Vermont Legislature SmartTranscripts:

[Sen. Martine Larocque Gulick (Vice Chair)]: Good morning, everybody. This is Senate Health and Welfare. It is January 14 and we are happy to have Sarah Rosenblum and Jill with us this morning here in the room as well as Caitlin Carell on Zoom to talk to us a little bit about the stage transformation updates. We are happy to have you here and look forward to hearing all kinds of good things from all of you and I will give you the floor. Great, thanks.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Thank you. I thought I would sort of just start with you. Okay, So good morning, Jill Mazzow Olson, I'm the State Medicaid and Health Support Director. Can I interrupt you? Yeah. I'm thinking about the two new members of our committee.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: I'm wondering if it would be We met, but you might see that. Yeah. And Sarah, you've met or you met I have not in person.

[Sen. Ann Cummings]: So Okay.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: I'm Sarah Rosenblum. I'm the interim director of Health Care Reform, which is oversees the office of Health Care Reform within the agency of human services. The Office of Healthcare Reform is within the central office of the agency, so we don't live within any particular department, but we work across all the departments within the agency. Katie has not met both either. You want to introduce yourself, Katie?

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yeah. Hi, everyone. I'm Katie Carroll. I'm the Care Transformation Director in the Health Care Reform Office at the Agency of Human Services, and wish I could be there with you guys in person, but I'm looking forward to meeting you all in person very soon.

[Sen. John Morley III]: Thank you. Senator John Morley from Orleans.

[Sen. John Benson]: And John Benson from Orange.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: And Senator Lyons will be back soon. She is temporarily in a different committee, So I'm going to just start us off. Go ahead. Thank Great. Sure. Thank you. So I'm just going to tee us up a little bit. The experts, just like the last time I was here for Medicaid, the experts are behind me right next to me. But a few things I wanted to say. So first of all, the word transformation is getting used in multiple contexts right now that is becoming increasingly confusing. And so I just like to straighten out which thing we're talking about, especially because today we're talking about both. So we have the Rural Health Transformation Grant. That's the 195,000,000 a year grant that we just received from the federal government. We're gonna talk about that at 10:00. K. So that is that. That's Rural Health Transformation program or grant. What we're talking about here is a state led effort on transformation of our health care system. So we're using the word transformation in both places. There is overlap, but it is two different things. So this is work that lives within state government, and it is it's really a it's it's part of the business of the agency rather than external funding coming from the federal government.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: I think the thing that

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: I wanted to just tee up before I let the team do their thing is that we have the Green Medicare Board and we have the agency agreement services. And I think sometimes there's, confusion and questions about sort of everybody's role. So the Green Medicare Board is really the body that has the regulatory authority over hospital budget. So they are the hospital regulator and are determining whether or not hospital budgets are approved or not approved. And so to hear about that process, you

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: really need to be in

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: that care board here. Our role in this work, all focused on affordability and access, is the assistance to the hospitals to help them and others too, to try to transform how our care is actually delivered in our communities. So what services hospitals might provide, what services others might provide to help us move care out of hospitals and into the community. So when we talk about transformation, we're talking about essentially technical assistance and consultation and there's another word that's just not coming to my brain. But really, we are providing it's a more collaborative consultative relationship. It's not a regulatory relationship. So, yeah, quick question. Are you gonna talk a little bit about how you came how you were formed, who conjured you up, and Are we gonna talk about how to get rid this? What the history? Yeah. Exactly. There's a little bit about, I think, the bills that

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yeah. I think that's it.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: How long you've been doing this work and, you know, just a little historical perspective.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yes. Yeah. Yeah. I can do that.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: I'm gonna do it from my brain,

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: so you're gonna bear with me. But Yep. Do that.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Yep. Great. Yeah. So I'm gonna turn it over to Sarah. I I think you know I'm new in my role. I've just been here for in the agency for a few months, I'm an old developer in Vermont. So have some relevant experience, but new in this in this particular world. Okay. Okay. Sarah and Katie.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Just a a little bit about what what we're gonna talk about today. I'll start and talk about why we're having this conversation, to your point, and why we have a statewide care transformation initiative agenda. And then I'll turn it over to Katie. Katie, as the care transformation director, is really the day to day lead of this work, and she's gonna talk more about where we are in it right now, specifically in the context of hospital transformation plans and then how hospital plans feed into or will feed into regional and statewide plan. Okay. So why are we having this conversation? I think there's system level factors that probably everybody in this room has heard at some point already this session, if not in Digger or in other media outlets. But affordability within the context of health care has become increasingly problematic in the state of Vermont. So health insurance costs were already have already gone up significantly over the past ten years, and that was before HR one was passed over the summer. And there were significant federal cuts to the health insurance exchanges and to Medicaid. More than half of our hospitals are operating at a loss, which is a financial loss, which is a big reason this work started, and I'll talk a little bit more about that a little in just a bit. And then there's also just from the community perspective, from the average Vermonter and their experience with the health care system. So we don't always have access to services that we'd like to be able to access in our communities, or we have long wait times. We don't have the highest quality of care. So we're both super expensive, which is a burden for Vermonters, and simultaneously, they're not necessarily getting good experience out of it. We also have related challenge you know, health care is very diverse field, also relates to housing and transportation, and these are challenges in Vermont, as you know, and in other rural states. Alright. Now I'm gonna do my riff on history and how we got

