 Good afternoon and welcome to the Green Mountain Care Board meeting that was recessed this morning until one o'clock. At this time we're going to move to a different discussion on provider reimbursement and to tee that all off I'm going to turn the meeting over to our executive director Susan Barrett. Susan. Thank you Chair Mellon. I want to welcome everyone to this afternoon's meeting. It's going to be a very interesting discussion on reimbursement in the state of Vermont. We have what I'll do is I'll give you an overview of the goals of the meeting and then I'll introduce the panelists and set up the rest of the meeting for you. So the goals today are to understand what's in a claim. What's in what's in a premium and how that relates to reimbursement in different settings. Another goal of the meeting is to to talk about the the role of the Green Mountain Care Board in the extent of its authority in the insurance market and we'll have to start things off our staff Sarah Lindberg who's the head of our data team and Amaran Aberjaley who's our associate general counsel go through some slides to tee up those those issues and and give some more background on those issues. So next I'm going to introduce the panelists but before I do that I did want to make a note that when I sent out this invite for today's discussion we realized that COVID was surging that we were that you many of the people on the front lines are dealing with the COVID issues. And now this week thankfully the vaccine is is starting to get rolled out. So I did put that out to all of the presenters that if this was just too much to handle with the schedule and the time constraints that we certainly understand and if they couldn't attend and and Vaz did take us up on this offer. They are as many folks know very in the center of distributing a lot of the vaccines and administering them. So I just wanted to make that note and that we will follow up with them on any questions from today but we really do appreciate their their work on the front lines as well as all of the folks here on the panel. I know it's been a long nine months. So why don't I just go through the panelists and just this is on our agenda but just to introduce folks. First we have Georgia Maharas who is the vice president of policy and strategy at by state by state primary care association. Next we have Matt McKinnon who is senior leader network management at MVP healthcare. Next is Andrew Garland vice president of client relations and external affairs at Blue Cross Blue Shield Vermont. Next we have Susan Ridsen the executive director of Health First and in addition to the panel panelists today we have also from Health First Paul Dr. Paul Rice who is the chief medical officer and partner at Evergreen Family Health. And then last but certainly not least is Alicia Cooper director of payment reform reimbursement and rate setting at the Department of Health Access. So what I'll do now is turn it over to Sarah Lindberg and Amaran Aberjaly who have a brief presentation to set up this discussion and give some background information then we'll go back to the panelists and we do have a few questions that we that I'll be putting forth to the panelists but then we'll open it up to questions from the board and then of course public comment. So I can great turn it over to Amaran and Sarah. Good afternoon. This is Sarah Lindberg who has the data team for the Green Mountain Care Board. There was a little bit of trouble with some folks seeing my screen this morning so I just want to make sure that folks are able to see the title slide I'm presenting. So I can see it but I saw your screen this morning and others did not. So is everybody seeing it. I can see it. I can see it. Yes. I can see it. Wonderful. Wonderful. If they can't see it we can always put that in the chat box and link to the website like we did. In fact Abigail could you just go ahead and link the slides in the chat so folks can get it if they can't see it on the screen. That'd be great. Great and I'll try to keep myself honest. When I'm presenting for the slide so I'm going to start off and then turn it over to Amaran to speak about the insurance rate review portion of our presentation. But here we're just here to just set out some groundwork about the overview and the GMCB authority as it relates to commercial health insurance reimbursement. So there's really three kind of major concepts that we felt would be helpful that everyone was kind of operating on similar definitions for. Knowing I always hesitate to try and tee anything up because there are so many exceptions to any rule in this area. So please know that we know there's always special cases but we're trying to speak as well as we can to general generalalities. So the first term would be health insurance premium which we're thinking of as the cost to a policy holder to maintain health insurance coverage which is usually paid on a monthly basis. And for most purposes that commercial insurance is provided either through an employer or through purchase in the marketplace through Vermont Health Connect. There's certainly also the option to directly purchase insurance through an insurer at this point. And then we're going to talk about when we talk about reimbursement where we're talking about the amount paid to a medical provider for delivering medical care. And that is often based on the amount negotiated between the provider and either the insurer and or the purchaser. The purchaser being usually an employer and a self-funded policy. And then a medical claim would be the request from the medical provider to the insurer or the agent acting as an administrator for the purchaser for the payment of those health care services that are delivered to the covered policy holder. So those are kind of like the three main principles we're going to try to just lay some groundwork for before your discussion. And with that, I'll turn to slide three and let Amron speak. Thanks Sarah. So speaking about insurance in Vermont we wanted to give you a broad overview of where people have insurance as a first place to start. So we have a chunk of the Vermont population has commercial insurance. And in this category, we're talking about fully insured and also self-funded. And then we have other government insurance which would be federal employee health benefit plans, military employee plans, and then Medicare and Medicaid. And then we have a very small percentage of uninsured for Monters. So when we're talking about the board's jurisdiction the board has jurisdiction over small group and individual plans and the fully insured large group plans. And in Vermont, that's about 94,000 covered lives. This is based on 2018 data which is our most recent full year data at the moment. Right now there's