Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Good morning, everyone. It is Thursday, March 26. Sorry, we're running behind, but clearly not on our slides because they're already up. So first in this morning, we have Michael Costa from Gifford. You want to come on up? So I kind of want to set the stage a little bit about what's happening this week. We have several bills coming over, which we haven't gotten yet, but there is a bill coming over from primary care. And we've talked about this a lot this year. And so this week, we're just kind of taking testimony on these are things that I want people to be thinking about when we're working on the Senate bill. And so we have all sorts of fantastic witnesses coming in to share with us. So while it may seem like the topics are a little disparate, I just want everyone to kind of get a grounding of things that we will be talking about. So we've asked Mike Acosta to commit.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Right. Madam Chair and members of the committee, thank you so much for having me here today. Good morning. My name is Michael Costa. I serve as President and Chief Executive Officer of Gifford Healthcare. Gifford is an unusual healthcare entity. We are a 25 bed critical access hospital, a federally qualified health center providing health care services regardless of the ability to pay to Vermonters, and we're a retirement community. We have a 49 bed independent living campus, a 30 bed nursing home, and an adult day care. We're located in Randolph, but we have clinics all throughout Central Vermont from Berlin down to the Upper Valley in Sharon. Gifford's been around for a hundred and twenty three years, and we are not presently affiliated with either Dartmouth or UVM. But of course, we have close working relationships with a variety of hospitals. I came into Gifford about a year and a half ago. My background was in public policy. I worked in government agencies in Massachusetts, California, Wisconsin, and Vermont. Came to Vermont in 2010 and then worked at the tax department, worked at the JFO, got involved in health care as deputy director of health care reform for governor Peter Shumlin, then stuck around to be deputy commissioner at Diva for governor Scott. I'm a lawyer by training and have a master's in health care delivery science. And I woke up and realized one day I have all these opinions about health care, but I've never actually worked for a place that actually cares for people. That seemed, to be blunt, that seemed dumb. And so I wanted to see how rural health care works. Instead of going to UVM or Dartmouth, I went to Northern Counties Healthcare, which is both a federally qualified health center and home health and hospice agency serving the Northeast Kingdom from St. Jay to Hardwick, to Island Pond to Newport. I'm passionate about how you might transform Vermont's health care system and take care of rural populations. And while I was there, learned that if you really want to transform the system, you need to have great relationships with hospitals. And although we did, we were in charge of any hospital, and so it was hard to get traction in the way I wanted to get traction. And Gifford at that time was looking for a CEO. So I came in in October 2024. I accepted the job at a certain point in time. Between when I accepted it and started, the Oliver Wyman report came out saying, hey. We really need to transform Vermont's health care system, a fascinating way to start a job. But in retrospect, it was a difficult gift than a gift that Gipper needed. Because although we are big hearted, our business was not sustainable. And so we spent the last year and a half trying to figure out two big picture things. One, how do we make our organization financially sustainable? And two, how do we play a role in improving Vermont's health system? I don't think it's enough for Vermont's hospitals to be competent and just offer great care in their own community. They have to figure out how to make the system more of a system. And so Gipard is passionately engaged in that work. And this morning excuse me. This morning, I'm I'm here to speak to a one part of that. Because one of our views on how Gifford might serve the broader health system in the future as being a place to train people that want to work in rural communities. So I come to you today as CEO of the Maple Mountain Consortium, which is an effort to try to launch and sustain a family medicine residency program within Vermont's health centers. This effort started several years ago with a group of FQHCs, mostly led out of Memorial Health Partners. Memorial Health Partners ran into some financial difficulty, the program was at risk of of stalling as an effort. We raised our hands at Gilbert and said, we wanna lead this. And people at the time, including my own board of directors, said, you kind of have a full plate. Like, what do you what do you mean you wanna take over and try to launch a residency program? And I said, that's true, but we've gotta get out of the day to day in health care. And that's real hard because health care takes care of people twenty four hours a day, seven days a week, three sixty five days a year. And when I tell my former colleagues in public policy, the major difference between policy and being out in the field is that you've got to execute every day. But if you don't lift your head up and ask deep questions about the system, you're not gonna be effective, and Vermonters are gonna suffer. And so, to me, we need to make some bets about the future and about how we're gonna transform. And so Maple Mountain is one of the ways in which we think we can train people in rural centers of Vermont, outside the academic medical centers to create the workforce we need and to get people to stay. And so if I might, I'll just quickly go through a few slides and talk about Maple Mountain, what our what our hopes and dreams are for it, what our progress is to date, and where we are with funding. So we're at a very interesting point about whether we might actually be able to bring this to life. I'm sure you can read faster than I talk, though I talk real fast. I'm originally from Massachusetts. I'm six generations away from being a real Vermonter. I kind of go fast. So please tell me. Slow down. You. So our hypothesis is simple, like family medicine strengthens rural health care. We have sick people in Vermont, particularly in the rural parts of the state that need care, and access to primary care has been an issue here and in other rural settings. As everybody in this committee undoubtedly knows, our demographics skew older. And so we by and large have an older and sicker population than other states. And people tend to travel long distances to reach primary care. But overall, the crux of the problem is we don't have enough primary care workforce today, and that problem is likely to get worse over time. Right now, we have too few primary care providers for our population, probably about a fourth of what is needed, and most of them are getting older. When I look at my workforce, it reflects the fact that when this was measured in 2022, nearly half of all primary care physicians were over the age of 60. We are engaged in the effort right now to try to recruit younger physicians because the people we have are super mission driven, and they have panels that they've developed with patients over thirty years. And they they lie awake at night in bed thinking, what's gonna happen to my patients when I'm no longer in the workforce? And so we know that we need to pass the torch to a new generation of physicians, but we somehow have to bring them to Vermont, and we think that we can train them here.

[Rep. Alyssa Black (Chair)]: Go ahead, Val, and have a question also. So looking at the age Mhmm. What is the what what's the general recurrent age you need?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: So I can definitely go and try to find some data on that. My experience working at several places in Vermont is around 70. People start slowing down or thinking about, hey, want to reduce my hours I wanna go to per diem or I wanna train people, but late sixties, early seventies. I will tell you something I've learned because I lead a healthcare organization, but I'm not a clinician. So I'm very respectful of the fact that I can't do what they do. That for a lot of Vermont's primary care physicians, they make the distinction to me, this isn't what I do, this is who I am. And so they don't suddenly stop being a doctor because they're not showing up in our clinics. And so they tend to work longer because it's part of their personality to get a lot of joy from it. But around 70, they're starting to look for, what's my off ramp here? There was a tremendous article, I believe, in Vermont Public couple years ago about doctor Bob Primo in Island Pond, who had been the only physician in Island Pond, for over three decades. When I led Island Pond, Bob was amazing. He's not afraid to give the CEO really direct feedback, about what's working, what's not working. But Northern County still hasn't replaced him almost two years later because it is that hard to get a physician into primary care, particularly in remote outposts. So for us, I'm trying to get someone to say Chelsea or Rochester, which is on the other side of the mountain from our from our hospital, like, are really hard jobs to get people going. You need somebody who lays up every day thinking that's what I wanna do. So

[Rep. Alyssa Black (Chair)]: That's just to say that that story on Vermont Public was riveting. I I found it riveting. Other people might not, but I encourage anybody to go listen to it.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: It's amazing. And I know I don't work there anymore, but the Island Pond Clinic is a really special place.

[Rep. Alyssa Black (Chair)]: So how many individual distinct clinics sites do you have does Gifford have within their FQHC? So

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: we have Sharon, Chelsea, Randolph, Bethel, Rochester, and Berlin. So we have six clinics, and they're a combination of primary care and specialty care.

[Rep. Alyssa Black (Chair)]: How many physicians, not APPs included, but how many physicians do you have serving all

[Rep. Leslie Goldman (Member)]: of

[Rep. Alyssa Black (Chair)]: your clinics?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: So I'm gonna reveal one of my biases as the CEO of Kifford. I cannot answer your question because I tend not to make a distinction between physicians and APPs. Because by and large, they're doing very small work. So I think of in terms of we have 48 FTEs of clinicians working for us.

[Rep. Alyssa Black (Chair)]: Does that include specialty

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: or is Specialty, that just but I can report back on pediatric and primary care and specialty together.

[Rep. Alyssa Black (Chair)]: I keep asking this question in this committee. I'm thinking what is the right panel size?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Oh, okay. We are in the midst of a really robust conversation about that right now because it affects access to care for for Vermonters. We are the general way we think about it, and for any of my team that's watching here, mileage varies depending on the acuity of your patient panel. We're looking for people to see about two patients per hour to start and have a panel of about 1,200 to 1,400 patients. When we look at national data, patient panels are generally 2,000 and above. We have a lot of health needs in our community, and so we generally are are aiming for about 1,200 patients on the panel. Gifford, to be candid, has a lot of room for operational improvement. We had not evidently prior to my arrival kept good data on panel size. But if we can't measure it, we can't improve it. And if we wanna create access to care, because I told team consistently, we wanna build bridges, not moats, with our community. We need to figure out exactly how many people we're aiming for. So we're aiming for about 1,200, and we're going to tinker with that over time.

