care system transformation. And I'm going to ask Patrick Flood, our former commissioner, to moderate this esteemed panel. And if you could introduce the participants, Patrick, and kind of be the referee, that would be greatly appreciated. Thank you, Mr. Chair. Can you hear me? We can. And you can see me too, although that's less important. We can. OK, thanks. I'm going to make some brief introductory remarks and then turn it over to the panel. First of all, thanks for the opportunity to speak to the board. We really value it. We represent a group of organizations and people very loosely connected that have been sharing their concerns about health care and health care reform in Vermont. And we believe the system is in crisis in many different ways, not just in one or two sectors, but in serious crisis. And it's getting worse. And you're going to hear about some of that from some of the panelists today. But you're also going to hear our suggestions for potential solutions, because we believe there are achievable and affordable solutions to a lot of these problems. I'd say at the outset would prefer to have a publicly financed universal system, but nobody sees that happening anytime soon at the federal or the state level. And to some degree, it doesn't matter. There's a ton that we can do and should do to make health care in Vermont both more affordable, more equitable, and more accessible. And we can do that. I want to make it clear that the people that I've been working with are not against the idea of an all-pair model, the concept, or against alternative payments, as you will hear today. We're concerned about the way it's been implemented. We're concerned about all the focus and all the money on what we consider to be a failed ACO model. We were very encouraged a couple of months ago when the board first came out with its hospital sustainability study. And in that report, you talked about some very different and we think potentially very exciting ideas, including global budgets for hospitals. And probably more, even more importantly, redesigning the service delivery system and a process of public engagement on how to achieve all those. We thought that was very promising. And we supported that idea. We supported it in our meeting with CMS that some of you attended. We supported it when it took legislative form in S285 in the Senate. We were less enthusiastic about the changes that were made in the House. We'd love to see the Senate version more. But more importantly, I think in the end, what we hope is that this is the first step in an ongoing process of hearing from Vermonters about what is not working in the health care system and what we need to do differently. So we've arranged for seven people today to speak. I asked each of them to try to keep their remarks to about 10 minutes, because they know we have less time than we originally thought. I think that will give us plenty of time for discussion and questions from the board, which we really encourage. We would love to engage with board members about some of the details here. And I will do my best to try to monitor the time. We would be fine if board members wanted to ask questions after each presenter. But you have your own process, and however you wanna do that is also fine with us. So the presenters today, we're gonna start with Bill Schubard, who I think many of you know as a journalist, someone who's been involved in health care for many years, was a chair of the UVM Medical Center Board. Some years and very knowledgeable, and has been really delving into health care issues in the past several months, and has become extremely knowledgeable. So Bill's gonna talk first, and we're gonna have Mark Hage from the Vermont NEA, who's been focused on hospital payment financing issues, including global budgets. We're gonna move on to Susan Riston, although I think Susan had a problem today and one of her colleagues who's gonna present from health first, the challenges that they're encountering. We're gonna hear from Deb Snell, who's a nurse at the UVM Medical Center, but also president of the Vermont Association of Health Professionals, nurses and health professionals. We're gonna hear from Julie Tesler, who represents the designated agency system. We're gonna hear from Sarah Launderville, who represents VCIL and the disability community. And I'm gonna speak a bit about community services and what we believe the potential is there. So with no further ado, I'd like to turn the microphone to Bill Schubart. Thank you all. I appreciate the opportunity to speak for you, and I'm gonna immediately start with a correction. Patrick, I'm not a journalist. I'm an opinion writer, and there's an important difference. I just wanted to be really clear on that. I always wanted to be a journalist, but I'm not. So let me jump right in. This is gonna be hard. I'm gonna try and keep this to 10 or 12 minutes, but there's an awful lot to say. Much of what I've written about, and you all have access to the five pieces I've written on healthcare so far. As Patrick said, I was former chair of Fletcher Allen at a deeply troubled time. It was when Bill Betcher was charged. And Ed Kaladney said to me, you're gonna be the next chair of Fletcher Allen, and I said, why? But anyway, it happened, and I was completely focused at that point on straightening out the governance, which was at Shambles. Then Governor Jim Douglas had recommended that the entire board quit, which they did. So it was a completely new board. The malfeasance that was later charged didn't occur with the whole board. The whole board was isolated. It actually occurred in an executive committee. And I am very non-enthusiastic about executive committees, and I changed all that. My principal order of business from a governance standpoint was to change us from a constituent board because we were comprised, and our membership was chosen from the three merging entities. Mary Fletcher, Fannie Allen, and the Foundation. And over the course of a couple of years, I managed to move us from constituent to self-perpetuating. I also was part of the team that hired Dr. Estes, who was just a terrific leader. I negotiated her compensation, and ultimately we made peace with Bishka, which was very important. And then we focused on the future. So that was my then role. From an overview standpoint, I just want to say a quick word about wait times. We're all talking about wait times in terms of the inconvenience. I, and I'm sure others know, because the pieces that I write in Digger elicit, probably an aggregate, hundreds of emails. And a lot of them are anecdotal, but a lot of them are from inside the system, and amazingly revelatory. But one of the issues that I've been tracking is I have four male friends who all have late stage prostatic cancer. And the time between their presentation with low back pain and that diagnosis is anywhere from eight to 13 months. And it's, you know, first they're sent to this, they're sent to the spine clinic, then they're sent to the pain clinic, then they get the steroid shot. None of that works. They represent an emergency room. They're told to go see their primary. They can't get in to see their primary. The primary does the obvious, the PSAs and so on and so forth. Then they schedule imaging, then they schedule biopsy. All of these things taking weeks. And then all of a sudden at the end, they're told, okay, you have late stage prostatic cancer. Now that what's intrigued me is what is the liability? Not the tort liability for the individual medical provider. That's a different issue. What is the systemic liability for the system for this? And I asked several attorneys about this and they said, the standard that's used in the court, in these court cases is the standard of care and the standard of care for cancer is early detection, early treatment. And if the institution can't provide that, their risk of significant liability. I then asked if there had been cases like that. And I was told, yes, there have been a number of cases like that. They're settled instantly with non-dysparagement and non-disclosure, get them off. So it's an interesting question. What are these cases costing? The other concern, again, in my overview is the flight of caregivers and shrinking clinical departments. You all are aware of what's going on in Berlin and how they're losing so much staff that some of their clinical practices are at risk. The one that was mentioned was endocrinology. Again, to the cost of travelers, which I now hear and Al Gore-Bays quoted on this is gonna be around travelers in temps, around $130 million. Imagine if that kind of money were used for nursing student debt forgiveness. How far that would go? Anecdotally, I've heard from several nurses as have friends who have switched from employed nurses to travelers so they could pay their tuition debt. Also, I heard from somebody inside the system that they're worried about Larner because they're losing lab techs hand over fist. There's a company coming into Burlington that is going to be hiring lab techs at $100,000 starting salary. And the health network salary runs 30 to 35,000. I don't have to talk to you about the upcoding scandals, the movement of private equity into Medicare Advantage programs and how they're manipulating upcoding. And then of course, there's the ongoing cost which I first learned from Dr. Estes of denial management. These are all costs that have nothing to do with population health, nothing. And they're in the tens of millions of dollars. I wanna say a few brief words about current state of mental health care and access. If you didn't see the piece by medical professionals in today's digger about the young people in the emergency room, you all need to read that. I heard that directly from Dr. Bromstead. I said to him, John, is it true? John used to be on my board when I was chair. I said, is it true about these young people in the emergency room? I hear this five or 10 in there every day. He said to me, Bill, and you can quote me. He said, five or 10 is a good day. 25 to 30 is a bad day. These kids are our future. And I could go on for half an hour about what I'm seeing, but you're reading it, hopefully in the Atlantic Monthly in the New York Times. This is a crisis. And we are absent without leave on that. Suicide and addiction statistics are up. I'm gonna move now to the health system itself. We have really got to reimagine it. We can't let it be the way it is.  