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: here. Okay. That's not there was a law that was passed and Yeah. Over one and all.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yes. That yes. Right. Exactly. So there's several years of specific state Vermont state legislature history here. So, namely, we'll

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: start

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: with act one sixty seven of 2022, I believe. You will still hear act one sixty seven thrown around in meetings. It is the piece of legislation that started kind of this inquiry into the sustainability of Vermont's hospitals resulted in the, quote, unquote, Oliver Wyman report, which was a report done by a consultant, Oliver Wyman. Sounds like an individual man's name, but it's a company. And was led by the Green Mountain Care Board as directed to them by act one sixty seven. And the Oliver Wyman report was released in late summer, 2024 and had some pretty stark findings about the sustainability of Vermont's health care system and its hospital system, namely that there were a number of hospitals that if you were to project their finances out from 2024 might fail, and the report included a number of recommendations to improve sustainability of the system. In addition, in 2023, act 51 was passed. So act one sixty seven was passed. The prior year told GMCV to do this study related to sustainability of Vermont hospitals. The following year, coming off of the Oliver Wyman report work, act 51 was passed by the legislature, which charged the agency of human services with carrying forward any recommendations coming out of the Oliver Wyman report or next steps given the findings of that in the context of hospital transformation. So that is why there was a little bit of a handoff there, and that is why the agency currently is focused on care transformation efforts. And then the last piece of legislation I'll mention is act 68 of 2025 or five. Yes. Which was passed last year. And also has a lot of additional focus on care transformation, kind of continues the same setup where Reman Care Board has a regulatory role and maintains and solidifies AHS's role as kind of supporting hospitals in this innovation and technical assistance role as we try and have a more sustainable system over the coming years. That was really helpful. Thank you. Yeah. I like to have the

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: people I wasn't talking about. It's good to have a big help with that. Yeah. Yeah.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: No problem. Okay. Katie, I will turn it to you.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Great. Thanks, Erin. So I'm gonna be giving a good amount of background as to what transformation work has looked like so far, and this slide is really what we've been using to talk about, care transformation work, that started just in 2025, some of this work around convening hospitals, and making sure hospitals are really engaged around the transformation efforts. We are, working on a new visualization as we move into the new year and a lot of new work, so this may be the last time you see this, but I wanted to ground everybody in, what we've been doing and how we've sort of been talking about the work.

[Sen. Martine Larocque Gulick (Vice Chair)]: Can you hang on one second? Can everyone

[Sen. Ann Cummings]: hear? Okay.

[Sen. Martine Larocque Gulick (Vice Chair)]: Sometimes it's hard with the light. You're good, but just try not to talk too fast. Thank you.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yes. I do talk fast, so I'm sorry for that little slow down. Oh. Okay. Okay. So this visual, is giving really a picture of what transformation work has looked like so far. The bar across the top is showing our progress to date. And so you can see we're really moving into regional and state transformation planning as well as implementation of some of the efforts. But the work that has gone into that is along those kind of gray boxes have been really the base of the work as we've been figuring out what this is gonna look like and how this work is going to grow into the future. So one of the big drivers has been regional convenings. We've been meeting with hospital leaders, in sort of geographic areas across the state to really get some conversations started around how those hospitals can collaborate, what care looks like for the population in those regions, and what's really needed to serve that population moving into the future. So those have been really valuable to us as we have been figuring out this work, and they have continued on. Hospitals are really engaged around the work, and we're now moving into regional transformation plans and, getting those solidified. And so those those meetings have continued to happen and been really, really fruitful and valuable for both us and the hospitals as they're, making decisions around what's possible within transformation. Through Act 68, which Sarah mentioned, we had hospital transformation grants that we were able to give out, and so those, have been mostly awarded. We're still working with some hospitals around what exactly they should look like, but those have really been supportive in making sure that hospitals have the resources they need to participate in transformation planning. And as we move into we're currently in draft plan stage, I'll get more into that, but as we move into final plans, many hospitals are using those resources to really solidify what they're able to implement in the coming year and what their final plans will look like, and so those have been really, a good basis of moving this work forward. And finally, we are still, providing analytics support. That's one of the big pieces that, AHS will be providing to hospitals and other care providers to really make sure that all the transformation work is data driven and data informed and that we're prioritizing things, in a way that we're kind of checking against the state needs and the state population as we continue to change into the coming years. Am I talking slow enough? Can everyone hear me okay?

