Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons, Chair]: Going on and then we've been through a lot of bills this morning that include the Green Mountain Care Board so maybe you'll see

[Owen Foster, Chair, Green Mountain Care Board]: where that goes when we have lots of interest.

[Emily Brown, Executive Director, Green Mountain Care Board]: Welcome. Thank you. So for the record, I'm Emily Brown. I'm the executive director of the Green Care Board.

[Owen Foster, Chair, Green Mountain Care Board]: My name is Owen Foxner. I am the chair of the Green Mountain Care Board since 2022.

[Emily Brown, Executive Director, Green Mountain Care Board]: Owen and I are gonna be working together on the slides presenting this morning. So we have Kristen running the slides. Kristen, if you could go to slide three or four. Yeah, there we go. So this is just a high level slide of who we are. So the Green Mount Care Board was established in 2011. It's a five member board independent. Each board member has six year staggered terms. As I said, it's independent, so we are not under the administration. We're independent. The chair is appointed and the members are appointed by the governor, but those are again, once they're appointed, they

[Senator Virginia "Ginny" Lyons, Chair]: are independent from the city. And there's a nominating process.

[Emily Brown, Executive Director, Green Mountain Care Board]: There's a nominating process. Correct. Yeah. And here are some pictures of the board members. And also wanted to mention that we are quasi judicial.

[Owen Foster, Chair, Green Mountain Care Board]: I gotta add is the board members have different backgrounds. So some of us, I'm an attorney, and to make sure

[Senator Virginia "Ginny" Lyons, Chair]: I don't miss it from

[Owen Foster, Chair, Green Mountain Care Board]: the meetings, Jessica Holmes is an economist and health econ policy expert at the Luthiery College, where she's a tenured professor. David Merman is a physician and doctor. He practices at CBOC in the emergency room. Tom Walsh is a physical therapist and also a health policy expert and professor. And Sarah Teachow, formerly in Blue Cross Blue Shield. So we have pretty good diversity of perspectives and experience, that lawyer, a health economist, a doctor, a therapist, somebody from the insurance company. I feel like the board is pretty well structured right now in terms of different perspectives and understandings of the health system.

[Emily Brown, Executive Director, Green Mountain Care Board]: Next slide outlines the board's mission. The mission is to drive system wide improvements in access, affordability, and quality of healthcare. What that means is that when the board is engaging in our regulatory activities, these are the principles that the board has in mind in making its decisions. The board regulates major areas of Vermont's healthcare system, which we'll go over in the next slide, serves as a transparent source of information and analysis on health system performance. We have a data team at the board, which oversees VUDs and runs VUDs of VUDs, are two data repositories. We also advance innovation in health care, payment, and delivery. We have a director of policy and a policy team who helps the legislature, the board make decisions that are based on data and policy, healthcare policy. The next slide is a visual of the Green Mountain cohort scope of regulation. So you'll see in the blue circle, there are a lot

[Owen Foster, Chair, Green Mountain Care Board]: of

[Emily Brown, Executive Director, Green Mountain Care Board]: actors and health insurance plans that the board does not have regulatory authority over. I like to mention that the board does not oversee Medicare and Medicaid. I think that's a frequent question. Medicare is regulated at the federal level and Medicaid is a federal and state run program. Medicare Advantage Plans also do not fall under the board's purview. Those are regulated at the federal level, as well as self insured plans. So many employers purchase self insured health insurance plans. Those are not regulated by the board and then also out of state plans. On the other side, you see a list of providers that do not fall under the board's regulatory purview, federally qualified health centers, independent providers, ambulatory surgical centers, urgent care centers, and out of state providers. The board does regulate health insurer rate reviews. So for those plans sold on the exchange in Vermont, the board reviews those rates. We also review certificate of need. So for providers wanting to open up new facilities in the state, the board reviews those applications. Very importantly, the board reviews hospital budgets. And also then here, we have ACO oversight and certification. Any questions before we move on there? I know there's some new members. So I wanna make sure there are any questions about our oversight.

