Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good morning everybody. We're live now. Today is Wednesday, January 7. Welcome to House Healthcare and we have in with us this morning again Jill Olson. I just Sasa Olson, it's on the agenda. I'm like, oh, should I include them as a Olson? I'm going to talk about the Rural Health Transformation and we've dropped the P. RHD.

[Francis "Topper" McFaun (Vice Chair)]: Thanks for coming back.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Thank you for having me. I'm glad to

[Alyssa Black (Chair)]: be here. Oh, I'm just drawing on you.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Hopefully, I've done everything correctly, and I will share my screen, and it won't make crazy noises.

[Alyssa Black (Chair)]: And

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: this is the hardest part for me right here.

[Alyssa Black (Chair)]: Watch her.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I know. And it's the audience part of it that it definitely just makes it difficult.

[Alyssa Black (Chair)]: I just want

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: to tell, I know you're in

[Alyssa Black (Chair)]: a new role and everything, but I would be incredibly disappointed if you didn't make crazy noises.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, you wouldn't want me to have to change my personality this time? Okay. Share my screen.

[Francis "Topper" McFaun (Vice Chair)]: Oh, take it back. Yeah.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: There it is. Did

[Francis "Topper" McFaun (Vice Chair)]: I do it? It's gonna be on.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Side deck. Okay. And then?

[Francis "Topper" McFaun (Vice Chair)]: Yes. Get larger. So sorry.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Have too many, like, things in the way, if you know what I mean. I didn't. Great. Good morning. Good morning. I'm Jill Mazzo Olson. That's my professional name. But if you just call me Jill Olson, that's fine. But when I sign my name or put my name on a document, I go with that. And when I was a kid, my father was a contract attorney. And when I got my first bank account, he I was in fourth grade, and he said he looked at me very seriously, and he said, you need to decide right now for the rest of your life. Middle name or no middle name when you sign your name? Oh, wow. Went middle name. And I've always done it that way. And when I signed my first mortgage with my husband, one of us had their name five different ways to sign this extra document. And one of us was very, very consistent.

[Alyssa Black (Chair)]: Thank you, Josh.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So I'm here to talk about the Rural Health Transformation. And actually, I see we still have an FP on this version, but people seem to be just saying RHT these days. I'm here in my role as you know my title is Medicaid and Health Systems Director. I was here yesterday. And so yesterday, I had my Medicaid hat on. And so Alex McCracken was here, and she is the point for us on all things related to Diva. And today, I'm here with my health care reform hat on. And so Eli Harwood, who I think many of you know, is actually on the Zoom today. Actually, of course, I shared my screen and wanted her to introduce herself. I fear unsharing, but I'm going to. There we go. Eli, do you want to I think I just mispronounced her last name, because I'm nervous. Go ahead, Eli.

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: Hi, I'm Eli Houghton. I am the health portfolio director and also the legislative liaison for health care reform.

[Alyssa Black (Chair)]: And Eli, just to because we see you all the time and you should know all of us. If our two new members want to introduce themselves to you, in addition to our our new committee assistant who I know you work with closely. Val, do you want go ahead? Valerie Taylor, District 11. Nice to meet you. Good morning, Eli, representative leaders from Addison 4.

[Tasha Putner (Committee Assistant)]: Hi, I'm Tasha Putner.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Okay. Nice to meet

[Francis "Topper" McFaun (Vice Chair)]: you Thanks,

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Eli. Sorry about that, that I It's in the right order. That looks like I did it faster than second. So I'm here to talk about the Rural Health Transformation Fund. And I think probably you've read about it in the newspaper, but just to orient all of us, this was part of HR1, the bill we were talking about yesterday. So these were dollars that were passed. Control my screen. So this was an opportunity from CMS that passed as part of HR1 to help states modernize their rural health systems. So one of the things I like to say about this is that this is not our health care reform plan. This is one tool in our health care reform toolbox. So it allows us to do certain things, and we're trying to take as much advantage of it as we can. It doesn't solve all the problems that we have to solve or that we're concerned about, and it's not the totality of everything we're doing. So I just like to make that distinction because sometimes there's confusion about what is this and how does it fit. The goal of CMS was to strengthen rural access. And I think there was a real understanding that in particularly in rural areas, have challenges with workforce. There is opportunity for innovation and there may be opportunities to use technology to better provide services in rural areas. And I think that's something that we need to we really need to work on. And my Internet connection is unstable. Well, we'll see what happens here.

[Francis "Topper" McFaun (Vice Chair)]: So

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: it's a $50,000,000,000 program over five years. Half the funds are distributed equally among the states, and then the other half was weighted. And so there were a couple of things that they did for the weighting. Some of them we could not change. They were immutable. So they had various scoring related to metrics of how rural a state was. But they were sometimes related to things like literally the geographic square miles of the state or numbers of rural providers in the state. And then also by various policy directions that CMS was more favorable towards. And so those policies had to be in place at the time that the application was created. And in Vermont, we did not have many of those types of policies in place. We'd gotten different policy directions. So for that second part of the distribution, we knew going in that for those things that we could not change, we were not going to score especially well. We knew just we could score ourselves in advance. And so we did get an award of $195,000,000 So we got nearly the $200,000,000 benchmark amount per state each year for five years. What that says to me is we had a strong application, because there was a lot there were things working against us.

[Alyssa Black (Chair)]: I've just been confused. Yeah. And I think I heard

[Leslie Goldman (Member)]: you say I thought it was $195,000,000 one time done.

[Alyssa Black (Chair)]: But you're saying that Every year for

[Francis "Topper" McFaun (Vice Chair)]: five years.

[Alyssa Black (Chair)]: Thank you. That's much better.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, I tried. This is when I start thinking it's just about a billion dollars. And I think, wow, this is a lot to feel responsible for.

[Alyssa Black (Chair)]: Thank you.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah. Yes. And we were sort of in the middle third of awards of states. And we are the second highest in New England. And we're probably about, we think, about third highest per capita. So I think we did really well in our process of applying. So we really good about that work.

[Leslie Goldman (Member)]: Thank you to you.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Well, to the team, really. Was quite something. And And was new to this.

[Alyssa Black (Chair)]: Yeah, I'm really having trouble advancing here. There we go. Yes. I want to make a point because I mean, this whole program and I want to make sure that the committee is aware. We talk in Vermont all the time about our rural hospitals and how they're in trouble. But it's really important to level set that Congress did this because this is a nationwide problem and rural hospitals are closing all We're over the actually pretty lucky that we haven't had any closures.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, and I would say it's not just hospitals that are in trouble.