[Rep. Alyssa Black (Chair)]: Can I make a comment about Chattra has a question, but and then you can make your comment? Because Leslie and I are having an argument over what the perfect panel is.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: We welcome your feedback.

[Rep. Alyssa Black (Chair)]: Disagreement. Go ahead, Dante.

[Dante (unidentified committee member)]: Yesterday I went to my farm in Cape York. What I am sensing is this trend for the doctors to work, not full time but part time. Now there is, I think nine doctors in that and there is only one of that group that works full time. My primary care used to work full time, but he said, I am getting burnt out. One thing I noticed is the time that he spent with me yesterday was way long. So, in your experience and seeing what is going on out there, Is that how they're trying to keep working?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yes, I think if you were, I can only speak for Gilbert, but I think if you were to talk to my peers throughout Vermont, when we bring on, say, a primary care physician as a one point zero FTE, so a forty hour week worker, though they all, between notes and phone calls, work more than forty hours a week, we all anticipate within twelve or eighteen months, they're gonna come back to us and ask for a smaller amount of time, like point 9.85. And I think the two things that generally physicians and other HP's talk to me about are one, burnout. Hey, we're feeling burned out. We wanna just try to protect a little more of our time. And two, quality of life and work life balance, particularly if although we try to remain very competitive with our compensation at an FQHC in a rural hospital, We don't have as many poker chips as Dartmouth and UVM. And so sometimes people say, hey. I I could go work for Dartmouth and UVM and make more money. Part of the reason why I'm here is because I love the mission, and I want some work life balance. I wanna spend more time with my kids. I wanna spend more time with my grandkids. And so, generally, they're drawing a little bit back on that. We are trying to employ some strategies like the use of AI scribes and other support staff to help them with notes and medications and refills to take away the parts of their job that they find tedious and get them to focus more on the time spent with their patients. Because we find that when we do that, they have more joy in that work, and they're less likely to wanna back off on what they're doing. So that we think a lot people talk about recruitment all the time, but we actually spend a lot of time thinking about retention because we want people to stay in their clinic, we want people to keep working at the pace that our patients need. Right? Because there's still a mismatch. We need more primary care that we can offer and provide.

[Rep. Alyssa Black (Chair)]: Forty hours. Is that forty schedule? Okay. I was gonna say, because that's not a forty hour work week.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: No, and you're absolutely right, madam chair. For any clinician who's seeing patients, we generally divide their time between patient facing time and administrative time. The ratio of that depends on where you work and depends on what your role is. But, yep, forty hour work week would mean that some subset of that is patient facing and some part of it is administrative.

[Rep. Alyssa Black (Chair)]: Leslie? Yeah.

[Rep. Leslie Goldman (Member)]: I mean, we've been talking about panel size. I'm a retired family nurse practitioner, work for primary care, I have that view, front of the house kind of view. The panel size is interesting because in some places anyway, say if you haven't seen your patient in three years, then they drop off your panel. So that's used against young people because young people don't need to be seen every year and that often. So having a panel that's balanced with acuity and age really can make a difference. And I was thinking more about when you said 1,400, that's kind of where I'm, like fifteen hundred in that kind of, well, hopefully there's a number of healthier people on the panel that don't require that kind of attention. Yeah. I I a 100% agree with you. I think part of it sounds very obvious, but part

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: of what I'm trying to do at Gifford is to bring more data to what we do. And so now that we've established panel sizes, we're having conversations about what it means to be loss of care. Yes. And if you're 25 years old and you're very healthy, you're not necessarily loss of care if you're not seen in twenty four months. Yeah. And if you're in your seventies and you have diabetic foot problems, we definitely we need to see it. And so we'll have to adjust the panels for acuity in exactly the way that you're describing as we get a more sophisticated understanding of how to manage our patient size.

[Rep. Leslie Goldman (Member)]: But I've seen what happens is that the younger person gets dropped off the panel and they have an acute event, sore throat, whatever, and they can't get seen because you're not one of our patients anymore. And I think that's a huge problem in how we define panels.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: I think you're describing exactly why we, as a leadership team at Gippard, talk to our clinics about, are we building bridges or digging moats? Like, we wanna build bridges to folks and just because, you know, you're super healthy, you ran a half marathon, and you haven't seen us in two and a half years doesn't mean we we don't take care of you. That's right. Right? So I I think your point's really well taken. Yeah.

[Rep. Alyssa Black (Chair)]: We also have a tendency to keep people on our panel. In order to keep them on our panels, we schedule them yearly when they don't need to be seen yearly, which then takes up space where provider could be seeing someone who legitimately needs them rather than someone who's just on their schedule to maintain the panel size.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: The committee is right on it. The way in which we describe that at Gifford is one of the most important jobs in healthcare and one of the most difficult jobs in healthcare is the front desk. And we talk all about how every single person in health care can make or break the patient experience. And so when people call you, you walk into the scene. And we noticed that we had this problem of people would call because they, geez, I haven't been in a couple months, and they would take all of our acute slots. And you need those acute slots to see people when they're really sick. And so we've done a lot of work in the last year to say, hey. We don't necessarily need to automatically bring someone back because we need to hold those spots for two types of things, acute patients and then people that wanna establish care. Right? Like, those we they're part of our community, and we have to do that. That's, to me, what's exciting about health care as I've, like, grown my skill set from policy and insurance to operations and execution, is how do you create a structure that allows to get the right patient to the right place at the right time? Because there are so many informal gates that make it hard for people to access health care. And we can make a lot of changes inside our four walls to help people with that.

[Rep. Leslie Goldman (Member)]: What's interesting, of course, and I know you must know this, is that social determinants, you mentioned here in your slides, only in medicine think about can access or impact 20% of a person's experience.

[Dante (unidentified committee member)]: Yeah.

[Rep. Leslie Goldman (Member)]: So there's the other 80%. Having the teams and having social workers who are really needed to do those kinds of things, I think really are important and need to be part of this conversation. I don't know in the residency that you're developing, how you think about that piece of it.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: I would stepping back a little bit, I think a lot, and this is not a novel observation, about how America and Vermont's health care system pays for sick care, not well care. I think it's a very exciting time, particularly with the new CEO of Blue Cross Blue Shield to talk about, hey, can we get paid in different ways to try to take care of folks and give them kind of the wraparound services that they need? Because your thing might be transportation, your thing like mental health, your thing might be, can I get help getting a job or straightening out my insurance? It's not necessarily I have a sore throat. Right? Yeah. And the residency program is comprehensive. You have to get trained on kind of all aspects of primary care. And then one of the requirements of the accrediting agency is to have a behavioralist on staff to both help them manage their work and help them think about health more broadly. And so that's part of our grant application. Oh, good. I'm glad to

[Rep. Leslie Goldman (Member)]: hear that. That's crucial, actually. Yeah.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: One of the the things that seems totally obvious but is a 100% true is that most family resident residents practice near where they trained. Right? Think about dental, like one of the most underserved parts of Vermont's health care continuum. I can't help but observe that so far, there's there's been traditionally, there have been no dental school here. Very hard to recruit and retain dentists when there's no dental school here, and the same is true of family medicine residencies. The data that we've seen, which is old at this point, but everything we've seen since is consistent with it, is that the majority of residents stay within a 100 miles of where they train. 57% stay within the same state. We see that in a long term study with the UVM family medicine program, that the majority of them stay with Vermont and the majority remain in Chittenden County. Kiffer just hired someone who is the chief family medicine resident, at UVM this year, with apologies to doctor Leffler. I don't know if he knows that. But

[Dante (unidentified committee member)]: but we did. She's gonna

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: come to Randolph in Berlin, and we're so excited about that. But she came to Vermont. Her husband's behind a couple years behind her in medical school. He just matched in Vermont. They're gonna move to our community in Vermont. They're gonna buy a house in Vermont. That creates a lot of momentum to stay and raise your kids and and be part of the fabric of this state. And so for us, it's okay, if you want more primary care physicians in the state, one of the strategies you should adopt is train more of them here. And then most importantly, get them out in rural areas. We've seen that in Chittenden County. We've seen that in Asbury. People that train here tend to stay here. And so we think of all the different residencies you can invest in that family medicine is very important. We talk a lot in Vermont about primary care being the key to health care and trying to get people to thrive and be healthy and lower the cost of care. We need to create opportunities to do that, and so we think family medicine is the way to go. Now why train in a health center? So nationally, there's a movement called the teaching health center movement who that basically takes the idea of, look, most people that get trained get trained in large academic medical environments like Dartmouth and UVM. They do a wonderful job. And so I have no complaints about their training of physicians. They do they do great work. At the same time, though, what we see nationally is that when people train at health centers, they tend to buy into the mission of health centers and then work in more rural areas. I will tell you that many of the physicians that are at Gifford at one point in time either worked with or worked at folks from UVM and Dartmouth, and those networks are critical. It makes them more effective. We we have one cardiologist. He does amazing work. It's very lonely to be the only cardiologist somewhere. And but he can pick up the phone and call his former colleagues at Dartmouth anytime and say, hey, I've got this interesting case. Like, what do you guys think? Or this person really needs to get in now. Please do whatever you have to do to get this patient seen. And so we think that if we train people in our communities, they can start to develop that relationship with other local institutions that will make them more effective when they're independent practitioners.