approximately between 620 and 630,000 Vermonters. So the board's jurisdiction is about 15% of commercially insured Vermonters. The breakdown within that 94, 95,000 people is usually in the last few years about 75,000 covered individuals are in small group plans and insurance plan and individual plans. And then about 20,000 are in fully insured large group plans. Next slide, please. Thank you. So in thinking about how reimbursement relates to the board's jurisdiction over rate review we wanted to give you a visual. I know I appreciate a visual when I'm trying to understand the math involved in rate review. So this is an example of a per member per month rate increase and we took this from a previous year's approved rate in the small group and individual market. So if you're looking at the very top line and say this was for a premium increase of approximately 10%, you would have a rate increase on a rate increase on a per member per month of about $51. So to read this graph, you're gonna look down from the top line and then read down each line. So if you're talking about a total rate increase of about $51, within that you have changes in claims is gonna be about $43 of that 51. And then on the right side in the green boxes and yellow boxes you're having admin costs and contributions to reserve, that's the CTR. So looking down through funneling down through the blue boxes we're gonna go down through claims. There are some boxes in here that get at, let's say actuarial adjustments that need to be made in order to understand the full impact of a rate change. So I won't get into the details of some of these boxes because it is rather a math exercise that I barely understand myself. So we go down through population claims and then the third blue row down you have medical claims. And then at the bottom line here we have unit cost trend, utilization trend and then cost trend and utilization trend again under prescription claims. So the box we're really focusing on here today when we're talking about reimbursement for medical claims is the unit cost trend there in the red. So I'm hoping that this will help provide a visual as we're having this conversation about the board's jurisdiction in rate review and what components go into a rate increase and what the board reviews as part of its approval of rates in terms of reimbursement and cost trend. Next slide, please. Sarah, next slide, please. I'm trying. Thank you. So let's talk a little bit more about unit cost trend as part of rate review. The board approves an average unit cost trend percentage increase for each rate filing. And if you go to the board's webpage and go to our rate review page, you can take a look into each of the past filings and see what the board looked at. You can see what companies have filed for their unit cost trend and you can see what the board has approved for unit cost trends. So for, well, let me go ahead and say that. Okay, so approved unit cost trend, what is it? So the unit cost trend is the rate increase that the insurer is permitted to add to its premiums to cover the increase in reimbursement rates that the insurer expects to pay for members covered by the filing. So the insurer is going to look at what they have for their current reimbursement rates with providers for the current year, what they anticipate those rates are going to be following contract negotiations for the plan you're covered by this filing and then presumably there are going to be some other reimbursements that are not covered by a contract. And so what is not in the approved unit cost trend? So when the board approves unit cost trend, the board doesn't set reimbursement rates between insurers and individual providers. But the purpose of the unit cost trend increase is to basically make sure that the rates that are being charged to policy holders are adequate to cover the cost of claims and the insurer's administrative costs in managing those plans. So, and the longer way of saying that is that the unit cost trend increase approved by the board is to adjust premiums to cover the anticipated reimbursement rate changes for insurers' payments to providers. And we're talking about providers both in Vermont, outside of Vermont, and we're talking in all the settings, hospitals, FQHCs, independent providers. And we're talking about all types of services, whether they be outpatient, inpatient, or professional services. And each of these unit cost trend increases are specific, what the board is approving is specific to the filing that they are viewing, whether it be a small group, individual filing from one carrier, whether it's a large group fully insured group from an insurer. And that, I think, is my overview. High level, but there you have it. I'm gonna pass it back to you. Thank you, Amran. So yeah, so I'm gonna start talking more about sort of more DDE type portions of this. And so when we're talking about reimbursement, I think that that is the way that the provider gets payments. And those payments could be based on the services delivered as we think of in a typical fee-for-service arrangement. It could be reimbursed based on a time period. So a per diem for a hospital state might be the way that the payment works. And there might be an episode or an event related to the reimbursement. So a joint replacement or a healthy newborn. There also can be reimbursement based on an individual. So care coordination payments or capitation are examples of reimbursements that are tied to a person. And when I think of the total reimbursement generally, I'm thinking about an allowed amount, which is what the providers are theoretically expected to receive, which is both the insurers obligation as well as the expected patient payment, knowing that a lot of mischief can happen in both of those buckets. Reimbursement is not the charger price. So that would be the amount requested by the provider to deliver a medical service. So that is not necessarily what is actually reimbursed for that. It's neither is it the cost. And when we talk about cost, I think that's where a lot of people have different definitions, particularly depending on their interface with the healthcare delivery system. So for patients, that's usually in their mind, the out-of-pocket obligation for their medical care. Whereas for a provider, it's usually they think about as the expense that they had to incur in order to deliver the medical care. And that can be system-wide, like including the cost to plow the parking lot or other kind of larger than just that one encounter. And then for payers, I think they're usually thinking about the expenses associated with the medical care. So the risk exposure they have, but also the administration to provide those services to the health insurance policy