It costs and access are completely out of control. We need a driving philosophy that it has to be the mission of population health, access, cost, and outcome quality. And we're losing on all those measures. The driving ethos, which is not the case today, has to be collaboration. When I'm speaking in public, I often say, businesses compete, nonprofits collaborate. And if nonprofits behave like businesses, they need to be regulated and they need to understand that they have an obligation to collaborate. And I remember hearing back when I was chair that one of the reasons Rutland hated sending people to Burlington was they never came back. An Atertiary Care Hospital should be Atertiary Care Hospital and they should be able to take high acuity cases coming up from primary care and deal with them and then send them home. That wasn't happening. The hospitals were competing. And if we haven't learned that competition in healthcare doesn't work, then I don't know what's wrong. As I said, we need to really reimagine it. I'm not gonna get into global budgeting because it means different things to different people and there are other people who will talk to you today who will talk about that. I understand absolutely the reason for doing it. I understand the reason behind the accountable healthcare organization even though it hasn't worked. But as one hospital said to me, he said, you need to understand my business model is completely dependent on my getting a steady stream of broken people in my emergency room, which is where I get most of my billing, me fixing them and then billing the payers. He said, that's my business model. He said, if I move my investment upstream to education, prevention, intervention, I've just blown my business model. That's from a hospital head. My own belief from having worked on the periphery of this field, both in education, criminal justice and healthcare, really since the Dean Davis administration is we have got to be moving our investments upstream. We've got to be focusing on education, intervention, early treatment, instead of remediation and emergency treatment, which of course is much more lucrative. I was asked, I was doing a snulling leadership thing last week in Montpelier and I was asked, because we were talking about complex systems and how you change them. And there were a number of people from AHS and different healthcare people there in the cohort of students. And one of them said to me, so what is a simple metric? Don't get all confusing about the data. Can you give us a simple metric for how things are working? And I said, yeah, actually I can. I said, the simple measure of our systemic failure is the number of patients in emergency rooms, homeless shelters and jails. And they're all connected. Finally, I just want to say a quick word about the state's absence of leadership. And this troubles me more than anything. I've discussed it with the governor, Jason. I've discussed it with many legislators and some jurors. And I've just been asked to meet with a state judge the week after next, who is really interested in this from a legal standpoint. But there doesn't seem to be any leadership from the executive branch. And I give full credit to the governor for what he has done managing the existing crisis in COVID. I give him full credit, but strategically we're getting silence on where healthcare is. I've talked to a number of legislators and they've reached out to me and it's a complex system. And we have bright committed, intelligent people in the legislature and the system is absolutely beyond, in most cases, their comprehension. They struggle and they work hard at this. And I understand, I get it. I'm hoping that the judiciary begins to weigh in. Most of the major social progress in Vermont, education financing, same-sex marriage and so on has actually come from the judiciary. And under the Equal Benefits Clause of the Vermont Constitution, they may weigh in on the issue of healthcare because it's not an equal benefit now. Finally, your role. I was on the Green Mountain Care Advisory Board when Con Hogan and Betty Ramber when it first started up, there were 50 of us. And after a while we realized it was really optics and most of us just sort of disappeared slowly but have watched it carefully. And the question I would ask is, what is your mission? I mean, I honestly don't know. Are you a financial regulatory group that ensures the financial wellbeing of hospitals? Do you respond to the sort of vacant state mission? What's the role of AHS? They have six divisions, all of which are arguably aspects of healthcare. Who's coordinating that? Who in Vermont is saying, this is the mission of healthcare? Here's how we're going to watch it, monitor it and regulate it. Here's how we're gonna hold it accountable. I have absolutely no idea. I don't even know your role. And I greatly appreciate the opportunity to talk with you. Who owns this? I don't know where the answers are. So thank you. I really appreciate your hard work and the opportunity to talk with you. Thank you, Bill. Mr. Chairman, do you wanna ask any questions or? Kevin, you're muted. You can put your half and half away. Okay. I don't wanna have to spoil. Okay, if those people who aren't speaking could mute themselves, that would be great. We're picking up some feedback from somebody. Bill, you've asked some great questions. The board is often very frustrated in what our role is because we're really, by statute, only able to touch about half of the system. And speaking as one board member, but I think knowing my colleagues, I think we would all greatly agree with what you put forward in the beginning of the presentation as far as the upstream investments and how important they are in that the global system doesn't seem to come together under Vermont's current structure. And those are important points. And I just wanted to also say, Bill, that I agree with you on the loan forgiveness, but I want you to put this into your thinking cap as well, because in Vermont, I think the even bigger problem when it comes to nursing is the two bottlenecks created. We're in a number of institutions, especially in your area of the state, they're turning away more qualified students than accepting. And there's two reasons for that. One is the lack of faculty. And that's problematic because faculty is making $50,000 less than what a nurse can make on a floor of a hospital. And two, they have to have that education credentialing. And I know that Deb is part of this presentation and we've worked with her on the past at a forum down in Castleton. And this is something that we've been trying to highlight for years. And finally, it looks like there is a workforce, Bill, moving in the legislature, although it seems to be getting a lot of cuts into it along the way and that's of concern to us. But the other flip side to that is these same institutions that are experiencing these large traveling costs, part of the bottleneck themselves by not providing enough clinical experience and precepting. And so if we could fix the precepting so that the programs could give the student nurses that clinical experience, which is necessary for them to graduate and fix the faculty situation, we could be expanding because we have Vermonters who want to fill those positions. It's not like other areas where there's these huge shortages of people even showing interest. So I just want you to think about that as well, Bill, because we could fix this problem. We've been talking about this problem for five years and nobody listens until there is a crisis, which is unfortunate. And when I testified in the legislature three years ago and said there was going to be a crisis, I was told that I was being a little bit overexaggerative in my testimony and that clearly was not the case. And but everybody's on the same page now. The governor has a great workforce plan if it gets implemented. And that's the key thing that we all have to do as Vermonters to make sure that the workforce plan is implemented and actually carried out. So thanks, Bill. Other board members? Thank you. Sure, I'll jump in. Hi, everyone. Hi, Bill, nice to see you. So to me, I think that the board's statutory duties and responsibilities fall into two camps. One of which is regulatory and most of our regulatory processes have a balance of factors, typically consumer affordability and solvency of the system. So that is the statutory charge of most of the regulatory processes, which is the bulk of our work. We also, as Kevin alluded to, have some oversight over what I would call system direction. So the workforce plan and the health information technology plan are plans that are developed by the executive branch and approved or modified by us. And as an entity that's created by the legislature, we only have the powers that are endowed to us by the legislature. So I do think that's an area which is not necessarily well understood generally in the public. And of course, because we do everything in public, there is a bit of a bully pulpit as well. I think the statutory sort of scheme, if you will, has coordination of AHS activities in the secretary's office via the director of healthcare reform. And the governor has delegated or designated AHS as his lead on the next all-pair model agreement. And so we're certainly a signatory to that and have our place in that discussion, but they've been designated as the governor's lead. So I'm, you know, as a lawyer, I do come at this very much from the statutory perspective. So I just thought it might be helpful to share that for what it's worth. No, that is really helpful. The only thing that I would say that's an important principle to bear in mind is the organization that sets the healthcare policy cannot be the organization that regulates it. They need to be two different things. So, you know, if your role is regulatory and you're working, you know, to find more clearly what that regulatory mission is, I think that's a terrific thing. I mean, this has all been very helpful to me and my thinking, but there still has to be something outside of the Green Mountain Care Board that's saying here is the mission, the vision and the policy and they need to be separate. That's the only thing I would add. Can I jump in, Mr. Chair, and just say, this is fascinating. This is the kind of discussion that could go on for two hours. Every single thing would wrap today. So if you could keep us in mind, that would be great. I'm gonna try to do that. So I'd like to introduce Mark Cage, who's gonna bring up another topic that's near and dear to your hearts, I think. Good morning all and my apologies. My camera is insisting on remaining disabled. So I will come to you strictly through audio today. So my name is Patrick Zettis Mark Cage. I'm the director of benefit programs at the Vermont National Education Association. I'm also a long time trust administrator with VHI, the Vermont Education Health Initiative. It's a self-insured risk pool. It provides health insurance plans to approximately 35,600 school employees active and retired and their dependents. I am testifying today exclusively as a union advocate. I am not testifying or speaking on behalf of VHI. So let me begin with an emphatic statement that I don't think will surprise anyone. The time is now to design and implement a model of global budgeting for Vermont's hospitals that will ensure they have sufficient and sustainable funding. And to be clear, I consider this a social, economic, medical and moral imperative. And equally imperative, all Vermonters must be assured access to affordable, high quality, equitable healthcare. And on that point too, there can be no equivocation or evasion. And these two imperatives are not separate and distinct. Yet for too long, our regulatory deliberations about hospital budgets and the cost of medical care generally, including in respect to one care, Vermont has not confronted directly and urgently the staggering inequities and out affordability of healthcare for many, many thousands of Vermonters. And this false binary respectfully must end. I would implore this board to exercise its regulatory power and its bully pulpit to implement a global budgeting process that is fair to and sustainable for hospitals that centers the principles of universal access, affordability and equity in budgetary decision making and population health planning for both hospitals and community-based care. And importantly, references hospital reimbursements to Medicare rates. And before I expand on these points, I wanna remind us that according to the 2021 Vermont household health insurance survey, 44% of Vermont's privately insured residents under the age of 65 are deemed underinsured. And the surveyors from the market design research used the model to arrive at that figure that had been developed by the Commonwealth Fund. As I'm sure you know, to be underinsured means that your private insurance plan does not adequately cover current or potential future medical expenses. And by expenses in this context, by costs, I mean out of pocket liabilities, deductibles, coinsurance, co-pays. The Commonwealth Fund's calculation for determining underinsured status excludes premium costs, which also you know present a significant hardship for many Vermonters. According to the survey, two in five privately insured Vermonters now have a deductible greater than $4,000. 