[Alyssa Black (Chair)]: Rural health care is in trouble. Yes.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: If anyone wants to look

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: at the rankings, you were noting that Vermont was probably in the rankings. Kaiser Foundation did a really good report on that this week.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Oh, great. Thank you. I actually haven't seen that yet, so I'll

[Francis "Topper" McFaun (Vice Chair)]: take a look.

[Alyssa Black (Chair)]: Google, if it's out there. Google what?

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: Kaiser Foundation Rural Health. Rural Health.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Sorry to interrupt. No, that's Okay. Yeah. And one of the things that I think helped us with the application is that, so I got to the agency in about mid September, actually overlapped with my previous role. I sort of was closing that out and came in just to focus on this because the secretary wanted to make sure that I was already engaged in this when and so I got there basically as the NOFO was the notice of funding opportunity had dropped. So we knew what the application was going to look like. So I had this overlap of just trying to get oriented. And so she had already done some really strong work with the team. And her focus was, if we have to move as fast as we do to put this application together, let's focus on all the good work we've already done in Vermont. So things that we've tried that we want to scale, things that we've done that we want to modernize, where we want to improve, or things where we might be able to build on. So we were really trying to build to the extent we put on work that was already out there, rather than reimagining what to do. And I think that was absolutely the right approach, because it was hard enough as it was to try to come to create a coherent proposal in the time that we had. One of the things that I think was really helpful to us is that we have a rural health well, actually, it's not just rural health. We have a workforce task force that's been in existence for several years. And where most of the provider groups, the educational institutions, various other folks serve on that. And so we actually had a workforce strategic plan in process when this came in. And so we had some things we could work from. So to the extent we could, we worked from work that was already done. There are some things that I think are really important to understand about these dollars. I hear from people a lot. I'm hearing from lots of folks about ideas about what we should do next. And so of all, have a notice of funding opportunity that outlined the rules about what we can and can't spend the dollars on. This is while it's over five years, I think it's important to think of it as essentially one time funding.

[Leslie Goldman (Member)]: That's what confused me. Yes. And one time funding.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: It's sort of like long one time funding. But it is essentially one time. It's short or short term might be a better way to think about it. But what we don't want to do, I think, in this is add to the base. And we, in fact, have to have sustainability plans for things that we might try to grow or create under this plan that would then potentially continue. And I think that's going to be some of the continuing challenge as we go forward. We can't supplant the state budget. So if there's things we would typically fund in our state budget, we can't use these dollars for that. We generally can't use these for otherwise billable services. So if something is covered under Medicaid or Medicare, we generally can't use these dollars for that. We can't use it for our state portion of a match. And there's restrictions about funding clinician salaries. So there's a whole lot of stuff that people really want us to do that we can't do. So just want to make sure that that's upfront because there are limits on some of what we'll be able to do. Something that I think is gonna be challenging for all states is that at the end of the year, and our annual report is due sixty days before the end of the year, and the end of the year is September 30, this federal fiscal year. So we have a report due in August, the August for this first year. And at that point, any unexpended or unobligated funds go back into the pot to get redistributed for the next year. So sometimes, as I understand it and I think you all know I'm new in my role, and I've not managed a project like this. But in some cases, for example, with home and community based services grant funding, it kept getting extended. So you could keep your same plan and just get an extension on spending the dollars. Our understanding is that that's not allowed here. If you haven't obligated it and spent it by the end of the year, it goes back into the pot and it gets redistributed. So I don't think it goes away, But it's not necessarily ours. We have to sort of go through another process. So. The details of exactly how that's going to work are not yet clear me. I think not really clear yet. Have CMS is starting to have created a special office dedicated to this. They're going to start holding webinars with us in March. We're going to have a point person that we can talk to. So there's just a lot of implementation work that's going to happen. But this is something I just think we all need to be aware of. We don't have a lot of time in this first year, and there's a lot of development work to do on some of the things that we proposed. Are

[Alyssa Black (Chair)]: we worried? Vermont has we have a lot of oversight and we've built a process for distributing grant funding. Are we worried that we might need to change something statutorily so that we can get this money distributed in the time that it needs to be distributed?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's a great question. Am I worried? I'm always worried. So worried? Yes, 100%. Yeah, if you say, are you worried? I will always say yes. So I worry a lot. I hadn't thought about it as I hadn't really thought about it from a statutory perspective because we certainly have a lot of internal process too. And I think the challenge we have is being fast and careful. Fast and defensible. We have to be both because we want to make sure that as we get examined later for how we did this, that we followed our processes either for grants, and many of these things are in grants, or procurement, which is, I think, the more sort of challenging element. So there's a lot that's in grants, some that's in procurement. And we are starting to meet as a team, actually have a meeting today, to really try to think through what are the things we have to do to try to move this as fast as we can? All states are grappling with this. We have a really nice group going with all of the New England states that some of the members of the team have been participating in. And it's definitely, it's very reassuring to sort of hear that everybody's grappling with this. People, all states are trying to figure out how to thread these needles. So there's a lot more implementation work to come that I just can't report on yet, but that we're starting to grapple with.

[Alyssa Black (Chair)]: Just keep in mind that if you all need something and you're finding I have your number.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Thank you. I appreciate that comment because I hadn't thought about it in that way. That's really helpful.

[Brian Cina (Member)]: I looked ahead to make sure it wasn't mentioned and it isn't coming up, so I'll ask it now. Are there any restrictions on investments in any of the following? Physical infrastructure like buildings?

[Alyssa Black (Chair)]: Yes, restrictions.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: There is. Major restrictions.

[Brian Cina (Member)]: Okay, because it doesn't say it here, so I wanted to check. What about other infrastructure, like public gymnasiums that people can work out in or public areas to grow food?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So let me just be clear. What we applied for is what we applied for. I see. Yeah, so this isn't a moment to sort of say, well, what about this? What about that? There's because we, we had to do an application in the time that we have. But to your question, we actually had our one of our original proposals was for, I thought it was really creative. Idea to try to create more workforce housing, because housing for the health care workforce is a huge part of why we can't recruit into rural areas. And CMS disallowed it. Okay. Yeah. In the question and answer, because what they so it wasn't clear in the application how they were going to treat housing itself. It was clear that for facilities, so there's sort of facilities upgrade section. But at the same time, they say that the renovations have to be minor. They can't increase the value of the property. So a renovation that doesn't increase the value of a property is not a major, it's like outlet covers, vent covers, partitions, that kind of stuff. So we didn't know if they would apply that standard to our housing proposal. And they did. And they said that it's not allowable. So we had just process wise, had an exchange with CMS Christmas week, I think it was, or just before Christmas, where they had four questions for us. Two were technical. One, they asked us just elaborate on something. And one was, are you guys thinking? This is unallowable on the housing. And then we had to resubmit a budget at that point. So we resubmitted the budget, removing the housing proposal at that point, because it was clear they weren't going to fund it. So now I have read that there are some. Applications that do include things like playgrounds. So I'm not sure how that fits because to me, it's not doesn't fit with what I'm hearing from CMS. But in any case, that was not something we proposed. And we're really not in a place to start adding big new ideas to the application. What we've applied for is the big buckets are, I think, what we'll be essentially working from for the foreseeable future.