holders, including costs associated with risk and reserves for unforeseen events. So just a very high level overview of a medical claim, which is related to these reimbursements. So a patient would, in the upper left-hand corner on slide eight, you see someone with a broken arm who received medical care from a provider. And usually, but not always, the patient is asked to pay some portion of that reimbursement either at the point of service or at a later date. Then the provider sends a bill with the requested amount to an insurer or a claims processor. And that's where the medical claim comes in. That's like the invoice for the services that they delivered. And then that request is processed by the insurer in the bottom right-hand corner. And that's when the request or claim is reviewed to make sure that patient was covered for that care at that time. And if so, the insurer would look at the negotiated amount of reimbursement and send their share back to the provider. So again, that's like the very simple overview of how a medical claim works in a medical encounter like this. And so those medical claims on slide nine generally come in two major flavors. Like I said, there's always exceptions, but generally services are requested for reimbursement on either a professional claim or a facility claim. So a professional claim is also known as a CMS 1500. And that would be associated with services provided by trained professionals. And those payments are associated with procedures that are performed by those trained professionals. Whereas a facility claim or a UBO4 is associated with the resources used to provide the medical care. So that generally ties to revenue codes that we'll get into a little bit more detail in a minute. And I promise I won't keep you here all day. So slide 10, at a very high level, professional claims. So again, each professional associated with the care would submit a claim for the services they provided. So for instance, if you're in the hospital for delivery of a child, you might get professional claims associated with an anesthesiologist and a different one associated with a pediatrician and a different one still associated with the OBGYN providing care to the mother. And these claims may span across time. So for instance, you might get one claim for multiple physical therapy visits. And these are paid at the line level. So that means that each procedure has its own own whole line on that claim where the reimbursement is associated or the request for payment. These procedures may also include a technical component or what we call a modifier, which would cover things like the supplies, equipment or clinical staff used to deliver that procedure. And the charges that are requested on this claim might differ based on the setting where the care was delivered. So for instance, Medicare would pay more for a procedure delivered in certain settings versus in a hospital due to the fact that they like to split up the billing between the facility and the professional providing the service. So moving on to slide 11, again, at a very high level for a facility claim that you're looking for one claim for the same person on the same day at the same place. And we're gonna try to capture all the resources that were associated with the medical care at that facility. And we tie those together with revenue codes, which is designed to tell us where the care was delivered or the types of resources that were associated with the care. The coding for this tends to be much more complex and a lot of the information that is tied to the reimbursement is in the claim header versus at the line level like on the professional claims. Usually the billing and coding are split up for facility claims, whereas the same person might be doing that on a professional claim, not always. Like I said, there's so many exceptions here. And then on slide 12, there are plenty of examples that aren't really tied to this fee for service reimbursement. So examples that are common are bundled or episodes payments. And again, that's reimbursement that would be tied to a qualifying event such as a healthy newborn, FQHC encounter payments aren't necessarily tied to actually what was done, joint replacement, dialysis. So these are things where a qualifying event is really what drives the reimbursement versus either the revenue codes or the actual procedure lines on the claim. And then of course, capitation would be a fixed payment associated with the care for a designated group of individuals. And in that case, the care that was delivered is maybe an opportunity to test how good the payment was or to reconcile the amount to take care of a population, but the payment wouldn't be associated with those actual requests for reimbursement. So just to wrap up here, wanna let you know about some efforts that we're doing here at the Green Mountain Care Board. We're in the middle of an enhanced data validation project. So a medical claim that request for payment is only really includes the amount requested by the provider. So the ultimate payments that are made or the reimbursements that are made and subsequent adjustments are actually something that we need to ask for extra by people who are paying those reimbursements. So when we ask for data to be submitted to our all-payor-claimed database, V-Cures, the people who are submitting that information have to give us some information about what was actually reimbursed. So that wouldn't be on a claim in and of itself. And we are in the process of a long overdue thorough validation of that reimbursement data to see how well it compares with both the records maintained by the payer for their financial transactions, but also with the provider's record. So in aggregate, how well are what we're seeing in our all-payor-claimed database tying to what these different parties would expect to see? So we're looking forward to being able to give analysts more direction about how to account for the error that we know is certainly present in this administrative data. And finally, as required by Act 159 of 2020, we will be producing an interactive dashboard to show some variations in reimbursement for certain services provided to Vermont residents. So once we have some good information about how off we think the data are, we can start doing things like this with more confidence. And some reasons we expect to see differences in reimbursement are the type of payer. So we would expect that Medicare and Medicaid might reimburse a different amount than a commercial insurer. There probably will be differences based on the provider, including those who are out of state. And again, that setting. So we already know that Medicare pays differently based on the setting that care is produced. So that initial report is slated for