38% of privately insured Vermonters under the age of 65 have a deductible that's equal to at least 5% of their household income. Now in 2014, the percentage of Vermonters under the age of 65 with private insurance who were underinsured was 27%. In 2018, it was 40%. And now as I said, it's 44%. That 44% represents more than 131,000 privately insured Vermonters and most have the lowest income. The survey also tells us that Vermonters who are black who are members of gender identity minority and who live with a disability are more likely to be uninsured compared to other groups. Which begs the question, what is the tipping point in this crisis? Is it 50% of privately insured Vermonters being designated as underinsured 60%, 70? When do we accept collective responsibility and say that this system has failed so many Vermonters and dedicated medical personnel for too long? And it will continue to fail them indefinitely until we reimagine, we restructure, refinance and rebuild our hospital and our community-based care systems. We must also stop engaging with a nonsensical and harmful skin in the game rhetoric that is used by advocates of high deductible plans to justify excessive prices and profits, cost shifting and blame shifting to workers, employers and patients, crushing medical debt and the fear of medical debt. And administrative waste. We know categorically from decades of research that we don't have a so-called utilization problem. We have a price problem. And that has to be tackled through global budgeting and reference-based pricing and through other comprehensive reforms my compatriots will speak to directly. When I speak of global budgets, I mean an empirically sound, rigorously regulated system of budgeting that allocates fixed annual payments to our hospitals to cover their verifiable operating costs that eliminates price variations for the same services and ensures funding for the delivery of vital healthcare services. By studying and distilling metrics and hospital costs, prices, revenue and surplus accumulation and the volume and acuity of care and break-even points, we should arrive annually at a fixed allocation of payments for each hospital that is fair, sustainable over time and can be explained and justified in lay terms to workers, employers and the general public. Imagine if we could talk about healthcare reform in terms people actually understand and they can see the medical and financial benefits for themselves, for their employers and for their loved ones. That is not happening now. Savings that accrue from hospital global budget should be invested in expanding access to community-based medical services, primary care and nursing, mental health, home healthcare and hospice and to resolve critical and long-standing workforce shortages in these fields. The process of building sustainable global budgets for hospitals must be done in tandem with the design and implementation of a model of reference-based pricing based as I said earlier on a multiple of Medicare rates for both inpatient and outpatient hospital services. And referencing hospital rates to Medicare makes eminent good sense because Medicare rate setting calculation process is publicly available. It's rates are adjusted for case mix, risk, quality and geography and as a common reference point those rates can be used to overcome price variations and charge masters and billing rates. When we arrive at the starting line of designing global budgets, I believe reference-based pricing will be critical in identifying current costs that cannot be justified on financial or clinical grounds. These costs must not be baked into future global budgets. I started investigating reference-based pricing seriously after learning of Montana's success in implementing a model pegged to Medicare rates for 31,000 state employees and their families in 2017. And I was driven to this research in part by the fact that better than 50 cents of every very high premium dollars devoted to inpatient and outpatient hospital services and also by the profound impact of medical inflation each year on the highest premium rates. I communicated with Marilyn Bartlett, the key individual who spearheaded the Montana initiative with a strong backing of state officials. And I learned that reference-based pricing can dramatically lower costs without endangering the fiscal solvency of hospitals without closing their doors and without reducing essential services. Montana set inpatient hospital prices at acute care centers at between 220 and 225% of Medicare rates and between 230 and 250% of Medicare rates for outpatient services. There have been no premium rate increases as I understand it for state employees for six consecutive years, 2017 to 2022. Montana saw an actual reduction in its health insurance cost by nearly $48 million from 2017 to 2019 alone. And here in Vermont, state auditor Doug Hoffer and his team released a report last November that examined the benefits of reference-based pricing, benchmarked to Medicare in the pursuit of lowering healthcare costs for state employees. And it found that if reference-based pricing was implemented for Vermont state employees alone for all services, total savings could reach as high as $16.3 million annually. In closing, I wanna urge you to speak with auditor Hoffer and his team about their findings and also to invite Marilyn Bartlett to share with you her experiences in Montana and what it taught her about any pursuit of global budgeting and reference-based pricing. I think she's a very smart, I consider her a remarkable person actually. She's now a special analyst with the National Academy for state health policy. She offered testimony in recent years to this board on Nashville's Hospital Analytical Tool, which has recently been re-engineered. And Nashville has experts and resources, including this new hospital tool that I think can assist this board and pertinent state agencies in developing global budgets and moving to reference-based pricing. It's my understanding that if the state requests this expertise or this board requested that these services and expertise would come at no cost. Finally, I look forward as do my colleagues to a robust public engagement on global budgeting, reference-based pricing and community care in the months to come. It is absolutely critical that workers, employers, patients, the advocates you're going to hear from today and the people they represent and others, including our hospitals, they must all be at the table as equals and they must all have a voice in this process. So thank you for your work and thank you for this time. Thank you, Mark. Chairman Mullen, any questions or comments? You're muted again, I'm afraid. Patrick, unless a board member feels compelled to ask a question, I think we better just keep moving because I can see that we're on schedule. We're just about on schedule, but we're doing okay. So I, Susan Ridden from Health First was going to speak this morning, but I understand she may not be available and Rick Dooley may take her place. Can we get him on the screen? Yep, I am here and I'm actually going to ask to share my screen. Is there an option to do that or do I need to? Does someone need to give me that? Next to the lead button, you should see the share button. Yep, all right, so I do that. Center mode. It may be turned off, Chairman Mullen. You can base time out the board past this presentation. So I don't know if it has to be turned on or if he has to get it to be turned on. Or is it turned off? I don't think it's turned off, but Kara, please. Shouldn't be. So you should hit share and there should be some documents to click on. And then- Yeah, hit share and it just tells me that no, hold on. Here we go. I may make in progress here. Give me just a second. My apologies, I usually like to be a lot more prepared than that for sharing things, but all right, let's try this. What's this looking promising? Okay, do we have success? I can see it on my screen. I don't know if you folks can see it on yours. I can now. Yes. Okay, excellent. All right, so I'm gonna go ahead and start. So my name is Rick Dooley. I'm not Susan Ridson, but I am the Clinical Network Director for Health First. Susan is on the phone and we'll jump in if I mess anything up. She's in Ohio and it's having some technical difficulties connecting. So my job is just to talk today a little bit about what independent practices bring to the board and what our concerns are as we move forward. I think Mark just spoke really eloquently about global budget, which I think is great. So I'm not gonna cover all the stuff that's been covered already. Just briefly, because I know there is a new board member here. I keep saying new Tom. I know you've been there for a bit now, but yeah, for the first two years you'll be the new board member. Health First is the Independent Practice Association. We've been in existence since 2010. We actually were the first ACO in the state of Vermont as well. We represent about 85 to 90% of Vermont's physician-owned practices. We have practices in eight counties spread across the state. And our primary care practices care for about 76,000 patients total, which is a pretty good chunk of folks in Vermont. And we do employ hundreds of Vermonters as well. So just a quick snapshot for what's happening. Now, this is not a great surprise to certainly to any of the board members. We are seeing a decrease in the number of independent practices and the number of independent physicians in practice. And you can see we've had almost a 20% drop in practices themselves. A quarter of those are primary care practices and about a 10% drop in actual individual practitioners in that same time period, which is concerning. That's a pretty large drop and certainly not a trend that is sustainable. I know the board's talked about workforce recruitment and retainment and what we can do to try to keep folks in practice. But as we all know, we have an aging demographic. We have aging practitioners. And then on top of that, we have real strains on independent practices that are causing those practices to see an even greater attrition rate. So why does it matter if there's independent practices in terms of health care reform and moving forward? The biggest reason is the first bullet right there. Independent practices have consistently demonstrated that we can provide high quality and keep overall costs to patients low. We've done it for every demonstration that we've done for the last 10 years, for CFS, for the SIM grant, everything we've done has always showed that our costs are lower, our quality is higher. The second bullet is super important. Patients want options for care. And we hear that routinely from folks. I see them in my office. They come in and say, I don't want to see a hospital provider. I wanna see an independent practice. I wanna see an independent provider. Our services are unique. Patients pick practices based on what feels good to them for their health care, what philosophy matches their philosophy of health care. Of our independent practices, and I've been in a number of them, I can tell you there's some very different practice styles. The buildings feel different. The offices feel different. The practitioners practice different.  