[Senator Virginia "Ginny" Lyons, Chair]: Let's ask this question. If you have a group of physicians practice that is part of the hospital, do you regulate that as well, do you budget? Yes,

[Owen Foster, Chair, Green Mountain Care Board]: if the physicians are associated with the hospital and they work for the hospital, their revenue would be included in the hospital budget and we would regulate that. The way we would do that is, the hospital comes in with its total revenue, how much money it plans to bring in for the year, and we review whether the charges are appropriate and how much money they're going to charge insurance companies on the money they're going bring. So the facility fees that are associated with doctor visits, so if a patient goes to a hospital, they have what's called a facility fee, which is a charge for using the hospital facility. And then there's a professional fee, which is the fee for the doctor and the physician. If the doctors are part of the hospital, they would have both charges, and that would come to us. If the physician group is not part of the hospital but performs services in the hospitals, think of an outsourced group of doctors. Can think of a car garage. You have mechanics that come in that don't work there, they give the money. In that kind of situation, that money associated with those patients would not be part of our budget review. This slide is important because I think there is a lot of misunderstanding as to what our care board does and doesn't do and what we can and cannot fix or work on. So Medicare Advantage left Vermont last year. The care board has no authority. There's nothing we can do. We'll get a lot of letters saying do something. We got a lot of letters. Relatedly, if you think about Blue Cross and Blue Cross' financial solvency, looks like you two drew the short stick this year on Pavideos Science. We got healthcare. No offense,

[Senator Virginia "Ginny" Lyons, Chair]: chair, lights.

[Emily Brown, Executive Director, Green Mountain Care Board]: I don't think so, bye.

[Owen Foster, Chair, Green Mountain Care Board]: But it's a meaty topic, so I'll try and make sure I explain it as well as possible. Blue Cross Blue Shield has around 300,000 members, I think, in its entire portfolio. What the Care Board regulates is about 70 thou maybe less than that. 60 50 to 60,000 of those lives. So the huge swath of Blue Cross's business that we have nothing to do with. You'll often hear a narrative or words like, well, the Care Board needs to give us more rate. Well, even if we gave more rate to Blue Cross and health care solvency problem, it would come out of constituents' pockets. And with the highest health care costs in the country, that's very difficult to do. Second, even if we did it from QHP plans, there's 200,000 plus other lives that we have nothing to do with. So it's just important to kind of remember where we act and where we deal with that. Rural hospitals across the country for the last two decades have really struggled financially. It is a business model that as the health system has evolved is not a very successful one. We're seeing closures and service line closures. Hospitals are going bankrupt across the country. There was one in Maine last year. There's been a number of service line closures here in Vermont in recent years, and it's a trend that's accelerating and continuing as the dollars to support healthcare and hospitals are being depleted. Vermont is particularly at risk and vulnerable for a number of reasons. One, we have 14 hospitals in the state with 650,000 people, so there's rurality challenges. We have challenges with hospitals being able to recruit to rural places. We have challenges with the facilities being old and dated, meaning a lot of money. There's not enough money to continue to pay for exactly what we have. The legislature and the governor and the chair board recognized this in 2022 when they passed act one sixty seven, which was about what does the system look like and how much money do we have, how short are we. That report was released in September 2024 and found that the status quo, how our hospital system, just the hospital system, not the rest of it, currently operates, we are about $2,400,000,000 short of revenue to maintain the status quo over the next five years. Fast forward, since that report, a number of federal changes have happened, which likely makes that $2,400,000,000 number look rosy. We are in an environment where we will be losing services. That is not necessarily a bad thing. There are services that we can consolidate and regionalize, and make it more efficient and more affordable. There are other services that we can perform outside of hospitals in a much more cost effective manner. And if we're able to do that, the hospital might lose the service, but the community keeps it and it's more affordable. The challenge is making that pie all fit and doing it in a very tough financial environment. This is a graph of Vermont's health insurance costs on the qualified health plan market. That's the market that we regulate as compared to national. So the yellow is Vermont and the orange is the rest of the country. And these are there's a couple different plans. There's different options, bronze, silver, and that's what these various lines represent. But if you look at it, we can really see this 2018, the rest of the nation has been essentially flat, really flat. And then Vermont was in the ballpark in 2018 and 2019, and ever since has just exploded. And we have become the highest, most expensive commercial insurance on the QHP plans in the country. If we don't give the insurance company enough money, they have solvency risks. If the insurance companies don't get more money, the hospitals have solvency risks. But we can't give them more money because as people pay more and more, they just drop insurance. So it actually doesn't even work at this point, and it's really bad for demographic growth, really bad for younger families who can't afford it. It's inequitable, and it's horrible for economic growth in our rural communities. I am proud that this last year the CARE Board's decision on rates was really small. The rate increases were quite low. In the nation, including the District Of Columbia, Vermont had the fiftieth lowest insurance premium increases in the country out of 51 states and District Of Columbia.

