Vermont Legislature SmartTranscripts:

[Robin Scheu (Chair)]: Unless Dave has that. Now we're live. Should have a We're live. This is the House Appropriations Committee. It's Thursday, 02/05/2026. It's just after 10:30, and we have the picture of we're still trying to figure it out. It's been confirmed, it's Autumn, please share. It

[Unidentified Committee Member]: is animals come from through how to fix it to this. Yeah, but it was a nice puzzle.

[Robin Scheu (Chair)]: We've been having this puzzle on

[Martha Feltus (Vice Chair)]: the space. Sure.

[Robin Scheu (Chair)]: Saying, gee, is that New York State of Cross Lake? And

[Martha Feltus (Vice Chair)]: really, can you see camel's hump this way? And anyway, the things that we have to do with. Welcome, Big. It's great to see you. We have the Human Rights Commission information

[Robin Scheu (Chair)]: in front of us. So introduce yourself and take it on, please.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Thank you so much. For the record, my name is Big Hartman. I use theythem pronouns. I'm the executive director and general counsel at the State of Vermont Human Rights Commission. Thank you so much for having me in today. We're here today to talk about our fiscal year 'twenty seven budget request. I do have I also kind of shared extra documents with you electronically, and I have hard copies if anybody would like our annual report. I have a two page summary of our case data and updates from fiscal year 'twenty five. And then I have a midyear summary for the '6 just for comparison purposes. Would it be helpful if I pass them around? You can take them if you want them. If Yeah, you don't, I'll

[Robin Scheu (Chair)]: sounds great. Thank you.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: There's the fiscal year 'twenty five data. And then here's a two pager with the fiscal year 'twenty six first half.

[Robin Scheu (Chair)]: And I see that Autumn has posted them. So

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: the mission of the Vermont Human Rights Commission is to advance full civil and human rights in Vermont. We are an independent commission of state employees. As you may recall, last year, we were allocated two additional positions, bringing us up to a total of nine full time exempt state employees. So I'll probably jump around a little bit in the slide deck here. So we have three, I guess, four primary programs. One is enforcement of our anti discrimination protections. Primarily, we are the sole enforcement authority for the Vermont Fair Housing and Public Accommodations Act that protects people from discrimination in housing and places of public accommodation. We also have jurisdiction in the area of state employee discrimination complaints. And we also are actively involved per our statute in attempting conciliation or settlement of any discrimination complaints that are filed with our office. And we are tasked with educating the public about our anti discrimination protections and advancing proactive public policy on civil rights. On the right hand side of this slide, you can see the list of our current employees.

[Robin Scheu (Chair)]: Yes.

[Wayne Laroche (Member)]: Can you just give us an explanation of what the five commissioners do with their roles?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Absolutely. Yes, we have five commissioners who are appointed by the governor to serve five year terms. They meet roughly once a month. Sometimes we skip a month. But generally, they meet about 12 times per year. And at those hearings, at those meetings, they primarily are tasked with reviewing our staff's investigative reports that were completed in the month prior. And they conduct informal hearings in executive session where the parties to each case that got completed that month are invited to say why they agree or disagree with the recommendations in our investigative report and answer any questions that the commissioners have. At the end of each hearing, the commissioners vote in the public session about whether or not they find reasonable grounds to believe that discrimination occurred. If they find no reasonable grounds to believe that discrimination occurred, that's basically the end of our involvement with the case. But if they find reasonable grounds, then the case remains with our office. We are then tasked with attempting conciliation again. And if we're unsuccessful at settling the matter, we have the authority to file an enforcement action in court where the Human Rights Commission is the plaintiff against whoever we believed engaged in discrimination.

[Wayne Laroche (Member)]: Not quite constitutional, but above advisory?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: I believe we would properly be characterized as advisory. Even the Supreme Court has said in the last couple of years that we are not engaged in quasi judicial functions. That would be more like something like the labor board, where they're actually taking evidence and taking testimony, whereas our commissioners do not do that. It's really an administrative process designed to ensure that our civil rights laws are enforced and that complaints are investigated, hopefully avoiding litigation in those cases.

[Robin Scheu (Chair)]: Yeah, have you ever had a case where they have voted no, yes, and then your group has not followed through on the recommendation? Like they said yes was discrimination, then you chose based on facts or whatever you felt was the issue here.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Not the court. Absolutely. That has happened historically more than it's happening now. We did not have a full time litigator position for the first thirty five years of the commission. It was solely the task of the executive director to make those decisions and bring cases to trial. So we just didn't have the resources to take all cases to court. Now we do have a higher rate of litigation. But even in the last couple of years, there have been instances where we have declined to file a lawsuit in court. It's discretionary. So we make that decision based on resources, the merits of the claim, other factors involving parties. But also, the complainant in those cases gets a full copy of our investigative report and all of the evidence collected by the investigator. So it's a good tool for them to go and hopefully find their own attorney if the HRC isn't going to be pursuing it ourselves. And sometimes, if folks do have an attorney and they've already filed in court, we'll make the decision not to move forward with our own litigation because we feel like the matter is being

[Martha Feltus (Vice Chair)]: addressed properly. That

[John Kascenska (Member)]: was a question I had, actually. They may say something's happened, but things could get settled as a result of that.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Yes. But as we sit here today, we have approximately 18 cases that are filed in court right now. And our senior counsel, which is the litigator position that was just created in fiscal year 'twenty three, oversees and is the lead attorney on all of those cases.

[John Kascenska (Member)]: 16.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: 15, I think, of today.

[John Kascenska (Member)]: Thank you.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: A couple more on the way, a couple more in the midst of settlement. Which is kind of the way it is all the time. As you may recall, last year, we were appropriated additional funds for a full time intake coordinator position. That position, I was able to hire someone who had previously worked at our office and was able to literally hit the ground running on day one. It was amazing. And I handed him, like, 100 open inquiry files on his first day.

[Martha Feltus (Vice Chair)]: Woah. Welcome. He came back on the second day. Yes. That's great. Wayne, what if it's major, the

[Wayne Laroche (Member)]: cases? Say you have 15 cases in one court. What's the nature of those? Workplace, what's the process? Just general.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Most of them are fair housing. They're fair housing complaints, either involving primarily either folks with disabilities who believe that they were wrongfully denied a reasonable accommodation request. And then we have a sexual harassment in housing case. We have some cases based on racial discrimination in housing. Then our other cases, have no, we have two cases that involve state employees having discrimination complaints. And the rest are public accommodations. These range from service dog cases, a retail shop that denies someone access because they have a service dog, as well as school cases, students who have been discriminated against in public school. Both housing, in litigation, yes. And litigation does I mean, fair housing does tend to be more than half of our overall cases at a given time. So this is a slide that just summarizes our three types of jurisdiction. I'm not gonna go too far in the weeds here, having respect for the time that we have allotted today. And here's an overview of our HRC process. Intake is where we now are grateful to have a full time employee, although that employee is absolutely struggling with the backlog of intakes. As I told you before, we don't accept every complaint that Vermonters would like us to investigate. Just don't have the capacity. And I think in my midyear summary, as of the December, I had declined around 40 cases for investigation in the first half of the year. I've declined probably about half that since the '6. And I think I've already outlined our investigation process that leads to a commission meeting and then our options after a determination of reasonable grounds. I did do a quick slide for you about our stats for fiscal year 'twenty five. We are continuing to accept more complaints each year that I've been director. This is my third, coming into my third year of being a director, and we've continued to increase the number of new complaints as well as increase the number of closed investigations. And we are very proud of that. And that is the result of our staff working very, very hard. We've also significantly reduced the average age of our cases at closure. When I was first talking with this committee in fiscal year 'twenty three, we had an average of six forty nine days for the age of an investigation. That's almost two years. Now we've gotten that number down to about one year. But it's still a very long time for many people to wait to find out whether or not their claim is valid or whether they were wrongfully accused of discrimination.