The third bullet is part of that retention and retaining folks. Independent practices, having an independent practice is a viable option. Actually attracts physicians to our state. We've had a number of physicians who have joined us recently who are specifically looking for independent practices. Independent practices across the country are going down. And so a lot of practitioners coming out of school don't want to work for a big hospital system. They don't see that as a benefit. They want to hang their shingler, join a small group of colleagues and have a little more control in their day-to-day work. And having a viable independent practice community in the state encourages that. Next slide here. The experience of care I just referenced as earlier at small community-based practices is different. The care is more personalized. Practices are more efficient and more nimble. And definitely less costly. And when I say efficient and nimble, I think having, I really like my colleagues at the bigger institutions, UVMC, certainly I have a number of colleagues that I am friends with there. The advantage of a small practice is that if there's an initiative to change something, there's a quality initiative. If I see something, I run down and say, I want to do X, Y, Z. I want to do a quality improvement project. I can probably get it up and running in a week in my practice. I can get a group of colleagues together. We can emphasize it's important. We can figure out what we want to do. We can run the data. And we can start making changes in that period of time. I guarantee you there's not a department in that hospital that can make a change in a week to save their life. The small practices really do have this ability to pivot quickly for trends, for whatever they need to do in order to keep themselves cost-effective and provide high-quality care. And lastly is accessibility. I know we started talking about Susan Barrow talked about the wait times. I can tell you the reason primary care practices, independent practices provide better wait times is just our practice models. If you're, to use the phrase eat what you kill practice, you're dependent on revenue, which means you're dependent on folks actually being able to see you and keeping them healthy and getting the care they want because that's how patients want to come see you because you provide good care and you get a good name of the community. You know, in our practice we have two providers every day who are considered on call who are there until the last patient is seen at the end of the day. If you call our practice anytime during the day and say, I'd need to be seen today, someone will see you in our primary care practice before the end of that day. That reduces the emergency room visits that provides better quality care. And most of our practices do that. We provide hours on the weekends. We provide services to key people out of the emergency room and provide that quality care. When you look at our specialty practices, the, you know, we just looked at dermatology. I know dermatology was sort of a, you gotta wait a long time if you get an abnormal mold, you know, wait time is almost half a year. For our independent practices, our dermatology practice, that wait time is, you know, about three weeks. So it's considerably less. And that's, we found to be the case across most of our specialty practices, you know, cardiology, I'd like to say orthopedics, but we don't have an independent orthopedist in Jiton County. You know, most of our specialty practices get folks in quickly. The problem is there are a number of specialties where we don't have independent practitioners in the county anymore. And that's because of, you know, absorption with the hospital inability to stay in practice. So what are the biggest barriers to independent practice viability? I have said this to you folks. I don't know how many times you've heard this. I'm just gonna reiterate. Reimbursements are not keeping up with expenses. It's an expensive world. We've all heard about the increase in cost of living, increase in labor costs and medical malpractice and our supply costs and employee health insurance. Cyber insurance is the new thing, that it costs a fortune. All those costs, we're not getting paid enough to keep up with those costs. From 2001 to 2021, our costs increased about 40%. And Medicare increases were only equivalent to about 11%, not counting for inflation. So, you know, costs are going up, revenue's going down. It's hard to run a business that way. And just to reiterate, I know everyone knows this, you know, independent practices have one source of income. It's our reimbursements from the insurers, Medicare, Medicaid and commercial payers. You know, there is no other big pool of money that's coming to independence. We don't get extra money from anyone. You know, this is sort of what we get. We get a little bit from Blueprint certainly and those who are enrolled in the ECO get a little bit of a care management fee. But really, there's just not a lot of money besides those revenues that we get from reimbursement. And so, I'm just under 10 minutes. I'm talking fast here to try to make up time. So, what do we need to do? And I think this is, sorry, my screen's being a little wonky here. It shrunk to little tiny, so I'm gonna try to read this on my own here. So, what? Nope. So, we need a Vermont Health System that supports all of our community-based providers across the board. That is, sorry, my computer's flipping out. Let me try it again. That includes increasing provider and facility choice by making sure there's fair reimbursement across providers, regardless of the site of care delivery. I know Mark just spoke about holding hospitals accountable, making sure the pressing's tied to a benchmark. Shifting those resources to the high-value services like primary care and mental health, which actually decreases the need for hospital services. And lastly, but certainly super important, we need to support non-hospital alternatives for services like ambulatory surgeries, procedures, and imaging. Just a quick example. I know we've talked about cost of services before. Mark just said that 40% of patients have deductible $4,000 or more. That's huge. I would hazard a guess that probably most of that 40% does not have $4,000 sitting in their savings account ready for a health emergency. I had a patient who needed an MRI of the brain and we tried to sit up at the big hospital and it was gonna be $5,000. And even with the patient discounts, I think they brought down to $4,000, which was his deductible. We call it Vermont Open MRI, which is a small independent imaging source. Their flat fee for an MRI of the brain is $995. And when I called and said the patient's a cash pay and doesn't have a lot of money, they said, oh, we can get that down easily to five or $600 just have them give us a call. And just that, he got the study done in about a week. So we need to support these other hospital alternatives for procedures that are appropriate for being in an outpatient setting for imaging for the things that we really can impact on the cost significantly. Also, I know I said this again, I wanna reiterate to the board that when hospital costs go up, when the money going to the hospital goes up, that has a double negative effect on independent practices because not only do we then pay more for our employee health insurance because the system goes up and rates go up, then we're paying more for our employees. On top of that, we have fewer dollars coming in because if more money goes to the hospital, there's less money for the rest of the system. We have to reduce the amount of money going to the hospital in order to support the rest of the system to bring us all into focus here. And with that, I'm going to finish up. Thank you, Rick. You're welcome. Thank you, Rick. That was excellent. So let's move on to Deb Snell. Deb, are you available? In just a time check, Patrick, you've got less than 30 minutes. So if you could keep everybody moving, that would be great. Oh, I thought we had till 11 o'clock. Well, we have to have public comment and such. All right, everybody's gonna have to cut back what they wanted to say. Sure, okay. Deb, can you do it in five or six minutes? I think so, thank you. Good morning, everyone. My name is Deb Snell. I'm president of AFT Vermont, the Vermont Federation of Nurses and Health Professionals and currently work as a nurse in the Medical Intensive Care Unit at the University of Vermont Medical Center. I'm asked to speak to you today about the nursing perspective of what is going on in our state. And I first wanted to acknowledge Sharon Mullins' remarks about education in our state for nursing and other healthcare providers. And I'm very thrilled to see that we're finally making some strides in that area, which is great for a long-term solution. However, my biggest concern right now is keeping people here. And that's a sad fact that people continue to leave every day. So to get onto my talking points, so there's a constant pressure in our healthcare system right now to do more with less, to find a workaround and tighten up staffing. It feels like we are working in a Rob Peter to pay Paul environment. It's not healthy for our patients, our staff or anyone working in the hospital. I know that you hear the stories about patients coming to the hospital sicker because they can't access primary care and end up having longer hospital stays. Of patients waiting for months like my colleague just spoke about for an MRI or CT scan. And it's getting to the point where and I applaud his initiative in helping his patient out, but we have physicians sending their patients to the ED to get scans done that they normally would have had to wait months for. And that's just backlogging our ED even more, which they're already, like when Bill had said, we've already got so many patients waiting in the ED already and like 30 kids would be a good day. And I see that happening all the time. In our outpatient setting, staff are going into work on Monday morning and potentially having hundreds of messages in their inboxes. Some leftover from the week before, whether it's prescription refills, committed checks, you name it. And these people all deserve a timely response and our staff is not able to provide that at this time. They're trying to do their normal cause, their triage calls, and the nurses are getting upset because they're not being given the time they need to meet the patient's needs. It's more about productivity than care. And it's felt like that for a while now. We're feeling the same pressure on the inpatient side as well. It's all about how fast can we move this patient out? How fast can we get him to the floor? Do we even have time to turn over this room before the next one's in the bed? In order for healthcare in our state to truly have the transformation it needs, it needs to have the people to do it. We need the doctors, the APRNs, your RNs, LPNs, your LNAs, MAs, support staff. We need them all to build our system back. And there's constant talk about growing and expanding. New OR suites, new equipment, but you need the people to run this stuff, period. And we do not have that right now. So not only do we have over, I think close to 400 nursing positions open in our hospitals, like a 22% vacancy rate for nurses, a 27% vacancy rate for LNAs, even community health in Chittenden County has over 50 openings, not for MDs, but for RN support staff. And those are basics that we need. We need community health in Chittenden County and across the state, but we need the staff to provide that care. So I don't think it's a surprise to anyone that VF and HP right now is currently in bargaining with the hospital over our next contract. I can tell you the first two sessions that Dr. Leffler has come in and basically talked about the Green Mountain Care Board, not surprising, and basically how poor the hospital is. And it's kind of alarming to hear when we're asked, well, what's the plan? Well, we don't have a plan. So, well, we went to the Green Mountain Care Board, but they didn't give us what we need. So we're like, okay, then what's plan B? There is no plan B. He could not give us an explanation about what steps we're going to happen next in our facility. And we know that what happens at our facility carries across the state often. When we asked, he says he wants to get rid of the travel nurses, great, I love that idea. What's the plan to replace them? There is no plan. Possibly cutting services. When he said that, my mouth, my jaw dropped. It was like such an irresponsible thing to say that, oh, we might have to cut travel nurses, so we might have to cut services. To be honest to God, we are the academic medical center in this state. We are the one who only provides some services and that threat to cut