[Senator Virginia "Ginny" Lyons, Chair]: How about Hawaii's lives? I thought these oh, it's a Hawaii's I'm trying to remember.

[Owen Foster, Chair, Green Mountain Care Board]: Maybe you're right.

[Senator Virginia "Ginny" Lyons, Chair]: Anyway, They have they have special dispensation.

[Emily Brown, Executive Director, Green Mountain Care Board]: That's a quick question, and I feel like I should know this, per capita, how do we compare to other states in terms

[Owen Foster, Chair, Green Mountain Care Board]: of the number of hospitals we have? Do you know? I don't know that off my head. I wouldn't say that necessarily, just anecdotally from my awareness of the New England market, I don't think that per capita were an outlier in how many hospitals, but I haven't done a thorough review. I'd be guessing how many Maine has in New Hampshire, but they definitely are not by significant amount of the populations.

[Senator Virginia "Ginny" Lyons, Chair]: I know in my time here we've added mandatory coverage for services. I get concerned when I hear that Maine cost as much as we do with a similar demographic. And I'm just wondering, do we look at what's required to be covered under our plans as opposed to other states?

[Owen Foster, Chair, Green Mountain Care Board]: That is an option for improving affordability. I don't believe the things that you're alluding to happened in the timeframe that we're looking at in this slide. So they were already in there in the base, I believe, like some of the dental coverage and the other coverage. It doesn't explain the growth, but yes, that would be a strategy to lower our costs. I think the question about how many hospitals per capita is a good one, It goes to this slide here, which is how are we allocating our money? This is really a prioritization question of how we spend our healthcare dollars and where. Vermont is a huge outlier in the nation in spending on hospital care. Hospital care is the most expensive care in healthcare. And as you spend more and more and provide more and more of your care in a hospital setting, it gets more and more expensive. Part of the transformation that we've been trying to do as a state for the last several years is to transition care out of hospitals. I can give you a couple basic examples. ED rooms in Vermont have patients going in with coughs, with colds, with strep throat, with tick bites. When you go to an ED for a tick bite, it's extremely expensive to the insurance company. Vermont has, I believe, only two ambulatory surgical centers. They often cost here in Vermont a fraction of what a hospital costs, a third, maybe half as much money. We don't have very many here, so all of that care is being done in hospital settings at really, really high prices. There's an article in Seven Days yesterday comparing costs at UVM for colonoscopies or MRIs compared to the Green Mountain Surgery Center open MRI, and they're a fraction. So without much access to that type of service, it increases expenses. When we did the all payer model, and our I mean, Senator Lyons could speak to this. For years, we've been talking about let's lower the spending in hospitals and try and transition care. It's been a theory of all of our health care reform for at least a decade. What's actually happened, if you look at this graph, next This slide is data from 2018 in the green and 2022 in the blue. You can see that the biggest growth in our spending in the state is actually in hospitals. That's during a period of time when the goal was to transition care to more affordable places outside of hospitals. But we haven't been effective, and what we have now is a strategy of providing all of this care, and solving hospitals will continue to cause extreme affordability and solvency risks as we can't afford to keep going.

[Senator Virginia "Ginny" Lyons, Chair]: Yeah, the hard part is delineating which care must be moved and then having it moving.

[Owen Foster, Chair, Green Mountain Care Board]: Correct.