[Rep. Leslie Goldman (Member)]: Leslie has a question. You mentioned one cardiologist. And of course, the ACQUAIN 60 seven report really talked about how you're regionalizing and how does one cardiologist cover your hospital because that's not sustainable for that individual. So how does that

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: work for you? Well, for us, what we do is we take a look at the number of patients they see and say, okay, is there any way we can make this more efficient? Right? So for example, we had one neurologist and we have patients that really need a neurologist, but we after taking a look at the data in the Oliver Wyman report and taking a look at our own data, we went to when our neurologist left for Alabama because she was tired of Vermont's winters, we went and advertised for someone to work 60% of the time when we found somebody.

[Rep. Leslie Goldman (Member)]: Okay. So you're not doing coverage then. That's why.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yeah. We're not doing coverage. That's the issue. Okay. Got it. However, I will tell you, it has been a really marked change in tone and collaboration since Doctor. Leffler took over UVM Health. So we know that even if you have one wonderful person, and we do have a really wonderful cardiologist, Doctor. Andres, and we do all Who's you with? Bruce is at Gifford.

[Rep. Leslie Goldman (Member)]: He's a wonderful He's our guy.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yes. It's it's on it's on point holding the heart with cardiologist. Doctor. Anderson is there and he's announced his retirement and he's very diligently trying to find his replacement. And fortunately for us, there are several cardiologists that wanna do that. But to the point of your question, hope is not a plan. And so we're also talking to UVM about, hey. How would you support our cardiologists? Could we develop a more robust telehealth relationship? Could you get somebody down here twice a week if we decide it's more efficient to partner with UVM or Dartmouth than have our own? So I think coming out of the Oliver Wyman report, there's more due diligence going on of, okay, we want the service line local. If you talk to UVM or Dartmouth, they would say, yes. You should have cardiology local. It's not about what you want. It's about how you do it. And so we're just taking a more robust approach to thinking about how you staff smaller service lines. And if you do it right, it can be a win win. Right now, to step back and put my Gifford hat on again, In this past year, we we had about 15% more clinic visits while having fewer clinical staff. So we just think we're running the business better, and we're doing a better job flexing resources where they need to be. So the neurologist is a great example. Like, we're we're paying for point six, and I'm just meeting the demand of the community. And so we just you know, with each and every time, we're gonna look at that. One other parenthetical comment, we, like every other Vermont hospital, are preparing transformation plans with the agency of human services. And it's it's not public yet, but we're in negotiations with another Vermont hospital about radiology services saying, hey. It's it's not really efficient for us to employ our own radiologists, and it creates a single point of failure, and no radiologist, no hospital. Currently, we're sending money to Georgia for teleradiology. That feels bad. We have to imagine that there's another Vermont hospital that is employing radiologists that are not fully using their time. Why don't we come together? And so far, conversations are going really, really well. And that kind of nuts and bolts collaboration, I think, has been a really good outcome of the last year of transformation talk. And so for me, when trying to how does this come together with the Maple Mountain work? It's everybody's gotta find their lane. We need radiology services. Maybe some other hospital takes the lead on that. Maybe we take the lead on educating family medicine physicians who want to practice in a really rural space at one of Vermont's FQHCs. We're all trying to find what's our specialty instead of building our own little kingdoms, but that's just not sustainable.

[Rep. Alyssa Black (Chair)]: This is not a question for you, but I'm putting it out there because they're not in the room and we will have them in. But on your last slide, you talked about UVM therapy and the office and program that's 58% in the state of Vermont. The question I have for UVM is actually because I've been thinking a lot about education and training lately, which one of our next guests later on, pass them. How many family medicine residents start in family medicine and actually end up practicing ultimately in family medicine. Because that fifty eight percent, is that just people who complete family medicine or is it including people who start and then decide family medicine, is it for me? Which is frankly one of the reasons I'm very excited about the Maple Mountain Consortium, is that it seems to be that it's targeted for doctors who really want to practice in a rural setting and that their residency training will be ultimately how they end up practicing and want to practice, whereas sometimes with an academic medical center,

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yeah, I don't.

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: I see Stephanie. Just, Anne Morris, who was the residency program director runs AHEC is in the room.

[Rep. Alyssa Black (Chair)]: How many people actually complete

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: family medicine that started? So at UVM, 100%.

[Rep. Alyssa Black (Chair)]: 100%. Correct. Everybody who

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: starts with family medicine says this is the great. Last five years, I would say we actually can probably extend that to ten years. We've had one who has left for another specialty. So I think then the question may be more about when do they choose family medicine? And it used to be that almost sixty percent of medical students were coming in having already chosen that family medicine was going to be their specialty. The American Academy of Family Physicians has data that's showing that that trend has really gone away. And now students are really waiting until their third year clerkship. So once they experience family medicine, so that becomes very important in terms of talking about training during medical school. For those who match into family medicine at the University of Rockford Medicine residency program, they are family medicine bound. They are going to do that. We are training them to try to provide full scope family medicine, and we are training them to be able to go anywhere in Vermont and do that, and that includes inpatient, outpatient and OP. I would be happy to discuss the qualifications of Doctor. Caledonia who is joining Gifford who will be doing inpatient medicine, outpatient medicine is qualified to do all nine procedures will be learning POKUS skills and office based procedures. Where do the work skills? POKUS meaning point of care ultrasound skills.

[Rep. Alyssa Black (Chair)]: The one you stole from them?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Steal is the wrong way to

[Rep. Alyssa Black (Chair)]: know. Enticed away.

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: As Doctor. Gelerman's advisor, I just knew that she's very thoughtful about her decisions and is incredibly exciting to be joining.

[Rep. Alyssa Black (Chair)]: I feel like I derailed you. Know. I'm gonna let now talker has a question. I've never done that for years.

[Dante (unidentified committee member)]: Very well correct. I love to be corrected if I'm wrong. Didn't we get testimony here that if you graduate 10 physicians, only two of them are gonna stay here?

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: 50% of residents will stay within 50 miles of where they complete their residency training, which is why the concept of Maple Mountain is so important, because you're putting them in the location that we need them most during training so that they will sleep.

[Rep. Alyssa Black (Chair)]: Is that across all specialties or just family medicine?

[Dr. Anne Morris, UVM Family Medicine Residency Program Director (UVM/AHEC)]: I believe it is across all specialties, but is definitely preventing family members.

[Rep. Alyssa Black (Chair)]: Do you have a question?

[Rep. Leslie Goldman (Member)]: Okay, thank you. All right.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: And I would say that one thing that Doctor. Morris said that's very important, when my own board of directors says, okay, you're going to work with a consortium of QHC and other partner hospitals, are all these people going to work at Gifford? And the answer is no. I said, what I would say to them though, is much like Doctor. Morris's comment about Doctor. Gelderman, if people stay in Vermont, we're really, really happy. Whether you work at Battenkill or Memorial Health Partners or Gifford, this is one of the ways where I think as a hospital leader and an F2HC leader, you have to think, hey, I can't just do things that are important for me in my organization. I have to do things that make Vermont function better as a health system. And so if some of them stay, that would be great. But as long as they stay within the Vermont orbit and with our other partners, the majority of the time, I think it's a huge win for Vermont and really helps all of us.

[Rep. Leslie Goldman (Member)]: Because I think you staff someone in the Grace Cottage, right, someone from your residency? Correct. Doctor. Weber, the current He testified. Present. Yeah. Got

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: it. And also just one one additional comment on that. It also helps retain our current workforce because I have to tell you our current physicians, just even the prospect of a residency program is incredibly exciting for them. They want to be part of something bigger. They want to pass along their knowledge. I didn't go through residency. What they share with me is that at the end of residency, they felt like marathon runners. It was like the most capable they ever felt, like they were fully ready to go as physicians and they want to tap back into that, whether it's in our primary care or as a hospitalist or whatever they happen to do. This slide just demonstrates that we have a lot of different partners. I just want to be perfectly candid about this. So there's a lot of momentum for this program. We did a lot of work. We got accredited by the ACGME, which is the accrediting body for residency programs. And then due to a lack of funding, kinda had to go, not fully dormant, but okay, gang. The next step is unlocking funding. Now that we have a couple different hypotheses about how to get the program funded, we as a group of organizations need to come back together quickly as a board and say, okay, how would this really work if funding comes in? And I don't know if I'm up on the screen there.

[Rep. Alyssa Black (Chair)]: Yeah, we lost you. Lost your slides.

[Dante (unidentified committee member)]: Okay, should I share my screen again? There you go.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: And then I'm gonna go into presentation mode, which I learned about today.

[Tasha (committee staff/IT support)]: You need some help. Yeah. Okay.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Tasha, it says I'm sharing my screen. Everyone see it up there?

[Rep. Alyssa Black (Chair)]: Not a meeting. I don't know what's in. Okay. You're gonna rejoin for this.

[Rep. Leslie Goldman (Member)]: You just dropped out of the Zoom.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yep. I'm gonna jump right back on. K.