them, to get rid of travel nurses, to meet their budget needs. There needs to be some rethinking at the top, some serious rethinking at the top about how they're planning on running our organizations. You know, we understand that COVID had a financial impact on our hospitals, but like threatening to cut services is just not the way to do it. We need to get fewer executives and VPs and more boots on the ground, period. So I do wanna share on a personal note, coming from not only a nurse perspective, but a patient perspective. So I had spied surgery last January, ended up in my hospital, had the surgery there. Ended up on the correct unit, got the correct care. I had the right nurses who understood the procedure that I had, that were able to help me with the steps to get home in a timely manner. Everything went right, except unfortunately, the surgery because my bones didn't grow back, right? So I had to have additional surgery, which I just had less than two weeks ago. I ended up on the wrong floor. On a floor that didn't do truly orthopedic or neurosurgery type surgeries. The nurses didn't know what to do for me. They didn't know that I needed a nice pack. They didn't know that I needed to have muscle relaxers along with pain medication. They didn't know that I needed to like log roll or that you even need like a toilet seat extender. Just the basics were not provided. I had six different nurses on the six different shifts I was in the hospital. Three of the nurses were travelers, only two of them were nurses that actually had worked on that floor. And even they were kind of like, yeah, we're not quite sure what to do. Even my surgeon came in and said, my patients don't end up on this floor. But unfortunately, our ORs are so booked and patients aren't moving out. So I ended up where I did. And I have to say thank God I was a nurse and thank God I had gone through the surgery before because I don't know where I would be right now because it kills me to say this that I got such poor care in my own facility. Sorry, I wasn't gonna get upset. But anyway, what we need to get back to are basically the basics. And we're missing the basics. We need to get back to just providing good patient care being a tertiary medical care center that provides care for patients that isn't looking to grow beyond its own scope of practice that we just get back to caring for our patients and doing the right thing by them. And thank you and I'm sorry I got emotional. Thank you, Deb.  This is Tom Walsh. I'm sorry to interrupt. Yeah, Deb, we haven't met. I'm a spine specialist, right? See patients going through what you did all the time. And I think it would be a mistake to just jump to the next speaker after you shared with us your experience. So I'm not gonna ask for a lot of time for my board members and the other guests. I just wanna say that I'm sorry. I work every day to try to make this better. And I'll keep working. So thanks for coming. And thanks for sharing. Thank you, I appreciate that. Thank you very much. I'm gonna try to keep myself to five minutes, but basically my message is very simple. We need to move away from a hospital-centric system of care and we need to greatly expand our community services, our prevention, our early intervention. We all know what happens in Europe. They have lower costs, they have better outcomes because they focus much more on primary care and on social services. We can do that here. We have the fundamentals in place. We have really a history anyway, of strong mental health services. And I have to tell you, as somebody who's worked in this system in a variety of capacities over the years, mental health is absolutely essential to controlling healthcare costs. I believe that upwards of 50% of everything that we deal with in ERs and in hospitals is either caused by or greatly exacerbated by mental and emotional health issues. And we are nowhere near prepared to deal with those. And so we spend a ton of money on conditions that could be better handled if we only had the mental health resources to do it. I assume the board members are aware of adverse childhood events and the impact that ACEs has. So I won't dwell on it, but it is like the silver bullet as far as I'm concerned. If we dealt with ACEs, we would reduce the chronic problems that we're dealing with in our healthcare system dramatically. So I feel very strongly that we have to find a way to move money over time from the hospital system to community systems. It doesn't even take that much actually. They're much cheaper systems. Mental health is at the top of my list, but also home health. Home health can do remarkable things if they're only staffed to do it and paid to do it. I ran a home health agency when I ran the FQHC and it's remarkable what those folks are able to do and to reduce costs and keep people out of the hospital. But we don't fund them to do that. We need to strengthen our hospice program. Hospice is a terrific program that saves money. It doesn't even cost the state a lot of money to run hospice. It's a very cheap investment. And yet on the back end, people get better care and costs are greatly reduced. We need to expand our FQHCs. I understand there's a federal component of that, but I believe that we could achieve nearly universal access to primary care if we would just expand our FQHCs and use state money to do it if we have to. So there's just so much we can do today. We know how to do it. The organizations are in place. We're just not funding them. We're sending all of our money to the hospitals and that won't get us the results that we need. So I believe it's entirely achievable to reduce funding to hospitals over time by reducing just their rate of growth and transferring funds over to community-based services. And we will get much better outcomes and we will save a lot of money and Bremontors will have access to care almost on a universal basis. I believe that's very doable. If I had more time, I'd lay out more of the details. I understand I don't have that time today, but I can't emphasize enough that that is absolutely key to changing the situation we're in and making our system more affordable and accessible is building up our community system and making sure people have access to it. So with that, I'll be quiet and turn it over to Julie Tesler from the designated agencies who has a very strong message about the dire straits that they're in. And as I said, mental health is absolutely essential. Julie. Thank you very much. Thanks for the opportunity today. Bremont Care Partners represents 16 designated and specialized service agencies. When I'm speaking today, I'm speaking for Bremont Care Partners as a guest of this coalition. Bremont Care Partners has some different perspectives on some of the issues, but everything I say today, I think I have the backing of the designated specialized service agencies. I just wanna step back to a little bit of history. Bremont used to have a very large state hospital for people with mental health conditions from Munstate Hospital. It had Brandon Training School for people with developmental cognitive disabilities and it had the weak schools for children and youth with emotional disturbance and behavior challenges. These are all publicly run by state government. They're costly. I'm not saying that they had good quality. I'm not commenting their quality of care, but I think most everyone wanted to see folks return to the community to the extent that that was possible, but there were some parents when Brandon Training School closed that said, not so fast, I'm worried, I'm worried about my children. How do we know that over time the services will be there to meet their needs? When they're in the institution and in state run, we feel secure that their care needs will be met. So the designated specialized service agencies in part grew to meet the needs of the people who had been in those institutions. We serve, well, we touch the lives of 50,000 Vermonters every year, of which 36,000 actually enroll as clients. So not everyone we serve in the community in different ways, whether it's crisis or wherever it becomes a client. We should have 5,000 employees, but in fact, on January 1st, we only had about 4,000 employees because we are undergoing a workforce crisis because we've been under resourced for years. That promise to the parents has not been fulfilled. We have a commitment to meet the needs of people in the community and their places of work and schools, in their homes. We do prevention, intervention, crisis work, residential support, care coordination and always focusing on a whole person because we're not serving the person who can go to the therapist for a 50 hour therapy hour and once or twice a month or every week. We're serving people whose needs are much higher. Their incomes are low, their resources are less, they have problems with transportation, they don't necessarily have housing that's secure and safe. So we're really looking at the whole person. We are nonprofits, we are focused on collaboration. We have a very strong public mission about the work that we do. And I think compared to other states, we have a very good system of care. However, in Vermont, we have very high prevalence rates too. Our prevalence rates of excessive drinking, it's high. Opioid deaths, it's high in getting higher as well as the drinking getting higher. Aces were again above the average and it leads to heart disease, respiratory disease, cancer, further addictions. Depression, well, I think the whole nation is dealing with an epidemic of depression. 41% of adults are suffering from depression nationwide. 61% of college students, and you think those are kind of the lucky youth who get to go to college. 25% of children and adolescents are dealing with depression. People with depression have over $3,000 more medical costs a year more than people who don't have depression. It is costing us, it is costing the people who are suffering from depression. I personally would much rather have physical pain than mental pain. It's very hard for people to experience that. The people we serve with developmental disabilities, those people that are in Brandon, 53% of them have mental health conditions as well. Some have had addictions, we've had overdose and people with developmental disabilities, many have medical co-morbidities. And the pandemic is really made it worse and it's not that when the pandemic is over, that trauma, the depression, the excessive drinking, the drug use is just gonna evaporate. All of that will have lasting impacts. So we kind of talk about the ongoing tsunami of the pandemic and as it affects the people that we serve and their needs. I hope I have a little quick time, just I think sometimes it's, we kind of wanna think about those issues affecting other people, but I just wanna share a couple of examples for my own family, two of my nephews, both experienced trauma as youth. One of them was in the DCF system in Ohio, was sexually abused and not surprising, ended up with addiction, ended up homeless, and his lung collapsed in his 20s, early 20s. He was hospitalized for a collapsed lung. I can gladly say that he tells me he's clean and he seems to be doing much better now, but he had medical costs that he would not have had otherwise. Another nephew, again, who had experienced trauma as a child, overdosed on medication when he was in college, and he needed medical care for the overdose. He also needed mental health care. And I can't say that the outcome in the long term was as good for him, he's now dead from suicide. So we can't cure everyone, but we certainly can do a lot to support many people. That I could keep going in my family very far, alcohol, tobacco use, I can see it, and I think you could see it in your own families, how it affects people's health. So what do we need to do? What are the critical investments? I think we've done some really good things. I think that the care coordination integration initiatives are good. One