Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: All right, good morning. This is Senate Health and Welfare. It is March 10 and we are entering crossover week. So we have a lot of work to do on a number of bills. We're picking up some testimony. I won't call it last minute because it's critical testimony to each of the bills. And so we're going to begin by welcoming Doctor. Bob Bordone, senior fellow from Harvard Law School, and then we'll also be welcoming Doctor. Peter Ponovost University Hospitals, I think, in Ohio. Is that correct? Well, Doctor. Ponofos, are you there? He's on Zoom. Okay, well we'll pick him up a little bit later. So this is with regard to S 197, the primary care payment reform program, and the difficult issue here for us is how to identify the payment process. It's all about payment reform and then where do we get the money and how do we distribute it. We put in a number of policy provisions regarding distribution and improving primary care in the state. We still have a ways to go on how to do it and where to get it. So I think that's what we're all about today. And Doctor. Zordomes, thank you for being here.

[Bob Bordone, Senior Fellow, Harvard Law School]: Thank you so much for having me, Senator Lyons, and I'm really delighted to be here. So I'm going to be sharing some slides with you, and let me maybe just give a little bit of background that hopefully the reasons why I think I'm here are connected to the reasons why you think I'm here. But Professor Fisher at Dartmouth Medical School really reached out to me to talk to you specifically about two processes in negotiation that he thinks perhaps can help around this payment plan. And so he asked me to talk with you a little bit, really to give a bit of a primer about these two things. It's because they're quite, I would say, different from standard negotiation. So one is stakeholder assessment, and the other is the one text. As some of you may know, the one text was actually developed by Elliot Fisher, so Professor Fisher's father, Roger Fisher, at Harvard Law School. And Roger Fisher was one of my mentors. So I'm to share some slides. Feel free to interrupt. It looks like I need some requests to share the slides. So I'm going to do that now.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: And while you're getting we're going to do that. We're going to go around the table and introduce ourselves so you can

[Bob Bordone, Senior Fellow, Harvard Law School]: Oh wonderful, that'd be great.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: So we'll start over

[Sen. John Morley III]: here. John Morley, Orleans District.

[Sen. John Benson]: John Benson with the Orange District.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Ginny Lyons, Chittenden Southeast District. Ann Cummings, Washington. And our missing vice chair is Senator Gulick, who is out today. She's sick. She'll be back and she'll be staying in touch with you through your slides and looking at the YouTube of the meeting.

[Bob Bordone, Senior Fellow, Harvard Law School]: Wonderful.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: So, thank you. And I have talked with Elliot about your involvement with this, and we greatly appreciate you taking the time to put your slides together for us. So why don't you go right ahead?