[Tasha (committee staff/IT support)]: Okay. It should be back in.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Alright. And so as we rejoin here Yeah.

[Rep. Leslie Goldman (Member)]: I have no idea, but I don't see it

[Rep. Alyssa Black (Chair)]: in here.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: It's still just circling. So as we get back to those slides, I mean, basically, you've heard

[Rep. Alyssa Black (Chair)]: Do you wanna see them?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: The value oh, I have them right here. Oh, just Oh, you must have

[Rep. Leslie Goldman (Member)]: them on your thing. Yeah.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yeah. The value proposition oh, there we go. My back end in my back end. We can't do that. Voices. Here we go. Here. Here we go.

[Tasha (committee staff/IT support)]: So close. There we go.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: So you've heard are we in the share mode or no? No. So, you know, we're our plan is to have four residents in each cohort up to 12 residents in the program at any given time while it's up to full speed. It would produce over 40 family physicians over ten years, and to the point that doctor Morgans made, our strong view is the majority of them will stay. Each of them provides visits, which is really important. The supply and demand curve in primary care have not met. To put that a little less bureaucratically, every single day, some Vermonter needs a primary care appointment and they can't get one. That's a huge problem, both in trying to create healthy families, thriving communities, and getting the right care at the right place at the right time, which is actually the transformation problem I think all of us should be working on. And if we do that, we'll find a way to bend the cost curve and be more affordable. And so having these residents out there making these visits, I think would be hugely important to the system. And we've had a long term view that access to primary care leads to better health outcomes and lower costs, and I think that's true. It depends on how long we measure that over. But for us, we think the residency program is a great way to try to get at it. So we've made a lot of progress. Years of work went into this, culminating in receiving accreditation in 2025. That means we have the car. The car is built. It's been inspected. We need to turn the key. Turning the key requires money. And so that's where we're at. And to really enroll residents, we need funding that is reasonably certain. I think all of us in health care are willing to take risks to recruit and train physicians, but we're making a commitment to people for multiple years. And so we have to feel really good about that. So just to give you a brief review, there was a half million dollar grant for phase one of those projects. Stuart May, who's over to my left, was instrumental in getting that grant into the state of Vermont. A ton of planning went into it. And then that culminated in getting accredited by ACGME and saying, yes, you can have a teaching health center program. Our view was that there'd be a phase two where we're looking for about $4,000,000 to run it for the first four or five years until we're making enough visits and can get long term stable funding. The gold standard for that is teaching health center funding. The federal government right now funds teaching health centers all across the country. And so ultimately, you'd wanna get that money in every single year. What we're trying to do is not wait five years for congress to figure that out. What we're trying to do is get funding to build a bridge to that point in time.

[Rep. Alyssa Black (Chair)]: I'm confused about that. So, I mean, federal government I know does have training, medical education payments, grants. Would that not start day one?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: So Or Let's talk about this for a second.

[Rep. Alyssa Black (Chair)]: A bridge for.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: There's a bridge, John. So the bridge is going to sustainable funding. But so if you ran this program, at least in my view, in a sustainable way, the federal government through HRSA would say, yep. You're one of the approved teaching health centers. And every single year, we're going to send you funding, a $160,000 per resident currently. That doesn't cover the full cost of a resident, but it gives you enough of a stable base to say, yes, you should move your family and your life to this community. You should do this training. And between the revenue from your visits and other grant and operational resources, you have a very stable program. The federal government has been funding teaching health centers, but not adding any new programs for a period of time. And so for us, we're like, okay, we have the need for a family medicine residency program. We are now accredited to operate a family medicine residency program, but the federal government has not reopened that teaching health center gate. And so do just wait five years for it? Or do we try to figure out some way to accelerate the launch of that program? And so we have a couple of different four different paths that we're looking for funding. One is the Rural Health Transformation Fund. Is there any way that that that those funds from CMS to the state of Vermont can help fund this program? We were part Maple Mountain was part of the state's original application. That application was approved, and so instead of an RFP process, we've gone directly to grant development. The Agency of Human Services is working very hard to try to navigate those funding restrictions. So I'm spending a lot of time on the phone with AHS saying, look, there are things you can and cannot pay for in the rural health transformation fund. Is there any way that we can fit what we need for the next five years underneath that grant? We're not at the end of the road in those discussions. We're trying to be really creative and see what the feds will actually permit. We're having a really good conversation prior to the committee hearing starting about what you can and can't pay for preceptorship, faculty time, travel, recruitment, housing is out. Right? And so we're trying to figure out how to maximize those rural health transformation dollars. Separately, last year, and we're very grateful on the state of Vermont, the legislature, all of you appropriated just over a half million dollars for this program. Originally, we're looking forward to unlock some Medicaid matching dollars for the program, and the federal government is not interested in that. And so the Agency of Human Services is trying to figure out whether that can be unlocked as a state level grant to maybe cover some of the things that we need to launch the program that are not permitted by the Rural Health Transformation Fund. Separately, there's that federal teaching health center fund. Now, curiously, and and I try not to opine on national politics here, the congress in its most recent budget appropriated more money for teaching health centers, which was a surprise to me anyways. But it's not a 100% certain yet whether that will go to increase the base amount for existing programs, because existing programs very much want an increase in the base amount, or whether they might permit additional entrants into the program. We do know that our federal delegation has a very strong view of this. And so they're working with HRSA to see whether what might be done or whether we have an opportunity there. And then to your point, this is a very long way of answering your question, madam chair. There are other ways in which graduate medical education gets, the more traditional routes like the UVM or Dartmouth go through. We've been reluctant to step out of the teaching health center lane because that's where we want to operate, a teaching health center program. And I think there does come a certain point if you don't think you can get funding for a teaching health center where the need for primary care physicians that train locally and stay locally where Vermonters need the most doesn't go away. And so I think as the CEO of Maple Mountain, at a certain point responsibly, I have to look at those other lanes and how we might partner with institutions like UVM or to see whether we can get the program off the ground in a different way. What I'm convinced of is that the organizations that wanna be a part of this, and most importantly, their clinical staff within the organizations, will move mountains to make something like this work. And so it's my job to try to figure out the funding scheme. So right now, our real focus is that rural health transformation funding and working with our federal delegation on teaching health center money to try to see whether we can quickly get where we need to go. Residents start in July every year, and so you have a window to recruit them, or you've gotta push it back twelve months each time. We're obviously not gonna have residents in July '26. Whether we could have residents in July '27 seems seems pretty tough at this point, but we're still working to unlock these funds to understand what our options would be. I don't work on this alone. There are a million people behind the scenes. Two of the real great clinical leaders behind this effort have been Doctor. Melissa Blansky of Memorial Health Partners and Doctor. John King of the UVM Health Network, with a lot of in kind support from Memorial Health Partners and the UVM Health Network. One of the when people say, hey, do you guys ever collaborate with UVM or Dartmouth? The answer is yes, and it's every single day. Like, small hospitals need partnerships with larger hospitals. It's just the way the system works. And and they've been incredibly gracious with their time and expertise when it comes to trying to stand up this program. I won't speak for Doctor. Morris, but the feeling that she expressed that we get that Vermonters really need care in these rural areas regardless of what organization you work for. I feel that from the top of UVM's leadership on that. Wanna find ways to be helpful in getting this program going. So I think for me, when I think of transformation strategies, I having sat through about fifteen, sixteen years of health care workforce discussions, like some of you. I think I tell people in my organization, know, pray to remove your feet. I think we keep waiting for, like, one big thing to happen, and and we've gotta grow our own workforce. So speaking from Gifford, whether it's the Maple Mountain residency, we did a new nurse residency program that we invented this year and got eight local new graduates on board at Gifford at the same time. All eight of them stayed, seven as nurses, one as a care coordinator. They felt like that was their jam, like they were better talking to people rather than being right at the bedside. Or we do a medical assistant training program, which we think is an awesome entryway into health care careers for smart local folks. We've got to grow our own, and this is a big part of that. This could have a huge impact. We're really at the point of it's ready to go where we need funding to make sure that we can keep whatever promises we make to those residents if we ask them to move here and train here. With that, thank you so much. I know I talked a ton, but I'm happy to answer additional questions.

[Rep. Leslie Goldman (Member)]: Leslie, well, this isn't really a question, just a curiosity about you you philosophically, the understanding of how much tax money goes into training specialists and not a lot into training primary care. And how do we deal with that tension of a very skewed workforce? And I appreciate that you're trying to deal with it by doing this and that's cool, But it's very it's small compared to the problem. Yeah. And I would I would invite other

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: you know, I work for the hospital I do on purpose. Right? It's at QVC. Although mostly, I'm trying to do my best for Vermont as a Vermonter. I'll just tell you one personal story. My mother in law's primary care physician, she owned her own practice for thirty five years. My spouse has a PhD from the Stanford School of Medicine. She's a scientist. And so we went to the medical school graduation, and she got her PhD. And it seemed like the majority of graduates were moving on to dermatology. And that was profoundly depressing to my mother-in-law. You know, in in the lane that I occupy, I deal with people who have already made the decision somewhere in the journey to become a family medicine or primary care folks. What happens before that? I don't know. I will say that the financial incentives all run-in the wrong direction. I occasionally remind my colleagues at Medicaid that while I understand as someone that used to set the rates at Medicaid, I understand why for administrative purposes we tend to follow what Medicare does, But you could make totally different decisions about what to invest in with invested in reimbursement. I noticed as someone who has the great privilege to operate a hospital with an outstanding birthing center, we talk a lot about moms and babies. We do not reimburse much for moms and babies. We could, as a nation and a state, make totally different policy choices about reimbursement, and at some point in time, it could affect people to make different decisions about how they wanna dedicate their professional life.