care has done a number of pilots with us, the Blueprint and SASH, FQHCs are doing lots of good care coordination. We're also looking at clinical community clinics for behavioral health care. They're a national model that would increase integration. These are really great, but I have to go back to that promise. Because we broke that promise, we've never put the resources into the community-based system at the level it's needed. All of these initiatives can only have limited value. You can't coordinate or integrate services that don't exist or with staff that aren't there. We have hundreds of people waiting for our outpatient services, waiting for six to nine months sometimes. Child psychiatry, very long waits. We need more resources for them. What if we had intensive outpatient treatment in every region of the state? Wouldn't that be a nicer alternative than inpatient care? And it's not gonna work for everyone, but for some people, if they could go to intensive outpatient, they might not need inpatient care. What are some alternatives to emergency departments? We've got some models. What if we had those models throughout the state? What if we had enough resources in our crisis system that we could do face-to-face in people's home when they were in crisis? Right now, that's our goal, but I can't say we can do that. We're not fully staffed enough to do that. We're not resourced enough to do that. So we need those resources. We need to invest in those resources, but we also need to invest in our workforce. The compensation levels are just terrible. It's not just that we're 20,000 below DCF workers and other healthcare employers that employ the same staff. It's that the levels of funding for staff, the compensation expectations are so low. So if you graduate with a Bathurst degree in nursing, you'll earn 60,000, 70,000 easily. I'm probably higher at this point, but if you could earn a master's degree with more debt and you go into social work, mental health, substance use disorders, you'll earn 40 to 50,000 when you get out. So why would you have more debt and earn less and never really have the potential to earn more? Our staff with master's degree doing clinical work are really struggling to make ends meet and that's not okay. So we need to look at those two things. What are the resources we want? What does it take to develop the workforce? What are the investments we're making? We're not making much of an investment in our workforce development, let alone the compensation levels. And two, then what do we need to sustain it over time? Sometimes we get increases, but they're never sustained. There's no rate setting system. There's no structure that ensures that we're gonna make these investments over time. And those things are the things I think we really need to most focus on. I shared some questions and I know some of them you're already looking at. What, how much inpatient do we need? But I don't think we can look at that question of how much inpatient psychiatric care we need if we don't look at how much community care do we need and what would it take to have the right balance of community-based mental health and inpatient mental health? What is the balance? How do you determine it? Who makes that decision? And I think it goes to all the community-based services and primary care about developing that balance and the level of investment. So I think those are big questions and I wish you luck in your part, in looking through them and glad to have this opportunity to speak with you today. Thank you. So let me jump in again and introduce Sarah Landerville from VCIL. She's also the president of the Vermont Association for Disability Rights. I know we're running out of time. I know Sarah has a lot to say. I'm just gonna ask her to try to condense it so that we can stay under the time frame. Sarah. Thank you. Can you hear me okay? Yes. Yes, thank you. So thank you.  I've spent time in the hospital system, grew poems and have chronic conditions and have had cancer. So I speak from personal experience as well. I'm coming from VCIL, we're a statewide organization and our board and staff are made up of people with disabilities and we support people with disabilities in the community. Our healthcare system from funding to care is biased against people with disabilities. It starts with the fact that our funding system depends on able-bodied young people to be in the system so we can reduce costs all the way to the inaccessibility of programs and services. One peer who was quadriplegic shared an experience years ago when they accidentally spilled a pot of chili on his lap and was brought to the hospital. The hospital decided that he wasn't in need of care as quickly as others because as they described it to him he couldn't feel his legs anyway. As a result, his burns were more severe as he waited for medical care. We see this bias play out when the types of equipment that's ordered in medical settings. We know that there's not many wheelchair accessible scales, mammogram machines, dental chairs, or eye examination spaces. In addition to physical access, we see policies enacted that provide discrimination and inequality for people with disabilities. When the pandemic hit hospitals were quick to enact safety rules of no visitors. This very subtle change made it so people with disabilities needed a support person had to ask for a formal reasonable accommodation so the policy just to access that care. Thankfully, through some advocacy through the Vermont Developmental Disabilities Council those policies started changing. At the same time, VCL worked on physical access issues because rules were changing on how someone could enter the building and we had to explain that those weren't always the easiest routes for people with disabilities. We hear from disabled Vermonters all the time about experiences they have and we know when someone doesn't have access to services that can lead to more severe illness, longer term issues, and additional costs. Some examples, plain language is just not used in healthcare settings, making it difficult to impossible for people with intellectual disabilities to make informed decisions about their own health. There are providers, we used to run the Vermont Interpreter Referral Service and we were told outright by providers that they were just not gonna provide American Sign Language interpreters. We heard that from dental offices, doctor's offices, and mental health providers. Some paperwork to sign is not provided in accessible formats for people who are blind, including information on rights and confidentiality. And there are providers who are located in physically non-accessible locations that have stairs to get in or bathrooms that are not accessible. One peer we heard was denied service of their service animal while visiting a psychiatric unit because the nurses thought she was lying about her dog providing her comfort in stressful and anxiety situations. Another individual shared that he had found the right titration of medication for diabetes management, but the insurance company denied coverage of that particular insulin that they were using. And now their A1C has gone back up. They were told by their doctor that the doctor can now fight to try to get back on that original insulin that was working because their A1C has increased. Another individual was refused care at urgent care because of biases around opioid addictions and this person has chronic conditions. Another person shared that when they went to get their wheelchair needed repairs, they had to take it back to the place that they bought it from and that medical store had it for three months and there was no loaner given to that person. I can go on and on and I will send you all the other examples I have. But I'm gonna flip to you in the past year I began serving on a newly formed Vermont Health Equity Advisory Commission. And in our work we're looking at the broader implications of health equity including training and data. The charge of the commission is to promote health equity and eradicate health disparities among Vermonters including particularly those who are black, indigenous and persons of colors, individuals who are LGBTQ and individuals with disabilities. The commission amplifies the voice of impacted communities, decisions made by the state that impact health equity whether in the provision of healthcare service or as a result of the social determinants of health. This is really important because as we look at existing data points we know that much of the evaluation and survey comes from a bias system rooted in racism, homophobia and ableism. And often data collects leaves out sets of people sometimes kids under the age of five or people living in institutions like prisons, nursing homes and psychiatric facilities. These institutions have higher levels of individuals with disabilities there and they're just left out of that data. The Vermont Department of Health took some time to work with the disability community and in 2018 published a comprehensive report the health of Vermonters with Disabilities which I'll send in my testimony to you. There is a lot of highlights but one I wanna just say is that adults with disabilities are two times as likely to have experienced sexual violence or intimate partner violence. And that number is higher with adults who have cognitive disabilities at 18% experiencing sexual violence and 43% experience intimate partner violence. I wanna focus a bit more on that point because someone that then goes to seek medical help for that the lived experience we hear from people is that they're not believed by professionals they have exams that are not physically accessible and people are not explaining in plain language and providing services that are not re-traumatizing. So our hope as we move towards a new global commitment way that there's a strong investment in the community and that there's a transparent process that allows individuals to have the same time to share their personal experiences. We hear from disabled individuals the need for services in their own communities. We hear from people with lived psychiatric disability experience, the frustration of the focus on building more hospital beds and not the same level of energy and money into the community and peer supports that would be less expensive and have stronger results. We hear from parents of children who have the highest medical needs and the need for high tech nursing that we know that these workers do some of the hardest work, nursing work and it continues to be paid poorly and that extends to personal attendance services, support workers, all supporters needing more of that funding. Medicaid is a safety net and needs to fully support individuals. The savings for Medicaid always needs to be reinvested in individuals. And we continue to hear anger of people found eligible for social security, disability insurance, but then have to wait two years before receiving their Medicare coverage. We also hear from peers who buy supplemental packages but when it comes down to it they're not actually covered in the industry profits and disabled individuals continue to not get their needs met. And I'm gonna, I'll share with you, there's a report that was released this April showing that many people were denied coverage that should have been covered and that was done by the US Department of Health and Human Services. That is a system that's built to save money and meet the needs of individuals. And I think some people believe that when you acquire a disability someone just shows up, makes your home accessible, you get all the medical equipment you need. And we need to have a shared understanding that people with disabilities are struggling and suffering not because of their medical conditions but because the systems that we have set up. I really appreciate your time today. It's important to note that people with disabilities are trying to live and thrive in our state. In addition to