[Thomas Stevens (Member)]: Last year, last two years, you've actually asked for more staff. You were able to find two positions last year as at the compromise. You've had an increase but have does the increase in complaints or what you're taking on a result of more cases coming forward or more cases that you're accepting because you're squeezing viral capacity that you have that you're already overcapacity staff. I mean, elements of discrimination growing noticeably for your portfolio? I know that legal aid lost federal money and you're carrying those more directly than before. So all of which does that add up to you need more staff?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Yes, we are continuing to see a need for increase in staff. Last year, I was asking committees to approve us getting eight new positions, and we got the two, which we desperately needed. We also got another so I talked about the intake coordinator. We also got a fourth staff attorney investigator. Again, I hired someone who had worked with us before as an intern. I hired her as a full time attorney. Right after she took the bar, she immediately received a full caseload of cases that no one had worked on for many months because they were in this pending status with no investigator assigned to them. The more investigators we have, the more cases we can accept. Everybody has a full caseload as of today. I'm reluctant to take on new cases when my staff feel they are at their capacity. And we don't want to see case age increase. We talked about getting to three sixty six days for our average. We don't want to have that go back up because we've accepted too many cases. So we are requesting an additional staff attorney investigator as part of the fiscal year 'twenty seven budget to enable us to continue to take more cases and address the gaps we are seeing now, both with the deprioritization of civil rights enforcement by the federal government and the lack of funding to organizations like CBOEO and Vermont Legal Aid, who would often do a lot of initial intake and referral to us so that our staff wouldn't have to be doing as much of that initial intake. Legal aid would commonly send us a draft complaint of someone they had done an intake with. We are not seeing that anymore. Instead, I think folks are calling us cold. And we're also not getting referrals from HUD. Not sure what they're doing these days, but it doesn't seem like they're answering the phone. So folks are just having to come directly to us, which is just an increase in how long folks are waiting for an intake decision from us. And I'm still making that decision on a regular basis to decline more cases than we accept based on resources.

[Thomas Stevens (Member)]: And so, Scott, I just want to point out we took testimony from legal aid how they lost money that was COVID error related money that was the bulk of the funds that would be working in tandem with the Human Rights Commission. We want to make that clear that the federal program ending and not continuing then comes back and affects us this way by putting this commission under more duress. Right.

[Martha Feltus (Vice Chair)]: Well, in addition to the 189,000 that HUD owes you and is going to pay for work already done that they approved. Yes. But

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Vermont Legal Aid also has not received their funding from HUD. And that would also supplement some of their fair housing intake and referral work. But just to be clear, Vermont Legal Aid would represent complainants who have cases with us. It would not they do advocacy on behalf of complainants, and that is not what we do. We do neutral investigations of those complaints. Most complainants in our cases do not have counsel. They do not have attorneys representing them. And it makes it very difficult to settle a case with somebody who can't get legal advice. We can't give them that legal advice. And it's also it's just a lot more labor and burden for those complainants to have a case with us when they aren't represented, while most of the respondents, landlords and businesses are represented by counsel. So there's definitely an imbalance in power that's resulting when there's no availability of legal aid to represent complainants in our cases. And then Liz, and then Dave, and then Marty. So

[John Kascenska (Member)]: good job. You've clearly reduced going two years to

[Robin Scheu (Chair)]: one year. What do you want to get in terms of closing cases here? Would like to see-

[John Kascenska (Member)]: Realizing, you're dealing with the court system here too, so that just keeps delaying things.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: We aren't dealing with the court system. These are the age of cases is through our administrative

[Robin Scheu (Chair)]: Just overall.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Our goal would be to finish cases within six to twelve months, so that our average is lower than a year. When our average is a year, especially our public accommodations cases, our school cases, and our employment cases are the cases that are much longer than a year on average to close. Our rules envision that we will be closing out cases within six to twelve months. And we are generally not able to achieve that goalpost. HUD has always required or expected a certain percentage of cases to be closed in 100. That almost never happens. That's just not realistic.

[John Kascenska (Member)]: I'm that figure at some

[Robin Scheu (Chair)]: point last year. Lynn and then Dave and then Martha. You have very good statistics. You've made great progress. Thank you. You're trying to get more efficient. What do contribute that success to with or without those extra positions you did not get? I mean, you've got two. Sure, they were a help, but what else do you attribute that to?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: We did streamline some of our processes since I became director. We took on a case management system that we had never had before that is making life easier, especially on the intake and investigative file side of things. But also, we simplified our investigative reports so that they were easier for investigators to write so that we could really be able to make sure that each investigator realistically can close one or two cases per month. That's the goalpost that has not been able to be done when I started as an investigator in 2021. It was very hard to complete an investigative report of a complicated case. And even after your investigation was done, it would take a couple months to write it. We were just writing a lot more in those reports. So we haven't cut short or cut corners with how we're doing our investigations, but we have simplified the reports that we're writing to conclude those cases based on my feedback from what other agencies like ours and other states were doing. When I shared with them some examples of our investigative reports, they were like, How are you guys getting anything done? And so we have simplified that process, that investigative report writing. And I think that that does help a lot. This year, we were also a little bit more stable with our staff. We had turnover. When staff are constantly getting new cases and feeling backlogged all the time and under that kind of stress, you're going to have more turnover. So we're hoping that we will be stabilized with our team that we have right now for the next couple of years, which would also lead us to having being able to close more cases. When one person at our office leads, a lot of work comes to a screeching halt. And it's a lot to onboard somebody new and teach them everything there is to know about the role.

[Robin Scheu (Chair)]: So using a template or a lean process reduced your turnover, probably?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Most likely. I I am now the most senior employee there, and I've been there four and a half years. We just hopefully are going to be stable where we are now.

[Unidentified Committee Member]: Good luck with it. Doing the best I can.

[Robin Scheu (Chair)]: You're working smarter instead of harder.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: We're trying to. We are feeling like we have to work harder right now. Know, civil rights are under threat. The federal government is no longer a partner with us in doing civil rights enforcement. And there's more need than ever. So we are absolutely working harder.

[Martha Feltus (Vice Chair)]: Okay, I'm mindful of time. We've got Dave I'll and Marty, and

[David Yacovone (Member)]: be very quick, thank you. How big is your backlog?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Right now, as of today, all of the cases that we have accepted have been assigned to investigators. And I would say our oldest case is under two years old right now. So it's a significant improvement. When I first came as an investigator in 2021, I was handed cases that were three years old. I don't I would just say we have large caseloads for each of our investigators. And the backlog is really on the intake side of things, that we have a lot of folks waiting for an intake process and waiting for a decision about whether we will accept their case for investigation or not.

[David Yacovone (Member)]: Okay. Is it in your annual report in terms of the number of people over a year? I'm trying to get a sense, if all the backlog was gone mysteriously, could you, would your current staff maintain the annual flow that comes in?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: I think I would still be having to make decisions every week to decline cases because of resources.

[David Yacovone (Member)]: Okay, when you decline them, there are some you say, yeah, this is likely something bad happened, but I can't chase it?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: No, we say we are not able to accept your complaint based on our current criteria for acceptance. And that doesn't impact your right to file a lawsuit independently, which

[Martha Feltus (Vice Chair)]: we

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: know is very unlikely to happen. Thank you.

[Unidentified Committee Member]: Just a clarification on slide, you have 62 new complaints compared to 59, which is an increase, but not a lot. Are those complaints that you have decided to work on or complaints coming in

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: the door? No, those are complaints accepted for investigation, assigned an investigator, and are actively being worked on. Yep. And you can see 62 new complaints, 53 completed investigations. Every year, we accept more than we close. And so it keeps kind of building up.