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: You're doing great. Thanks, Katie. Okay. Thank you.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Just wanted to make sure.

[Sen. Ann Cummings]: No. It's not a question. Thank you. Especially John newbies, because it was confusing to me. Keep talking about Act 67, and we just did Act 68. We passed bills. They have a number. When the governor signs them, they get an Act number, which is sequential as to when the governor signed them. It's the 60. But every year, you start over and there is a new act one, so we could end up with two act 67s impacting this committee. That would be fun. And it I wasn't here when we did act 6seven, and so I'm learning what happened in the two, four years I wasn't here. I've been here on more than one occasion. And you should make this get some background. Yeah. I mean, that is it it it can be confusing because there are there is probably an act 67 every year.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Mhmm. Yeah. Yeah. And we do have a slide that we didn't include in this deck that actually does show the different acts and it does include the year. So the technical way to refer to it would be more like Act 67 of Right. Two Be specific. If you want to look it up, you'd need to know the year as It's like '68. As one

[Sen. Ann Cummings]: one other question is, are there specific goals laid out in what you're trying to achieve?

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yes. Common. Good segue.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yes. There yes. There are specific goals, and I am gonna give some background of how we're how we're framing transformation and what we're working towards. But, I would say the high level goals that are laid out in act 68 of 2025 are really, you know, the the goals we all talk about around health care, which is, affordability, access, quality, you know, those really high level things that we're really looking to achieve. Those are really our drivers of all of this work, you know, along with the rest of the work within health care reform. But we will get more into the details of how we're framing transformation specifically.

[Sen. Ann Cummings]: Bottom line for transformation is to ensure that, as you said, access across different regions for everything that's needed. So there's a gap analysis and a needs analysis that's been going on since Act 167 of 2022. So there's There's a lot also thinking about well, I'll stop there, but anyway, it's all integral. Everything is happening all at once. We want to save hospitals, we keep metal red, and we want to make sure that hospitals are delivering the care that folks need at the cost that they can afford. Sorry. I'm here again and I'm just trying to- Back Martine. Go ahead.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: No. That's great. Yes. And any stop me anytime to give more background or talk about questions or for others to fill in because everyone there are many in the room who have some really good context here. So this blue box in the middle has really been, where we've been able to synthesize all this information from more of the statewide lens of what the transformation goals are, making sure everything's aligned around, you know, everything, we've just been talking about around affordability and access and keeping all those things at the forefront. And we are now moving into transforming having transformation plans and starting to really think about what's going to be implemented to really move towards some of these, these bigger goals. And so I'm gonna move to the next slide, I think, unless there's any other questions on this.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: I have one I have one comment on this slide, Katie, before we move on. Just just to call out the final box here since we're talking about history. Act 68 of 2025 charged the agency of human services in collaboration with a number of other state agencies and organizations to create a statewide healthcare strategic delivery plan, rolls right off the tongue, by 2028. So we do have a legislative charge to create this statewide plan. So when we talk about hospital plans and we talk about regional plans and then they talk about it culminating in a statewide plan, just wanna call it that that is tied to a piece of legislation.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Can I just say something about that? One thing that I think is really important to understand is that that strategic plan is always going to be a dynamic document. So there's lots of planning happening now. Of course, I mean, think about your own experience in the healthcare system. A lot of healthcare is regional. It's not generally statewide. Most healthcare is happening in your region. Some things might happen at Berkshire Medical Center or might happen even in Boston, depending on the level of need. So we are planning now. We're not sort of waiting to create a static roadmap that we will then follow piece by piece. So in a lot of ways, I think the strategic plan is going to help all of us be able to sort of see and visualize all of the different pieces of health care reform, which are many. Thank you. The strategic plan seems incredibly important, and it seems like everyone is, like, desperate for it. Yeah. And I'm just wondering what you have a timeline for that? When that will be? And I know that's a hard question. Well, this is, I think, the point I'm trying to make, which is that And I was I yeah. I don't I'm not sure it's gonna have the sort of I I think the work we're doing now individually with hospitals on transformation is going to be the a big body of the work that's in this strategic plan. We're not waiting for this sort of final document to do this regional work with hospitals. That's happening now. But it's due in 2028. And we do have the Rural Health Transformation grant some funding to help actually support the effort to create the plan, because it's another element of the work that a pretty small team is working on. But I don't think we're waiting to would say like that. We are not waiting for 2028 to work on how can't we need to transform, we can't. We're doing it now. No, I get that. I just, there just seems to be confusion as to like which hospital is going to provide what and when and where. That's like those, I mean that's real. It is. And that's where this transformation work that Katie's talking about is that's exactly what you're

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Exactly. Doing right We're

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: not waiting for 2028 to do that work.