public release in February of 2022. So that's all that we had to present for you today. I don't know if there's anything we can address before you move on to your fascinating discussion. Chair Mullen, would you like to see if any of the board members have questions first or should we move over to the panel? Unless a board member wants to cut in, I think that the board probably doesn't have any questions based on this presentation and we should probably hold it till after we hear from our guests today. Great. So thank you, Sarah. Thank you, Amrin. That was really helpful. I could hear that 10 times and still not understand everything. It's very complicated. So I am going to turn it over to the panelists now. We have I put together four or five questions that I shared with the panelists up front and with the board up front to get things started. Some of the questions are applicable to all the panelists. Some of them are only applicable to payers or providers. But I would also say and Chair Mullen, hopefully you're okay with this. If the board has questions as we're moving along, I would certainly like them to interject if they need to, if that works for you. I'm sure if you have clarifying questions that otherwise we'll hold most things to the end. Perfect. And I'll just ask if you're not talking, if you could just mute your line. Just heard a little background noise there. So I will start off with the questions and as I said, not every question is for every panelist but feel free to answer any of them. And Susan, you had a question? Susan Ridson. Yes, thank you. I just wanted to, I was under the understanding that we would each get five minutes. Okay. Yes, and I was just going to say before I go through the questions, I think I'll have each of you as I introduced you but if you each want to, if you have a few words before we go to the questions, that would be great. So Susan, why don't I start with you, since... Okay, sure, thank you. Just for the record, I'm Susan Ridson. I'm the executive director of Vermont Health First, Independent Practice Association. We represent 70 primary care and specialty care practices across Vermont. I believe Dr. Paul Rice might be on the phone as well. He's our chief medical officer and here just to chime in from the provider side. And I just wanted to say or step back for a moment and just say, everybody can blame me for having to be here today because I'm the one who requested this meeting. And the request came from a very simple question actually, having to do with the pay or rate review process. And there is a handout on the Green Mountain Care Board website that goes through what I'm about to talk about briefly. But basically, we're seeing that payer rates are going up every year, 5%, 8%, 11%, not as much for next year, which is great, but they're still going up. And all of our independent practices, they are small businesses who are bearing the brunt of those rate increases in the form of higher healthcare premiums for health insurance for their employees. Meanwhile, I'm hearing from the clinicians in our network that reimbursement rates have been basically flat, certainly not keeping pace with the increases in costs that they're seeing. So my question to the board is, is the intention during the payer rate review process for independent clinicians to see a 0% increase? And when I asked Susan and Chair Mullen this question, the answer was no. So the next question I had, well, what is the follow-up process to ensure or at least examine where the rate increases ultimately go? Because what we have is we're in an unsustainable situation where small businesses cost keep increasing year after year, yet their reimbursements are flat, essentially flat. It's just not a sustainable paradigm. And at this point, it appears that our system is expecting these small businesses to essentially function as if we're in a free market. But Vermont's health care system is not a free market. And I was hoping that we could address this today. And our request is simple, create a follow-up process to see where the payer rate increases go. Right now it's a black box. So we can get back to that when we go back to the board questions. I certainly can, I think I can open it up to the board if anyone wants to comment on that or Sarah Lindberg or Ameren. But Kevin, it seems like you want to wait until we go through all the other panelists. I think that was- I prefer, you know, unless it's a clarifying question that we follow the normal protocol. Okay, that sounds great. Well, and I guess then there is a question out there for the board after we ask some questions of you. So we'll leave it at that. Thank you. Susan, did Dr. Rice want to have any other comments or are you good, Susan? He may have been called away for a family emergency. So if he's not chiming in then. Okay. Great. Thank you. So why don't we turn it over to our other provider organization today by State Primary Care Association and Georgia Meharis. You have a few introductory comments. I do. Thank you, Susan. For the record, my name is Georgia Meharis and I'm Vice President of Policy and Strategy at by State Primary Care Association. We represent federally qualified health centers, Planned Parenthood of Northern New England, the Free Clinics and AHECS in New Hampshire and Vermont. All of our members must care for patients regardless of their ability to pay and their mission driven and focused on their patients and communities. And while I know that today's conversation is about reimbursement, I also want to take a moment to focus on people because that's why we're all here, I think. The staff at our provider practices are continuing to manage increased call volume, staffing pressures. Pandemic is no fun for anyone, right? However, they're continuing to really dig into what they can do for their patients. So, for example, their dental practices were meant to open throughout the spring and summer. One FQHC took over a grocery store in Richford to ensure the community did not become a food desert this past June. And another opened and expressed care clinic with its local hospital in St. Jay. For the remainder of today's conversation, I'm going to focus on the federally qualified health centers. The Free Clinics, by nature, don't get reimbursed and Planned Parenthood goes for the general fee schedule or negotiated rates with payers. Vermont's FQHCs serve 180,000 Vermonters, give or take, and they serve a high percentage of the uninsured in the state. By design, as I said, that's part of the program design. 