[Rep. Leslie Goldman (Member)]: Yeah, I was a little overwhelmed, the data that you gave us was over ten years. Ten years feels like a really long time in order to create the workforce. But thank you for that work, it's important obviously.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: We're trying, we're trying not

[Rep. Alyssa Black (Chair)]: to let it.

[Rep. Leslie Goldman (Member)]: This giant cultural boggle. But like you say, there's just so much debt, and you can't charge or repay debt in primary care.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: I entered Gifford at a really unusual time with all of the Lyme report. And I think when Gifford looked in the mirror, I think a lot of people would say, okay. We fell into that, like, big hearted Vermont trap of we're good people doing good things, and maybe the business isn't being run the way it should be. And Yeah. The way I said it to my team was, hey. The best way the best time to solve this problem would have been nine years ago. The second best time is right now. It's like, let let's not spend too much time looking at the rearview mirror. Like, let's figure out what we can do this week and next week, week after that to go make things better. Like, I I don't know. I I feel like nobody yet in any state has figured out rural health care. Ramon has a lot going for it if we can all work on the same page and get out of this dynamic of change means doing more of what I've always done, which I I think health care leaders can can be guilty of having that status quo bias, and we're gonna have to get out of that dynamic of, oh, we just can't change anything. Yes, we can. It's our job as leaders to try to do that.

[Rep. Alyssa Black (Chair)]: Any other questions? Unrelated topic, but you are here and you are a critical access hospital. This community has been delving into the ongoing discussion around Medicare and Medigap reimbursements for critical access. Is Gifford looking internally at their own pricing methodologies to see if there are solutions that can be made.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Yeah, I think it's really important on this one. So the short answer to your question is yes. The additional comments I would make are there's actually a lot in this discussion between critical access hospitals and the Green Mountain Care Board that we all agree on. Health care costs too much, prices are too high, and Vermonters struggle with that. And we take care of our seniors every day. And in my seat, one of enormous privilege, but I know that there are people every single day that struggle with the price of health care and medicine. And there was a three hour agreement on care board hearing on this the other day. And to be candid, Gifford has really struggled, I think along with other critical access hospitals to get our arms around the data to fully understand the impact. And and that's not a delaying tactic. Like, we we really are trouble struggling with that. But people are asking us to compare what we do to a totally different system of health care reimbursement. What board member Holmes asked for in that hearing, which was so helpful, was, can you tell us one thing as critical access hospitals you can do in the next two weeks to make progress on this? So we're gonna send a letter back to the board members today to say that was a great way to frame the question. We appreciate it, and here's what we're gonna do. We're gonna look at our financial assistant and bad debt and charity care policies to see if there might be some way to get to the same end results without having to completely redo the charge master. Now separate from that, between the discussion of affordability for Vermonters and the effort to go to reference based pricing, we need to look at all our prices anyways. Like, that's just a project that we have to do. But on this critical access hospital outpatient cost issue, the chair and the board are asking us to move pretty quickly. And so we're gonna report it back to them in the next two weeks of, okay. We think financial assistance might be the fastest way to get where you wanna go. We're gonna learn more about that and report back to you. So I think it's a yes and. We'll look at our prices, and we think there are some other ways we might be able to get to the same point for Vermonters. So I hope that's helpful reply. It has the benefit of being what we're doing right now to try to address this. And by this, just to make an obvious point, this is how Medicare works in all 50 states. And we are also I know the hospital association is reaching out to the federal delegation to say, hey, the most helpful thing would be federal changes. But in the meantime, we should be looking at what we can do to provide relief for Vermont seniors struggling with their bills.

[Rep. Alyssa Black (Chair)]: I mean, ultimately, it is a federal fix, but it's incumbent on Vermont hospitals to take care of Vermonters, and that means their financial situation as well as their health situation and not make it worse. I do hope that you're exploring the topic of what the charge mastery means is ongoing discussion. Does anyone even know?

[Rep. Leslie Goldman (Member)]: Yeah, thank you.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: You're Let's quite

[Rep. Alyssa Black (Chair)]: move on. Thank you very much for

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: coming Thank you for coming in. It is really joyful to be able to talk about something future facing and strategic. So I appreciate the opportunity.

[Rep. Alyssa Black (Chair)]: I'm very excited about it. It seems like it'll be time and it's frustrating that when things that we really want to have happen just don't happen. I understand that. Thank you. Is Boris?

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: Boris, yes. So,

[Rep. Alyssa Black (Chair)]: you know, as we continue on talking about issues around primary care, I thought it would be a good idea to have support us in, kind of lessons learned from our all payer model and things that we should be thinking about so that we're not making those same mistakes, I guess.

[Tom Boris, CEO & CFO, OneCare Vermont]: Well, thank you all for having me today. My name is Tom Boris. I'm the current CEO and CFO for One Care Vermont. Appreciate being here. I don't like following up Michael because he's so eloquent, but I'll do my best. So this this feels like a pretty open forum to talk about lessons learned and just observation. So I try not to preach and come across like that, but I do have a lot of thoughts when I reflect on the past, and and I'm happy to come and, share them today. My intent is to be helpful and forward looking and just provide insights to help us as a state advance. So, I always like to start a little bit of context about One Care Vermont just to make sure everybody understands. It's an interesting organization, but I think of it as an administrative entity that has helped manage ACOs going back to about 2012, so pretty long run. The general business models, I think of it at least, is a shared infrastructure. By regionalizing ACO administration, it can help avoid duplication, maximize expertise, and generate some economies of scale that can be really helpful. Through the work, the way it manifests is that an ACO is developed first by contracting with a network of providers, everybody working together, and then as a whole, with payers upstream to engage in continuous improvement activities. That's the the simplest way to think of it is you assess where you are today, you try to get a little bit better tomorrow. You may know that one care is in the process of winding down. We concluded our contracts in 2025. We're now in the run out period of our general business and also shutting down the business simultaneously, but that makes this the perfect time to stop and reflect a little bit and just think about what worked really well in our world and how can we learn from it so that we don't repeat any mistakes, but also that we can learn from the success stories as well. A lot of what I'll say today is summarized from a letter that we sent to AHS last June that is called retaining the capabilities of certified ACOs. That was something the legislature actually asked AHS to work on. We submitted this letter in spirit of being helpful and was shedding a little bit more light on what it is that One Care actually did, in spirit and hope that some of it can be recreated recreated because there's a lot of value in my opinion. So I'm going go through a couple of summarized topics. Do invite you to read the letter I sent around earlier, but this is going to be kind of a distillation of some of the themes or concepts with it. So the first topic I'd like to speak to is administrative burden, and that can mean a lot of different things in health care, but I'm gonna narrow the focus here a little bit and say it's administrative burden related to value based care contracts and programs. So whether you're a fan of value based care or not, and an ACO to me is a type of value based care arrangement, they're here, and it's one of the few ways that providers can increase their revenue generation without volume alone. The problem, though, is that they're super complex, and it takes a lot of work to run them. So what I think worked really well conceptually for One Care over time was having an entity that can manage some of the heavy administrative lift associated with these programs so that the practices didn't have to deal with that. They could focus more on the patient facing work. I think that's a really important concept in learning to take forward as more big initiatives are launched, whether federally or from the state or homegrown things even, finding ways to decant some of the administrative burden and back office functions that just are necessary off of the practices, particularly rural primary care practices that have scant resources, is a really important idea and concept. It's a complicated time in healthcare right now, and one of the things I worry about is how much burden is kind of passing through to providers, especially the small rural practices, but not exclusively, even FQHCs will have to deal with this in hospital primary care as well.

[Rep. Alyssa Black (Chair)]: I'm sorry. I'm not quite sure I understood quite where you were going with that. You're saying that one of the things about One Care was that you were able to alleviate the burden. Can you give examples of what you mean by, I mean, discrete examples of what administrative burden

[Tom Boris, CEO & CFO, OneCare Vermont]: that was? By One Care, let's see if can

[Dante (unidentified committee member)]: get there

[Tom Boris, CEO & CFO, OneCare Vermont]: on this, but One Care is the shared entity to manage the administration related with ACO. So if you want to do, if you're a small practice and you want to participate in your own, build your own ACO, need to have staff to do it personally, but you need to have contracting expertise to set up the arrangements for yourself, any other partner organizations you want. I think ACOs are best when you bring multiple entities together. That's the real value of it. So you need to have contracting expertise to set up those contracts and work out terms. You need to negotiate upstream with payers. So we had the opportunity to work with Medicaid, but every year, a lot of work going into designing and developing the contract and the program. You have, governance requirements to satisfy ACO rules, particularly on the Medicare side. If you're in the MSSP program, there are a lot of rules about the governance structure you must maintain. That takes a lot of effort. Data. Data is one of the tools that you're given as an ACO, and you need to have systems to manage those data. Compliance is a huge thing in an ACO world, appropriately so. You have a compliance department. So all these contracts come with a lot of work. They're valuable, and they do a lot of good and help providers be their best, think, in my opinion. But all that work, if it's borne by primary care practices, I think, in my view, we're wasting their time. They should be more focused on the patient care side of what these value based contracts can do, if that helps.