[Sen. Ann Cummings]: I think one of the concerns about the action plan, I consider it an action plan but ongoing, is that we know that there's regionalization going on, but the hospitals are making decisions not individually, but with other hospitals and with other providers, community services and others. So we know that when the decisions are made, they're made in a way that lead to full coverage, full claiming. Then the question I have for you folks is as you're going through this and at some point it would be helpful to know what more do we need to do to clarify legislatively. So there are some, for example, criteria for decision making at the Pre Mountain Care Board level about service addition and reduction. You're seeing that now as you're going through the regional planning stuff. So I think, yeah, we're in a really neat place right now. Sorry. One concerning thing we heard yesterday was from North Country. They had a neurologist who left, leaving them with no neurology. Because that neurologist isn't sure that that hospital will be providing neurology and wanted a more stable environment, and I can see especially people with children, they're going into school, you don't want to find yourself having to commute from North Country to Rutland or Central Vermont every day, and you don't wanna have to pack your kids up. So there's some human decisions being made. I'm sure people that are coming here are weighing that in their choice. And so that to me, that adds to the urgency of setting some things in concrete, because as long as it's fluid, it's impacting individual decisions, and that's concerning. We have a hard enough time attracting medical professionals.

[Sen. John Morley III]: Oh,

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: sorry. I was just going to say I think that what we are talking about now with hospitals around their transformation plans and these regional plans that kind of come next, a lot of that is coming into focus of what is the care in this region gonna look like, and we are also expanding now out from just talking with hospitals to kind of care is gonna go outside of hospitals and those kind of things. So, I think we are getting there as quickly as we as we can, with these conversations and really trying to help hospitals and regions, really focus in on what they need to serve their population so that we can get to more of that stable place of where it doesn't feel like things could change at any moment of what's offered where. So this slide, transformation can be a lot of things, and so we have really tried to, bring some definition to what transformation is, what contributes to transforming our healthcare system. Hospital optimization is a big one. I think it's a lot of what we've been talking about kind of so far within this process of, what are improvements hospitals can make within the existing model of care to make sure that they're doing things really efficiently, that they're becoming more stable, and that they're really, as we were just talking about, addressing services that are offered, either, you know, potentially increasing or decreasing services, but being just really mindful of what services make sense for them to be offering for their population. For that for those kinds of decisions to be kind of within transformation, they need to be considering the bigger picture of access and quality population health management. So that's a lot of, you know, what was just being discussed is that, you know, these bigger the hospitals aren't just making these business decisions. They really need to be considering their broader population and other partners to make sure that we're, offering things in the right place at the right times for the patients. This middle box, delivery innovation, I think is really where AHS is really the engine for some of that innovation to really get bring people together to think about, are there different ways we could be providing care? Is there more innovative partnerships that we could be thinking about? And then also bringing in new technologies and those kind of pieces through some other supports that we might have. And so these are a lot of the conversations that we're having now of, you know, what are the things that we can really think about transforming into something different, that is going to better serve the population and be more sustainable into the future. And then regionalization is also a big topic. This is really coordinating organization of health services across multiple hospitals. This is also a place where AHS's role is really critical. We've been able to convene kind of groups that weren't otherwise talking as regularly, and ensuring that they're really thinking about how they can share potentially, you know, services, potentially, specialties across different regions, and making sure that we're really thinking about how to make all of that work in a way that's focused on ensuring patients receive the right care in the right place at the right cost. This bar across the bottom is really some of those initiatives that are all of these things. They're hospital optimization, they're innovative, and they're contributing to regionalization. So the unified health record, expanding telehealth is really critical to all of these things. Coordinated transfer and transport is a big, topic that's, really important going into the into this year of how we're thinking about, making some big changes, and then shared specialty networks.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Diane? Please, yeah.

[Sen. Ann Cummings]: No, very quickly, I understand we are going to go through the Rural Health Transformation Grant, and within what you're presenting here are some sort of capital costs and for example EHR, what kind of health records and having the infrastructure for that. So is there a dovetail between RHT and the transformation work you're doing with those things?