[Brian Cina (Member)]: So what I'm hearing is we should hear what you applied for before we think of other things.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, I'm not really looking for new ideas. Yes, exactly.

[Alyssa Black (Chair)]: That's one of the reasons why I wanted come in today because I have been getting a lot of questions about let's do this. People have great ideas,

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: And there is some I'm sorry. No, no, Let me pause. There is some room. So this is not totally rigid. We did include, and I'm going to get to the programs. We did include some more open ended dollars for transformation to both for hospitals, but for other types of providers, which I do think will, because we didn't have a whole lot of time for an iterative stakeholder process because we had to move so quickly. And so I do think that that will allow for us to work with our provider partners in particular on what kinds of projects do they want to do and kind of have a little more development time. But CMS will not obligate those. They will not release those funds to us till that is crisped up. So they're not going to give us dollars. So we have a lot of TBDs in the proposal, a lot of things that we're like, this is our best guess right now. I mean, it's just a reality of applying for something this big that fast. And so until we're able to really firm that up, those dollars won't even

[Alyssa Black (Chair)]: be released to Vermont. I think Leslie and then apparently talk Leslie, go ahead.

[Leslie Goldman (Member)]: Mine's quick. Okay. I was just looking to get a sort of to get to see the application. And then I see that you have some links, but mine aren't active. Oh. So I don't know Try

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: hitting control and then clicking on them. I had a little trouble today too. Oh, it may be because I made it a PDF. Okay. But that may be why. You just send them again. We can send the link, but it's art. If you Google like Vermont rural health transformation, it will go right to our page.

[Leslie Goldman (Member)]: I tried that yesterday. I didn't succeed.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So that's why I'm happy to

[Leslie Goldman (Member)]: we'll follow-up. I appreciate that.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah. Happy to do that. Well, yeah. And what we, yes, what is on that page are three documents, the actual application. If you want to read all, I don't know, lots of pages, sixty, seventy pages. You could do that. There's a very high level summary to read that. There's also a list for the list of people, and it's just, it's like, it's essentially a spreadsheet with a list of the projects with a very short description. For me, it's actually, that's my favorite document. That's the one I looked at the most because it sort of reminds me like what all the pieces. So I think we'll continue to refine how we describe this. It's quite hard to describe 40 things that are not all the same, different departments impacted. But there are lots of materials. What's not there is our budget because we're still in negotiations with CMS. So we have a final budget negotiated between now and January 30. We'll have a final or I would say our starting budget. There is room to renegotiate. Okay. Not getting very far out of supplies.

[Allen "Penny" Demar (Member)]: So you got the request of the grant with the money. And now we must have many requests from rural areas on getting some of this money. What's the procedure of that?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So that's where I think we have real work to do. So in fact, because this is a public forum, I will just let providers know we are not going to leave them behind. I think there's a lot of anxiety that we're going to move so fast that they're going to miss it. And so I just want to say here now, it's very important to me that we don't miss anybody and that we don't leave anybody behind. We have to figure out our process. So we have some work to do internally to create a process whereby dollars will be distributed. And particularly, as I was saying, we've got this more open ended element on transformation where I think providers could apply for grants. That's going to be something we're going to have to work out and we're going to have to push that out.

[Francis "Topper" McFaun (Vice Chair)]: It's the time frame.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Well, I don't know yet. And it is really challenging. So yes, remember what I said, I'm always worried. I'm really worried about time frame for sure. Yes. This will continue to refine this and provide you back more information. And we're going to keep updating our website. We're working on developing a listserv so that people who want to hear about notices when we change something or something big happens. Will not have to just keep checking the website because I hate it when I have to keep checking the website, but will instead get a notice like, hey, pay attention, something's happening that you might care about. So all of those things are things we're working on standing up right now.

[Alyssa Black (Chair)]: Chopper, and then Daisy.

[Francis "Topper" McFaun (Vice Chair)]: Just to start off, if you need some help with your computer.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: You're my guy. Got it, thank you. When

[Francis "Topper" McFaun (Vice Chair)]: you talked about renovating Oh yeah. Rural health, we are trying to expand our rural health delivery system. And sometimes there aren't any buildings except some old building that's been abandoned, might need to be renovated so that all the capabilities services can go in there. Is that something that

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: It really does not appear

[Francis "Topper" McFaun (Vice Chair)]: to be

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: minor renovations. Apparently this is typical of CMS, this is what I'm hearing from the experts at the agency, that they typically don't like to pay for renovations, large renovations of facilities. So people are so nobody the sort of expert people behind the scenes are not especially surprised by this, as frustrating as it is that we because I agree with you. There are some obvious cases where rehabbing a building might be a thing that we'd want to do. But it does not appear that that's going to be allowable. Yeah.

[Alyssa Black (Chair)]: Daisy? I have two questions.