[Senator Virginia "Ginny" Lyons, Chair]: It's not always gonna happen. And it's a habit that actually patients get into as well.

[Owen Foster, Chair, Green Mountain Care Board]: It's also, it's not a light switch. It's not a can't open up a new surgery center overnight and it's challenging. Part of the issue too, and I think that the Seven Days article spoke to this, is a lot of hospitals own primary care, and so when you get the referral from your primary care, they're gonna refer to that hospital. So it's a closed loop referral system that stays in that expensive place. The independent primary care of the FTC is more likely to utilize some of those other services. I think you have a bill this year discussing

[Senator Virginia "Ginny" Lyons, Chair]: Well, we just went through it this morning.

[Owen Foster, Chair, Green Mountain Care Board]: Yeah. Great.

[Senator Virginia "Ginny" Lyons, Chair]: And what you've just said suggests to me something we can add in. It's just something you Uh-huh.

[Owen Foster, Chair, Green Mountain Care Board]: Just something to be cognizant about.

[Senator Virginia "Ginny" Lyons, Chair]: Yeah. No. To make more specific about what needs to happen.

[Owen Foster, Chair, Green Mountain Care Board]: But as we do these things, if we transition care out of hospitals, we have to recognize that it's going to hurt the hospital's finances and they're going to have to look different. If you move the care, they don't have the revenue. They're not getting $6,000 per colonoscopy, and that will hurt their stability because of the state of the state state. We have choices of age, and there are hard choices. We want to go through the next two slides, Kristen, some of the recent legislative action that was taken last year and in recent years, and walk through what's happened ever after an alternate boundary.

[Emily Brown, Executive Director, Green Mountain Care Board]: So we've been very busy at the Green Mountain Care Board, as well

[Owen Foster, Chair, Green Mountain Care Board]: as the

[Emily Brown, Executive Director, Green Mountain Care Board]: legislature. This slide is an example of some of the legislation that was passed last year, which impacts the Green Mountain Care Board. Act 68 implemented a reference based pricing framework, expanded data requirements, as well as improved clarity on the notice of service reduction submissions. These all impact Supreme Mountain Care Board work and we're currently in the process of implementing all of these processes. Act 55 was a major factor in hospital budget review this session or this last summer, as well as rate review. It caps the amount that hospitals could charge for outpatient office administered prescription drugs at 120% of ASP. It requires hospitals to report 340B drug acquisition and payment data. That is now live on our website and can be accessed currently. It also requires hospitals to disclose how they use the 340B revenue to support community benefit programs. I know a lot of these terms are, in a way, terms of art, so we'd be happy to come back in and talk about what all of these reporting requirements, as well as the CAF do. Act 62 clarified and updated Green Care Board's regulatory rules. Act 49 protected insurer solvency by giving Green Mountain Care Board to adjust rates in the case of an insurer's solvency falling below a certain level. It established hospital observer authority under the Green Mountain Care Board and enhanced transparency of reimbursement structures. Act 15 required updates to the certificate of need threshold, so we are currently in the process of updating our regulation, our rule to come into compliance with this legislative change. And what those changes also did is streamline the review for smaller CON, certificate of need projects, to allow them to go through without review. And it maintained oversight for major health system investing. Anything you'd like to follow-up with?

[Owen Foster, Chair, Green Mountain Care Board]: Sure.

[Senator Virginia "Ginny" Lyons, Chair]: Oh, I'm sorry. So, we just went two questions I'm gonna ask. I'm gonna ask them the bottom first, the second and first. You don't know that. But the notice of service reduction, we just went through the bill that we have in here that talks about reporting to you and responsibility it is for making a recommendation on service reduction. It'll be important for us to understand how and why. I think that was something you were interested in having happen why it would go to AHS and why it wouldn't be Pre Med Care Board and how that fits together. We continue to try to get a grasp on who's responsible for what because there's so much going on and I appreciate the chaos that exists from time to time between AHS and the Human Care Board and that world. So just to let you know, we did look at it. It will be great to have you come back in to talk about that bill as well as others. And then the reference stage pricing piece generally through a little bit about what it is but will also would be great to have you come in and talk about where you are with that.