[Rep. Alyssa Black (Chair)]: Why can't a provider just get paid just the way they are when you get paid? Why do they need? I'm okay. I'm gonna I'm gonna let you continue. I I'm not quite sure I'm quite understanding, but

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: We'll continue through. I'm happy to take

[Tom Boris, CEO & CFO, OneCare Vermont]: questions at the end of some of these thoughts I'd like to share today. But just to put a pin on that concept, as future initiatives are explored, the real lesson learned here, the takeaway for me, is just to be thoughtful about the administrative load that falls through to these practices. Like I said, it's complex, the world is complex, and if we have small primary care practices juggling with administrative concepts, I think it's a bad thing for burnout and their productivity. Next lesson learned for me that I want to share, I think is important. It's a concept about size and scope. One Care grew really explosively between 2019 and 2020. Was a pretty amazing period. And what was really amazing is we got to this point where we had a critical mass of providers across the whole state of Vermont, from Newport to Brattleboro, and we could all work on the same things. That was really valuable, really important. And if the goal is to raise the bar on population health outcomes, this is a good way to do it. Get everybody working on the same thing, agree upon some priorities, work together. There's opportunities for partnerships and collaborations, sharing stories, and successes. That's really effective. Links to number bullet number four on that board there. So I think that's really valuable and to think about these big and broad initiatives as a good way to address macro level population health outcomes. There is a cost to it though that I think is important to understand. One Care is a small business or a small place. We didn't have a lot of resources and people, so we got spread very thin across a broad geography. Mean, Vermont's not a huge place, but relative to what we had, we were spread really thin across the entire state. Also really important, we had to develop policies and programs that could fit over the entire healthcare landscape, which means we needed to be a little bit more generalized, a little bit more up here, rather than really tailored and specific. There is no right or wrong to either approach, but I think a big takeaway for me was to know when it's appropriate to have a more micro strategy and approach to solve a very specific problem or take this macro level approach and try to solve a big problem. There were times where in our One Care journey and seeing a community, it would have been great to customize or tailor an initiative for a specific need there, but we couldn't we just couldn't get into doing something here, and then something very different over here would have been overwhelming for everybody. The takeaway for me, as the state explores future initiatives, is to think about macro level problems need these big and broad solutions, and then micro level problems really need tailored solutions. I'm going to take this with me in my career as I move forward. I think it's a really big takeaway. Depending on what you pick, you need to set reasonable expectations accordingly. Higher that you are, in my view, it's going to take longer to get those results. There's more to do, more to accomplish. Smaller focus initiatives might have a quicker turnaround and might get the results you want to see faster.

[Rep. Alyssa Black (Chair)]: Leslie, did you have a question? I'm just wondering if

[Rep. Leslie Goldman (Member)]: you could give examples of a macro and micro, just so I'm understanding.

[Tom Boris, CEO & CFO, OneCare Vermont]: Sure. Say, macro level, we want to improve the control of hypertension across the whole state of Vermont. The model that One Care was working under was a good one for that because we could get all the providers to have some sort of incentive around that. We could supply data, a lot of opportunities for collaboration and working together. A micro problem might be in a community, there's trouble getting the right people referred to the DA in a timely manner, and that might be unique in community A, but not in community B. You could set up an arrangement between primary care and the designated agency and community to really kind of work together and incentivize and share data in ways that you otherwise can't outside of an ACO initiative or some sort of initiative like this.

[Rep. Leslie Goldman (Member)]: How would the ACO know that? How do you know that there's a problem in this little micro world?

[Tom Boris, CEO & CFO, OneCare Vermont]: It could come from data. It could come from dialogue and discussion where somebody's saying, we're having a really hard time getting patients that we see with a mental health diagnosis referred to a mental health provider. They bring that up as we have an opportunity here to have more efficient care pathways and get more efficient referrals. And often there's quality measures related to this. And I think that a very specific initiative in that case would be more effective than some macro level kind of strategy.

[Rep. Alyssa Black (Chair)]: Can you give an example? You'd said that One Care, when everybody was working together, then implement initiatives for public health, can you give examples of what some of the initiatives were? What are the outcomes? Yeah, I want to understand,

[Rep. Leslie Goldman (Member)]: and maybe you're going to get to this, is why did One Care fail? And you don't have to answer that now. I think you should answer the question first, I think that's what the takeaway is. What happened?

[Tom Boris, CEO & CFO, OneCare Vermont]: Sure. Well, I'll just say I don't think One Care actually did fail. I'll get to that in a second. So for an example first, one more recently was around mental health screening. We felt that there was an opportunity to really champion the idea of mental health screenings in the primary care setting. And in a lot of cases, this was in alignment with the blueprint, try to help resource primary care practices to have some mental health capacity or capability in office. So we pushed through our program designs incentives for practices that were able to raise their mental health screening rate. And we saw pretty amazing results in a one year period. We saw a ten percent increase in mental health screenings across the primary care practices participating in One Care. And with some real dedicated focus and consistency and a lot of talking about it, we saw some really important improvements in population health outcomes like that. What's really cool about this work, this continuous improvement work, is that there's no shortage of things to work on, and I'm going to get to a lesson about this in a second, but that's just one example that comes to mind. The other areas of focus that we had over time were hypertension control, annual wellness visits became a really important topic in the last few years of time. You can pick really whatever you want, but if you get a critical mass of providers working on the same things, you really can raise macro level outcomes. Who chose the initiatives? That's another nice thing about the ACO model is that the governance requirements are that you have participants on the board, and that we use committees and lots of dialogue within our participant network to talk about what the priorities were. We use data. Some of it is complicated. The payers often have priorities as well if they push foreign contracts, but ultimately it was assessing what we're accountable for in our contracts first, using data to identify which are priorities because some measures we'd look at and say, you know, the numbers are already pretty good, probably not worth the time and energy, or as an ACO, we just didn't have the ability to really focus on that particular area. Substance use disorder is a good example. The data are blinded to us for that, so we're limited in our ability to lean in even though I wanted to. So it's a process and a collaborative process to identify and prioritize different areas or metrics or goals. Next is around financial support. I don't need to go too deep on this, but in general, One Care's strategies from the beginning was to try and invest in primary care. In general, I think that those investments were wise. I've seen enough to lead me to believe that those investments yielded positive outcomes. It's complicated is a true answer there. But in general, I think investing in primary care and supporting them financially is a really good idea, and doing it in a way that helps them move towards team based care concepts or advanced primary care concepts is really important. A couple challenges with that, though. One is I've found it's very difficult to know how much is the right amount, and if you ask a primary care practice, they'll always say more. I don't blame them. I'd say the same exact thing, but in terms of really quantifying the need, I found that difficult. As bills are contemplating the future around primary care support and investing in them, either through payment reforms or PMPMs, I think there needs to be a lot of work done to find a way to agree on what the right amount is, and that's particularly important in a resource constrained world. So more is good, but I think some specificity there is going to be really important.

[Rep. Alyssa Black (Chair)]: I'm sorry, are talking about administrative quality? Were you referring to then when you said more is good? More what? Financial support. More financial support. Okay.

[Tom Boris, CEO & CFO, OneCare Vermont]: The other challenge I've found with the work that we've done through One Care is that I don't think that paying every practice the same PMPM is appropriate all the time. Going back to what was saying before about being big and vast versus small and tailored, because we were so vast and spread so thin across the state of Vermont, we had to standardize. So a lot of our PMPMs were equal for our big quality improvement initiatives and programs. For the smaller programs that are a little bit more tailored, the comprehensive payment reform program, for example, which is a specific initiative for independent primary care, we built in variables for the risk of the panel, social determinants is a great idea too, but also the service lines that a primary care practice offered and we'd had differential payments. So in some of the bills that I've read being contemplated by this committee amongst others, thinking about whether it's appropriate to have equal investment PMPMs, for example, paid doll practices versus differential is something I think needs some discussion and some thought because there's a lot of difference between primary care practice A and primary care practice B in terms of the patients they serve, the panel makeup, and just the dynamics within their communities. Last in the financial realm is just a quick couple of thoughts about risk. ACO contracts come with the potential for shared savings and the specter of shared losses. We refer to that as risk. Might be surprised to hear that. I'm actually not a huge fan of the way that those arrangements are set up at the federal level, then a lot of others mirror those or copy the concepts. What I wanted to share today is I think that we all should be really careful about big risk levels right now when it comes to any programs, whether it's some future state level initiative or federal initiatives, and the ability to take risk in my view should be linked to the strength of your balance sheet and whether you're bullish or bearish in the future a little bit too, and right now feels like not a great time for our provider system to be taking on significant financial risks. So as any new initiatives come down, whether from the federal government or again, homegrown, I would worry personally if primary care in particular and even our hospitals now are subject to significant risk in today's environment.