[Daisy Berbeco (Ranking Member)]: One is, can you talk a little bit about what you can do around clinician salaries? And then the second question is, can you clarify you mentioned that you're not looking for new ideas. What you proposed, what was accepted is kind of a done deal, but yet things aren't going to be funded until you firm them up with So can you clarify

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, exactly let me keep what going. I think if I keep going, it's going to get to what you're saying. If it doesn't, we'll stop again. But let me try to keep going. I have not allowed myself to get past maybe my second slide or third. No, no, no, it's okay. There's a lot of sort of overview and I want to make sure I'm oriented and so all of it. So, okay. This is my attempt to put as much on one slide as I can about what this thing is. Okay. So on the clinician salaries, as I understand it, we generally can't fund clinician salaries, but there may be some. I think what it is, is if we're building something new, starting something up, there might be a little more flexibility. It's a little bit of a nuance that we're going to need to go deep in, but we generally can't pay for provider salaries. It's just that it's not like a complete blanket. So, may have to get back to you on exactly what we can do. Yeah, that's a little bit nuanced. Okay. So, rural health workforce. So, I've already talked, I'm actually not going to go in order. On the workforce, housing, crossing that out, can't do it. Training at clinical sites across the continuum. So, organizations often call them residency programs where you actually have clinicians and you have experienced people home health. Does it hospitals do it? Lots of organizations do it. So we'll have funding for that. Essentially financial assistance for education, which we can partner with VSAC for. So that's going to be something where I think we'll be able to spend the money pretty fast because we have one obvious partner and we've done it before. So we've had, We've called it in the past forgivable loans. We've called it something different in this application. For technical reasons, but essentially it's a program whereby. There's tuition assistance with a five year service requirement that's required by the grant. CMS is requiring that. And the mechanism for compliance for the individual is if they don't complete their requirement to stay in Vermont for five years, the assistance they got becomes a debt. So it's not loan forgiveness in the sense that they're bringing us existing loans that we're paying off. That's definitely not allowable under this. It's a mechanism to essentially effectuate this obligation for people to provide us. And I've noticed I'm going this way. Going to try to go this way a little bit more. I must say, oh, that's great.

[Alyssa Black (Chair)]: I'm not

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: really seeing the staff at the table very well. So anyway, so that's and then we've also put in dollars for there was a critical occupations project with it was at the time Vermont Technical College, where it was essentially free tuition. So we did get funding for that. We haven't really worked with them yet. So we're scrambling to get that all sorted out. But that kind of stuff, I think, is gonna be the easiest lift because single partner, pretty clear path, been done before. So that's and so I'm really excited about the workforce components, really excited because there's a lot of work to do at all levels of our system. Some really good proposals from across the continuum. And yeah, so there's that.

[Alyssa Black (Chair)]: Are we able to use the money to bonus or pay for supervising, like supervising clinicians?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I think so. That is how we described it. But I think this is as we start to sort of ask for the dollar, some of those like, can we can't wait questions are going to start to get hammered out. But yeah, that's a really important part of it is to support the, the supervision, the oversight, because that's not a billable service. It's definitely not that. And then is it a clinician salary? Well, they're operating in that case as an instructor. So that's the kind of details that I think we have to start out.

[Alyssa Black (Chair)]: I just, I mean, we've done so much, talked to so much around workforce. I know that one of the levels of challenge is finding people to supervise you during a clinical rotation.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, exactly. Exactly. That is the concept. It is to support those residency programs. That is the idea. But also a piece of that is to support the individuals who are both trying to be educated and be, also be at clinical sites. So they need to work and be educated. Yes, there's a lot more details to come.

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: Lori, do you think in

[Alyssa Black (Chair)]: the long term, over

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: the five years, we'll get to a point where we will have more Vermont based clinicians and the cost for travelers will continue to go down. So that's a benefit long term.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's absolutely the hope. Yes. Especially to train up people who might be a personal care attendant now, but who might be interested in then becoming an LNA or becoming an LPN and helping people sort of make their way through the career path. I think that especially for people who are already here growing the workforce, I think is the sort of the most viable from people who are already committed to being here and can be helped along a career ladder. But those are folks often left to work while they educate. They don't have time to just go to school. I don't mean just go to school. Going to school is hard, but go to school without doing anything else, earning dollars. So that is absolutely the hope. What's harder is recruiting people from away. I'm not sure that this helps so much with

[Alyssa Black (Chair)]: recruiting people from away. And when we're talking about workforce, are we talking about workforce across a continuum? I mean, dental, mental health. All of it.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: We left it as open as we could and with a sort of like and the rest sentence for anything we forgot.

[Alyssa Black (Chair)]: Okay, great.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah. For you Gilligan's silence. Some of us are old enough to remember. So yeah, we really, to the extent I mean, that's just a theme for the application. To the extent we could leave it open ended, knowing we were moving fast, we tried to leave it flexible, but we had to try to be specific enough to be credible. So all of this was a balance, some of which was happening the night before we were trying to dot all the laugh guys. So that's workforce. I'm going to move to technology. So there's a lot of option work for technology here. So there are some, there are a number of hospitals in particular that are interested in a shared EHR, probably a shared instance of Epic. So I just want to be clear because this makes people anxious. We believe in interoperability. We are not saying all providers of all types need to use the same EHR. Not doing that. People really there's and there's good reasons not to. I've worked for home health for a long time. Their EHR has to work on a tablet in a car. It's just in the workflow is totally different. So a hospital based EHR might not work for a home health agency designated agency. So there are reasons why we don't have a universal EHR, but if hospitals all wanted to be on Epic, it would be easier for them to share information with each other. So it helps with our interoperability, but it's not our only strategy toward interoperability. It's it's a leapfrogs us for some of that. So that's one piece. Remote patient monitoring, shared HR systems. So it's sort of like back end for hospitals, support for AI transcription for those smaller practices that might not be able to purchase it. So there's lots of technology solutions that are going to need to be built out.

[Alyssa Black (Chair)]: And this

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: is where I really hear from all kinds of vendors who have all these ideas.

[Alyssa Black (Chair)]: Think, Debra, I have a question.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I'm so sorry. No. Because he's going to be my technology guy, so yeah, ready.

[Francis "Topper" McFaun (Vice Chair)]: As I read this, I'm a little concerned about how we can accomplish these things if they're not gonna let us do much renovation at all on a building. If we're talking about rural health, I just feel like if we're getting into this thing that I used to have to fight, is people in cubicles that don't know what they're talking about making decisions about what we should do up here. In a rural setting, you have to do some of these things. Now, my next question is, what is meant by strengthening primary care? What are we expecting there?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah. Let me go there. So your first thing I'm just going say, the rules are the rules. We have to

[Francis "Topper" McFaun (Vice Chair)]: follow them and we're going to

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: do as much as we can with the dollars that we have in the allowable ways. That's what we're doing. As I said, it's not our entire strategy, and there are things that I wish we could do that don't appear to be allowable. So I can't change I don't spend a whole lot of time on I wish the game board was different. I just focus on what does it look like and what can we do. It's just, that's all I have. I just try to

[Alyssa Black (Chair)]: control I'm not trying to take up a

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: lot No, of I know.

[Francis "Topper" McFaun (Vice Chair)]: But when I hear that there's housing or renovation and other grants, and they're not here, A strategy. I used to just get out of Washington and go to the Senator's office and they would come over with me, where I have to be, and then it would get changed. Because you could explain it to the individual that was in the cubicle.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I don't think that that is likely to happen here.