[Emily Brown, Executive Director, Green Mountain Care Board]: I believe we planned There's a sort of question in there. Can you come back? Yes, we will come back. We would be happy to. The next slide actually speaks to, it's an implementation update on our reference based pricing. For those who are new to the committee, reference based pricing is a cost containment strategy, which would set a maximum price for hospital services. That price would be tied to a Medicare benchmark. We're currently engaging with stakeholders, our board members, our staff to develop the policy for that program. The first step being approaching rulemaking this summer in FY27. We plan to have the rule implemented by FY28 and effective, which would then start impacting hospital prices. Again, we'd be happy to come back and talk to you. We also have a report due to the legislature on reference based pricing implementation in February. The next slide is a high level overview of where we are with some of the legislative changes that I went over in the prior slide. We have an interim notice of service reduction policy. This is in response to the legislation that outlines what hospitals required to submit to us prior to eliminating a service. We did have one application submitted to us in December, which was the Rutland Regional Medical Center Pediatric Inpatient Changes. They have withdrawn that that notice of service reduction, and now I believe are working with AHS on a solution to that issue. We are engaging in rulemaking for our ACOs. Prior to this, we had one accountable care organization operating in the state at which the Green Mountain Care Board oversaw. That ACO is, I believe, ceasing operation effective 01/01/2026, or at the end of the last year. We're moving to a certification process for all ACOs operating in the state. We had a meeting on a board meeting on Wednesday where we went over that rule and it's expected to be adopted by the board and we're moving into the LCAR process next. Issued LCAR being legislative committee Yes, sorry. A lot of acronyms.

[Senator Virginia "Ginny" Lyons, Chair]: I'm sorry. We haven't talked about that level of things yet. Thank you. Appreciate that.

[Emily Brown, Executive Director, Green Mountain Care Board]: Act 134 was our report on prescription drug affordability. We submitted that last week. That addressed some suggestions on how to control prescription drug costs in our state. One of those actually being the ArrayRx program, which I believe is contained in the bill that trigger is now working for. We issued reporting guidance for Act 55 on the 340B reporting, and we've implemented the 120% ASP cap that was in Act 55 through our budget hearing process as well as our rate review process. Ongoing projects, which are annual part of our regulatory cycle, the hospital budget guidance development. We're currently undergoing that, which is expected to be finalized in March 2026. We have worked with AHS on a Rural Health Transformation Fund grant project, which would enhance our IT systems at the Green Mountain Care Board and hopefully enable us to do more with the healthcare systems data and provide more real time results on any impacts to our healthcare system. Out of curiosity, will you be linking in with Vital in this? Or who what entities will be connected with that project? I I don't have an answer for you on that. Can get back to you. I know Wendy Geller, who's our director of data Mhmm. At the Green Mountain Care Board would be happy to come in. I believe she's going to be in house health care soon to talk about that project and what it entails. So we would be happy to have her in here. We'll we'll do that. Okay. We'll do that. And I can get the specific question on vital

[Owen Foster, Chair, Green Mountain Care Board]: answers for you.

[Senator Virginia "Ginny" Lyons, Chair]: Well, it's vital.

[Emily Brown, Executive Director, Green Mountain Care Board]: It'll speak everything. I know it will interact with Z Cures because that know. Be there. Right. I'm not sure of that. Well, how micro do you get?

[Senator Virginia "Ginny" Lyons, Chair]: Do you get down into clinical data? Or is it all claims database? What is it? It would be good to have that.