9 percent of our FQHC population is uninsured. Those figures are all from 2019. We're anticipating 2020 will be slightly higher and we'll be happy to get that to you when we have it. In 2020, nine of our health centers are participating in the One Care Vermont network. And notably, it's all of the larger health centers that are participating. And so I just wanted to say we appreciate being able to work with U of the Green Mountain Care Board, the administration, One Care payers, other provider groups, generally on reimbursement, but also on furthering the goals of the all-pair model and value-based payment in Vermont. Thank you, Susan. Thank you, Georgia. And you don't have a question for the board at this time, it sounds like. I do not. I may later, though. Thank you. Okay, perfect. We'll answer them. So thank you. And now I will turn it over to Matt McKinnon, senior leader at MVP Health Care. Good afternoon. Now, yes, it's Matt McKinnon, senior leader at MVP. I appreciate the invitation and thank you for inviting MVP to this valuable discussion. Really, just in my opening remarks, it's just to remind everybody that MVP is a regional plan. We're based in New York and Vermont. And our goal is really to enhance our members' experience by driving value. And by doing that, it's partnering with our hospitals and physicians. Our focus is on access, population health, quality care, and then obviously being cost-effective. I think one of the things that MVP has pried itself on, especially over the last few years, is recognizing that the fee-for-service models certainly is not working today. And we've actually had many different reimbursement models that are very successful. Again, through value-based payment, partnering with health systems under ACOs, partnering with large physician groups on quality incentives and so forth. And then I think one other thing that, and I don't know if we'll get into the discussion today, is just a big piece, especially since COVID, access to health care is changing. And we've certainly invested a lot of money in telehealth. In fact, promoting telehealth both to our providers and our members, because we want to make sure our members are getting the access they need. And one of the first plans to offer telehealth to all our members and all our products, and then more importantly, making sure there were no access since COVID and waving co-pays and so forth. So I think that's going to be a little bit of today's conversation. And again, thanks for including us. Thank you, Matt. And now I'll turn it over to Andrew Garland, Vice President of Client Relations and External Affairs of the Cross Blue Shield Vermont. Andrew. Thanks, Susan. Can you hear me okay? We can. Great, I've been having some technical difficulties here. Good morning, everybody. My name is Andrew Garland. I'm the Vice President of Client Relations and External Affairs of Blue Cross Blue Shield of Vermont. I've been with the plan more or less since 2001 and working on these reimbursement challenges since 2007, 2008, something like that. So I've worked with a lot of you before and appreciate today's discussion. You know, I think you probably all know about Blue Cross Blue Shield of Vermont, but just as a reminder, we are a local plan. We all live and work here in Vermont. We're a non-for-profit. So all the dollars we're going to talk about today are our member's dollars or the community's dollars. And it is a huge part of our mission to make sure that not only are our members healthy, but our communities are healthy as well, including all of our provider partners. I don't want to repeat everything that Matt just said, but we've been focused on a lot of the same things. As you know, we've worked with OneCare Vermont in support of the all-payer model. Since its inception, we also have a number of really exciting payment experiments that have moved us away from fee-for-service. Almost all of them have been provider-led experiments where providers have come to us and said, hey, fee-for-service is limiting our ability to practice in this way, or it's limiting our ability to provide access in that way. Let's change the system so that we can do something better. And those pilots have been extremely successful and we're really excited about them. So I'm looking forward to today's discussion. I think I'm here primarily to listen, but of course, I'll do everything I can to answer questions for you about Blue Cross Blue Shield of Vermont or provide a reimbursement in general. Thanks. Excellent. Thank you, Andrew. And then I'll turn it over to Alicia Cooper, Director of Payment Reform Reimbursement and Rate Setting at the Department of Vermont Health Access. Thank you, Susan. Good afternoon, everyone. I'm Alicia Cooper. I work at the Department of Vermont Health Access, which is our state department within the Agency of Human Services that administers our Medicaid program. I have the pleasure of working at DEVA with three different units. First, the reimbursement unit, which is responsible for some of our more traditional provider reimbursement methodologies and maintaining those over time. With our Division of Rate Setting, which establishes rates for nursing homes and for private non-medical institutions providing residential care for adolescents and youth. And with our Payment Reform Unit that focuses on identifying alternatives to fee-for-service reimbursement and opportunities for value-based payments. Within DEVA and across the Agency of Human Services, we have some generalized reimbursement goals, which include being a reliable and predictable payer partner with our network of providers to continually professionalize the Medicaid reimbursement methodologies that we are using to pay providers, both more traditional methodologies and alternative payment models to efficiently allocate limited resources and ensure access to cost-effective care for our Medicaid members and to continually identify opportunities to pay for value and enable delivery system transformation. Like others on the panel, I'm very happy to be here today. Thank you for the opportunity to join. Thank you, Alicia. And thank you all. Thanks for taking time out of your very busy days to be with us today. So I'm going to start off the discussion with some questions. As I said earlier, we will turn it over to the board afterwards for their specific questions and, of course, the public. But I think this would be a good way to get the conversation started. So the first question, and this is primarily for the provider representatives, is what are the largest issues regarding reimbursement for you and your practices slash providers? And, of course, the payers, please be more than welcome to comment. But I think I will start with the providers. So I can call on you. Susan, you went first last time. Why don't I have Georgia go first this time? Thank you, Susan. So the issues regarding reimbursement that we would categorize as looming large for our FQHCs are directly correlated to their designation