[Rep. Leslie Goldman (Member)]: Go ahead, Leslie. Can you give an example of what you mean by risk? Sure. Because I'm

[Rep. Alyssa Black (Chair)]: not sure that the

[Tom Boris, CEO & CFO, OneCare Vermont]: community So is proven, I understand generally the way an ACO contract works is through a negotiation with the payer, let's pick Medicare for example, there's a complicated actuarial process to determine how much healthcare should cost for the patients covered by this arrangement. And then the ACO, the providers that participate, are challenged to go beat that. If at the end of the year, the payer, Medicare, paid less than that amount, the providers get a share of that. That's called shared savings. It's an incentive to be efficient and care delivery and hopefully cost the payer less. The other side of the equation though, is if the healthcare costs go up and are above that agreed amount, that turns into shared losses where the providers owe that money back to the payers. It's a way of passing financial accountability for total healthcare costs down to providers. That idea, I think, is good in spirit, but the magnitude and the complexity of the financial transactions has become a bit of a challenge to me, especially in Vermont right now. In general, these value based care programs can be set up in a lot of different ways, but if they have that downside, that risk where you might be writing a check back to Medicare, my recommendation today is to be very cautious.

[Rep. Leslie Goldman (Member)]: You know, I worry about that. We've talked about it because a clinician, if they're in a great situation, may see a patient for thirty minutes four times a year, just

[Rep. Alyssa Black (Chair)]: two hours a year. And to assume risk for behavior they can't control doesn't make sense to me. And so the theory seems flawed. I would expand on that, which I think like the deeper, the question isn't whether risk or not. The question is why on earth? On earth would we make primary care responsible for the system's affordability? Mean, it makes And And the the systems systems outcomes. Outcomes. It makes as much sense to me as saying, okay, well, primary care is responsible, not responsible, but urology is. Why on earth I don't even know why we're thinking in terms

[Rep. Leslie Goldman (Member)]: of Why is that even an acceptable theory?

[Tom Boris, CEO & CFO, OneCare Vermont]: Fair question. Mean, that's a question for Medicare because they develop these programs and then everything that we've been a part of is some sort of a kind of a tries to replicate the concepts of it. I think one thing, I don't disagree with your concept. If you're looking at any individual patient, this whole idea of this is not true. The idea though, I think, is to try and transition healthcare to more of a panel management concept where a practice organization has an eye on how much it's costing for their whole panel to receive healthcare and takes a more active role in that approach of healthcare. I think there's some utility in that. The financial arrangements to me can work well. There's opportunity for practices. If a practice does a really good job avoiding things like unnecessary ED visits, they have a financial incentive now to do that, whereas absent that and just a fee for service environment, they don't. But in general, I agree that there's imperfections in the general approach to this, but I also think there's value in having any part of the healthcare system have a greater awareness of and appreciation for the total healthcare costs of their patients, and an ACO arrangement is a way to get that information and data and an incentive to work on it.

[Rep. Leslie Goldman (Member)]: But it seems like the incentive is to prescribe medicine, because if you're only looking at numbers, if you're only looking at your blood pressure numbers or your A1C, and you're looking at your whole panel and what percent of your A1C is greater than nine or whatever, I'm going have to prescribe a lot of medicine in order to do that because I can't control if someone's going to take a walk or what they're putting in their mouth. And I don't have that support necessarily. Medicare is not paying for all the other supports that are needed in order to address a panel's health.

[Tom Boris, CEO & CFO, OneCare Vermont]: I can't speak to that. I'm not a clinician in terms of the actual strategies that anyone would employ, but it's certainly plausible somebody could take that approach. I don't think we've seen that necessarily. I'd be interested to see if you have any data that supports that hypothesis, but there are a lot of different ways to approach trying to be more efficient in care delivery and improve population health outcomes. And at the end of the day, I think an ACO is a useful tool to do some of that work. But there's a lot of nuances. I go back to the compliance at the beginning and all the administration, that's part of it. If you're going be an ACO, you have to look out for these things. You have to look out for stinting on care, which is not delivering the volume you should, or other dynamics that might be undesired. There's an oversight component of ACO contracts that it's really important in my view. It's one of those administrative functions that if it lands on the primary care practice, it's going to be a lot of time and effort. Alright, we move on from risk. Long story short on that, again, just be cautious. Next is about simplicity and focus. You can't boil the ocean, right? I joined One Care in 2017, and the organization was already laden with altruism and its desire to solve every problem under the sun. It was fun to be a part of, and while those intents were noble, I think it became pretty clear that it's easy to bite off more than you can chew, and it's easy to become too complicated too fast. We were often ordered to do extra things too, so that added to it, but we own a part of that for sure. So I think what's really important is for any of these initiatives to start out simple. If I could go back and do this is my tenure at one care. Do it over again. Come out of the gate with very simple, very focused program designs, make sure they're clearly understood, make sure we can operate them effectively, and then get some wins, get some progress, and then start to build out what else could we add to this, or how else could we address a different problem or a different area. The other side of the equation with that is, while it could be difficult for us if we bid out too much, it made it really difficult for provider participants to follow along, understand what they should do, lean in and be a contributor. It's easy to confuse people, and if you have a 40 slide presentation to explain a program, you've already lost. Being really simple, out of the gate, for any new initiative that Vermont is exploring is strongly recommended. The other is, sustained focus over time. If we want to improve hypertension outcomes across the whole state of Vermont, it's not gonna happen in a year. We need to work on it collaboratively and consistently over a long duration of time to get some real macro level results. And, again, back to the size thing, maybe a small initiative with one practice, could get outcomes up, more quickly, faster. But if you're trying to do a broad population health initiative, it's going to take time and maintaining focus on your priority areas over that over a longer duration is really important. If you change the rules and change the focus areas, it will waste energy and you'll sacrifice outcomes. So just a little example of the focus that we're able to generate over time that yielded some good outcomes in the last couple of years. When I started at One Care, we were running an MSSP, a Medicare shared savings program contract, and at least one commercial ACO as well, there were 113 quality measures we were accountable for. When the all payer model came around, that helped us a little bit in the sense that it went down to 70 quality measures, and then through negotiations with payers over time, we got down to 20. It's not to say that there aren't other quality measures that are useful and valuable, but there's no way we would be successful if we were focusing on 113 quality measures. It's just overwhelming to everybody. So getting down to a more manageable number of high priority areas has been affected, and we saw the results improve once we were able to do that.

[Rep. Alyssa Black (Chair)]: I'm sorry. The results of what?

[Tom Boris, CEO & CFO, OneCare Vermont]: Like our quality measures and and our population health outcomes.

[Rep. Alyssa Black (Chair)]: Addressing the quality.

[Rep. Leslie Goldman (Member)]: Addressing your processes should improve quality.

[Rep. Alyssa Black (Chair)]: Exactly. If the quality improves?

[Tom Boris, CEO & CFO, OneCare Vermont]: We've seen steady improvement in a number of the measures that we focused on over time. That to me suggests that this idea of focus and some consistency is proven effective, and that's why I'm here to share it for the future is whatever is selected, make sure it's something

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: that you can focus on for a period of time and keep that focus there. What measure were you thinking about that was successful?

[Tom Boris, CEO & CFO, OneCare Vermont]: Well, mentioned the mental health screening. I'm not here, don't have all the qualities for part of the year, but mental health screening was kind of an immediate impact. That one really launched quickly. We've seen real improvement in hypertension. There's a lot more to do out there, but a lot of the partnerships with the blueprint seem to be yielding some positive improvements over time. We've seen annual wellness visits and those rates improve and increase. An area that we really struggled with was anything, like I said, related to substance use disorder, which never had data, so that was kind of an area that was flat and we didn't see great improvement in our contracts there. Areas that we focused on and had consistency over time really did show improvement. Diabetes was another one, although that's one of the measures that Vermont is already pretty good relative to the country, so a number of them have really improved over the last few years.

[Rep. Leslie Goldman (Member)]: Do you look at mortality?

[Tom Boris, CEO & CFO, OneCare Vermont]: We haven't really studied mortality. Everything that we do is built into our contracts and we don't have a specific mortality quality measure. It's an interesting one. I've certainly looked at it financially, the benefits of hospice care versus other ways of passing have a financial cost, but mortality hasn't been a specific area, folks.

[Rep. Alyssa Black (Chair)]: It's I'm struggling with this a little bit because we consistently hear in this committee that Vermonters are experiencing more acute illnesses and more complex. And screening for mental health conditions, what good is that if we don't have the supports that people need once we've screened them? Also, I guess, because I'm thinking about quality measures, in whatever way we move going forward, it's going to be this constant quality. I have yet to find anyone that can actually measure, even determine what quality is and measure it and show improvements on it because frankly, I haven't seen improvements. But what about access? Was access a quality measure? How many Vermonters are able to access high quality primary care, regardless of I mean, to me, what good is having value based care when people can't even access it because of the affordability piece? And I'm wondering, could one care use access as a quality measure?