[Wayne Laroche (Member)]: Get a standard triage system for intake, so that means which ones you want to take and how much time, the standardized kind of criteria.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Yeah, we've been able to refine that a bit this year with the addition of a new intake coordinator. Last year, I was doing more than half of the intakes myself. I was conducting the investigative meetings. I mean, the intake meetings. And now we are streamlining and refining that with a full time intake coordinator. But more folks are contacting us every day. So we never get ahead. We are always behind and always feel we wish we could get back to people sooner. It's often a couple weeks before we can really take a look at a new what we call an inquiry. But we are continuing to explore how we can improve our process and serve more folks.

[Martha Feltus (Vice Chair)]: Your budget looks standard. We saw it

[Robin Scheu (Chair)]: I don't know that we need

[Martha Feltus (Vice Chair)]: to go through the ups and downs specifically. I know that you already moved something up into personnel and salaries, the new intake person. So that was kind

[Robin Scheu (Chair)]: of the big change. Right.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Yeah, the ups and downs, when we have a new position created, they

[Robin Scheu (Chair)]: put

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: it in the other personal services line. So then they spread it out over the top upper line items the following year. So that's why it kind of looks like we have a big increase in our salaries, but we don't. It's just coming out of the other personal services.

[Martha Feltus (Vice Chair)]: We know that's how they do it. I'm wondering where you You said you would like to get another person. Is there something in writing here that says what?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Yep, the second page of my memo, But just on the ups and downs, I do want to point out that we are, there is an up in our vacancy turnover savings that the governor is recommending. Last year, we were struggling to deal with a $25,000 vacancy turnover savings. We tried to make up that in the Budget Adjustment Act. It came in so late. We had to realize that savings. And the way we were able to do that is we held the director of policy education and outreach position vacant for about five months. And I did those two jobs for the second half of the legislative session. So this year, in order to meet the governor's target, we are being asked to increase a budgeted vacancy turnover savings to about $65,000 total. There is not a reality in which I can achieve that vacancy turnover savings unless somebody voluntarily leaves and I again choose to not fill that position for many, many months. That is going to be a screeching halt in some very important work that is currently done by an employee. We do not feel that it is wise or realistic to predict that we will have a vacancy turnover savings of that magnitude in the next fiscal year. So on the bottom of my memo, I have proposed that that be added back into our total appropriation, as well as the funding for the three additional positions that we are proposing to be added to our staff. And I also want to point out on the ups and downs, because we aren't able to count on any federal dollars next year, the governor's recommend actually results in us receiving less in fiscal year 'twenty seven than we have received in fiscal year 'twenty six by twenty seven thousand and nine dollars And while the cost of everything goes up, it's really difficult to envision how we could serve the Vermonters that are seeking our services, accomplish our mission, meet the needs of this moment with even less money than we have this year.

[Robin Scheu (Chair)]: Last question, and then we have to finish up.

[Thomas Stevens (Member)]: Any mysterious ADS charges?

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: The ADS charges are built into the projections. That was last year, but we dealt with that.

[Thomas Stevens (Member)]: And I'll work as part of my portfolio, so I'll work with big, really taking what you've provided and reducing it to what legislators can understand.

[Robin Scheu (Chair)]: Yep. So I think you explained it clearly.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Okay, great. And I'm happy to come back in if there's more questions as you are moving forward with your overall budget. Yeah, and thank you.

[Martha Feltus (Vice Chair)]: I appreciate the offer. And Tom is the liaison too, so we can also follow-up questions. So thank you very much once again. Thank you. Committee we're going to go straight to the Greenmap Care Board.

[Robin Scheu (Chair)]: Is

[Martha Feltus (Vice Chair)]: that your joke for the morning?

[Thomas Stevens (Member)]: I don't make jokes, I make comments that might have to

[Unidentified Committee Member]: work. Oh

[Robin Scheu (Chair)]: and Emily, if you want to come to the table. They yeah just bring chairs up however many you need Well, they're getting settled except we have the

[Martha Feltus (Vice Chair)]: clean and care board with us then

[Robin Scheu (Chair)]: after that we break for lunch Goodness, short morning. We started late, and before lunch, and then at 01:00 we'll have the Defendant General's office in,

[Martha Feltus (Vice Chair)]: and then VP is in after that, and a few other things after that,

[Robin Scheu (Chair)]: but that's where we are.

[Martha Feltus (Vice Chair)]: So welcome. Thank you. You all want to introduce yourselves for the record and

[Robin Scheu (Chair)]: take it away?

[Owen Foster (Chair, Green Mountain Care Board)]: Good morning, my name is Eileen Foster, and I'm the chair of the Green Mountain Care Board.

[Emily Brown (Executive Director, Green Mountain Care Board)]: I'm Emily Brown, I'm the executive director of

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: the Grey Mountain Care Boards. I'm Jean Stetter. I'm the administrative services director of the Care Board, which means all things back office. All the numbers. That's great. Thanks.

[Martha Feltus (Vice Chair)]: So we have your presentation and are you do you need to share screen or?

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: Yeah, we can share the screen. I'm joining the

[Martha Feltus (Vice Chair)]: Do we have a question before you start? Sure.

[Thomas Stevens (Member)]: Can you just explain for us Emily and Owen just the relationship between the board and the executive director? I mean I can make an assumption based on non profit work but just I know it's different for the board and for the Green Care Board.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, good question. It is different. So the way the Green Mountain Care Board is set up, there is a chair of the board, that is myself, and then there are four other board members. Each of the board members has one vote on any regulatory matters that come before the Green Mountain Care Board, so decisions on hospital budgets or insurance rates, that's a vote of five people. The statute provides that the chair of the board, myself, has control and runs the office. So everything about our staff, everything about our financial decisions, all of that is ultimately the chair's responsibility. The chair through statute is allowed to hire an executive director. It's Ms. Brown, and the executive director, I think of as essentially the CEO of the organization. It's not really ultimately like a board as you'd normally think of it, where we go to quarterly meetings or anything like that. It's a daily job, we're there every day, but Emily is essentially the chief executive, really. Emily, you want to

[Emily Brown (Executive Director, Green Mountain Care Board)]: No, that was it. Happy to

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: answer So any more

[Thomas Stevens (Member)]: you said you're there every day. So you are Again, we just talked to about the Human Rights Commissioners, which is a different function than it sounds like what this board is. It's Thank you.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: Yeah, John?

[John Kascenska (Member)]: Too down into the weeds here, but what do you manage outside of what's going on?

[Emily Brown (Executive Director, Green Mountain Care Board)]: So we have a staff

[John Kascenska (Member)]: We know you do a lot. She does more. I know. In general,

[Robin Scheu (Chair)]: you do a lot.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Yeah, we have a staff. When we are fully staffed, we're going to be about 40 people. I manage the staff, the work, make sure that the staff are meeting the priorities of the board, our regulatory processes, making sure that those are being run effectively and efficiently in compliance with our statute. I work very closely with our general counsel. I'm also an attorney, but not practicing. So it's really a lot of the day to day, but I also help make sure that the work we're doing is in alignment with our statutory and internal mission.

[Robin Scheu (Chair)]: Okay, we have a presentation. Think we'll have additional questions about projects and successes and things like that.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: All right, so as we said, we're O and Emily and I'm Jean again, just to refresh our names. If you look at the budget factors that you're considering, we did not have a request as part of the BAA for the FY27 base budget. We met the Governor's recommendation and we have no FY27 budget requests. So that's refreshing.

[Robin Scheu (Chair)]: So

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: if you're We'll have questions. Of course. So this is part of a slide that Finance and Management has requested. Our mission, we're focused on access, affordability and quality and healthcare. And in general, the statute that governs the vast majority of the Green Mountain Board Board spending is that there is 40% general fund, which is matched by 60% bill back. What that specifically means is that we charge the insurers, hospitals, and accountable care organizations for the pleasure of being regulated by us. The additional 2.9% other special fund is we have two positions that are funded specifically by the evidence based fund, and their focus of their work is prescription drug regulatory costs. What was the

[Martha Feltus (Vice Chair)]: name of that fund again?