[Bob Bordone, Senior Fellow, Harvard Law School]: Wonderful, and I'm really delighted to be here. So I'm gonna start this. For some of you who have been involved in these processes, this may feel extremely basic, and perhaps for some of you who have not, this may feel a little speedy. I'm happy to elaborate for those who would like more and to be interrupted for if you feel like we know of this already. But I want to start by just actually talking about this work of stakeholder assessment. So stakeholder assessment is something that negotiation professionals hopefully always do in all sorts of contexts, whether they're coaching someone in a negotiation, whether they're coming in in a mediation capacity, or whether they're trying to help parties assess what kind of a process might make sense for a particular either multi party complicated negotiation, like the one I think you're all facing, or even a simple one that might involve just a few And in short, the stakeholder assessment, which depending on how complicated it is, can last for a few weeks to even many months. But it's really an opportunity for really gathering an understanding of who are the stakeholders in a particular conflict or consensus building effort or negotiation, what matters to them in the particular negotiation or conflict, and then trying to get a sense of, is there a rightness for some kind of a negotiated agreement? And if so, what would be the appropriate process for doing so? And I say this as we think about stakeholders, we usually mean more than just the parties who would be at the immediate negotiation table. But we think about things like constituents, folks who might not be at the table but have resources to make whatever agreement is possible, people who might otherwise block an agreement even though they're not at the table, so a wide sense of stakeholders and who they are. And there's all sorts of reasons why it's tempting to skip over a stakeholder assessment process because it feels like we know who the parties are already. Let's just get into it. Why are we wasting time and money? And also, just the kind of vast majority of literature in my field and experience also on multi party processes is that stakeholder assessment work is really helpful. It helps map interests. It helps really explore parties' incentives and willingness to negotiate in good faith. The very process of the assessment helps build some relationships. I appreciate and know from talking with Elliot that obviously Vermont is not New York City or even Massachusetts, where I am, so it's a much smaller place where there are lots of relationships in place already. But it provides the parties with a more impartial map, a sense of what would be some of the challenges here, both personality wise, but institutional and legal, etcetera. And should there be a sense of we want to move forward with the one text process, it helps the drafters in the one text process understand what matters most. So note here, the stakeholder assessment is really different from a one text. When I spoke with Elliot, he was interested more in having me talk about the one text. Then as I talked to him, I said, well, a one text is really a decision to do a particular kind of process that has all sorts of advantages. But there are other good processes as well. So there's another whole approach that's called a consensus building approach, which is different from a one text. One could imagine something that is more of just a traditional mediated negotiation approach. One could imagine a recommendation that says the time isn't right. So the stakeholder assessment does not necessarily lead to a one text, although it certainly could. And there's parts of a one text that would require some stakeholder assessment, which I'll say in a bit. In terms of just getting started with an assessment, it's important to choose an assessor or a team of folks who can actually do this work, who have some expertise in doing it, who would then work with some of the parties, presumably all of you in the room, to understand who are the set of people we should be interviewing, that is the stakeholders, and inviting them to participate. And then there's really kind of three pieces to this, right? The information gathering part, the analysis, and then some kind of a report that could be anything from quite informal, an oral report with a few slides, to something very fancy and complicated. And I've seen both happen, and I've been involved with both. So once you have a team in place, though, they'll put together some kind of an interview protocol and arrange a set of interviews with stakeholders, where the purpose is try to understand parties' interests, in particular, in this case, this negotiation around paying for primary care, and get them brainstorming, at least from each of the stakeholders and parties' perspectives, what might be some solutions or options and getting a sense of their willingness to even be a part of some kind of process after the assessment. Usually, part of an interview, we'll ask folks who else should we be talking to here. Now, of course, that can lead to a never ending assessment, but part of what assessors are doing is if you keep on hearing a name from a number of stakeholders who wasn't on the original list, it might lead to a little bit of an expansion of that list to make sure that you're not missing people who, again, if they weren't a part of a process, would either not have their interests met, could block an agreement, or otherwise be problematic down the road. The next part of this is just putting together, again, some kind of report that summarizes interests and maps areas of what we call shared interests and differing or competing interests. And that might highlight some areas for mutual gain, where there's either shared interests or what we call differing non competing interests, and then areas of obstacle or disagreement. And then part of this usually would have some kind of a recommendation of, yeah, we think a one text could be good here for any number of reasons, or we might suggest something more akin to consensus building or something else, or we might say, I know folks were really hopeful here, but it just doesn't feel like the timing is right because there are key stakeholders who really feel like no agreement is better for them and you can't get them to the table, at least at this point, in a way that's going to be constructive. So you're welcome to move forward, but that's not our recommendation. Let me just and then it could look I mean, this is like a super simplistic idea of what a stakeholder map might look at, mapping the issues with each of the stakeholders, their interests, concerns, obstacles, and challenges. So I want to say one thing. I'd keep on using this word interest here, and it has a really particular meaning that I think is really important for any kind of stakeholder assessment in One Text process. And it's distinguished from a concept called positions. So the way most people negotiate is around positions. And a position is what someone says they want. I want $50,000 I want an office with a window. I want to be the governor of Vermont. All of those things are positions. The interests are kind of the underlying reason or concern that is animating or motivating the position. So just for example, if I said I want an office with a window, it could be because I really want natural light. It could be because I just bought a brand new car. I'm afraid it's going to get stolen. I want to monitor it in the parking lot all day. It could be because I want status or prestige. Getting at the interest usually expands the range of possible solutions in a way that's being stuck on the position doesn't. So for example, if my interest is I want status or prestige, we can get me a fancy business card or give me a fancier title. We don't need the office. If I want to ensure the safety of my car instead of an office with a window, you can give me a spot in the garage. So part of the work of stakeholder assessment and the one text is to rigorously work with parties to get them to feel comfortable enough to actually share what the underlying interests are instead of the positions. And one of the advantages that assessing teams and the drafters in a one text can do is often elicit those interests in a way that it is sometimes harder when it's just the parties in the negotiation and there's a little bit more of that kind of bargaining behavior. So let me just say a few words about the one text and then open it up for questions or reactions. So the one text is a very particular negotiation process. And the purpose of the process is to facilitate joint problem solving that avoids the problem of competing drafts and tries to create as much value as possible by focusing on stakeholders' interests instead of their positions. And the idea of a one draft, one text rather, is that you have a single drafter or drafting team, which will basically put together a draft of a negotiated resolution, or in this case, perhaps the text of legislation, and then circulate it to parties and stakeholders to get criticism of it, use that criticism to recirculate another draft, and to do this iteratively until, at some point, the drafters say, we really can't do any better, at which point the parties are invited to either agree to that one text, or if they say no, the process is over, the drafters are no longer involved, and everybody is back to where they are. So let me say a few words about why this approach can be useful. And some of this is, in a way, redundant of what I've said, right? One is that it encourages an agreement based on the party's interests instead of their positions, because we know that parties are more likely to share their true interests with people who are in a role that is not seen as partisan. I don't mean Republican, Democrat. I just mean as having a particular viewpoint, they're more neutral. And so instead of engaging a negotiation process that rewards hard bargaining or just tit for tat concessions, you can really be focusing on the interests. It also avoids some of the psychological downsides of competing drafts. So some of the downsides, for example, there's all this research on what's called reactive devaluation. If you're on the other side of a negotiation, I bring up an idea, psychologically, you automatically downgrade the value of that idea because it's my idea and vice versa. So if we don't have Bob's draft or Terry's draft or Sandra's draft, we just only have this one draft by these drafters, we avoid that. The other interesting thing is that people who may be unwilling sometimes to actually share all of their interests are typically quite willing to criticize and tell you what's wrong with something. And the one text procedure actually takes advantage of that willingness to criticize and, in the process, unearths parties' interests that they might not have shared. So the way it works is that there is a drafting team that's selected. And if there's already been an assessment, oftentimes, the assessor would be invited to become the drafter. But even when that happens, sometimes there are more parties that are needed in the drafting process. So for example, you may have, as the stakeholder folks, people who don't know really how to write legislative language, and you might need to add them to the team in some way. Now, at times, the folks who do an assessment are entirely different from who would do the one text, and you might do that for any number of reasons, more often than not, I think from a cost consideration and efficiency consideration, it's similar to the team. When you're thinking about who should be on that drafting team, you want folks who are respected and trusted, who have listening and facilitation skills, ideally who have no direct stake in the decision but who understand the context sufficiently. More often than not, a drafting team has some folks who are from more of a mediation conflict resolution background, along with some representation from some of the major constituencies, but who, when they are put on the drafting team, their role changes from advocate to their side to helping to really just optimize the draft and the interests around the draft, right? So they kind of take away the advocacy hat. And that becomes really important because if they're not doing that, then they're not really great in their role. So the one text kind of has three steps to it, eliciting the interests and criteria, the drafting of feedback, and then the decision moment. So if there has been assessment, this information gathering doesn't happen again, right? It's already happened. If, however and this has happened at times, right, where folks say, we're not going to do the assessment is for the purpose of doing the one text. We know we're going to do the one text. Then you still are going to have the drafting team do some of the assessing. It's the same thing as the assessment, except that you wouldn't necessarily be writing a formal report, largely because you already have a sense that the parties are willing to move forward in the process and you know who the parties are. Once you get to the drafting, this is an iterative process. There's usually an initial draft. It might not even be kind of formally written out in legalese or legislative form. It might be even just outlines or bullets. But it's circulated to all of the stakeholders with the invitation for feedback, what is wrong with this? What interests of yours are not met? And it's really important for the drafting team in that stage to elicit those, not to say, oh, it is met, or here's why you're wrong, or but this is good for you. It's just really to understand, from your perspective party, why doesn't this work? All of that feedback is then used to produce a second, a third, a fourth draft until the point at which the drafting team basically says, we can't do any more. So typically, there are three ways in which a draft is presented as final. One, the drafters say, some of these interests are just opposed. We have done our best to try to find the most value creating outcome around the interests. We can't do any better. Or alternately, there may be some minor incremental improvements we can make, but they're so minor that it's not worth the kind of cost and effort and time to try to make them. Or third, sometimes there is something in the process that is an action forcing event or deadline that just kind of forces a decision. And at that moment, all the parties either say yes or no. And one of the advantages, hopefully, of the one text is that the entire process has helped parties really clarify for themselves the consequence of what a no means. So you've seen in my slides this use of the term BATNA, I think, at least twice. BATNA is just your best alternative to a negotiated agreement. And so part of what a one text hopefully helps parties better understand is if they say no, what is their away from the table alternative? Because if they say no, the drafting team is no longer involved, and you're back to square one. And so it hopefully sharpens the mind of all the parties to make that decision. And if you have had a good process and good faith without folks who are holdouts or spoilers, hopefully, you have at least created conditions where the document is at least somewhat better for everybody than their BATNA. And part of, I think, the advantage of this process is that it's not getting messed up with the kind of emotional bluster and banging on the table that might make somebody walk away from something, even though it's better than their BATNA, just because they're upset or they kind of have found themselves in a war of ego, emotions, and escalation. So that's all. That's the processes. So I'm going to stop my share there. I know that's a lot. Again, maybe for some of you who've done this before, it's maybe redundant. For some of you who are newer, it may feel like a lot. But let me pause and invite questions or reactions.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Okay, thank you. And so from your perspective, how does this differ from really well done qualitative research?