[Francis "Topper" McFaun (Vice Chair)]: Okay, all right.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Okay. So

[Francis "Topper" McFaun (Vice Chair)]: now we get back to it.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: All right, let's go, let's talk about rural health networks. So let me just go there. And again, I can't, Yeah. Sorry.

[Alyssa Black (Chair)]: Okay. Before you go on. Okay. So shared EHR, are we talking about supporting the initial implementation? Yes. Are we talking about the monthly for five years? Will pay like the monthly user, you know, because EHRs, you pay for them once and then you keep paying for them over and over and over.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I think it's to make my I believe it's to make the transition. Make the transition. Yeah. But I have to say, I am not subject matter expert of all of the any of the I'm going to even say any of these pieces. So there I can't go overly deep on every and I think over time, as we start to move this forward, you may want to hear from our subject matter experts over time as we evolve. Okay.

[Alyssa Black (Chair)]: You're not going to go to strengthening rural health workforce because we have three questions. No, get there.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Mine's fast. Okay.

[Leslie Goldman (Member)]: Will So the grant pay for lost revenue to implement EHR?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I don't know.

[Leslie Goldman (Member)]: That's huge issue.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I don't know. It's a great question. Are you taking track of my questions? I'm not tracking the questions. Okay, think I might be too, but I can't see her.

[Allen "Penny" Demar (Member)]: Real quick, rural health transformation. Is that all of them What's the definition of it?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, so that's a great question. I can't give you a definitive answer. So generally, Vermont is considered rural except in most of Chittenden County. That's how the feds have typically defined us. It does appear that there is flexibility to provide, and we're working on this now. Is a question we've been asked is can we provide funding for, say, a Chittenden County designated agency or a FQHC? So I'm figuring that out with our attorney. So maybe I don't think it's must we, but we'll check that too. And then the final question will be, is that should we or will we? And I think it may even depend on the project. So I think that's a really fair question. We're also getting input from our other states to understand how they're approaching this. Maine is not dissimilar to us in that they have tertiary care centers in essentially non rural areas of Maine. Vermont is, for my kids who live in the city, to Burlington, they don't think that any part of Vermont is not rural. That is a great question. Part of what we'll be grappling with.

[Alyssa Black (Chair)]: I'm just thinking about the health network. If two of their hospitals in the state are considered rural, Middlebury and Barrie, Berlin, Can you help the entire?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, this is where I think it actually may even end up having being different potentially even depending on the project, because some projects won't impact, say, an FQHC at all. So it won't matter or a it's a fair question. It's on my list. I don't have a definitive answer today.

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: Daisy. First of all, I just, for the record, disagree with you that Chittenden or that the definition of rural Feds consider it everywhere else, I chittenden. Think the Feds have multiple definitions.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's true. That is fair. That is fair. That's fair. Just totally fair. We note that.

[Daisy Berbeco (Ranking Member)]: But the other thing is around EHR. We're noting Epic consistently in this. Is that already committed? Is the contract signed to go with Epic? Have we leveraged and this is just for Brendan to come back and talk about later. But I want to make sure that we're leveraging the opportunity with all vendors. I think it could be a huge opportunity for some vendors. And I understand that Epic might be more widely used. But I think we have to hopefully go through the usual process with vetting vendors and making sure we give

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: feedback on. Yeah. Is how exactly we do this is on my list of things I'm worried about, like how to specifically make this happen. It was conceived. I think the request came in as a concept around sharing Epic. It was.

[Daisy Berbeco (Ranking Member)]: And I think technology is one of the biggest opportunities in this project and also the most expensive and cumbersome for providers to implement. So I hope we can get some good expertise in here talking about the plan for CNG.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, that will not be me. Definitely will be me. Okay, more work there. Okay, let me get to some of the other things, because I'm watching the time. I mean, this is the slide with the most up on it. So strengthening primary care. And I think you're going to want to hear from our blueprint team at some point, but a lot of what we're trying to do is modernize the blueprint. So enhance our community health teams that work in our communities and have our multidisciplinary team that can support individuals with chronic diseases, support primary care practices, supporting individuals with chronic diseases. People with multiple chronic diseases are definitely a critical group of people to work with in order to help reduce things like hospitalizations and ER visits. That's where some of the opportunity is. We're probably most of the opportunity is. So it's really an opportunity to modernize our blueprint. So, to think about whether we can. How it strengthen the relationship between specialists and primary care through some kind of shared payments, whether we can have a PMPM payment for primary care for some capacity, some kind of capacity building, whether we can do that. So the idea and then strengthening that community health team, but also in order to have a payment model around community health teams, which it's right now more fee for service, as I understand it, We need to have it be a little more consistent from community to community. It kind of grew up organically with a lot of local input and flavor, which is great, it also makes it really hard to implement a payment model consistently across the board. And so there's some rethinking to do about how to balance those individual needs of communities with the desire to actually find a payment model for that work. So that's the concept. And I think you're going want to hear more detail as that unfolds. So there's also support for we're talking about trying to figure out a way to support transfers better. There subscription services Oregon has one where there's just more information about where there's availability of beds. I have to say, as a long time provider advocate, this is hard because it is not the pillows and blankets that make a bed. It's the people staffing them. So this is a people thing. And then there's also in certain settings, that some individuals who might be served can't be served with other individuals. So just because it looks like there's something available doesn't necessarily mean that it actually is going to work for the individual transfer being considered. So it's complicated. So that's going to be one that we're trying to build out to improve our ability to see where people can go. Because we know we have a lot of individuals who are sitting in hospitals who no longer need hospital care. And one of the critical things we have to do is reduce the number of people who are getting care in a more expensive setting than is necessary for what they need. So I feel really strongly about continuums of care. We've got to have a strong nursing home system, and it's definitely in trouble. We need to have a strong hospital system. We need those most expensive parts of the system. We really do. But we don't want to use them when there are other options. And so figuring out and we have done some work, policy work even, to we actually made a real strong effort to reduce our reliance on nursing home beds and move care into the community. And we went too far, in my view. We went too far, and now we don't have enough nursing home beds. And taking capacity offline is scary because it's very hard to build back. Very hard. Once you close it, really hard to reopen it. So something you've got to really think about. So anyway, figuring out our transfers, moving people, figuring out ways to bring specialist consult into rural communities without physically bringing specialists, because it's really hard to recruit all the specialists people need physically into every part of the state. There might be ways that providers can share specialists. There might be ways that they can do e consults. Some things are actually fine electronically with a local clinician and an electronically available specialist. There are ways to do it. So working on that kind of, I think technology of bringing care to people. I mean, again, I have a home health background. Even bringing people to a doctor's office is hard. Mean, think about it, right? Like my mother is 86 and she's mostly mobile and can drive. At the times in her life when that has been affected by a fall or she's had various things happen, she'd love it if she knows talking about it right now.