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: It's the Evidence Based Advertising Fund, it's 21,912 if you like numbers.

[Martha Feltus (Vice Chair)]: Yeah, we have the special fund list, that's good to know. Our

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: other one is $21,009.37, that's our main bill back.

[Thomas Stevens (Member)]: So the bill back fund, does that have any relation to the other taxes we charge hospitals?

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: Provider taxes? No.

[Thomas Stevens (Member)]: Provider taxes are all Medicaid oriented and so they're paying a different fee or charge or whatever we're calling it for the build back fund.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: Correct. Specifically focused on the Green Mountain Care Boards funding the Green Mountain Care Boards work.

[Robin Scheu (Chair)]: So how do you decide what

[Martha Feltus (Vice Chair)]: the build back number is for?

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: So it's what we earn. So it's our we actually do it based on prior year actuals. So for the funds, the general fund dollars that we spend that qualify under the bill back, so not certificate of need, not like the healthcare advocate payment, which is a separate statute. For those general fund dollars, those are the dollars that we use to show that we earned. We spent 40%, 60%. So that shows the pool of money to be allocated among the regulated entities. And then there's math in the statute for the percentages. Who pays what percentage of the total? I assume we tweaked that Yeah, tweaked that. And then, so within the buckets, the hospitals are allocated by net patient revenue. So it's basically like a market share equivalent. And then the insurers are by earned premiums made comprehensive major medical in certain categories. So that's how it's allocated. Okay.

[Martha Feltus (Vice Chair)]: And then, but the general fund, so is it based on time at all?

[Robin Scheu (Chair)]: I mean, I'm trying to figure

[Martha Feltus (Vice Chair)]: out when you say you've earned it, is that sort of based on time, time

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: spent with these entities or? So, we have done it a variety of different ways over the board statute, a board time. What it is now is we've earned it by spending general fund dollars. So for fiscal year, we spend, let's say, 40,000 general fund dollars. Then that means we can charge back for that as long as it meets the criteria. We can charge back 60,000 I'm just wondering how

[Martha Feltus (Vice Chair)]: you decide what is general fund before you do the bill back. I think there's a step before somehow, because you're using a demo of $40,000 but how do you get to that number? How do you decide what's general fund? It's the budget that you approve. Budget assumes the bill back. Correct. Which assumes a certain amount of general fund. Yes. And so how do you

[Robin Scheu (Chair)]: get to the general fund?

[Martha Feltus (Vice Chair)]: Making any sense. I think

[Owen Foster (Chair, Green Mountain Care Board)]: so I think the example would be if if the legislature and the governor signed a budget for us as $40,000, that allows us to build back six. You gave us an $80,000 budget, we'd build back a 120.

[Robin Scheu (Chair)]: Okay.

[John Kascenska (Member)]: So that's the ratio. Correct.

[Robin Scheu (Chair)]: Right? Okay. Or So you're moving out a $100,000 total, forty percent's general fund. The other sixty percent's bill back. Okay. Right. A little tiny bit of spectrum. Yeah.

[Owen Foster (Chair, Green Mountain Care Board)]: Or six or or or The majority of the money is spent either on our 40 employees, health benefits, retirement benefits, all of that, and then the additional majority of the money will be spent on contracts and contractors that we are reporting to the legislature data that we have to use provide to the federal government as part of the agreements we have, system wide transformation. I think the one that probably most people are familiar with is the Oliver Wyman report that reported on the state of the health care system and had some recommendations. That was around a million dollars, so a million dollars for our budget went to produce that.

[Martha Feltus (Vice Chair)]: You spend a lot of time reviewing hospital budgets, but there's a lot of regulation is how a lot of your time is spent.

[David Yacovone (Member)]: Yeah, and another easy example is rate review. When the insurance company comes and says we need 15% more rate, we have actually the whole deep actuarial analysis that happens. We don't do that in house. That's an actuarial firm, a national actuarial firm who pay about $300,000 to perform that work. Do you believe you have the administrative capacity, the staff capacity and resources to make a determination whether there are enough administrative savings that could be achieved throughout the healthcare hospital system that might have a material difference on premiums. Do you have that capacity?

[Owen Foster (Chair, Green Mountain Care Board)]: Let me make sure I got the question. The question is, can we perform an analysis that looks at the entirety of the hospital system to determine how much administrative excess spending there is? Part one. What is the administrative savings achievable across Vermont's hospitals? Correct.

[David Yacovone (Member)]: Do you have that ability? Well,

[Owen Foster (Chair, Green Mountain Care Board)]: there's a lot of nuance of what would be an administrative savings, there would be a lot of debate as to what should and should not go. I think a lot of hospitals would argue these administrative costs have a good output. Nonetheless, it's a prioritization of what you're spending money on. It depends on what kind of quality the report would be or analysis would be, because it really take a hospital by hospital analysis and then a second layer of, like, how does the whole system interact? I would say that directionally speaking, yes, we probably can.

[David Yacovone (Member)]: I was looking, a follow-up.

[Robin Scheu (Chair)]: Yeah, go ahead, David.

[David Yacovone (Member)]: I was looking at the 990s of the critical access hospitals, and I was surprised, I guess, by the difference in the leaders for CEOs, from a high of 550,000 annually to a low of, I believe it was 167,000. Now keep in mind a nine ninety, that may not have been a full twelve months because I started it in September. But in any event, if anybody looked at them quickly, it was quite a variation. And I understand that reducing those to some type of level may not move a needle at all. But do you do those kinds of deep dives and ask those kinds of questions of hospital management as to why they're doing what they're doing?

[Owen Foster (Chair, Green Mountain Care Board)]: Yes, we do. We do dive into the administrative costs and the budget hearings. It's something we ask about every year to try and find an opportunity to reduce costs where we can. We do take a pretty hard look at executive compensation. If I were to go to, like, the bigger number so if you took a a critical access hospital CEO salary, made it $5.50 down to $3.50, it wouldn't materially move the needle. That is true. I actually heard an interview on VPR yesterday. They they asked a question of an executive. What about your salary? You make a million dollars, whatever it was. I actually don't know what the salary is. So whatever. It might be 500,000. And they said, well, it doesn't matter if I get paid that much because it doesn't impact the premiums. But my answer to that is, well, then should the governor make a million dollars because it doesn't impact the tax base? Should the care board chair make $500,000 because it doesn't impact I don't think that really justifies the answer. My response to all of this conversation is really whether or not we're getting value for that money. Is that hospital run really efficiently Is it really expensive? If it's really expensive, I would argue the hospital CEO could do a better job. But the way we think about administrative cost, big numbers that I'm looking at thinking about, the truth is most of them are at the health network or UVM Health. They're the biggest. They have the biggest operations. What you really look at is, like, the population health services organization. It's about 28,000,000 a year now. That's a big number, and we do ask about it. What are we getting for that $28,000,000? The ACO, that was about $15,000,000 for many years. What are we getting for that 15,000,000,000? I would look at the big numbers, the big budgets, and then question very hard what we get for it. Thank you.

[Robin Scheu (Chair)]: Bennington? Speaking about what's going on at Winter Helen or whatever they call it now, S-one hundred twenty six, we passed that last year. We inserted a team in there to go over what's going on there in terms of their costs and try to help them. We wanted to be more lean, I guess maybe would be the way to put it. How has that worked? And I read in the paper, read a thing with Brattleboro, is that they are now, they're all financially unstable right off the bat, other than Fletcher Allen. But Brattleboro seems to be extremely unstable. How is S-one hundred twenty six working? Are you doing that? Or how does that fit into this picture?