[Bob Bordone, Senior Fellow, Harvard Law School]: You mean the process itself?

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Yeah.

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah, I think that the process itself, I'm not sure the mapping of the interests is all that different, except that we're really wanting to make I mean, we are doing it with the purpose of identifying and not missing the parties and mapping their interests. I think that the other thing just about the process is that it's kind of very action driven ultimately, right? And so the one text is really trying to produce a document that will will work in the actual negotiation.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Okay. And then you did identify the spoiler

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Holdout. That was a big question that I had. Someone upfront, you know, we just hold on to this and we can wait till we get back to the legislature. I'm thinking about this in the broader context of what we're doing and so you can have someone who says we really don't like what the drab grits has produced and we're just going to hold out until we get back home and peculiar and do our own thing. How do you deal with that spoiler alert?

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah. Such an important question, and I have an answer that might not be totally satisfying to you on this. So a few things. One is that if the assessment is done well, it should help incentivize potential spoilers to see this process as attractive to them. Now, like in our literature, we talk broadly about what we call kind of three different types of spoilers. What we call a limited spoiler and a greedy spoiler and a total spoiler. Right? A limited spoiler is somebody who says, I just need x. And if you don't give me x, I'm gonna blow it up. A greedy spoiler is somebody who says they want x, you give them x, they ask for y. Then you give them y, they ask for z. Then you give them z, and they want AA. Right? And then a total spoiler is prepare to blow it up no matter what. Part of and this is not this is really much more art than science. Part of the hope of the assessment phase is to get a sense of, if there are potential spoilers here, are they the kinds of folks who, if you appreciate that there's a red line for them, but meeting that red line could otherwise bring them into a process, this is a process that I think can be quite inviting to them. On the other hand, if there's a sense that there are a number of parties who are really not going to enter into good faith and are really necessary to a deal, that's where and this is where I go this is one of the things that I said to Elliot. That's where then a recommendation, which would be sad, would be like, this isn't ripe because you have we can go through this whole thing, but we're we have we have a party here or that is really not into it. They're gonna use this process to delay, to delay, delay, to run to their BATNA. And so our recommendation is we some work needs to be done to change the landscape because the process itself can't work. People don't have to come into the process enthused and all signed up and ready to go. They could come in skeptical. But if they don't come in with a sense of good faith, if it really is for them total spoiler behavior, then I don't think this process works really well. And so I think part of that is assessing as best you can through some of the questions in the assessment phase, where is this party that might be presenting in spoiler land, but maybe isn't really a spoiler. I don't know if that's helpful or responsive.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: No, that's okay. And I think in this state we've been working for so long on having some basic accessible, at one point it was the single payer and now it's primary care for all, universal primary care, and there are people who are very committed to that and also believe that they have the right answer to get there. And then we also have folks who are highly skeptical of that who are in the business world who say we aren't going to pay that tax or whatever the cost is. So the bifurcation of positions is very clear and has been ongoing for a long time. How do you deal with that in this process?