[Owen Foster, Chair, Green Mountain Care Board]: I'll go over our hospital budget review process. So all this work we're talking about, in a hierarchy of what's the most important work and most relevant work that we do, it's really, number one, hospital budgets. Number two, that qualified health plan insurance rate review, we decide the rates. And then three, everything else, I would say, kind of goes into this informative policy world. So hospital body review, just to give you an overview of the process, right now we're currently working on guidance for fiscal year twenty seven. And what guidance is, it tells hospitals, here's where the care board would like to see you come in and sets an expectation for how much growth we think is appropriate. It'll say, one, how much total dollars you can bring in, and then two, how much more you can charge insurance companies. Hospitals have inflation, they have costs, and sometimes they need more money. Actually, they always need more money. That has a trickle down effect on the insurance rates. Those go up higher and the insurance rates go up higher. It's not a direct linkage. Hospital budgets are actually only a fraction of what goes into an insurance rate. There's all these other things, including the prescription drugs that people take, how often people go to doctors, which doctors they choose to go to, hospitals that patients go to in other states. There's a whole bunch of things that go into a rate. Also, the reserves at the insurance company. The insurance company has really low reserves. They need more money or they're at risk of insolvency. We just really experienced that with Blue Cross. Think of this like a bank account. A reserve is really just they have to pay claims every single month. We need weekly. I'm not sure the case. And if the claims are higher than they had anticipated, it eats into their savings account, and that savings account goes down. What we saw with Blue Cross in the last couple years is those claims were way higher than they had anticipated, and their reserves just frankly plummeted. But that then happens what happens then is they come before the care board and say, look how low our reserves are. Let us increase rates 7% just to build back up our reserves the next few years. That means before we even say hello to what's going on and everything else, the rate is up 7%. That QHP just went up eight 7% just for their reserves, and that's really problematic because our ability to lower things get gets very, very difficult and constrained. Last year, how we achieved those really low rates for Vermonters was, in my mind, really a one time event, because we looked at mostly the University of Vermont Health Network and Medical Center, and we found that they had enormous reserves, and their prices were really high, and they had been doing some operational things with some other hospitals in New York that we thought was inappropriate. We essentially used a lot of that money that the network had to keep rates lower. We lowered UVM's rates by quite a bit, and that allowed us to lower the insurance rates. How often you can do that is limited. Right? It's limited. EVM could do it that year. Can they do it this year? I don't know. Can they do it next year? I don't know. But there's a limit to how much you can do that, and the other hospitals who provide don't have high reserves either, as we'll get into. That concerns me for this coming year when we get rates that they're going to be quite high. With the hospital system largely also facing solvency risks, there's really nowhere to go other than the system needs to change rather dramatically pretty quickly. So the guidance goes out. We finalize it March 31. Hospital budgets are submitted to us on July 1. They're large, and the binders are huge. It's a lot of complex data. We have an outstanding staff that pours over this for a couple of months. By September 15, the five board members need to vote on each hospital's budget and say yes or no, and if not yes or no, what isn't? And generally, we're deciding again how much revenue. A lot of times now, we're saying, look, you've had all the rate increases over the last ten years. You have some of the highest prices in the country at some of these hospitals. We can't give you more rate. You already got it. So you're gonna need to do something Or we look at that total revenue and say, okay, some of this care has been moved elsewhere. You need to find a strategy to move this care out of your hospital to other places. Some situations that's easy, some it's difficult. I'll spend just Cherilyn, is we until noon, or how long would you like us to

[Senator Virginia "Ginny" Lyons, Chair]: Yeah. We have until what far? Okay.

[Owen Foster, Chair, Green Mountain Care Board]: This is an important point. Our hospitals are in financial distress, and I'll explain which ones and to what degree. On the right is a chart of Standard and Poor's methodology for evaluating hospital system health, and this is days cash on hand. That's how much money they have in their bank that allows them to operate. They brought in no more revenue. The rating agencies consider anything under 110 to be either vulnerable or highly vulnerable. And over here is a chart of the days cash on hand in fiscal year twenty six budgets. So as you can see, Brattleboro with seventy two days cash on hand is highly vulnerable. If you go to Springfield, thirty three days cash on hand, If there's something higher than higher, that would be here. SVMC, that's misleading because they have a parent company that actually has more money, and Copley has a parent company with some more money as well, and so does UBMMC. But Springfield, NVRH, St. Johnsbury, Grace Cottage, Gifford, Brattleboro, and CVMC are all clearly in the vulnerable or highly vulnerable stage. And this is current data. This is for fiscal year 'twenty six. And then you need a positive margin, you want a margin of zero to 3%. Generally, that's how much money you're making off your operations. So think of the mechanic who has business every day, and at the end of the year they lose 3%. That doesn't work. You can see here a number of Vermont hospitals, fiscal year twenty six, have actually negative margins. What happens then is it eats in the day's cash on hand and those reserves continue to go down. So when you see a steep operating margin loss of like 12%, that's huge. That's going eat into a lot of your reserves and threatens solvency. At these stages, something needs to give and needs to give pretty quickly and change quite rapidly.