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah. So S-one hundred twenty six was unconnected to, I think what you're referring to is the board. The board and UVM agreed to have an outside team help UVM. And it was through a settlement that the board negotiated with UVM. UVM exceeded its budgets, and we could have gone to court and could have thought about it. Instead, we got together at a table and said, let's figure something out. And we put in three experts, really great people, to help provide oversight over UVM's operations. So that's not part of the statute, but I would say it's going exceedingly well. I would say that there has been cultural change at UVM. I would say that they are looking at their operations in a different light. When I hear them speak, they're very cognizant that their prices need to come down, that they need to be part of the solution to our affordability challenges. Some of the things that they're working on right now, two, they put out some RFPs to get some experts in to help them with what should the UVM health footprint look like. There was a time where it was growth, growth, growth, growth, growth, acquire everything, a lot of things in Chittenden County. And now there's a question of, well, we can't afford that footprint. That footprint is too expensive for them to run. So what can be jettisoned and done independently or through an FQHC or elsewhere? So they call that the Project 2,030. What's a reasonable expectation for UVM's revenue in 2030? And historically, everyone this is what happens with insurance rates too. Everyone builds up from the bottom. Let's build up, and then, oh, look. You would need 20% more money. That's what UVM did, but now we need to take a top down look and say, revenue, realistically, if you can afford it, is gonna be this. What can you do underneath that? Some of it's got to go. How are we going to do it? So that's the main project that's going on. The other one is provider productivity. We found, to represent Yacovone's question, a really deep dive we did on administrative costs was into how much of the doctor is working. And we got data that showed that it's really actually quite low. There's benchmarking, and their productivity number of patients they saw was exceedingly low. That costs a lot of money because you have to hire locums and patients can't get in and have access. So by pushing on our budgetary tools, we said you gotta tick that up. And that's something that the liaison team is working on as well.

[Robin Scheu (Chair)]: And I will accept it. When I understood this that that bill is that this was going to be applied to other hospitals sort of as needed potentially, with the outside person coming in and telling us independent hospital and their board, there was controversy about that. That was a different bill.

[Owen Foster (Chair, Green Mountain Care Board)]: That was age 42. I think what you're referring to is the observer bill. Like we had, the board was given authority to put observers in that house.

[Robin Scheu (Chair)]: Yes. Yes. Yeah.

[Owen Foster (Chair, Green Mountain Care Board)]: We've never exercised that authority. We could have and arguably should have on Brattleboro. Brattleboro gave us data that was inaccurate, wildly inaccurate. And we weren't able to make budget decisions because truly the numbers were not correct at all. And that would have called or allowed us to put in an observer. Rattleboro's board took some pretty immediate action to remediate the problem, so we didn't exercise that authority.

[Robin Scheu (Chair)]: And so the other thing is that these are all work functions. You're a board making these functions, working within these statutes. So whether it's the budget process or the sealant, this is another added responsibility to them, to you and to your oversight before you?

[Owen Foster (Chair, Green Mountain Care Board)]: Correct. So, if we were to appoint an observer, there would have to be a board hearing, we'd have to make a number of findings, and our lawyers would have to write an order explaining why we did what we did. So we are pretty judicious in using some of these stronger authorities. So we have subpoena authority. We've used it once in the fourteen years of the board. Observer authority, we've never used it. And yes, it is more work.

[Martha Feltus (Vice Chair)]: I'm going to continue here because we have Wayne in that job.

[Wayne Laroche (Member)]: So when you discussed what are you getting for the money, we're talking effectiveness. And then when we talk about the doctors not having as many patients, we're talking about efficiencies. So in terms of looking at the whole I don't have any kind of concept of where the big dollars are. All of this used to be personnel, I would assume. Then we also got structures, buildings, hardware, and all that stuff. Fixed costs, if you have more fixed costs than what you should have, that kind of thing. Do you have a good idea of where to look for those efficiencies?

[Owen Foster (Chair, Green Mountain Care Board)]: I think we do. The problem in Vermont's health care system, as I see it, is the health care system we have can't be sustained financially. This has been something that's pretty widely recognized. There's no silver bullets of efficiency that the board can go and grab and not have dramatic impact on the system. So people often say lower the insurance rates. Well, that would mean two things. Either one, Blue Cross is a worse financial position or two, the hospitals won't have enough money to maintain what they're doing. There's no easy trade offs here. We have reduced spending at hospitals by a couple $100,000,000 in the last few years. So a lot of those efficiencies, I think we have grabbed. Is there a lot more left? I don't I don't know. There's some, but probably not a ton. The problem is that the system, what we have, is inefficient. Like, that whole care delivery system's inefficient. That's what Oliver Wyman found. That's what the act one sixty seven work and the AHS's transformation work is meant to do. What I mean by that really is that in Vermont, much of our care is concentrated in hospital care. That is the least efficient place to deliver care that you possibly can. Part of it's reality, part of it's like how we've just come to be as a state, but we really need a much more robust system of primary care, mental health care, and small practices, which you can't just flip a switch and have them. It takes time.

[Wayne Laroche (Member)]: I was hoping that that rural transformation money that was coming would at least have us on a path this way. So one time, obviously, the thing is that it could help transform the system. It's a kickstart to getting the primary care fixed and getting care for people that are staying at home or some things that don't end up in the emergency room could start cutting some costs. But we don't you folks should know a lot more about how those things work.

[Owen Foster (Chair, Green Mountain Care Board)]: Think that's think I sorry. Interrupted you. Well, I think that's exactly right. I mean, we were just given a huge, huge, huge opportunity, $200,000,000,000 a year for exactly this. And to the state's credit, we're ahead of the game because we have spent three years studying the system and now know what the problem is, and now we have 200,000,000 a year to do it. The question is really being able to implement that 200,000,000 a year quickly and well, and then following it and making sure that we're accountable for it. When we got all the COVID money, effectively, it can bail out money for two years. What we don't want to see is that this money ends up effectively being bailout money. We want to make sure it's driving these other outcomes that we want.

[Martha Feltus (Vice Chair)]: And you have seen the report, the grant documents, and you know the projects that they're proposing, that we have no authority in the legislative to change anything. It is what it is. So do you think that the projects that they have identified that they're going to do are going to help us get there?

[Owen Foster (Chair, Green Mountain Care Board)]: We are not that closely involved in the selection. Actually, we're not involved in selection of the projects, and so we have not studied granularly how they're going to work or whether or not we think they'll be effective.

[Martha Feltus (Vice Chair)]: So, yeah, hopefully, you'll take a look at what the projects are. It'd be interesting to get your did they did they I'll add you to the list, Linda. Did they consult with you at

[Robin Scheu (Chair)]: all when they when they put together the application?

[Owen Foster (Chair, Green Mountain Care Board)]: Yes. We had some involvement and gave some feedback during the course of the application process, and now they're in the budgeting process where I don't believe we've had any.

[Emily Brown (Executive Director, Green Mountain Care Board)]: No, and I do want to highlight too, we were asked by AHS to put forward a project essentially to help provide accountability and transparency. So for those who may not know, we have a great data team at the Greenmount Care Board that works on providing transparency around our health care system and how care is delivered, pricing data, claims data. And HS asked us to create a data infrastructure project, which would allow us to develop more internal infrastructure so we would be less reliant on our contractors. As Chair Foster mentioned, we currently rely heavily on consultants for a lot of our data work. So the hope being with this grant money, I believe the total project was about $14,000,000 over the five years. So about I'm doing my math correctly, a little over

[Owen Foster (Chair, Green Mountain Care Board)]: A little under 3 a year.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Correct. To provide staff augmentation, to build up our data infrastructure in coordination with ADS, and with the hope being that the Green Mountain Care Board will be able to provide data to show actually the impact of the transformation work and actually see how the work is impacting access, quality, affordability.