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah. I mean, think part of this would be some education about what the process is. So specifically, right, I love your question, because one of the things that I would really want to do with for the folks who say they know whatever the right answer is, this process has to be an invitation to let that go. Because the right analytic answer here is nice for a paper, but is not what negotiation is about. Negotiation is about how do we get people from point A to some other point together. So I think part of this, for the folks who feel like they know what the right answer is, would be to help understand what is it about the right answer? What are the interests that they see being met there? And then for the people who are skeptical about that particular right answer, to say this is a process that is going to help us identify across the board what are some of the shared interests And maybe what are some of the different non competing? And what are some of the competing interests? And then how can we together find something that we could all, at worst, live with and at best feel good about that will meet them. So I think that the initial there is an initial negotiation involved is helping people understand what this approach is and isn't and why it's different. That we're not coming in with proposal a and then people saying proposal a doesn't work for the following reasons. But we're not coming in with proposals.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Got it. So it seems important to build trust in beginning as it is with any process like this. And then I just have a couple other questions, so I want the rest of the committee to be able to ask you questions as well.

[Bob Bordone, Senior Fellow, Harvard Law School]: Please. Obviously,

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: here we are in the legislature and we're very committed to taking testimony from all the stakeholders and putting it together and having a drafted solution by our alleged counsel. You're talking about a single drafter who is a consultant who comes in with or without knowledge of the state of Vermont and the state of Vermont's laws. How does that intersect and work?

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah. I mean, so I think you could not have a single drafter. What you would I think in the case like this, you would to have a single drafting team of a small number of people that typically, and I would say in this case, would involve someone who has the kind of process expertise and enough kind of goodwill to do some of the relationship building interest soliciting work. But would really need also, as part of that drafting team, people who know Vermont and the law and how to draft. But when they become part of the drafting team, they let go of whatever partisan set of arguments they might have. And that they've just become the kind of drafting team charged with optimizing the interests that they've heard from everybody. So to kind of give you an example, this was used for the Camp David Accords. And there were some American, Israeli, and Egyptian diplomats who, even though they showed up as partisans, were then basically put and said, you're no longer partisans. Your job is to respond to the partisans' expression of interests and try to draft. So is helpful?

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Yeah, no, that's helpful. Thank you. Okay. So why don't I let other members of the committee ask questions? And Senator Gulick is up on the screen, so Senator, do you have a question at this point?

[Sen. Martine Larocque Gulick, Vice Chair, Vermont Senate Committee on Health and Welfare]: Senator Thank you, Chair Lyons. I'm good, thank you.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: All right.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: So anyone else with a question?

[Sen. John Benson]: Just one question that I've got. And I know it will vary depending upon what the issue is, but in general, what would you see the timeline in terms of going through this process be?

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah. That's the $64,000 question. I want to give you something that feels more satisfying than it depends. It does does depend a little bit. I don't have a good sense of how many stakeholders there are.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Let me interrupt you right there. You're talking about stakeholders.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: I think about the multiple public hearings we've had about health care. So we have six and sixty, more or less, thousand residents in the state of Vermont, and probably voters, if you take all the voters and a few others, that's how many stakeholders there are. So, if you narrow it by position, then you get to a better place. Go ahead.

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah. Okay. Well, I think part of what we'd wanna do is figure out who can reasonably stand as proxies to have a workable set of stakeholders? Is it are there industry groups? Is it three hospital systems? Is it doctors? Is it patient advocacy groups? So if it's whatever, let's say 15 I'm just making that I mean, it could be 40. It could be it's it could be a 100. It can't be probably more than that. But, you know, I imagine that, and then part of it is also how available how readily available do people make themselves for interviews. I mean, a typical process that might involve, like, 30 or so stakeholders could be done in a matter of a few months. And then the negotiation process, you know, if there's a one text following that, could also be done probably in another month or two. But that a little bit depends on folks' availability

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Mhmm. Yeah.

[Bob Bordone, Senior Fellow, Harvard Law School]: For interviews. And so it's not years, but it's not you know, it's like, I can imagine for, like, six months would be not unreasonable.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Does that answer your question?

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Yeah. Questions today? I have one other question. Yeah. And that is, as you're talking about stakeholders, it seems to me, as with primary care, have identifiable folks, I would think. And we're writing a bill now that would suggest a process for collecting information, building recommendations, whether it's this process or another process.

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: And so to the extent that we would use the process that you're talking about, would we enumerate the stakeholders in the bill or allow for that to happen organically with individual or individuals doing work?