[Alyssa Black (Chair)]: It's a

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: project. She's going go to the doctor. Now it's a project. It's a family project. How do we get her to the doctor? She lives two flights up. She's not married, lives alone. Now it's a family project. So that is something I think about a lot. And so trying to get care more to people. So that's where remote patient monitoring comes in, where people with chronic conditions, they can monitor their own vital signs in the home. Nobody pays for this. Home health does it, primary care does it. There's no payment for it so that people can be monitored and then have experts know like, oh, this is a sign that you are starting to have something that's not fully controlled where we might if we can help you now intervene now, not be able to add hospitalizations. Now, the big area that I'm really excited about is using the EMS workforce in a different way where we can because the EMS workforce isn't always busy. That's how I think about it. They're not always busy, whereas like a home health network, Daisy, everybody's busy, busy, busy. There's so many people to see. But EMS isn't always busy. And so there are some pilots in the Broward area around what they call community integrated health. It's essentially EMS doing things like pre lab work for your surgery. They go to your house. And they do it at your house. And so there's scaling that figuring out how to scale that and also how to. This gets tricky, how to pay EMS differently so that they don't only get paid if they take you to the right now, they only get paid to take you to the hospital. They take you to a clinic. They take you someplace more appropriate than the hospital. They don't get paid, but we can only adjust their Medicaid payment. We can't fix their Medicare payment and Medicare. There are a lot of what they do is under Medicare. So we don't have control over everything. But lots of work there. Expanding complex care in skilled nursing facilities, dialysis and ventilators. I believe we have one nursing home that has a ventilator right now in the state. And more and this is stuff we can buy, right? This is like we can buy stuff. This is that's a good use of limited funds. So getting dialysis and ventilators into nursing homes, so they have higher capacity for, a higher acuity is really important. So that is a smattering of all of the mobile units, urgent mental health and substance abuse, urgent care. There's a lot.

[Brian Cina (Member)]: I mean, it's just it's so

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: hard to go over every single piece in one hour. But I so this is it gives you an overview. And then I think I only have a couple more slides. Because this is a big piece and then we have that list that's on our website that you can look at if you really want to see, like, are all the pieces.

[Alyssa Black (Chair)]: Karen, you have a question? Yeah, I'm curious about just continuum of chair concept. And so no longer appropriate to being in hospital, maybe the home is not a safe setting to go to.

[Leslie Goldman (Member)]: And so that intermediary place is

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: sort of like it's not Medical respite. Kind of stuff. Yeah.

[Alyssa Black (Chair)]: Yeah. Is there any support for that kind of continuum?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So I think some of that could fit under this sort of transformation bucket that we've come up with. And so this is where writing a good RFP so that some of these ideas can come forward and they don't have to all be uniform. I mean, we don't have have good ideas in some places might be worth doing. So I think that's where I feel like that is really figuring out how to do regional transformation. I will actually just say this is just a philosophical thing. You've given me an opportunity. When I think about how we need to transform the system, I'm really thinking regionally. I'm not really thinking statewide. Very little matters healthcare wise statewide. There are certain things we have to have in the state. We need to have tertiary care. So there's some big things. A lot of stuff can happen in your region surgeries, and then some stuff has to happen close to home. You have to have prenatal care close to home. You have to have primary care close to home. But most of the work that happens in, you know, it's like from hospital to home health designated agency it's happening in a region. And so when I think about our transformation work, this is bigger picture we'll talk about other days. But it matters for the support we have for that in this grant. I think about it more regionally because that's where the people are moving around. That's where most of the care is happening. And that's where most of the referrals are happening. Sometimes hospital to hospital, but often hospital to home health or physician to. So just when we think about it, I think that is important. Again, like that respite housing or recovery housing is something that we have in here, more recovery housing.

[Alyssa Black (Chair)]: Talk a little bit because we haven't really heard about it in this committee, the pilot in Brattleboro, you know, using EMS.

[Francis "Topper" McFaun (Vice Chair)]: Yeah. Like

[Alyssa Black (Chair)]: how does that, it doesn't work. I mean, are they going, are they, I'm thinking about I'm thinking about ways we can spend this money. Yes. Yeah. Can we buy ambulances?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, we can buy stuff. Yeah. I think we can. I'm not sure. This is a great question. Have maybe cars too. Project is going to be led by the health department because they have that EMS office and expertise and relationship with the EMS providers. So I definitely am not a subject matter expert to go deep enough. I just understand it conceptually. So I think you're going to want to hear more from them as that develops. I don't feel like I can give you accurate details or adequate details. Yes, but I see what you're saying. Like, why you don't necessarily have to drive to the ambulance to go do to do blood work. I don't think they're doing that. Yeah. I doubt they're using.

[Alyssa Black (Chair)]: I hope not. That's a lot

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: of wear and tear. Why would you do that? Yeah. No, it doesn't wouldn't make sense. And I mean, the other thing is also like, I've thought about too, like, are there other ways to use our home health, although they have less potentially workforce capacity, but their home health is often limited just by essentially what the rules say about what they can spend money on, like what they can get reimbursed for. So you start to think about other non billable services that we might want to experiment with. But then, of course, we have to remember this is going to end. This is going to end. So we have to have a plan for what do we do then. Yeah.

[Alyssa Black (Chair)]: Know. Lori?

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: I had asked this when you guys were putting this all together. I'm curious now that we've gotten even more than we were going to. Are there immediate legislative

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: policy changes that you need? I don't think so. There may be one related to looking at reinsurance for the exchange plans, and there's a waiver, and it's possible that there's something there that we'll need. I don't think it's going to be this year, but that's the one thing. Somebody asked me this and I was like, oh, it might be this year. The other pieces we're going to have scope of practice issues around, EMS. There are a few other things, but I don't think we need them this year. I think we're going need them next year. Now I will say this is a good opportunity for me to say we did this fast because it was a fast turnaround. We are now diving deep. And I have no doubt that as we dive deep, we're going to identify things that we need to adjust. There's no way we did it perfectly in the time that we had. And so I just want to say this is how it looks to me now. But there may be some we may come back and say I was wrong. I reserve the right to be wrong. We all do that. I mean, it happens to me a lot. Yeah.