[Tom Boris, CEO & CFO, OneCare Vermont]: Access wasn't specifically a quality measure in any of our contracts. There were measures related to, call them primary care visit rates or annual wellness visits. And you can call that a proxy for access, but it's not the same problem that you're describing. What you're describing is more of a system level issue rather than what an ACO would work on specifically. So short answer is not directly. Access was not a measure that we were contracted to work on. And in fact, would be difficult for an ACO to work on that because the list of patients that we receive to, that we're accountable for, is based on an attribution process, which assumes or requires them to have seen a provider previously. So in a way, the patients that we're tasked to work on and for, those are the ones that are already are accessing care. So those who cannot access care are kind of out of scope, which isn't ideal for the state at large, but it's kind of a reality, the difference between what an ACO does and what I think you're talking about, all of you today, about these system wide issues, they're different.

[Rep. Alyssa Black (Chair)]: No, I think it's like, you know, you're talking about how the goal was to help with public health outcomes.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: And

[Rep. Alyssa Black (Chair)]: to me, the worst quality care that anyone can ever have is the care that they never get. And I'm just I guess I'm a little shocked that the question wasn't even asked about are Vermonters able to access any care regardless of what their hypertension, what their blood pressure was on a discrete given day.

[Tom Boris, CEO & CFO, OneCare Vermont]: I wouldn't say it was Smith. Oh,

[Rep. Alyssa Black (Chair)]: sorry. Go ahead. Did you want to And then I'll allow you to answer. So I wasn't I'm new to Vermont. I arrived in 2019. I heard and still hear a lot of confusion around One Care, the goal was, a lot of frustration around the cost of it. But before I came to Vermont, I worked in a lot of other states that had very different health care reform projects going on. And I wonder how you reflected on whether One Care did an adequate job educating Vermonters on the goal so that they could be active participants in the goal. Well, I have my own perception of what it is, but I don't feel I have yet to really meet someone that understands the concept

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: of Thanks the

[Tom Boris, CEO & CFO, OneCare Vermont]: for that question. I agree. It's been difficult because there really have been multiple initiatives going on at the same time that are similar enough but different enough also that has made the dialogue really difficult. Over here, the state was running the all payer model, and that had locked the goals. The state agreed to fulfill certain terms with CMS, and that was a contract too. Then over here, we're trying to run an ACO in Vermont. There's conceptual overlap in that the all payer model was trying to challenge Vermont to build ACO business and make it more robust to help address some of these population health opportunities. But as we were trying to talk about our work, it got very intermingled with what was going on with the all payer model, and everybody's head spun, myself included, like, how do we talk about this work without getting into the all payer model space too much because those are different. They're different parties. They're different initiatives. So it became really difficult for us to have constructive dialogue, especially in the public forum about what we do because what the all payer model was supposed to do got mixed up with what our goals were. An ACO is a provider organization trying to work together to improve the outcomes for their patients. It's very plain. It's very common. They're all over the country. One Care is not unique really in any way. The only thing unique about One Care Vermont is it's domiciled in Vermont and we're all, I mean, don't think this is unique either, but we're funded by providers rather than some of these others, national companies that have other investments

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: It supporting

[Rep. Alyssa Black (Chair)]: was a statewide effort. I don't think that's common.

[Tom Boris, CEO & CFO, OneCare Vermont]: 1Q Vermont is not a statewide effort. The all payer model was. 1Q Vermont is separate from that.

[Michael Costa, President & CEO, Gifford Healthcare; CEO, Maple Mountain Consortium]: We were

[Tom Boris, CEO & CFO, OneCare Vermont]: operating in Vermont before the all payer model came around. By choice, we could have been after. So I think that's where it's got really confusing for a lot of people is a lot many people will view OneCare as some sort of a state entity. That's not the case. We're We're a provider entity. We tried our best truly to align with the state's goals. When the all payer model came around, we said, all right, great. We'll be a force for good here and do our best to shift our focus to the priority areas that were within the all payer model. But because of these two things going on at once, it became really confusing and hard for us to talk about it and hard for people to understand it. So that really was a difficult circumstance. It still is.

[Rep. Alyssa Black (Chair)]: Makes a lot of sense. Can you clarify one thing, though? I thought that One Care was a statewide effort amongst providers.

[Tom Boris, CEO & CFO, OneCare Vermont]: So One Care is a private entity, When the all payer model came around, it was challenging Vermont to really expand ACO business. OneCare was already here. We agreed to be a part of that. We leaned in hard to try and grow our participation, and we took a come one, come all approach, which is unusual for ACOs. Most ACOs

[Rep. Alyssa Black (Chair)]: talking about. It's just that one care was a really unique effort. There's only a couple states that have done it that way.

[Tom Boris, CEO & CFO, OneCare Vermont]: That part is unique, where in spirit of the state's goals to grow ACO business, we really took anybody who was willing to participate. And that made it difficult, frankly, for us to get results where other ACOs will be more selective about who they pick. They will prioritize, participants who have poorly managed panels because you can get those folks under control quickly and earn some shared savings. There's a real financial motive and incentive. We didn't take that approach. We took more of a long range, let's try to work together to improve some of these outcomes over time on behalf of the patients that these providers serve. And for a provider participant, I think those who really leaned in and got it, they understand the value equation for them. They got financial resources, which I think are good, but they also got access to data they wouldn't otherwise have. They could partner and collaborate with other organizations and speak about business in ways that you can't in a disaggregated healthcare system. Waivers are a huge tool under these programs where you can, through oversight and action from a board, delete some of the barriers that prevent smooth patient flow and transitions to the system. So those are all tools that the providers can use to deliver better healthcare.

[Rep. Alyssa Black (Chair)]: Yes, I do. I want to put a time limit. We have another five minutes because I do want to take a break before our next SWIP. I'm really curious. And if you want to take us a different direction and finish what you have, I'm really curious to given what you just told us, is there an opportunity in Vermont to, say, take all the designated agencies and invite them into an ACO, Something that is more contained, you could have more common goals, outcomes, and manageable size of participants.

[Tom Boris, CEO & CFO, OneCare Vermont]: Short answer, yes. ACOs, just technically the way they work, they center around primary care. That's kind of the root of the foundation of the ACO concept. That's how you get your list of patients you will treat. So without the primary care component, it would probably be something a little bit different, but that idea, that spirit of getting different organizations to start working together, collaborating differently is a really good one. It just happens to be legally complex without some sort of a safe harbor or umbrella to do it. In spirit of wrapping up, message received there. Quick thought on data. Data is super important. It's also super complicated. Unfortunately, it's expensive. With sensitive data, healthcare data, you have to have robust systems, compliance, security, you have to have accurate permission, you have to be an analyst to be able to extract the data, so it's an extremely important tool. As OneCare fades out, we lose this robust data system that we had and all the historical data. I think it's really important that the state tries to find a different way to make sure providers have good access to comprehensive data and a really tight data strategy to help them succeed. All right, my last thought here, it's an important one, a conceptual one, I think, One Care's journey has been very interesting, and the big takeaway for me was that if you have an objective, it's really important that you clearly and specifically define the problem that you want to solve. You also need to define what success looks like. What are you trying to get to? What's the outcome where you know, great, we got it. There's probably more to do, but at least you hit a milestone, right? Then you got to pick the right tool to do it. A lot of my reflection about One Care's experience and journey, over time, we just started facing endless criticism, mounting criticism. It was often bizarre, you won't even believe it. But it just dawned me through time that people were so dissatisfied with One Care because it doesn't solve the cost shift. It doesn't solve commercial premiums. That's not what ACOs do. If ACOs could do that, we wouldn't have this cost shifting problem across rural healthcare all over the country. They are great tools for providers. They're valuable. They help providers, I hope, exist in a in a more dynamic environment and allow for more partnerships and have more data. There's a lot of good that can come from them, but we were just gonna brand it a failure because the cost shift wasn't solved. And if you look at One Care Vermont as an ACO, the way ACOs are evaluated, generally, it's whether or not you were in shared savings more than you owed in shared losses over time, or whether or not you could generate positive quality scores over time. Through that lens, I think One Care was a fairly successful organization despite constant headwinds, but the real problem is that all of us, this is all of us in the state of Vermont working on this, never really got crisp on what is it that we're trying to solve here and how do we know if we're making progress and how do we know when we succeed. And it got really murky between the goals of the all payer model and the goals that would be more germane to ACOs and ACO business. So as you all are thinking about new initiatives and new programs for Vermont in the future, my recommendation is to be really crisp on what's it trying to solve, how do we know, and then asking, is it the right tool to solve that job? Because if the goal retrospectively, the goal was to solve the cost shift using ACOs to do it was not

[Dante (unidentified committee member)]: the right tool despite the value.

[Rep. Alyssa Black (Chair)]: Thank you. Thanks for coming in.

[Tom Boris, CEO & CFO, OneCare Vermont]: My pleasure.

[Rep. Alyssa Black (Chair)]: I really appreciate it. I still have a question. Yeah. Was just gonna so could you tell me know we're done here, but what should we go for you? Yes. Let's let's Well, it's

[Rep. Leslie Goldman (Member)]: a one on one. Yeah. Because we're all