[Bob Bordone, Senior Fellow, Harvard Law School]: I would definitely say the latter.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Okay. Yeah. Okay. Yeah. Alright. Other questions? Alright, so this is, we're good for now, so I think what we should do is maybe turn it over to Doctor. Is also here, and thank you very much. Is it Doctor. Gordon?

[Bob Bordone, Senior Fellow, Harvard Law School]: You can just call me Bob, but yeah, yeah, yeah. I'm not a medical doctor. I have a JD, so folks don't call us doctor.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Okay, so honorable Gordon. Thank you. Okay, so yeah, terrific. So we can move to Peter Ponovost, Doctor. Ponovost, and

[Dr. Peter Pronovost, University Hospitals (Ohio)]: just want to And thank call me Peter. Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Peter, okay. So we don't have anything from you on our, we don't have your testimony here.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Correct. I was gonna share comments with you and happy to put something in more formal in writing if if you want, but I

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: If if you have a if you have a slideshow for us, a PowerPoint, and then if you can send it off to Calista, that would be really helpful for us.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Sure. Perfect. So let me just Ann

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Cummings, before you start, briefly, were you here when we introduced ourselves?

[Dr. Peter Pronovost, University Hospitals (Ohio)]: I was. Yes.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Yes? Yes. Yes. Okay. Good. So then why don't you go right ahead? Thank