[Alyssa Black (Chair)]: Allen, did it No,

[Francis "Topper" McFaun (Vice Chair)]: I'm not stuck.

[Alyssa Black (Chair)]: Leslie, did I see your hand up?

[Allen "Penny" Demar (Member)]: Love you mentioning my name, I have a comment.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Oh, dear. Oh, okay.

[Allen "Penny" Demar (Member)]: Okay, well we've five years to do this. I hope whoever's in charge will at least think about the consequences after this ends.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, absolutely. And CMS is making us think about that because everything has to have a sustainability plan. So yes, we have to think about what

[Brian Cina (Member)]: we build something.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes. We build something. And then now what do we do? Yes. Okay. And, but a good use of the dollars is it's expensive to build things that can then be a service that could be built like through our normal channels. That's to me, like a, would make sense. Right. We get something stood up that can then be sustained through sort of a more normal reimbursement process. Yeah. Is there

[Alyssa Black (Chair)]: was Maple Mountain?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Oh, Maple Mountains in here. Yes. And they're named. They're named. They're Yes. They're the only named thing.

[Alyssa Black (Chair)]: Okay.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Just as a reminder. The only thing that we don't have like, so you were asking me about like EHR is like there's nothing is named about the EHR. It is open ended in the application. It's just more how I've heard people think about it. But the Maple Mountain residency is the one thing that we actually listed as a subrecipient. So that should be a faster thing. Isn't BT?

[Alyssa Black (Chair)]: That's what I was going to ask.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Oh, That too. What was that? That's in there because of you. I didn't hear you.

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: BTC TAP, which Jill's going to tell us the acronym. Yeah, like child and psychology. You just tell

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: other people. Thank you. Thank you all the other people for Psychiatry. Yeah. So we want So that's a program that has grant funding ends in September, I believe. And that is a program for essentially, it's essentially an e consult for child psychiatry. And so we should be able to continue it, but we're going to have to figure out the sustainability piece, but we did add it because somebody noticed that one of you noticed it in the e consult. So we were able to add that. Sort of we had it was it fit well enough that it was a pretty quick change. We did not put in. No. I would say that might fit under in. There's some option under transfer. Again, I think this transformation piece is going to be the place where we've got to get more input on what that is going to look like and what our requirements are going to be. That's where I see the most sort of continued flexibility. And we'll have to limit it to we don't want the secretary says, 1,000 flowers bloom is not a great It doesn't work well. Everything happening, we can't We have to We're going to have to make choices. Yeah. I think I've come to the end of the things I wanted to say today. I'm going to stop sharing.

[Brian Cina (Member)]: I saved all my questions for the end. Oh great.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's why

[Alyssa Black (Chair)]: I have to get approved. Justin in my chair.

[Brian Cina (Member)]: Maybe the thing that my mom grabs in the car when I go around the corner.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, the thing. I do that one. He loves it. And when I gasp, he really loves that. So

[Brian Cina (Member)]: you had said we can't use it for housing, but then I saw recovery housing. Can you explain? Oh,

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: yes. So we can't use it to build housing, including recovery housing, but there are also operational costs to standing up new recovery housing. We work for the health department on the language so that we're directing it toward the things we can use it for. And then other dollars would have to be used for the actual renovating of the buildings. We can't use it for that.

[Brian Cina (Member)]: So it could be used for the social infrastructure, but not Okay, the thank you. That's great, actually.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's a much better way to say

[Brian Cina (Member)]: Well, that's me summarizing as I understand it. Second, you talked about public engagement. Is there any talk of working with the regional planning commissions on the idea? Because when I brought it up to them, they said they haven't really been asked to look at resources on a regional level, like when they're doing the regional plans regarding healthcare. So there is a short form bill that I'm introducing related to them that has a component around this. But it sounds like there might be room in this proposal to work with our regional planning commissions as they develop regional plans to look at the coordination of health services regionally, because you mentioned wanting to do that. So just something to throw

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: out Yeah, I'll put that in my thinking cap. I haven't thought about it that way. I thought more about our blueprint and our regional community health teams. We have other sort of regional infrastructure set up, so I hadn't thought about it like that. Thank you.

[Brian Cina (Member)]: That's There's way to integrate that. And then last but not least, I noticed on the final page, and this might not really fall under this committee's jurisdiction, but it is on the presentation around limiting

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: the SNAP waiver. Yeah, yeah, didn't get

[Brian Cina (Member)]: the Decide what's nutritious or not.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, it's a whole thing. So we did say in this application we would pursue the SNAP waiver. My understanding is that that's actually sort of outside the purview of health care reform. It just happened to be in the RHT. I know that people have concerns about that as a matter of policies. A number of states have put it into effect. My understanding is we have not made a final decision about whether we would implement the SNAP waiver. I believe we've already been scored on it so that what mattered for the application was whether we had it in place or not at the time of the application. So I don't think it has an impact there. And I think you're going to hear more about that as it gets explored further, but probably not in this committee.

[Brian Cina (Member)]: So my last comment for you to just take into consideration would be the potential, is there potential for implementing rewards for healthy behaviors instead of punishing people or restricting Imagine if we get a tax break if we ate healthy.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, we actually had a whole conversation about whether we could do tax credit based and the answer was no. Yeah, we had a whole thing about whether we could figure out a creative way, mostly for workforce purposes to incent workforce. So we dug into that and it was definitely not allowable.

[Brian Cina (Member)]: Okay, that's too bad. Because it sounds like we can punish people for their choices, but we can't reward them. And motivational incentives is an evidence based practice. Contingency management be funded through this? Don't know what that means.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Okay, you

[Brian Cina (Member)]: can look into it. Your policy director knows.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I'm sure.

[Francis "Topper" McFaun (Vice Chair)]: Everything's talking about. All

[Brian Cina (Member)]: right, thank you.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I don't know all the things, I probably never will.