[Robin Scheu (Chair)]: Great.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: So that's That

[Martha Feltus (Vice Chair)]: made it into the one of the Exactly. So the Joint Fiscal Committee, which a couple of us sit, is meeting tomorrow to accept the grant. And we're doing it publicly and from eleven I don't if you've already heard about that. But anyway, we'll be getting details about that, because we're going to have them present the whole thing before we accept the grant. And we want the world to understand that the General Assembly has absolutely no ability to change anything in that cooperative agreement. The only thing we have authority is to accept or reject the grant.

[Owen Foster (Chair, Green Mountain Care Board)]: Is the timing that it's yay or nay? It's not nay with some changes potentially?

[Martha Feltus (Vice Chair)]: We can't do a thing. So we want it to be ourselves really transparent about understanding it and having more people understand how this is going to work. So we will be doing that tomorrow at 12:15. So John, you have a question and then I'll just have to

[Owen Foster (Chair, Green Mountain Care Board)]: share it

[John Kascenska (Member)]: with the team to see us and say we got this right

[Owen Foster (Chair, Green Mountain Care Board)]: after, I know they had to go back and get that

[John Kascenska (Member)]: much into the award here. So they had to make some adjustments on that. So I'm curious as to what that ended up being too, with the report. My question, so thanks for being here today. You all worked many hours on lots of things over time, for sure we appreciate your help at the It's hard work, personal experience, you know, serving up on a board here trying to figure out how do we balance all this. So one of the balancing things I know that came out of Wyoming report was to kind of think about ways that maybe some services or support could be perhaps spread across hospitals here in lots of different ways here. And our two hospitals in the Northeastern part of Mount UNO this year, we're working together in BRH North Country, sharing one position here, trying to help each other, but they have to be careful about how much they work together on those things. Any trust things could come into play there, does that make sense? I mean, we want to kind of work together, kind of shares of service, there's only so much we can do. One hospital may be a little bit less volume of orthopedics, for example, you know, all the inquires may be sent to a different hospital, which we try and make up that slack the best we possibly can because they only have so many providers do studies based on size. So those are things I know that it's not just our two Impossible's and others that stuff there too. So I just wanna hear your perspective on that.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, that is a challenge. That move, it's a challenge. Well, I think there was addressed, think it was addressed in one of the bills last year. There's state action immunity from antitrust violations, which means that the state is involved and the state directs it, it's not an antitrust violation. AHS is the coordinating entity for the state on transformation. So understanding of the antitrust exemption would be that if AHS is involved in the discussions, in the meetings, and directs the action, it would not be an antitrust violation. I have worked with VOS. They asked me for some I'm a lawyer. Practicing lawyer. I gave them recommendations for antitrust counsel that could provide compliance. Where that stands, they would have to answer it. I I do not think it's appropriate for hospitals to, without the state, negotiate and slice up the pie. I mean, because what the incentive would be would be, okay. I've got high prices on this. You've got high prices on that. I'll take this. You take that. And that wouldn't be good for the system. Right. So having the understand that part. Yeah. Of course. Having the state service. Right. So you can get around the issue by by having the state.

[Martha Feltus (Vice Chair)]: Okay. I have Lynn and then Dave.

[Robin Scheu (Chair)]: Okay. I just wanna ask about the ACO. Do we still have an ACO?

[Owen Foster (Chair, Green Mountain Care Board)]: It closed January December 31.

[Eileen “Lynn” Dickinson (Member)]: So that's outside your court. You don't have to deal with that anymore.

[Owen Foster (Chair, Green Mountain Care Board)]: Not that one. There are other Medicare only ACOs. So we do regulate other ACOs still. Are

[Eileen “Lynn” Dickinson (Member)]: they anything like the animal we had before in terms of money? Or how does that work?

[Owen Foster (Chair, Green Mountain Care Board)]: No, but there's more of them. But I would say that what is required from a regulatory standpoint is a lot less.

[Eileen “Lynn” Dickinson (Member)]: Okay. And the second thing I wanted to ask, you don't do anything with nursing homes, or do you? It seems to me like at some point, the DOC bids.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, we do not. Not in my time. I'm trying to think if there's some nuance in the law where maybe there's a

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: theoretical. It was shifted shifted to AHS. To AHS. There was a role we had, and then we shifted to AHS. Probably like 15 to 16, my friend. Don't quote me

[Owen Foster (Chair, Green Mountain Care Board)]: on that.

[Robin Scheu (Chair)]: A while ago.

[David Yacovone (Member)]: I Yeah. Don't mean to put you in an awkward position commenting on other things going on in state government, but I'd appreciate your insight as to what's important enough to preserve. We have a program called AHEC, which you may be familiar with, but essentially it's a loan forgiveness program for providers, which is not just being level funded, it's being recommended to be defunded. Guessing, which I shouldn't do, I don't know if it was ever a therapeutic dose, whether there's enough of it to make a difference, but it seemed like a very important part of our portfolio, given what you said about the importance of primary care and how EHEC helped with the loan forgiveness to many primary care physicians. Would it concern you if that were eliminated? Would you recommend that somebody try to replace it with something because of the importance of primary care on the entire system? Or is it such in the scheme of things that you let it go, it's not big enough?

[Robin Scheu (Chair)]: Do you have any reaction?

[Owen Foster (Chair, Green Mountain Care Board)]: It's a good question. I'm not intimately familiar with the program or the details around it, but generally speaking, I'd say two things. One, loan forgiveness for physicians who are, no matter who they are, they're going to be higher paid in our state as compared to a lot of other people who work very hard as well. So there's some equity there as to whether or not somebody with a college degree going to grad school should get forgiveness, as opposed to many other people in need. Putting that aside, I think that supporting primary care providers and encouraging more primary care providers is really a priority, something we should encourage. The only nuance I would say is that I think that it should be encouraged as to independent or FQHC primary care doctors, not hospital based primary care doctors. The reason why I say that is because, one, there is some tax benefits to being at a hospital for primary care doctors because they're nonprofit. Whereas if you're actually at an independent, you're not nonprofit. And that's actually a little ineffective because the hospital based ones make more money. And then second, the non hospital ones, they charge a lot less than the hospital based ones. And then two, their referrals are not in a closed loop hospital system where they're getting ancillary services at higher prices. So they might use an open MRI or a Green Mountain Surgery Center at a higher rate than just using UVMs, MRIs at cost form. So I would distinguish between those two sets of criteria.

[Robin Scheu (Chair)]: Very interesting. That's fairly independent of the problem.

[Martha Feltus (Vice Chair)]: You're done. You've it, Lynn.

[Robin Scheu (Chair)]: Yeah, there's another issue, and that is the federal government limiting the amount of forgiveness or the amount of loans that you can take out as a professional. This is a real The nurses were here this week about that for graduate degrees. But the real problem is your medical, dental I understand why the logic in DC would be that if you can borrow more money, this is for all college, we can charge more. And that increases the debt, except that when you're in something like graduate school for a health care provider, whether it's an OD or an MD or a DBS, the point is that those places cost $100,000 a year. Even state schools cost $75,000 $80,000 I mean, you can come out with anywhere from $200 to a half million dollars worth of debt. And how are we going to attract? The only people who are going to be able to afford this is people with a lot of money, or they're going to have to take in even more debt. I don't know if that's even on your radar.

[Owen Foster (Chair, Green Mountain Care Board)]: It's not something in our particular lane.

[Robin Scheu (Chair)]: May not be in your lane, but

[Owen Foster (Chair, Green Mountain Care Board)]: it may be

[Robin Scheu (Chair)]: your concern that we're looking about accessibility.

[Owen Foster (Chair, Green Mountain Care Board)]: There's a lot of things that are concerns that are way outside of our lane. The changes to Medicaid, changes to Medicare, we can't get everything out of our lane. Yeah, exactly. I mean, it's just like

[Martha Feltus (Vice Chair)]: people want our legislators to solve all

[Robin Scheu (Chair)]: their problems. I know, yeah.