[Dr. Peter Pronovost, University Hospitals (Ohio)]: First, I applaud what you're doing in Vermont and this group. I mean, the country needs a model for how to improve quality and reduce costs and improve access. And, you know, despite many decades, we still, I think, lack that model. My deep belief is part of the reason is that we've assumed that this is a complicated problem rather than a complex problem. And let me just it was the same mistake we made in COVID, by the way. Complicated problems are like baking a cake. I know one goal. I have a checklist of things to do, and I'm pretty confident if I do those, I'll get the results I want. A complex problem is like raising a child. There's multiple competing goals. You're not quite exactly sure what to do, and you don't have confidence that if you do those things, you're going to get the results that you want. Well, complicated problems could be solved with a strategy or a tactic, go do this, go put in X in the healthcare system. They don't solve complex problems. Complex problems are solved with aligning around some common purposes or principles, and then innovating ground up solutions to figure out what works and spread them. And I would say the main reason why healthcare is horrible, or maybe you can see more broadly society, of solving complex problems is a lack of love. And if that word sounds jarring, let me just be really clear. Love simply means that we see all people as worthy and capable. And they are worthy to participate and capable of excellence. And we need to build systems that support that excellence. But in healthcare, we too often have separation. We have the employers and the health systems fighting, or we've been doing it for forty years or even health systems fighting each other. And we will never solve problems that way. Because as you said, Senator, earlier, we know change progresses at the speed of trust. And trust grows when we do things with rather than to people. So I want to share with you, as I could, as full of flaws as I am and the experience is what my health system in Northeast Ohio outside of Cleveland, an aging population, we don't have population growth. The only payer that's growing is Medicare And we were losing around $220,000,000 a year, and it wasn't going well. And we tried the top down across the board cuts. We are fighting with payers, and it wasn't getting us anywhere. So we said we were going to try this transformation model that is based on this love framework. And what we had to agree is some simple principles. We say, forget this fancy word, the value. Our job as a health system is to keep people healthy at home rather than healing in hospital. Could our whole community and organization get behind that? Like, yes. Could we agree we need to be paid fairly for what we do because we need to have a margin to be, we're 160 years old organization to be serving our community. But that doesn't mean our purpose is to have a full hospital. Our purpose is to care for the community to keep them home. And third, could we agree that we have ridiculous amounts of waste and needless harm in this city in this, and we're gonna work to reduce our health care costs so that we could be profitable on Medicare level payments. If we wanna be sustainable, we have to own those commitments. And we got aligned around it. We operationalized love, and I won't bore you, but by basically linking three principles that have been around in the literature in management for decades that no one's put together. The first is when frontline employees are engaged in their work, they perform 40 to 50% better. 80% of healthcare employees are disengaged. Why? Because we don't treat them as worthy and capable. We do top down solutions that might work for a complicated problem. They're horrible for complex. Second, we know innovation and learning flourishes in every industry when you create a culture and structures that allows the free flow of ideas and anyone's voice to be heard. It's gotta be psychologically safe and just bring ideas in, but we don't do that. Why? Because we don't see people as worthy and capable. And third, there's overwhelming data that if we build discipline or organizations that build disciplined management and shared accountability systems perform much better than those that don't. And good management is largely absent in healthcare and accountability is absent. They exist. So we package that together into this operating model of transformation that it's no fancy consulting. We just call it believe, belong, build. Believe is that we will ensure that all of our leadership and team says that every employee is worthy and capable, and their job is to improve value and they need to be inspired to do that. Two, ensure everybody's voice matters. So whatever problem we're solving, and it sounds a lot like Bob's approach, every stakeholder needs a seat at the table. And then in this case, it means any role, any site of care being delivered. We're not doing it to you, we're going to solve this problem. And we map that out from board to bedside. And third, we will have disciplined management and shared accountability systems. And that means really simple. If you could show me a run chart that is improving for a measure that matters, you have a management system. If you don't, go back to the drawing board because you don't have confidence in what you're managing to. And if you stratify that measure by region, by market, by hospital, by floor, by provider, and you publicly praise and learn from those doing well and privately nudge or support those who are struggling, you have an accountability system. Though we rarely, if ever, do that. So I'd like to share. So we put this program together and it is messy. I mean, it grew and grew in our organization. But a little bit just like what you can see now. We realized that we had to do a number of things. One is we had to improve access to our community. And our hospital volumes in our primary care appointments went up by 14%. How did we do that? And you can see it's based on this collaboration of love. We didn't have standard templates. So our physician group put whatever they wanted to block access. And these, in this case, is our employee provider groups, but we're about a $7,000,000,000 health system. But when we said, hey, when our community can't get access, it's suffering. We need to, of course you control the final decisions, but we're not scheduling inefficient. Our physician productivity at the time was probably around 40 or 50%. Now it's 75 to 80%. We knew we had to get length of stay down to make space for these people to come in. And we had to prevent avoidable admissions because about sixty percent of medical patients don't need to be in the hospital. They need care. They don't need to be in this expensive place. So over the last two years, we took length of stay down by 16%. We took out $600,000,000 of cost in our system. And we first did across the board cuts that didn't work. And then we did functional lower charts. But then we just said, okay, what outcomes are you trying to produce and how do you manage? We also need to be paid fairly. The Medicare Advantage plans deny ruthlessly. And we, through some better coding, reduced the Medicare Advantage denials from twenty eight percent to twenty percent. A big impact to us. We took down surgical complications by seventy percent, sepsis mortality by eighty percent. And Medicare costs over the last four years were a third of what they have been. We improved our shared savings on the Medicare shared savings platform, which is a great chassis so that it went from up $2,000,000 to now $55,000,000 And our overall operating margin went from $220,000,000 lost to $51,000,000 positive. And that wasn't just fighting saying, give us a nickel more, increase the unit rates, because we know we had our homework to do. On the primary care side, which I love that you're putting money into primary care, that has been the engine of our transformation. Mean, there needs to be the hospital side. We, about 120 Medicare patients, went from an annual wellness of 14%, which is one of the most important measures for Medicare patients to seventy five percent. Right? And let me just share with you what accountability looks like in that model. Because the national average is fourteen percent. We set a goal first this was like over four years to be at sixty percent. And we provided tools to make it easy. But we were clear, this is our goal. And as those practices made it, we celebrated them and say, hey, look at them. The ones who weren't making it, we nudge them and say, go connect with those who are doing it well. Here are some tools. We'll send out a coach out to you. And we got two out of about five fifty primary care physicians. All but 120 were at the goal. So we reached out to them and said, Okay, you're not at the goal, but you need to be. You will be. And about 80% of them said, Okay, I didn't really know you were serious. But there were another 40 who said, I don't really want to engage with you. And again, we've never done this before. We said, Okay, that's not really an optional. Excellence is not something that's optional. It's an expectation. We have high standards, but relentless support to achieve it. But not engaging isn't an option. And that escalated to an in person visit of those clinicians who didn't want to do this to say, this is a quality measure. And we will go through disciplinary action as such for this through what's called a peer review if you don't need it. And at the end, all but one physician made it who left and said, I don't really want to work for an organization that's gonna hold me accountable. And we said, we don't want a physician who's not gonna be accountable of that. But just some other things, because what I hope you can see is this accountability elevates people. It doesn't put permission. Our net promoter score, which is an industry standard, is now up to 81%. I mean, that's higher than Google and Amazon. It was like 67%. Our turnover is our nurse turnover is down to 13%. And our engagement is somewhere around the 1% nationally. And this happened not because we relaxed expectations, but because people finally felt safe enough to learn and improve. And so this idea of love doesn't lower our standards, it raises them because when people feel they're worthy worthy and capable, they speak up. When they speak up, problems surface early. When problems surface early, harm becomes preventable. Now, this doesn't mean that we will end conflict. We still disagree. We will fight. But when love is present, at least the conflict moves us forward. That we fight for something that matters, not that what we fear or despise. And love, I think, that energy that draws us what we most value most because I believe deeply that your provider groups and your citizens all wanna give your community great care. They're frightened, they're fearful because they're in really bad shape in a lot of places. But I think if aligned around some common principles, I think love could unleash learning where fear silences voices. And I think this tension right now is we have a whole lot of fear. But this needs to show up in our health system leaders as humility, curiosity, compassion, and accountability with dignity. You know, I want to just go into accountability for a little bit second. In In our organization, we believe accountability is at three The personal, I own my commitments. At the team, we protect each other through candor and inquiry. And at the organizational level that we will define fair and transparent systems. And I think as you're looking to put your bill, I think it's critical that you would devise some measures that would be fair and transparent. But I think spending is good but I think adding measures like annual wellness, like in our case, and I'm sure in Vermont, access to behavioral health is just horrific and people are suffering. And in our primary care model, we now at this current moment have advanced primary care in half of our practices and the rest will have it by the end of the year. But that means we have a social work in every practice. We started with about two percent of our patients were screened for behavioral health needs. Now about ninety percent are and those who have needs are referred. We don't have enough psychiatrists. They're referred to the social worker who could do about 90% of the work and then the specialist just does those 10% of care that needs their level of expertise. We've done the same thing with diabetic nurse practitioners or educators where we flipped it from the specialist is doing 90% to primary care. Then there's support for those doctors with the specialist to care for the very sick. But that kind of collaboration happens through trust. Vermont's going to solve its quality problems and its cost problems. They absolutely will. And let me just share a couple other stories about the power of belief and seeing people as worthy and capable and setting expectations. When we started this effort, just 23% of our hospitals had their patient experience scores above the fiftieth percentile. Some were under the tenth percentile. And in the past, we would likely set our goal like a one percentile increase. So if you're in the ninth percentile, you may have to go to the tenth. And we started driving this message of we believe in people. You are all worthy and capable. We challenged and said, we're only gonna set a goal if you're at the fiftieth percentile. And and there's a financial incentive with this. And some pushed back saying, oh, you're setting our people up to fail. You're gonna demoralize them. And then I said, I think it's gonna demoralize them more if you tell them you think they're only capable of the tenth percentile Because I don't believe that's true. I believe they're worthy and capable, and they're certainly capable of performing at the average percentile at the fiftieth percentile. And so this idea of balancing high expectations and unwavering support. We provided tools and today 80% of our hospitals are over the fiftieth percentile. And I share one story, one of our hospitals was at the first percentile, the first percentile. And again, we care for sick people, we care for old people, we care for poor people, we care for the rich people. There was all kinds of reasons. And we said, we're with you, like you're gonna get better, not acceptable. But today, just six months later, they're at the sixty eighth percentile. And so what does this look like to set clear metrics? Well, I think it is, you know, we're very specific about we have goals guided by those principles, metrics and targets. We have a process to set people up to be successful, which we call building an enabling infrastructure. They have measures we design for learning. So we structure the process about not blaming people, but hey, what's working? And it always involves the frontline people because they have the wisdom. We have feedback loops about how this is working, typically weekly meetings, and then there's an escalation. If the team isn't meeting it, there's reviews. And not reviews to be a hammer, reviews to be a handshake. It's a covenant to say, we've committed to do this together. If we're going to do it, expectation isn't excellence isn't optional, but let's figure out why. I wanted to close with just a story that I found so remarkable because when I speak about this work, it's frightening because healthcare in many ways does so much good, but it's broken a lot. And I think we have to believe, belong and build that we could improve it. We have to believe in hard goals that healthcare could be cost effective and it could keep people healthy at home. We have to belong to a workplace community that includes the employers and the providers and the payers to achieve those goals. We need to build the support structure that enables the providers to do this system, not hamstrings them from doing this. Each part person is accountable for their part. And I think that underlying this principle of love, disciplined, accountable, operationalized love is the force that powers that. So the story I'll close you with is, I mentioned how we have these principles that every role needs to be involved in the process and we need to share the free flow of ideas. So we are working on improving some of our hospital infections and our patient experience, particularly around room cleanliness. We struggled in some of that. And so we had our environmental service workers join on that. And when the team was first starting it, the woman who was being asked to join, she looked down and away. She wouldn't look the team in the eye because she was ashamed of her role. She had never been asked to have her voice heard before. We explained that like our view is know this, everybody's worthy and capable and you have something to contribute. So she started offering ideas and had brilliant ideas about how when people have MRSA infections, as you know, they need a room cleaned a different way. There was some ambiguity in how to do that. We weren't training them the right way. She helped design that training. And also about the sacredness of a patient's room. She said, you know, when I walk into a room, this is like their home. And many of the patients feel their, their, that nightstand is like their shrine. And we have to honor this as their sacred place. And she shared how she does that about asking them what they want touched and what they don't. I mean, just like beautiful examples. And their infection rates came down. Their cleanliness scores went up and we post them on the units. So she took some of these grafts and put them on her refrigerator. And her two daughters who were kind of struggling in high school not sure what to do started asking her, are these mom? Because she never talked about her work. And she started sharing how she helps prevent infection. She reduces suffering in patients when they're in the hospital. And she's like, they started saying, wow, I want to make sure I could be like you to go into health care to have a job. And when we were celebrating this with the teams, she looked at me and she said, you know, Peter, I used to think love belongs in the home or the house of worship. I now believe that it is essential to be in the workplace and in all of society. And I think what this means, I think healthcare organizations have to now see themselves as virtue forming organizations because that is the only way we're going to solve this and that's transformation. And that I think is what love in action is. And so I think as you write your bills, I would love to see some type of collaboration of engaging the health systems brought large to commit to doing some kind of engagement in this work. Probably a primary care and a cost reduction section that might go hand in hand. It would be a commitment or the mindset of shifting, we're in this together to agree on some principles. And Bob is an expert methodology to help you get to those. We're going to agree that people should be healthy at home. Our goal is not to fill the hospital. We know you need to be paid fairly and you've got to get your costs down and and so you can serve here for our communities. And my sense is with that approach, I think Vermont could be the model because the reality is you're spending so much. Now the resources are there. It's just a matter of kind of unleashing them and unleashing the energy and the goodwill that I think is embedded within our health systems if we could reduce some of that fear and replace it with hope.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Thank you. And so as you're talking about love, of course, know, there's what, poor definitions of love?