as federally qualified health centers. As I'm sure you're all familiar with, they're heavily regulated by the Bureau of Primary Health Care, which is within HRSA, within HHS. Their oversight includes compliance. So, for example, only the board can hire and fire the CEO. The board must be 51% or more patients. HRSA, the Bureau, defines quality measures. They also define financial metrics. So they have to offer sliding fee scale discounts that are reviewed and approved by the Bureau. They also regulate the services they offer. So they have to provide certain services, and they can't just stop or start services without federal approval, for example, dental. And they also have to meet certain clinical staffing requirements. So all told, they comply with over 90 requirements that are evaluated through written reports, operational site visits, and they have to apply to continue their certification every three years. Most importantly, unlike some other provider types, they must accept all patients, regardless of the ability to pay, as a condition of being a federally qualified health center. The program was specifically designed to serve underserved communities and ensure that those patients have access to cost-effective primary and preventive care. So within this framework, FQHCs are reimbursed in a few different ways, depending on the payer type. So for commercial payers, generally, it's the physician fee schedule or a negotiated fee schedule. You know, I can say that I think in Vermont, all our health centers get the blue cross physician fee schedule. For a subset of the commercial market, the exchange or marketplace population, the Affordable Care Act requires that those carriers pay the PPS rate that is the same rate that Medicaid pays to federally qualified health centers. And finally, for Medicare and Medicaid, they have either a prospective payment system, which Sarah Lindberg referenced, or an alternative payment model, different than the alternative payment model we have negotiated. So same acronym, unfortunately. The PPS for Medicaid and Medicare covers the majority of claims that they process, but not all of them. For example, labs are billed separately and according to a fee schedule. So I'm going to focus a little bit on the third because it directly relates to the issue I'm going to raise. In 2000, the Medicare Medicaid and Ship Benefits Improvement and Protection Act, BIPA, was signed into law. This established a minimum Medicaid per visit rate for FQHCs, the PPS. And it was offered with annual growth inflators, the Medicare Economic Index. So annually, this MEI has varied between about 0.8 percent and just under 2 percent, while below rising costs, as Susan Wisden noted earlier. This law was passed to ensure that Medicaid paid appropriately for services and to avoid health centers using federal grants to subsidize the Medicaid program. So that federal law is still in place. And because of it, FQHCs are extremely limited in what services they can take risk for from a reimbursement perspective. So given this complex federal framework, the issues with reimbursement predominantly revolve around administrative burden. So health centers are held to many masters, including the Bureau of Primary Health Care. And to give some context, the Bureau of Primary Health Care covers 30 million patients a year. And it is not likely that they are going to shift to go to what a local payer would do, right? That's that's a hard a hard negotiation for any health center to be in. Along with the reimbursement regime is a quality measure alignment. And so unfortunately the quality measures are not completely aligned with those in the all-pair model. So multiple quality measures being tracked simultaneously. So an opportunity that we would offer would be to more tightly aligned quality measures that correlate to reimbursement and reduce the number of goals that FQHCs and other primary care practices have to meet each year. I'm sure you know it's hard to have a hundred number one priorities. Another reimbursement concern we have is around the area of telehealth. So the pandemic has brought us many things, including significantly more uptake in this newer service modality. For Medicare specifically, FQHCs and also rural health clinics were not allowed to bill as distant site providers. And so under the pandemic they are allowed to use this modality and bill to Medicare. But it's not clear where this is going to end up after the public health emergency ends. So it's just another area and a wrinkle in the reimbursement world. So I will pause there with the two issues that that are floating to the top today. Thank you. That's great. Thank you Georgia. And Susan Ritzin, why don't you go ahead. Thank you. My answer is much simpler. Our largest issue is continually rising costs without associated increases in income. For independent practices, they have one source of income reimbursements from payers. And individual practices essentially have little or no ability to negotiate those rates. That's the problem. And I see Dr. Rice has been able to join us. If you want to add to that, please do. From the practice perspective, yes. Thank you so much. And sorry to be late. I have a family health emergency going on. But I guess the main thing in terms of that that we're learning lately is that the payers are actually being not only encouraged, but made to in some strong ways, put their additional funds into one care than to be paid out to us. So if we're not participating in one care because we're not all on board with the way they're moving along with things, we get no increases. They're basically telling us, or they're basically telling us, if you want any more fee increases or any more payment for your services, you have to get them through one care. To the point where even if we wanted to do a innovative model directly with a payer separately, they will not do that. Any innovative models or any alternative payment models have to go through one care. So we're stuck and have no ability to act as if it's a free market to negotiate with equals. That's the unfortunate situation that we're in. We don't really have any ability to negotiate whatsoever. Thank you. Welcome. So I'm sure we'll have follow-ups on that point. You just made Dr. Rice and I hadn't heard that before. So we'll look into that. And I don't know if any of the payers want to comment on this question. If not, I can move to the next one. And don't feel like you have to. This is Matt McKenna from MVP. Just the one thing I want to add when we talk about issues regarding reimbursement. For a lot of us payers that we're in a mix of different products, we're also at risk with the regulatory agencies that we cover the membership. So the challenges that we face is when