[Martha Feltus (Vice Chair)]: They want us to fix national healthcare. Go ahead, John.

[John Kascenska (Member)]: So I'll ask you a question that's

[Owen Foster (Chair, Green Mountain Care Board)]: in your lane, because look what I did. Okay. I'm right here.

[John Kascenska (Member)]: I just know the reference based pricing, but it's about implementation updates on that here. And and that's a lot of work. And we try and figure out how that's going to work here and how the impact would be just budgeting wise with hospitals once that becomes fully play here. So as you're going through that process of things here, just give us an example of one thing that you're looking at. Well, or a couple of things here, could be general here, could be a categorical here as well. But as you're moving through that, will you work with the hospitals here? You probably got plans to do there. When that does fit into their budget model, how would that look for them? What might they have to make adjustments with to come up with what you set for guidance for all of this? Which helps us a lot.

[Owen Foster (Chair, Green Mountain Care Board)]: Yep, so two things. So reference based pricing, to remind everyone, essentially what it is, is Medicare tries to pay around 100% of the cost. That's their goal. Might be 98, might be a 101, but it's right around a 100% of what it should cost for a service. Medicaid tends to pay quite a bit less, probably more like 60% of what it costs. What hospitals effectively end up doing is charging commercial more to make up the difference. Where Vermont sits on the commercial prices, the essentially Medicare as a multiple of Medicare is really, really, really high. Some of our hospitals are exceedingly high. What reference based pricing is trying to do is to drive that number back down, which will give us some rate relief for our insurance. I'll just give you an example. UVM is I don't have the number in my head, but I'll say hospital A, because I actually don't know the numbers, but it might be around 300% of Medicare. Reference based pricing will do is say, hey. Over time, you need to get more around the national norm, which is more like $2.50. Okay. So you gotta reduce your prices from 300 per three multiple to 2.5, and our job is to figure out at what cadence and what schedule that will happen because we don't wanna be too disruptive. You're not gonna do it overnight because the system, as we talked about, is not there to take these patients elsewhere. And your question was like, how do we work with hospitals on that? Already our system, we do guidance, which we're doing right now, we tell hospitals effectively, hey, we want you to come in at a 0% rate increase this year, and you need to make a budget that fits this. We work with the hospitals all the time on doing that. Reference based pricing also has a stakeholder engagement process where we get feedback. The rub in all of this is our hospitals can't survive at lunch. That's the rub. So everyone talked about reference based pricing, they kind of ignore the fact that that means the hospitals are not gonna look how the hospitals look. We're going to have service and delivery changes because they they can't give us what they give us currently at lower prices. Or to some degree, they can, but, like, not as far as I think the state will need to

[Thomas Stevens (Member)]: go for the price. You know, the

[John Kascenska (Member)]: concern there too is we don't wanna reduce access for certain services that we provided for whatever period of time.

[Owen Foster (Chair, Green Mountain Care Board)]: Completely true. Yeah. There's two pieces

[John Kascenska (Member)]: That's the

[Owen Foster (Chair, Green Mountain Care Board)]: That's the that's that's the The other piece is when we when we think about access, like, sometimes we're thinking about just in the hospital based system, and when the hospital makes access changes, it's in the news, and it's something that is in your mind and you're hearing about it. But when the FQHC makes access changes, we don't hear about it. When the independent primary care makes access changes, we don't hear about it. We barely hear about it when the Howard Center does. Right? So it's important to keep in mind that if we're giving all the money over here to prevent access changes, we're actually having access changes over here that we're not even aware of. And that's actually what's happened in the Vermont health care system in my mind in the last ten years is we've we've made sure we don't lose access here. We've actually cost a lot over here. That's consolidated the system into a hospital based delivery system.

[John Kascenska (Member)]: And I use the hospital example because that's what I'm most

[Wayne Laroche (Member)]: worried about.

[John Kascenska (Member)]: Yes. But the larger picture

[Owen Foster (Chair, Green Mountain Care Board)]: We all are. We all

[John Kascenska (Member)]: are. And we just don't wanna put ourselves unintentionally in a spot that all of a sudden, someone's not there, has to figure out where to go to get X service, whatever it might be.

[Owen Foster (Chair, Green Mountain Care Board)]: That's why the whole work is really like the cadence, the scheduling, and giving the system time for the Rural Health Fund to help us build these other systems. Do

[John Kascenska (Member)]: you have an indication what that might look like? We're still you're still doing a lot of homework here. I'm trying to figure this out here with this new and new money coming in here, which would help here tremendously, lots of different ways.

[Owen Foster (Chair, Green Mountain Care Board)]: Well, right now, are looking at how we're going to design the reference based pricing system, and there will be a lot of thought, I think, in the next six, nine months of what the schedule looks like, how fast the rate reductions are. I think we're doing reference based pricing already in a lot of ways because by keeping CBM is one of the higher priced hospitals that we have. We're keeping them pretty low or even reducing their prices. And as we do that, they're getting more in line with national norms. Or even this year, if our guidance ends up being zero, everyone else is gonna go up 4%. So we're getting closer to averages by staying flat. And that hopefully prevents the disruption and allows for everything else to get developed as we go.

[John Kascenska (Member)]: Thank you. Back

[Wayne Laroche (Member)]: on the primary care doctors, of course, you said the hospital's non profit status reduces their costs, income taxes that they're paying, state and federal income taxes? Is that where the discrepancy would be so that the device will be completely possible to make more than the others? Is that the primary?

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, it's twofold, yes. This might not be uniform across every set of primary care providers, but generally speaking, hospital based primary care providers' commercial prices with Blue Cross pays are higher than non hospitals. And then two, the amount that those physicians get paid, I'm comfortable saying are generally higher than outside of the hospitals.

[Wayne Laroche (Member)]: Again, I'm trying to get to Do they have a tax benefit because of the nonprofit status? Yes.

[Owen Foster (Chair, Green Mountain Care Board)]: Have to pay so much taxes. There's a deduction that they can take if they work for a nonprofit. Significant?

[Wayne Laroche (Member)]: I don't know the numbers. All federal or state tax also? I don't know the detail on that. The reason why I'm asking obviously is you know changes in tax, if we really had a deficiency in rural primary care providers, if there was a tax incentive there, then that's something we might be able to set, but that's Equal the playing field, yeah.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: A wind and day. Yeah, was going to

[Robin Scheu (Chair)]: say you also have a utility fee, hospital fee for people who are employed. So they have the docs, and then they have the hospital put some extra Medicare only, or is that for everything? Facility fee? Yeah. Everybody. So that's one reason why the hospital collects more money. They can maybe afford to pay more. And I'm confused by rep Laroche's question about taxes. Hospitals don't pay taxes, but they pay Social Security at all the usual salary.

[Owen Foster (Chair, Green Mountain Care Board)]: These are salaried physicians. It's the physicians that get the deduction, deductions on their on their w on their tax returns. Deduction of what? Their school loans. I guess their school loans, they can deduct the expense associated with the interest on the school loans.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Yeah. I can speak to this cause I have

[Unidentified Committee Member]: some I

[Robin Scheu (Chair)]: know I can do this offline. Yeah. I'm just curious, because then they kind of docs a lot of them because payer mix, increased people on Medicare aging population, more increased on people with Medicaid because it's been expanded. They make less money and they go out of business or they get hired. They go to the hospital, get recruited by a hospital to work. We're able to make a whole lot more stable money than they would in any kind of independent practice. Now, FQHCs are different, if I understand correctly, because they're employed.

[Martha Feltus (Vice Chair)]: Okay, I'm going

[Unidentified Committee Member]: to Maybe

[Martha Feltus (Vice Chair)]: take that part offline.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, yeah,

[Emily Brown (Executive Director, Green Mountain Care Board)]: Keep going. Dave, did you have a question too?