[Alyssa Black (Chair)]: We only have you scheduled till ten. Are you okay going a little longer or do you need

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: to get I can, but I actually do. I should really stop by

[Alyssa Black (Chair)]: 10:15. Do you have more? I was hoping that, because it's going to be a theme this year, primary care, if you could just go into a little bit more detail because I know you have multiple different things. And then I have one other question after that.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I always feel, I will just say, I feel a little like I don't have my arms. I don't really have this in my head in the way that I would like. I'm trying to get there because people keep asking me, and it's a really, really fair question. I'm opening my list. It's all very new still. Yes, and there is no possible way that I'm going to learn all the things about all the things. It's not possible. And I'm used to it, honestly, in my previous role, I pretty much like if you ask me a question, I probably know

[Brian Cina (Member)]: the answer is like, This is how it works.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Actually, how

[Alyssa Black (Chair)]: do you make it easier? Oh, great. Super. Is the ideas and the proposals around primary care, is it purely built upon our blueprint?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, is built upon modernizing our blueprint. Yes. The blueprint is the foundation.

[Francis "Topper" McFaun (Vice Chair)]: Okay.

[Alyssa Black (Chair)]: And I realized that we can't use the money for services, for billable things. Can we use the money for blueprint? We think we can.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Okay. But again, not all the details are worked out with CMS. So I could come back and say, when we got it all hammered out, they said no. But we think that there are parts of Blueprint where there is funding, there's reimbursement happening like community health teams that isn't billable. And so it does fall under a lot and allowable creative use of these dollars.

[Alyssa Black (Chair)]: And yes, and just to go back, I mean, I know everybody's super excited about this money. I just want to go on record as saying, I'm really concerned that we're infusing more dollars into our system of healthcare. And once there's more dollars, you can't take those dollars away. And you're going to have to sustain it. So if someone is going to come here five years from now and say, we need to bridge funding for the blueprint.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I can hear it already. Yes, hear

[Leslie Goldman (Member)]: it already.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yeah, I agree. And I think some of this will, you know, there's questions about whether we pursue the ahead model and what are the options going to be there? How are we going to sustain things is, I think, a shared theme and a shared concern. And that will probably make a difference in terms of what we say that we should move forward with and how we might frame some of these requests for proposals, because we really need to think about the sustainability. I think we are in lockstep on that.

[Alyssa Black (Chair)]: And I know the secretary is concerned about that, too. And my last question is, are we allowed to use the funds initially to fund administration of spending these funds?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: We have positions. We have positions in the grant. In the grant.

[Alyssa Black (Chair)]: So they are

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: allowing us use

[Alyssa Black (Chair)]: us or to use us. So this to me sounds a lot like ARPA funds.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: It is. Yes. I think that is a fair comparison. And yes, I think it's except that we had more flexibility for extensions than we're gonna have here.

[Alyssa Black (Chair)]: They had a that they modified a couple of times along the way. There anything like that that you could use for reference?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I don't know. So the team that worked on the ARPA funds, there's a lot of those people exist in the agency of human services. So they are making those linkages. And yes, we are expecting more and more information to come out from CMS about what the rules are, what the expectations are. Yes. And can we build on that? What we learned from that project? Yes. We're already looking at a better grants management tool than the one we have. Just because there's so much complexity and there's going to be so many recipients potentially over time. Did I get that, what you're asking?

[Alyssa Black (Chair)]: Any other questions? Copper.

[Francis "Topper" McFaun (Vice Chair)]: We've got two minutes. Know, I only have to Chittenden, this is a question for you, but you have to be here to answer it too. We have in our clinic quite a few places that are blank. Yes. And I'm wondering, a lot of questions were asked this morning that didn't have an answer, but could get an answer.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Some need time.

[Alyssa Black (Chair)]: Think Ms. Olson just said she has

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: to be out of here.

[Francis "Topper" McFaun (Vice Chair)]: No, I don't want him to

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: it He's all done with me.

[Francis "Topper" McFaun (Vice Chair)]: I'm talking about in this document there are blanks.

[Alyssa Black (Chair)]: Oh yes!

[Francis "Topper" McFaun (Vice Chair)]: Is it possible to schedule somebody that can get those answers?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: So there's a few things I think we can answer, but some things it's that not enough time has passed and we haven't done enough work yet. And so I'm really, I'm sensitive about, I don't want to sort of have lots of like, well, we don't know yet, we're trying to figure it out. We're going to get there, but we do need a little time. We don't even have a final award with CMS until January 30.

[Francis "Topper" McFaun (Vice Chair)]: So is that a roundabout way of saying, I don't think I would do much good by coming back again?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: On this, I need a little more time. But you'll keep us posted. You know where to find us.

[Alyssa Black (Chair)]: I'm gonna let Jill go, but I'm on a level set because I thought it was important that we hear from her today. The people sitting around this table really have very little control over and with this. We don't even get the spending authority. This is a grant. It will not come through for them to spend it. So it's informational and we're going to be watching and observing and overseeing, but we don't really have any control.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: Yes, and asking questions, which I have an expectation I'll hear. And some of you have more expertise than I do on some of these pieces. I have every expectation of that.

[Alyssa Black (Chair)]: Yeah. We'll probably criticize you a little bit.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I'm figuring on that too. Yep. That's okay.

[Alyssa Black (Chair)]: That's okay.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: That's fine. Did

[Eli Houghton (Health Portfolio Director and Legislative Liaison for Health Care Reform, AHS)]: I just say on the positive side of that, you coming here and educating us helps the word get out to the public. Yes. So it's a two way street.

[Brian Cina (Member)]: Absolutely. Yes, absolutely. Are we allowed to give suggestions?

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: I can't stop you. We are working on formal ways to do more listening as well.

[Brian Cina (Member)]: For example, me suggesting you talk with the regional planning commission. If it's unwelcome, I'll just keep them to myself and roll my eyes and not say anything. But if they're welcome, I'll make suggestions. But I don't want to give unwelcome suggestions and then have people get annoyed.

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: You can give me suggestions. Yeah. I mean, we're trying we have a lot to figure out here. So I would like know, I appreciate more brains in the mix for sure, but I also just need to make it clear we're gonna have to say no to all kinds of things. That's just I will be trying to disappoint people at a sustainable rate. That's my theme. And again,

[Alyssa Black (Chair)]: thank you. Thank you to everybody at AHS. Even though I personally don't think we should I don't want this money, You guys worked really, really, really hard to get it. People worked hard. You should be

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: If I have learned coming from the outside, you can't believe how hard people work in that place. People work so hard with such a high level level of commitment and dedication, usually without credit. It is something. There's some incredible public servants that we're really lucky to have.

[Alyssa Black (Chair)]: Yep. Alright. Thank you very much.

[Francis "Topper" McFaun (Vice Chair)]: Thank

[Jill Mazza Olson (Medicaid and Health Systems Director, VT AHS)]: you. Thank you.

[Alyssa Black (Chair)]: Alright. Bye.