there's cuts just across the board from Medicare or Medicaid and how does that impact. MVP has always been in at-risk plans. And as part of that, we work with our provider community. Again, access to quality care, making sure everything's accurately coded in the charts and so forth. So it's a challenge from the payers side too to justify the services that we've paid for. Great. Thank you, Matt. Anyone else? Okay. So now I'll ask, I think this could be for everybody. How has your practice providers or your, as a payer, how have you adapted reimbursement strategies to value-based care? I think I can open this up to everybody. I think this could be very long-winded. But what I'm trying to get at is how is everyone looking forward. We know that from where Medicare is at the federal level that value-based care isn't going away. In fact, I'm certain it will probably ramp up even further in the next four years. So I'll just open this question up to the group. I see Paul, Dr. Rice, you have your hand up. Yes, only if you could help us out with that, because it's a catch term, this value-based care. It'd be helpful to have us understand what you mean by it. If we're providing fee-for-service at low cost, everybody knows about the value equation is quality over cost. So fee-for-service is real high value if it's low cost and high quality. So it'd be helpful for us to know what you mean by value-based care. If you're purely talking about prepaid care, maybe we should talk about capitation if that's what really we're talking about. No, thank you for that question, Dr. Rice. It's a good one. I would look at this and the other board members, members of the board can chime in here, but I'm looking at it in terms of our reform efforts within the state and where we're going with the all-payer model. And so, yes, I agree with you not, and even in that model, not everything is going to be in a fixed payment. And if we do have high quality, low cost fee-for-service areas for certain things that are appropriate for fee-for-service, that works, but that's what I was envisioning when I put this question out there. So I would say in our Vermont movement towards value-based care and fixed payments. Thank you, Dr. Rice. Susan, this is Georgia. I'm happy to offer our briefer than before response to this question. So FQHCs have long been eager participants in patient-centered medical homes. So, yeah, I consider that part of our history in value-based care as we continue moving forward, and currently all of them are certified as PCMHs. At this time, they do not get fixed payments from OneCare or any payer, but we're eager to continue the discussion. We actually had a really great conversation just this past Monday with OneCare and some consultants from HMA. So I think there's definitely some nice opportunities and some nice things that we can learn from other states in this area. Thank you. Great. That's helpful. Anybody else want to comment on this? Add any updates with that? I'll comment. So just looking at it across our network, there's actually not a huge percentage of reimbursement coming in as value-based payments, maybe 5% for those practices who are in the normal OneCare program. For those who are in the CPR program, which we do have a couple of our primary care practices, perhaps up to 30% of their patient panel are reimbursements, and Rick might be able to chime in or Paul to correct me if I got that wrong, would be associated with value-based or fixed payments, which is far below the estimated 63 to 65% needed to actually change patient strategy or reimbursement, change the way the practice does business. The other issue that we have in our network is there really is no program for specialists, so there's no value-based payments or fixed payments available to them. So at this juncture, although the majority of our practices do continue to participate in the healthcare reform efforts through OneCare, it's not at a level that is changing practice behavior. Great, thank you. That's great feedback. Thank you, Susan. Anybody else? Any of the payers want to comment? Your strategies? I'm sure you've... Susan, this is Ann Carlin from Cross. I'll try not to go on too long about this. We've been working with providers in Vermont on value-based care. Frankly, before value-based care was even a term that had any currency. Going back 25 plus years, we had phenomenal partnerships with physician and hospital organizations across the state where we collaborated on quality programming access to care programming, care management and what we would today call care coordination. And as those programs sunsetted, we immediately turned our attention to all the work that came out of our initial focus in Green Mountain Care, collaborating with the Director of Payment Reform to pilot value-based care initiatives across the state. And then, of course, we transitioned into the all-payer model program with everybody else. And have been big supporters of that from the beginning. We partnered with all three ACOs that were initially a part of the all-payer model and have worked really hard with one care since then to build support for that program across the state. We have retooled our claims processing engine to support the prospective payment system and to automate really complex work like our state-wide attribution, our support for the blueprint for health. And we've continued to experiment with really exciting value-based payment initiatives either underneath the all-payer model umbrella or in support of the all-payer model. So we've piloted a number of great programs with provider types who have not yet joined the all-payer model but are rowing in that same direction. And we work with them to help build a quality focus that aligns with the state's priorities. And as I said earlier, to find those barriers in the fee-for-service reimbursement system and remove them from them. So we have, for example, a really exciting program with mental health providers who told us that they wanted tools to improve the outcomes that they were getting from therapy sessions. We sat down with them and understood how fee-for-service was limiting their ability to pursue those tools. We made a change and as a result of that, we've seen unbelievable results in avoided ER and inpatient stays related to mental health crisis. It's been a phenomenally effective program. We have similar programs with visiting nurses. We have a really exciting program with the University of Vermont Health Network. And all of those have been based on clinical leaders coming to us and saying, hey, we have an opportunity to improve the care that we're providing to your members if you can help us change this aspect of fee-for-service that's holding us back. And we continue to look for those