[Senator Virginia "Ginny" Lyons, Chair]: Well, a couple minutes. Go for it. It was just a little bit.

[Owen Foster, Chair, Green Mountain Care Board]: So just 50,000 level, again, we're gonna have less services, and rates are probably gonna go up. Correct. Okay. Just wanna get that. And and and the rural health fund, I mean, some of it, I I just think I saw on the slide you guys are gonna be using. And I'm just trying to figure out is there a way that the hospitals can all agree on one or two IT expansions, upgrades, updates, whatever, to make them look more affordable moving forward, make an investment they wouldn't normally make, but will make savings. And I don't know, I haven't talked to Hong Kong, so I didn't know if that was something that you're hearing discussions about. Yeah, great question. Laid back up to your first question, higher rates, fewer services, yes. But also we want to see, not like the services are gone, but they're transitioned to other places, increasing the access to urgent care, spending hours in urgent care, submitting the services at a group hospital, but it's elsewhere, or they're consolidating their services to somebody else. Your second question, the Rural Health Fund, the application did include potential investment in infrastructure for hospitals. And there's a number of other strategies in there that gets to this.

[Senator Virginia "Ginny" Lyons, Chair]: But I want to go to the EMR, That the medical records is a huge part of what we did in 01/1926 last year. So it had three components, That was one of them. And so the Rural Health Transformation Grant simply is an opportunity to help invest. Good. I see that we're out of time. Don't know

[Owen Foster, Chair, Green Mountain Care Board]: if you're scheduled here in schedules.

[Senator Virginia "Ginny" Lyons, Chair]: Take until five after. Are we back? Okay. Alright. Let's do it. We'll have you back.

[Emily Brown, Executive Director, Green Mountain Care Board]: Kristen, if you want, just go to,

[Owen Foster, Chair, Green Mountain Care Board]: slide 21 please, Kristen. This is the rate increases on those plans I spoke about for fiscal year twenty six. So you can see Blue Cross had originally proposed an average of 13% for small group plans. The Board approved four. MVP requested seven on average. We approved two. And Chris, if you go to slide 21, or slide the sub before, individual plans, please. Blue Cross requested a 23% increase, the highest cost in the country, we need 23% more. That's big. And MVP proposed seven. The board approved 1.39.6%. The point I wanna make on this slide is that on an individual market, that's this market, the subsidies, a lot of Vermonters get subsidies from the federal government, those have expired, which means the real pain is starting for families and people who will be dropping insurance, which also hurts hospital finances if they don't have all the patients that are insured, delay care, it's not good. That makes it even more important to keep the rates as reasonable as possible, cognizant of all these other challenges. And I'll stop there unless there's questions.

[Senator Virginia "Ginny" Lyons, Chair]: So, so we're gonna have you back in for a number of bills that we're working on, but also just for the more general conversation. But this is really helpful. One of our, I think our mutual goal is to get to a place where we're lowering premium costs for patients. So making that connection between rates and premium costs, hospital expenditures, That's your job. It's limited. No. It's also our job in establishing policies that will help you. Forward We to that work. Thank you very much. Thank Appreciate it. Happy to back.

[Emily Brown, Executive Director, Green Mountain Care Board]: We'll have you back in. 18.5 hospitals per million nationwide.

[Owen Foster, Chair, Green Mountain Care Board]: 18.5 per million. Yeah. So we're We're 14%. Sorry.

[Senator Virginia "Ginny" Lyons, Chair]: Yeah. Were in July. But we're geographically dispersed. Right. Right.