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: There is some dovetail, yes. Yes, and I think I would say we'll talk about the grant. Sure. I would say for here, we're trying to leverage the grant to help us with things that we would otherwise want to do that the grant can be used for. The grant isn't our plan. The grant is a tool in our toolbox. It's significant, but it also can only be spent on certain things. Yes, we're trying to make sense of what we're trying to accomplish with what the grant can be used for.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: We definitely think of the RHT funds as being able to accelerate some of this work or really make some of this work possible more quickly, but it all really aligns with what was already in the conversations of what we wanted to accomplish for the state. It really I think they really match up very well. Any other questions on this slide? No. Okay, great. So we also have some guiding principles of transformation that really help us to make sure that things that we're talking about doing really align well with where we're trying to go as a state. So, this is kind of taking it a step down from those high level goals into what are we really trying to do and what do we wanna make sure our initiatives align with. So I've said a lot of these things already, but they're obviously, you know, really critical to this work, delivering care in the right settings, making sure hospitals are evolving their service profiles, really making sure the regional networks are strong and that they're all aligned around their population and the population's needs. And then preventative services are, a big focus, especially as we move into our sort of next phase of transformation, moving into thinking about, what prevention looks like and how that impacts the rest of the care, for kind of the rest of the continuum of care, in those areas. We have some examples of initiatives. Increasing hospice utilization is a big one. You know, all of these are probably things that have come up as well in conversations around this work and also will come up in in RHT conversations, but mental health urgent care, mobile integrated health, and then advanced primary care management are all example initiatives that we're looking to start implementing, in the in the year ahead.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Can I ask if I could ask a question, just to kind of reiterate, underscore what senator Cummings said, And then as we look at the state as a whole, there seems to be a little bit of a whack a mole where you've got pediatric services ending and you've got birthing centers closing? You talk about delivering care in the right setting, When that does seem to, you do seem to need a hard and fast plan for that. I understand that a lot of this is fluid, but can you give us an idea of when we will have that plan of where care is going to be delivered so that we don't have this sort of disjointed system that's we've got closures and then reopening? And it's just very confusing and I agree. It's very unsettling for both employers, employees, and folks in the communities. Yeah. Sorry, go ahead. Yeah, so I think we're also blending certain things because there's also these sort of immediate questions about service reductions that are not necessarily part of, or have not been part of the transformation conversations. And so I think figuring out how that sort of individual, I think as Katie calls it, like an individual hospital business decision in terms of trying to make their budget work versus the collaborative, consultative work transformation, they're not the same exactly. So there are some immediate things happening and we're trying to make sense of, I think Katie can actually talk about this, some of the needs of the population and sort of what are the care needs so we can make rational, planned decisions about where services should be. So this is not easy. There's no roadmap for I mean, nobody's doing this anywhere. And the hospitals are still independent organizations. So we can help with consultation, we can help with technical assistance, we can help with ideas for innovation, we can help with convening, which is no small thing because there's some conversations they can't have without us in the room. Right. But see, I get it, and believe me, I'm sitting in the education space.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yes. Yeah. It

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: just seems so if there's a good plan, we won't see those kinds of fluctuations. We're still going to always see pressures. We have incredible pressures that we have no control over in Vermont. We have to remember that. We're not in control of how much Medicare pays. We're not in control of various things that have to do with how our population is insured. We're not really in control of our workforce. There's things we can do, but we are living in a very complex workforce environment across the country. There are a lot of pressures hitting Vermont that are national pressures, and we are trying to be as thoughtfully responsive to them as we can be, but we also can't entirely So be protected from there's a lot happening.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: I think that's true. In addition to, we don't control hospital boards. Hospital boards make decisions about house you know, there's, to Jill's point, it's like, they're we run into a business decision point, and I think we could have the best plan in the world, but we're not in those hospital board discussions.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: You're getting very depressed.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Okay. I'm excited. Excited.

[Sen. Ann Cummings]: I have a lot of

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: this work, so that's not the goal.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: I'm gonna say some positive things.

[Sen. Ann Cummings]: Let's keep going. No. No, no, no. I do have a question here, I also would say, you are putting some pressure on the hospitals to make change that will achieve the goals that we're looking at, so it is an iterative process. It is iterative. Understood. I mean, respecting hospital autonomy and workforce autonomy is one thing, but on the other hand we have some really urgent issues here that you are, we're just here understanding that you are doing the work that we've asked for. Absolutely. And the hospitals are responding. And so far everybody's happy. Think they're stressed. Senator, further depression. And I'm gonna have a question. According to the news and emails I get, Medicare is no longer going to cover telemedicine. Oh, yeah. And we have put a lot of stock into televise. I think it's changing, well that's what

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: I have look at. I thought there was just a waiver extension

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: on the televise and the people were really working on and they get extended it.