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Arrows are very simple.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: And so it's so you're thinking about agape or we're thinking about caring? You're so yes.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: So so we I you you could say, it basically is the principle that all of us are innately worthy and capable. And that's simple. And we believe when you bring worthy and capable people together, you solve problems better, faster, and cheaper. But we don't often do that. We separate. You say your voice doesn't count because you're a payer. Your voice doesn't count because you're an employer. Or the employer say, you just don't get a doctor or health system CEO. And we separate and judge rather than saying, okay, no, no, I get we're at odds, but fundamentally, we wanna provide for the citizens of Vermont. And I believe deeply that all the stakeholders do want to do that. And what I think they need is some leadership to kind of get out of this fear or pugilistic approach to see some common common interest for their community.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: So thank you for that. And I I will say as you're as you're talking, I go back to the Oliver Wyman report that came out and just caused significant fear in the hospitals across our state, and it's taken time for us to work together, and I think, I understand that you did present at grand rounds for UVM and perhaps others. It was very helpful to bring people together. And I'll I'll go back. I'm I'm gonna try and connect the two of you today because you're both here together and it's helpful. So you talked about holding folks, seeing them as valuable, knowledgeable, worthy, and capable. That one of the messages that I heard that I have heard, and I'm not sure I heard it from either of you, but I haven't heard the opposite of what I'm going to say, is that there's an assumption about political bias whenever we include legislators And we are legislators. And so our goal is to be as dispassionate as possible when we solve problems, hopefully, although we all bring our bias and our knowledge and experience. So when you're talking about excluding, you, Honorable Doctor. Bordeaux, would you exclude legislators in your process because of political bias? I mean, you did talk about that a little bit. And then my other question is to Doctor. You include legislators in the process? And I'm not talking about necessarily the formal process, but the attention to worthy and knowledgeable and capable that you were talking about. So a question for each of you regarding the role of both the legislature and the executive branch because they each bring experience, knowledge, and information to any of the things that you're talking about. And that's one question. And the other question I'll ask to get done with it is obviously accountability implies having a robust quality metric, quality data metric analysis, which we are hoping to build. So I'll leave that one just on the table.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Hey Bob, have to leave it