the barriers within healthcare system we also deal with day-to-day discrimination of other systems also rooted in a place that keeps disabled people from living our full potential. Systems of benefits, discrimination and employment not accessing our communities. It's a heavy lift for our community and we are often exhausted. The good news is that I think that this can start to shift now and you have the power to help make that change that can impact the lives of disabled Vermonters. When I send my testimony I've included a list of organizations that can help and I'm hoping that you can reach out and maybe have a panel of people with disabilities sharing these lived experiences with you to take a deeper dive into the issue. Thanks so much. You're on mute, Patrick. I just want to say that we have summary that you've heard a lot of criticism today of our healthcare system which I think is all warranted. Hopefully very little of it is new to you. I also am an optimist. I do believe we can address these issues but we have to change the way we approach our healthcare reform or we'll never solve all these other issues and we'll stay locked in a very frustrating system. With that, I turn it back over to you, Mr. Chairman. Thank you, Patrick. Before I go to public comment, does any board member have any questions for the panel or any comments? I don't have any questions. I do have just an observation and a comment. The arena of healthcare and Vermont's economy, I think people say it's around 20% of the Vermont economy and the Green Mountain Care Board has some influence, not total influence, but some influence over maybe 50% of that, mostly aligned with rate review and hospital budgets. And so I'm thinking as, and there is some new stuff here that it's good to have this kind of engagement but I was thinking if we're in a whiteboard session, kind of whiteboarding all of the ideas and demands and criticisms and aspirational opportunities, it would be many, many whiteboards full. And so for me, it's just trying to sort through what is the critical path? I mean, when the pandemic hit, the board actually spent time putting ourselves aside, getting ourselves out of the way of the providers and the frontline folks that had to address the pandemic more directly. So we've lost a couple of years, two or three years of time in terms of making progress towards the goals of reform. But now we should be getting ourselves back on track. And for me, some of the things that I think are significant are the cost shift, whether it's the cost shift or the monopolization of providers. Some folks say, yes, there's a cost shift and I think that there is and it's documented but others will say no. It's a predatory pricing issue having to do with certain providers. The transition to a fixed perspective payments kind of global budgeting. If you look at the commercial side of that relative to hospitals, only 2% of the payments to hospitals by the commercial carriers are in some kind of a capitated form. And so I don't think we're ever going to achieve the kind of efficiencies and savings in the healthcare system that we can move to some of the aspirational issues that we've heard today if we don't make significant progress with the commercial payers and fixed perspective payments. Obviously, workforce is a major issue. It's an issue that Kevin has been chasing well before the pandemic. And I think is feeling that progress is being made. So for me, the issue is trying to sort through what are the critical paths toward healthcare reform now that we have the pandemic sort of behind us and we don't live in a world with inexhaustible resources and we're going to have to make some decisions as to where to invest our energies. And for me, part of that is investing those energies in making our existing system the parts of it that we support making them more efficient. Cost shift to me is basically a backdoor. And as a former finance commissioner, I can maybe I'm a little guilty here in my past life, but the cost shift is as we get efficiencies that the cost shift is a way for money to be kind of siphoned through a backdoor out of the healthcare system. And I can say looking at recent documents that in 2021 Medicaid ran a surplus in 2022, they are projecting a surplus. And for 2023, the legislature's house incentive votes on the Medicare budget are lower than what they were in 2022. So, I look at that with my former hat on and say, well, where did that money go? Why couldn't it be used to increase reimbursement rates? I'd also just finally like to talk about price variation. We've put out a very good study called price reimbursement variation. It looked at 60 procedures across the system and found wide differentials in pricing. I'll give you one example for obstetrical ultrasound of fetus, the maitre healthcare for women got paid for that procedure, $184. UVM Medical Center got paid $437. Central Vermont Medical Center got paid $750 and Porter got $405. I think that's a pattern that you can see if you look in this report, it's obviously across 60 procedures, it's not extensive, but there are inequities and inefficiencies in the existing system. And we need to be disciplined about pursuing those in order that the money that we do have in our healthcare system is used as best as it can be. Thank you, Mr. Chair. Bill, did you wanna respond? I saw your hand was up. Yeah, I would just very briefly say, Tom, I hate to say this, but it goes so much deeper than that. I mean, we really, really need to rethink the principles and the design of this system. We need to move the investments. If we keep tinkering around the edges, the way we've been doing for decades, I mean, since I was chair, we are tinkering around the edges and frankly, we're adding more cost rather than taking costs out. This system needs to be rethought. We don't need to wreck it, we don't need to take a wrecking ball to it, but we need to really reimagine it with the stakeholders present. I just, I'm watching the legislature, the, you know, I'm watching all this incremental, oh, we'll fix this, we'll fix that, we'll fix this. We are adding complexity to a vastly complex system and we're adding cost. Thank you. Thanks, Bill. Other board members with comments or questions before I turn it over to the public? Chair, no, go ahead, Jess, please go ahead. I was just gonna say, you know, I agree with many of you that have expressed concerns about our system being in crisis.  We've heard a lot about over the last few months, particularly for mental health, really sympathetic to some of the stories that we heard today and that I've been hearing for months about access to the mental health care system. And obviously, you know, there's no limited discussion there of healthcare costs and how their skyrocketing and healthcare is becoming less and less affordable. You know, I've been testifying to these issues in the legislature for the last few months. I agree, we need to explore new payment models. I agree, we need to reimagine our delivery system. And our hope is to engage with stakeholders and communities on both of these issues in the near future if funding is made available to us through the legislature to do some of that work. And as I think about what those community conversations should look like, we have to build a shared understanding of the current state, which many of you have outlined today. We need to really go to our communities and talk about the system, talk about the costs, the financial health of their local hospital, community services, access, you know, what does access to essential services look like in each of our communities? We need to build a shared understanding of the future state. What are the trends that are coming our way? What are the headwinds and what does that look like? And how do we best prepare for those headwinds? And we do need to think about creating opportunities, reimagining the system so that we do have better access to low-cost, high-quality care. And what does that reimagination look like? What are innovative solutions that other states, other healthcare systems have found? How do we bring those potential solutions to communities to engage them with the possibilities? So I guess when I think about those components, I would ask, and I know we don't have time today, but as a follow-up, I would love to hear your ideas on what meaningful engagement with communities would look like. How do we ensure that that process is successful? Who needs to be at the table and how do we start engaging these conversations? Because some of the data that we might bring to communities might be, you know, a tough data to see and digest. And so how do we do that? And I just offer it up as a question as we think about designing that process. I would love to hear from all of you who have thought about this quite a bit. So thank you. Okay, Tom. Thank you, Chair. And I'd also like to thank everyone for joining us today and all the thinking that you've put into coming and presenting to us today. It's very helpful. I think there's a thread that goes through the conversations that we've had so far and listened to. And I'd like to share what I see is that thread and then open that up for anybody to reply to. First, I think in an environment of scarcity, whether it's perceived or real, empathy and compassion go down. People are afraid things are gonna change and they're gonna lose out in the change. And so we see situations like Sarah, the stories that she told us and Julie's nephews. We see those things over and over and over again in our system because people are afraid. We know there needs to be a change. We're not sure how the change is gonna go and we're afraid that we are going to lose wherever we're sitting. And most of the presenters today have talked about improving access and funding for community-based care. And I think that that goes back to, we saw Patrick with the need for better mental healthcare in communities. We heard Deb talk about the nursing issues and the difficulties that nurses have with their role and their current role in reimbursement. Mark and the independent practitioners, and I'm sorry, Rick and the independent practitioners. Mark and the union situation. Mark talked about Montana and I wanna learn more about Montana. I want to hear more about that from him and I like our staff to look into that because he talked about changes in the state where more resources were put outside of hospitals, community-based resources. And that brings me all the way back to Bill in the beginning, he talked about the business model, the current business model in healthcare and particularly in hospitals is the care of people who are sick. And if we attempt to go upstream as Bill talked about and invest in resources that are upstream, that money comes out of resources that are currently going to hospitals. So they are afraid. And as regulators, if we say no when they ask us for more money, they threaten us and they threaten the citizens with closing. So I'd like help managing their fear. I'd like to know what happened in Montana. I'd like to know how we can help people address that fear that if we start moving resources out of hospitals and hospitals need to change, they're afraid and they're fighting back. How do we allay that concern? How do we build trust in order to make these necessary changes? It's not that the changes are unknown. How do we make those changes? And that's, I appreciate all the thinking you've all done. I've learned a lot today and I hope to keep learning more from each of you. Okay, is there any other board member with any public comment? Not, I'm gonna open it up to the public and I'm gonna call on Betty Keller. Betty? Can you hear me? Yes. Thank you. First, I wanna thank you all for providing this opportunity for this panel to speak with you today. I've been participating with them as a member of Vermont Physicians for National Health Program. I'm also a member of the legal men voters and on their healthcare committee. And so from both perspectives, I look at these issues closely. I wanted to comment about the global hospital budgets. I know the way Vermont has defined global hospital budgets is not at all what I mean by it. And I don't know how many people in the public fully understand that. So the way we do it now, the hospitals show a budget that they expect to use, Green Mountain Care Board approves it. Then they go back and they do business as usual, fee for service. At the end of the year, they see how they came out.  