[Sen. Ann Cummings]: And Yeah. Reports that they're not covering it. And we've in rural Vermont, we put a lot of stock. And we have an older population that has a tough time getting out of the house and into the office. Like tomorrow morning when it's gonna be icy. Yeah. Yeah. Just okay. Well, sort that one out and give us a

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Yeah. I think there was just an infection on that.

[Sen. Ann Cummings]: It gives it a good Yeah. They did something right. Do have a different I have question that relates to the community needs. So as hospitals are increasing ambulatory care centers and mental health urgent care and mobile integrated mental health and advanced primary care complex care management. Most of that's actually outside the hospital. Yes, know, and outpatient services is where a lot of hospitals are making their money. At the same time they're drawing away from our community based services. So are the hospitals working collaboratively with community based services? Are you bringing those folks into the room together?

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Katie, do you want to make sure I you're

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: can actually speak to that. So I'm going to answer that question and kind of speak to the right services in the right place. I just wanted to say that delivering the right care in the right setting is definitely not a one size fits all just as far as all the different factors that are at play in each of these sort of regions. So I just wanted to mention that it's not, it's not quite as easy as saying, like, this service should be in the hospital. This service can be offered outside of the hospital. This service, you know, this group can do this service. There's really different organizations in each region, different staffing that's available in each region, and there's and different kind of innovative solutions. So we are working within all of that to make sure the right decisions are being made within all of those many factors. So, it would be, you know, great if it was just as easy as saying, like, all hospitals should have this, and all of this should be moved out of hospitals. It's unfortunately not quite that easy, but we are very focused on that and making sure that we're thinking through what the needs are of each region and what's already available there and trying to bring the right groups together to collaborate around where care should be delivered. So we are definitely doing that work. And then we to the the, question that was just asked, we are starting to bring in some of those other community organizations. We're we've been convening them and talking with them through, you know, kind of different context of when we're gonna bring the full groups together, and we are at that place now of really bringing the groups together to think about, what is available in the communities and how they can kind of inform what hospitals should or shouldn't be doing, now as hospitals are sort of moving out of the focus on their own hospital optimization. And I will say the engagement is really great with the hospitals as well, around being really open to different solutions and what makes sense for serving the population, and not just being as focused on, you know, where they might be be bringing in money and being a little bit more flexible in those areas. Any other questions there? Did I answer your question?

[Sen. Ann Cummings]: No, thank you.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Great.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: So hospitals, as I've mentioned, have been working on transformation plans. We do have the drafts due this week, so we have been working with them closely on those and making sure that they contribute to the Act 60 of 2025 goals that we've been talking about, and that there are things that can be monitored and measured, but we are also, continuing to work with them towards final plans that are due in March, but we do also anticipate that those will be, plans that continue to be updated. As we said, we're still bringing in, you know, other community partners, other ways of thinking about changes that hospitals could make or where hospitals should be going. You know, and the plans also look really different for different hospitals that are in sort of different phases of doing this work and have more capacity to make certain changes, but they are all moving forward with a lot of engagement, and we're, planning to, have some more kind of concrete implementation plans for the final, work that's due in March. Any questions on the plans?

[Sen. Ann Cummings]: Now, will you come in and share with us some of the work that's going on?

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yes, absolutely. When we get the draft plans, we're planning to put them summarize them into some of these groups that we've been talking about, who's working on hospital optimization, who's doing some innovative things, you know, who where do are we seeing, sort of progress towards regional more regional work happening, and categorize all those things and be able to summarize it for you all very soon.

[Sen. Ann Cummings]: Are they due tomorrow? March. March.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: The draft. The Okay. The draft through tomorrow, the finals are due.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: There'll be more work on them between

[Sen. John Morley III]: now and March.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yes. So the draft plans are really what what the hospitals are are thinking about, are trying to get some more information about what it would look like for them to make those changes, so that will give us some really good information about where they're focused, what what kind of the thoughts are around what could move forward more quickly versus what will take more time. And then the final plans are really meant to be able to, show what they're really going to be able to implement and have more implementation planning in place.