[David Yacovone (Member)]: I did. Assuming you've had a sufficient increase in resources to accompany any lane changes, are there any areas that you believe should be regulated in such a fashion that might yield savings we need across the healthcare system and provide? Or do we pretty much have it right?

[Owen Foster (Chair, Green Mountain Care Board)]: I think we pretty much have it right with two caveats. One is it's really incumbent on us at the Green Mountain Care Board to be very cognizant of those other parts of the system that aren't regulated. And to Monday morning quarterback, some of my own decisions and the board's work in the past, that was where we had made mistakes. We essentially took a view of here's what we're doing. Here's our budget process. Those other things aren't us. And I know I've said that's not my lane, but those are federal national. But but one of things we have worked on very hard in the last four years is making sure we really understand the rest of the market. Don't think the care board should be regulating the small independent practices. It's too much work. It's very expensive on them. It's cumbersome. But I do think we really should be reporting out on how the rest of the system is doing. I think that's really important. The other caveat I would have too, I think we have it about right, is there's a lot of different cooks in the kitchen working on different things, and it's not necessarily always that well coordinated. So, you know, we're in charge of the hospital budgets. So if we make a let's say, AHS's transformation work. If they make a change, it will impact what the hospital has in their budget. So we have to know how that's going to fit. If they're gonna put a bunch of money over here to primary care in a rural community, that will change the care delivery. Like, all these things interact, and I think they really need to be coordinated. Also, in terms of, like, administrative expense, I think that there's a lot of administrative expense in how Vermont policy works in health care. And I wanna speak to this a little bit. The state spent a ton of money on the all pair model, and it did not work. We did not see the savings, quality, access, affordability have all been very, very poor during the life of the all pair model. When I got to the care board in 2022, it was verboten to speak ill of the au pair model. Not just at the board, but I mean, like, in this building and everywhere. Socially, you were, like, asked to leave. And I'm still asked to leave. Ask you. But but I think it's really important that we recognize that these systems we have, we have BPQHC, we have the Green Mountain Care Board, Blue Cross has quality, we have the Blueprint, they've got quality, UVM has quality, we have quality. There's a lot of duplication across the system that's really expensive. The all payer model, one, you had the ACO that was $15,000,000 a year. Two, you had the care boards regulation of it, which might have been $2,000,000 a year, roughly, something like that. It's a lot of expense. As we look at health care reform, people love health care reform. Right now, if I walk down the hall, I'll talk to someone about the AHEAD model. I'll talk to them about global budgets. I'll talk to about reference based pricing. I'll talk to about site neutral payment. I'll talk to them about all these things. You can't do them all. You can't do them all effectively, and they're all expensive. Even evaluating the AHEAD model costs a fortune. We're gonna pay contractors half $1,000,000 to evaluate it. At the end of it, I don't know that we're really gonna know whether it's gonna work or not. So all these things have risk and they're costly, and I think we need to get down to kind of the basics of health care. Not spend money around health care, but spend money on health care. And you asked about administrative costs. I'd look at the statewide system administrative costs too, including us.

[Martha Feltus (Vice Chair)]: Sure. Thank you. So you mentioned the head model, and that was one of my questions. We sort of agreed we'd pursue it, and then we have a new administration in Washington, and I don't, is there even gonna be in a head thing, model, whatever?

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah. So the board so the governor and AHS signed it, and the board signed it too with some pretty heavy caveats. The board, we needed three votes to say yes. We barely got three votes. It was a lot of pessimism. The issue was whether or not we're gonna get more money from the feds or less money. It's a cap. Right? So why do we wanna cap how much money the feds are giving us on Medicare? And the answer was, well, if you look at these very complex projections, there'll actually be more money, and then we'll draw down the delta, and we're gonna get all this money. But it depended on the trend rates and all these various lines. It could actually theoretically be less money. So really understanding if it's more or less, it's not that easy to do. The new model, when the Trump administration came, they wanted to renegotiate. That started, I think, this week. Correct.

[Emily Brown (Executive Director, Green Mountain Care Board)]: It started we had a meeting with them last week.

[Martha Feltus (Vice Chair)]: So we don't even know if we're gonna go ahead with the head.

[Robin Scheu (Chair)]: We don't know if we're gonna move forward. Yeah.

[Emily Brown (Executive Director, Green Mountain Care Board)]: There will be an amendment to the existing agreement that all parties will have to agree to.

[Owen Foster (Chair, Green Mountain Care Board)]: And it added a new layer of complexity, and then now it's an ACO based model again. So the question was, if there was a delta before, which I think was an open question, could we draw down that money and take it and redistribute it? Right. Maybe. But now you have the ACOs that will be involved in that drawdown of the money. So now the question is, is there a drawdown? Do the ACOs take it? If the ACOs take it, how do we take it back? Right. So there's just more complexity.

[Martha Feltus (Vice Chair)]: Makes sense. Worse and worse. Okay. So TBD.

[Owen Foster (Chair, Green Mountain Care Board)]: Yes. TBD. And then the other thing I'd add with the all payer model, one of the reasons why we didn't leave was because the way it was structured was there's Blueprint and Sash money there. We essentially got $10,000,000 a year of free money. So it was really, really hard to ever execute the model because you would be hurting Blueprint or Sash in their funding if you were to exit. People That's right.

[Martha Feltus (Vice Chair)]: And I don't think Sash was put in the governor's budget this year,

[Robin Scheu (Chair)]: and that's $5,000,000. Right.

[David Yacovone (Member)]: It's another conversation. But it's hard

[Owen Foster (Chair, Green Mountain Care Board)]: to exit these models when somebody's getting money out.

[Martha Feltus (Vice Chair)]: I know. I know. Yeah. Jean, did you have

[Robin Scheu (Chair)]: something you wanted to say?

[Unidentified Committee Member]: Just a follow-up. Chair Foster was talking about the $10,000,000 for blueprint and sash. That's really clear, and in this building, that's a line item that comes through very clearly. What's less visible is the cost that all the departments for reporting on the model, for all the other costs. So the $10,000,000 is the benefit, but where do you look across?

[Martha Feltus (Vice Chair)]: It's a gross number, a net number, basically. Net number, not a

[Robin Scheu (Chair)]: gross number.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: It's a net number, net number, not a gross.

[Robin Scheu (Chair)]: You don't have the understroke number. I know, it goes with it.

[Owen Foster (Chair, Green Mountain Care Board)]: It's a gross, so the amount that Blueprint and Sash got was gross, we didn't net out of that all that we paid.

[Jean Stetter (Administrative Services Director, Green Mountain Care Board)]: It's a gross number, yeah. I was thinking, yes, person.

[Owen Foster (Chair, Green Mountain Care Board)]: We're getting

[Martha Feltus (Vice Chair)]: there in different ways. Did you have one last question, Wayne? You're good. Okay, really appreciate you all coming.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Thank you

[Unidentified Committee Member]: for not asking for more.

[Robin Scheu (Chair)]: It's going to

[Martha Feltus (Vice Chair)]: be a very hard year. It's already going to be challenged. So appreciate all the work you do. You have huge challenges

[Robin Scheu (Chair)]: ahead of you, but I think we have great people in the job to do the work. So

[Martha Feltus (Vice Chair)]: thank you very much.

[Wayne Laroche (Member)]: Thank you.

[Big Hartman (Executive Director & General Counsel, Vermont Human Rights Commission)]: Okay, Sarah, be well. Okay, so committee,

[Martha Feltus (Vice Chair)]: three minutes till lunch, but you

[Robin Scheu (Chair)]: have less time, and then one

[Martha Feltus (Vice Chair)]: of things I hear the Defender General is only here for thirty minutes, so we're going to start