In the global hospital budgets that we're talking about, the hospital figures out what the community needs and they go to and get their budget approved, they go back, they do not charge fee for service. It's publicly funded and that money that they had approved in that budget process is given to them on regular payments, whether it's quarterly or monthly, but then they have a baseline to work from and it's a sustainable model for your rural hospitals. So that's really important for the public to understand because there's these different definitions rolling around there. And so I actually have a little confusion, maybe Mark and I are not entirely on the same page on this, but the idea of referencing your fees to Medicare would only be for those people who came from out of state and we don't want to give free care to the rest of the world. So those people would have to be sent a bill to the state and the state would seek the reimbursement. And so one of the huge benefits of that process is that you don't have all that administrative cost on the hospital's part with the billing and then the collections and the long delays before they get paid back, basically giving loans to insurance companies if the insurance companies delay on paying. So the three things I wanted to say about the global hospital budgets, one is that it's really important to support the infrastructure in our communities of having that local hospital, not just the building, but the staff that you need there. The other thing is that you're directing the resources to where they're needed, instead of to what's profitable for the hospital so you can have a sustainable hospital, what's profitable based on fee for service structures. Instead, you're putting the money into the services that you actually need. And then the third thing is that reduction in administrative expense, that money instead of going to all the administrative costs would be able to be directed toward healthcare. And at least in my area, I feel like our hospital would be responsive, their board would be looking at what are the needs of the community and be relieved to not have to be thinking about which are the profitable things to help us cover for our mental health that's not profitable and that sort of thing. So those are some issues. The other thing is that one of our speakers had mentioned about having more competition by having more, for instance, free-standing surgical centers. But that's not necessarily, we've seen competition doesn't actually work in healthcare, it doesn't follow free market principles. So the other thing with hospitals is that if you were getting more community-based services and shuffling the money on different places, there might be more space in the building and you might want to use it for different things. For instance, you could have an urgent care center that people could roll in and out faster if there was a shortage of primary care and there weren't openings for a quick response to see somebody. They could be seen in the hospital building by somebody who cost less and it didn't have as much administrative hassle as going through the ER, but you would be making good, efficient use of the building that's sitting there in the infrastructure that you paid for through that global hospital budget. And one of you, I think it was Jessica Holmes asked about meaningful engagement and maybe I'm misremembering who it was. When we were working on Act 48, there was a process of going around the entire state and having meetings with the public and explaining what was going on and what we were looking for when you're putting together the benefits package, we did that. I would like to see something as robust as that, explaining what is going on in our healthcare, what transformative changes are needed. We cannot do the tweaking at the edges. It's just not gonna work. And we've been seeing that for years. And as one of our speakers had said, where is that tipping point? Like is 34 not bad enough? How bad does it have to get to say, yes, this is the crisis we will finally transform? And in addition to Montana, I would suggest that you look at the Pennsylvania rural hospitals. When I try to do a little Google search, I can't get that much information, but I've been hearing here and there that in Pennsylvania, there have been several hospitals that have been working on getting rural hospital global budgets so that they can sustain them in the countryside. But you will have more of a foot in the door to try to ask them, the public health department, what are you doing and how is that working? Then I can just find on a Google search. So thank you so much for your time and for taking public comment. Thank you. Next, I'll turn to Barbara Black. I'm Barbara Black. I am a weekly patient. I'm an advocate and have been for 20 years at the University Hospital in Burlington. I am an advisor. I sit on many different boards and I listened to Tom summarize what he heard today and I agree with it. And I agree with the fact that there is tremendous fear within the hospital administration. And how do we correct that? Right now we are hiring a CEO for the hospital and unless that person comes in or for the network rather and unless that person comes in with an open mind and a willingness to look at everything that's out there and to come up with innovative ideas on their own, nothing is gonna change. Thank you. Thank you. Next, I'll turn to Mike Deltraco. Can you see me and hear me, Chair Mullen? I can definitely hear you. I do not see you, Mike, but I do hear you. Okay, well, I can see myself. So anyway, where to start? I'll start by saying thanks for the opportunity to comment. There clearly were several compelling items discussed this morning and I think they all illustrate and point to the fact that every part at all levels of our delivery system are stressed. Just to clarify, I agree with many of the comments. Vermont's not proper hospitals are not without their challenges. They work to collaborate every day, most notably leading the way in the pandemic response. They share physicians, they manage resources and they make investments that go well beyond what might be considered hospital related activities. One example is housing. We do consider these important part of reform and efforts towards value-based care. Clearly we have many shared issues such as workforce, mental health and financing challenges that unfortunately affect all patient care activities. This is our goal, this is our shared discussion here today. I think we need to work on this together. We can't have a divided conversation on what the goals are and how to meet the goals. Really, we need to focus on providing equitable and affordable care. We need, most importantly, we need a shared understanding of what this means and how to measure it. I look at this effort and I can see that Vermonters have benefited from some of the expense reductions and revenue growth from hospitals since the inception of the Green Mountain Care Board. Clearly that's not understood broadly, but it has happened. So I think my point here is we need to measure and share how we're measuring and move forward here. So just in closing, thanks for the opportunity to comment. And there's a lot of work to do ahead of us and this should be the start of a conversation, again, that's not divided, but sort of unified with the goal of patient care. Thank you, Mike. Next, I'll turn to Susan Aronoff. Susan, are you there? Susan, are you there? Susan, we're not, at least I'm not hearing you. Is anybody hearing her? Okay, Susan, you may wanna try to call back in. I'll ask, is there other public comment at this time? Is there any other public comment at this time? And while we're waiting to see if Susan calls back in, I just wanna thank the panel this morning. As expected, we are over time and bored to relax. I will give you a five minute bio break before we go into deliberations. So I think that for the board's information, as we give a couple of minutes here to Susan, that we will begin our conversations on the large group deliberation to 1115. So if you could mark that down, I do not see Susan back on the screen or with a hand up.  And who's that? This is Betty Keller again. I was waiting to see if others had something to share before I raised my hand because I forgot one other point. Very quickly, the word stakeholders frequently invoked. And I would just like to point out that we should really focus on essential stakeholders. And by that, I mean that when we're looking at how to transform, we should see what's really, who are the real stakeholders? And in other countries that don't have insurance companies like ours, they wouldn't be at the table. I think that we need to pull them into the table to have the conversation after we see what would be the useful role for them. But that when we're first just looking at what do we need to do that's new and different, transformative, we should have the essential stakeholders at the table and not have others that have different sets of priorities. Thank you. Thank you. Susan Aronoff, can you communicate now? Oh, don't we love technology? Thank you, Mr. Chair. Thanks for holding the floor open for me. The one point I really wanna make, well, I did start out when I was muted by really thanking you, Mr. Chair, and I'm sorry to hear you're leaving us. I think you've done a tremendous job. I think that this panel today is so refreshing and the attendance is so encouraging. And the quality of the presentations were fantastic. The end note I wanted to leave everyone with was a point that Bill Schubert made at the beginning that I'm afraid might have been overlooked. And this is this a little question of the role, the proper role of the Green Mountain Care Board. And Mr. Chair, you began your tenure with this very question before Elkhart. Are you regulator? Are you reformers? Are you regulators? Are you promoter? You guys had assigned the contract of the all pair model committing to making it work and to do so, you kept moving the goalposts. You can't do that and be a regulator, not of a monopoly. So I hope the Green Mountain Care Board really takes to heart this conflict of roles that Mr. Schubert so wonderfully pointed out and that some of us including Elkhart have been pointing out for, I don't know, six years. You might recall that Elkhart had a colloquy with you, Mr. Chair, and sent a letter to the committees of jurisdiction which have been so devoted to supporting you and the all pair model. I think that they've just, I know, they've just never taken up that issue and never taken it seriously. And I think it's been really unfair to you and all the board members, this double role you have to fulfill of keeping this reform effort alive and going and revising one carers budget so they can make it and dealing with the letters of correction and then trying to be an honest regulator and have the faith of people like me and the rest of the stakeholders and advocates in the state. And I really hope you can, your successor and the remaining board members can really try to grapple with this. Choose a path, be the regulators, be the reformers. You can't be both. Thanks. Thank you, Susan. I don't see any other hands raised. So at this point I'm going to recess this meeting and the meeting itself will reconvene at one o'clock but board members, we have a deliberation and we'll start at 1115. Thank you everyone and have a great day. Thank you. Thank you.