[Sen. Ann Cummings]: Great. So,

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: HHS's role in all of this has really been to, make sure that what transformation planning is is really clear to the hospitals, and that it really is aligned with how they should be thinking about their business moving forward and, you know, being sustainable within the current climate. We are able to, provide, as I mentioned, data support, policy guidance. We've given them a lot of planning tools, and ways of thinking about how innovative ways of thinking about how they might be providing care or might be partnering with another organization. And we also can bring in subject matter expertise, and, we've thinking about even around different service lines or different ways of thinking about care, bringing the right people into the room to make sure that we have all the information to make these important decisions quickly about where we should be moving. And then another big way that we're supporting them is in those convenings that I've mentioned with many kind of different groups in the room able to talk about these topics.

[Sen. Ann Cummings]: So questions? Okay. Okay.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: And then we've mentioned regional and statewide transformation. So again, these topics have come up as we've been talking, but we in the in the regions, we are talking a lot about, clinical specialty staffing and what coverage should look like and how services can be, offered in a way that makes the most sense for that region. And then there's also shared purchasing arrangements that are really just that way of hospitals thinking about being the most efficient with their, with their finances and how they're thinking about how their business runs. And then the acuity capacity and transfer work stream has been a big one. As I mentioned, that's a big focus of these regional and then statewide transformation, conversations. So there's been a lot of really meaningful conversation around what it would look like for the most, you know, least call, a least call system to really know where the best bet is for a patient within the state and really bringing some optimization to how acuity management looks across the state. And so, really bringing the right groups together to talk about that has, we've made a lot of progress there, and I think we're really at a place where we could make some meaningful change with the right resources, in the year and years ahead. Sorry. I know I was talking quickly again at the end there, but I hope you guys could hear everything.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: And I'll say least call a least call system in layman's terms. So thinking through through the regionalization process, we might not have every single service at every single hospital. You might

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: have an accident. Even today, we don't do Yeah.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: You have an accident, and you end up at one hospital, but you need to go somewhere else. And that process of trying to figure out who has an open bed and and can accept you involves physical calling of hospitals and trying to find an available bed, which we've heard is a time consuming and inefficient process. So when Katie says, like, a least call model, she means, how can we do this in a way that it's less painful and more efficient for everybody involved so you're not physically calling six different hospitals to try and find an open bed.

[Sen. Ann Cummings]: And transportation becomes the same conversation. Who owns the transport? Who does transport all of that? So, why do we have a question here? And it's really pretty fundamental to whether we can get this stuff done, and that is there's a lot of planning going on and people are meeting and this is a good idea, this is what we can do. How much of this is being actualized?

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Yeah. Go ahead. Do you wanna start?

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: No. Yeah. So I was just gonna say I think there there are actually some, like, walls and barriers that have been broken down around how different hospitals think about others as resources and how kind of the bigger tertiary hospitals have thought about being able to share the systems that they already use and how they work, and they've been really open to sharing those things. So I think in those ways, things have moved forward around how people are thinking about what this could look like and what their hospital could be within this larger system. But I think there's obviously a technology component, and, you know, some changes to, like, how transportation works. As you mentioned, some of those bigger, like, changes to how those groups are paid, but are those bigger kind of questions of how we can move that forward from more of a funding or a policy lens in the time that we have. I don't know if Jill was going to mention that piece, but.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Yeah, I think what I would add to this is, so one of the things that I think Vermont had, we're going talk about the Rural Health Transformation brand soon. And where I think we were advantaged in our application is that we had done, is the amount of planning work already done. And so we have when someone said there's going to be a whole bunch of new money available that would not have otherwise been available, how would you spend it if you could? We had a lot of ideas because of this work. But it all does cost to create new transportation systems, to add some of the new technologies. None of it is free. And so I think that we didn't know the Rural Health Transformation Grant was going to happen, but I think we were very well positioned to take advantage of it. And I'm really hopeful that that would be a way that we can make some of all this planning. I mean, think you're saying like, how do we make this planning real on the ground? No, Are we moving? Yeah. Yes. And I think that's And so some of those tools that we need to put in place, I think we have some Now we have the potential to actually fund them. Yeah.

[Sen. Ann Cummings]: And some of the things require funds.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: And some don't require It's a

[Sen. Ann Cummings]: matter of just saying, okay, we're giving up this tower and giving it to you, and we're gonna make it happen. So what I wanna avoid is having to establish a timeline and date for certain things to happen. Because I'm hearing from folks as well. I hear the good things and then I also hear, oh, nothing's happening. So we wanna make sure that things are happening and so it's refreshing to know that they are. But, you know, this committee doesn't want to have to say, like, such and such a thing, this is going to happen.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: It's not our job.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: Yeah, I'll just- Well, it is our job.