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: for you.

[Bob Bordone, Senior Fellow, Harvard Law School]: Yeah, yeah, go ahead.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Have a-

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Sorry first is the question. Go ahead, Doctor. Pronovost.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Yeah, so what I would say, absolutely, you need to be at the table because you have essential wisdom, you represent your citizens. But let me just say, I think we need to be at the table with the right mindset. So let me share with you. I work a lot at the federal level with CMS, for example. And not everyone, but many people in that are saying those bad doctors and hospitals, we're gonna design things because they don't wanna improve. And so there is this adversarial mindset and then like, and they don't work very well as opposed to saying, yeah, we need controls. We need accountability, but how do we work together? The other point that I would encourage you, and I'll give you a concrete example. I did some work where we made a checklist and reduced deadly infections by like eighty percent across America. And they used to kill more people than breast or prostate cancer. And there was a lot of well meaning legislators who wanted to make my checklist a national standard. And I pushed back because I said that the legislation is too slow and too blunt for evidence based medicine. Make the public reporting of infections, you know, put incentives to pay for them, but don't legislate the practice of medicine because you're gonna anchor us to outdated practice because a year from now, something new is going to come up and the legislation's too slow to keep up with that, right? So I think absolutely your wisdom, but design, you know, make required that we take total cost of care out or, you know, that we get the citizens of Vermont to have more annual wellness visits or the Medicare patients. But that's my, of course, have your voice just recognizes these are complex and not complicated problems. And so we need to be mindful of the levers that you have the ability to pull with, which are immensely powerful, that truly do move you in the direction that all of you and all of us want to go.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Thank you. Go ahead, doctor.

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Thank you for having me. I'm happy to follow-up with anything. I just have to go run and do

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: If if you could send some testimony in so that we have

[Dr. Peter Pronovost, University Hospitals (Ohio)]: Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Through that, that would be very helpful. And someday I'll share with you our story about zoonoses and how our a friend of mine who's a was a professor of microbiology worked with them with the environmental staff to clean up the hospital. So it's very it's a common

[Dr. Peter Pronovost, University Hospitals (Ohio)]: I'd love to see that. And I hope we can follow-up. That would be enjoyable. That's great.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: You will. Thank you.

[Bob Bordone, Senior Fellow, Harvard Law School]: I have a very, very simple, easy answer, which is absolutely. The legislature has to be involved. The executive has to be involved. Anyone you know, part of any kind of one text process is if, you are a party who has an interest in the outcome, if you're a party who can help either make it happen or prevent it from happening, then you need to be included. And yeah, so that is just really critical. Think it would be, and it doesn't matter whether and one of the challenges is sometimes in a one text, people say, well, I won't be a part of a process that they're a part of. But we handle that as it comes. But everyone is a part of the process. One of the challenges, of course, right, is as we just meet with different groups, you can't, at the negotiation table, have 600,000 parties. Right? So you need to have a reasonable set of proxies that have enough legitimacy with their stakeholder groups that you feel reasonably confident that as we move forward, they can deliver those stakeholder groups.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Thank you. Other questions, Ginny? I think we're good and I really appreciate your taking the time to be with us. It's very helpful and it looks like a process worth exploring. It always when we start talking about this type of work, of course it requires resources and we're at a very narrow place in our world, in our budget for resources, but we'll certainly be looking to do something in the bill in 01/1997 as we go forward. Thank you.

[Bob Bordone, Senior Fellow, Harvard Law School]: Great. Well, if I could be of use, please let me know, and thanks so much for listening, and good luck on your continued work.

[Sen. Virginia "Ginny" Lyons, Chair, Vermont Senate Committee on Health and Welfare]: Well, thank you very much in taking care. Terrific. We're gonna take a two minute break, and then we'll come back to, Katie and