[Sen. Ann Cummings]: I'll have to go on.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: I'll just explicitly call out, you know, Katie, while we've been on this slide, talked a lot about how hospitals have been sharing with each other, and

[Sen. Ann Cummings]: there has been a lot

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: of progress and conversations over the last year. And I'll say, like, that takes time. You know it. That takes trust.

[Sen. Ann Cummings]: Yes. So Trust is huge.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: You know, in in the hospital transformation planning process, we have gotten many times questions from hospitals saying, I'm scared to put this in writing to you, AHS. I like, we are certain we're gonna do this. It feels scary to write it down on a piece of paper. You know? We we're not sure about sending this to you. And, you know, we've had to have very honest conversations that are like, we are not your regulator. You can share these ideas with us. Sharing an idea with us is not committing, you know, in a in a blood oath that your hospital do something. It is saying we're interested in this idea, and we'd like to learn more about pursuing it. And I just wanna be honest and say I think we've made a lot of progress over the

[Sen. Ann Cummings]: last year in gaining that trust, but that is not a fast process and has to pass. Agreed. And we also know that sometimes failure is a big teacher of how to.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: The other thing actually, this is maybe a moment to also just remind us that we're not only going to make changes that that say, mean that hospitals are sharing certain clinical services. Hospitals, part of this work and the technical assistance is also for hospitals to make internal efficiency improvements, which don't look different in terms of who's sharing what services or how care is being delivered, but they do have an impact on that hospital's budget when they're working with the Green Mad Care Board if they're able to reduce their own internal costs, creating efficiencies. So, want to make sure we don't think that the only tool here is sharing of services and regionalization. Those are tools, but there are other elements as well. Senator.

[Sen. John Morley III]: So yesterday we had Sean Tester from NBERH and Senator Cummings mentioned earlier on. So I think the hospitals were driven to try to cut costs last year and I think they testified that they they ended up reducing $230,000 $230,000,000 and A, where does that come from? Like, who's, is it the Green Mountain Care Board that is? Okay, think you can.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: I would say that would be a Green Mountain Care Board conversation.

[Sen. John Morley III]: And then there's another conversation, sounds like their goal was coming against another 100,000,000. So

[Sen. Ann Cummings]: 30,000,000 by 01/1930.

[Sen. John Morley III]: Oh, okay. I didn't know that.

[Sen. Ann Cummings]: It's a lot yeah. They put that on their

[Sen. John Morley III]: slides. And so I think that could potentially be difficult, madam chair. I don't know if it will be or not.

[Sen. Ann Cummings]: Well, you know, there's low hanging fruit.

[Sen. John Morley III]: That's what they got. In my opinion, $230,000,000 probably was low

[Sen. Ann Cummings]: hanging fruit. And then there's the difficult work and that's where maybe there's some pushing that has to happen and some giving, but I don't think we're there yet. I think now with the Rural Health Transformation Grant, there'll be another stage of really moving forward with some things that can end up with

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: I

[Sen. Ann Cummings]: hope. And I'm asking that question of you folks.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Yes. Yeah. Mean, that's an opportunity to make some investments we would not have otherwise had funding to make, to start some things that might have better value.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Yeah, to accelerate the change that we're already trying to do.

[Sen. Ann Cummings]: That's why she's here. There you go. Accelerate the change. Accelerate change. Oh, that's a good one.

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: That was a good one. Anything

[Sen. Ann Cummings]: else here?

[Sarah Rosenblum, Interim Director of Health Care Reform (Agency of Human Services)]: The last one? The sixth, the last It's

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: the last one. Glad we had to share. Thank

[Sen. Ann Cummings]: you for our. Thank you. Thank you.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Thank you for having us. And thank you so much

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: We're actually we'll be back in five minutes because we're on the we're your next agenda either.

[Sen. Ann Cummings]: We will. And you'll be there. For us, 10:10, Caitlin, thank you very much for being available to us. It's really

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: Of course. Thank you all for being flexible, and I look forward to being there in person next time.

[Sen. Ann Cummings]: Oh, don't you worry.

[Katie Carroll, Care Transformation Director (Agency of Human Services)]: I know I'll be back.

[Sen. Ann Cummings]: Well, no, and here's the thing. I mean, we are so interested in what's happening, and we need to express self you know, take this out to our constituents and hear from our hospitals and providers. We need to know how all things are sugaring off. At the same time, you are extremely busy and we don't want to interrupt the process. So again, it's a balance. Let's take a seven minute break.

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: Sounds good.

[Sen. Ann Cummings]: And we'll come back to

[Jill Mazza Olson, State Medicaid and Health Support Director (Agency of Human Services)]: rural