opportunities wherever they occur. Great, thank you. It's helpful to hear. Anyone else? So this is Paul Rice again. I guess I might just add to what Susan said in that even though there's fixed payments going to one care and the hospitals from one care, the real question is how are those being, how are you turning that into value within those, within the various systems? Are the physicians, for example, or other healthcare practitioners who is actually making the decisions about whether, are they being incentivized to provide only the highest value care? Or are they still being incentivized based on RVUs and total volume? I guess that's the real question. So is it going to really meet our directives if it's not being applied within a large organization as the way it's intended? Just drawing that out there. Yeah, thank you. I hear you. Alicia, I think you were going to chime in as well. Yes, thank you. Just a few additional thoughts from the Medicaid perspective. As I mentioned in the introduction, Diva has had a priority of moving more of its payments away from fever service reimbursement methodologies and toward alternative methodologies for payment. We have been working with one care now for several years implementing the Vermont Medicaid Next Generation ACO program. This is our largest alternative payment model that we have implemented to date. And it has given the Diva team platform for Medicaid innovation within the broader context of the Vermont All-Payer model. One of the things that we've been able to do through this program is increase the proportion of Medicaid funds that are distributed in these fixed prospective payment arrangements, increasingly over time in each of the years that we've had for the contract with one care. And it has also given us an opportunity to learn how payment and delivery system reform can result in different types of health outcomes we've seen some promising quality results from our most recent year of the contract. And so we're anxious to continue the model to understand some of what its potential is. Beyond ACO-based reform, however, I mentioned that Diva has a payment reform unit. The payment reform unit works across the agency of human services and its departments on various cross-agency payment model design and implementation efforts. We try to integrate Medicaid payment and delivery system reform across the care continuum in this way using sort of a standard approach to developing payment models and then implementing alternative payment structures regardless of which department in the agency of human services we're working with or which subset of providers we're working with. And this also has given us the opportunity as we think about ourselves as the broader Medicaid program within the agency of human services to align the core concepts of value-based models that have started in our ACO contract with some of these newer models that are being implemented. And so I think we're continuing to have that commitment to alternative payment models and to moving away from deeper service reimbursement in the future whether that's through ACO-based reform or through alternative models that relate more specifically to other types of services or providers that interact broadly with the agency of human services and departments. Terrific. Thank you, Alicia. And I'll just remind folks if you're not speaking, if you could put yourselves on mute or just heard a little background noise. Anybody else who hasn't commented, if not I'll move on to the next question. Okay. And I'm mindful of the time. I want to make sure that we do have an opportunity for additional board questions and the public comment. So I'm going to combine two of the questions. First, many of you folks, all of you folks actually touched on this issue in your introductions and that's COVID-19. I'm looking at the wording of the question that I sent out and I put COVID-19 in the past tense, which it absolutely is not as we can tell from what's happening throughout the country and even here in Vermont with the latest surge. So I would rephrase the question and say, how is COVID-19 impacting your practice and your providers and your coverage as a payer? And then thinking about what has been beneficial throughout the pandemic in terms of either payment models. I'm thinking in the back of my mind, some of the fixed payments from the all payer model and the ACO that got some of the independent practices by, I know they weren't all their payments, but it was something that was definitely predictable and sustainable during that time. And then Georgia talked about the telehealth issues that they're fine now, but we'll see what happens when we come out on the other side. So why don't we start with a payer this time? Why don't we start with Andrew? If you want to share first, and we'll go back through the line. Sure. And I'm sorry, I'm not as expert at this particular topic as other people in our organization, but what I would say is that since the moment we became aware of the potential impacts of COVID-19, our focus has all been on access. We knew that this was really going to be disruptive to our members, to our provider partners, to our clients, all the businesses who work with us. And we've had our sites firmly fixed on the things that we can do to make it easier for folks who need care to access care. That that's included obviously a huge ramp up in telemedicine, both the service that we provide and also in partnership with a lot of our provider partners who have stood up their own telemedicine capabilities. It's included looking at benefit, cost shares, medical policies, and really finding anything that we could do to make it easier for people to get care during this time. We also were very cognizant that the state is in the middle of this extremely important program with CMMI. We've put so much hard work into building the all-payer model framework and really getting the momentum of our community behind that transformative work. And we didn't want to see that slip away either. So we spent a lot of time with our partners at OneCare talking about how deep the model going. You probably know that we spent a lot of time over the last couple of years working with large organizations across the state to help them understand what the all-payer model is about and why it's beneficial for all of us to be participating, throwing our support behind that transformation. And we really didn't want to see that slip away during COVID because we've accomplished so much. So that's what we focused on. And of course, we've had a lot of conversations with providers across the state about what they need and what we can do to help support them during this time. Great. Thank you, Andrew. Now, Nat, do you want to comment on this question? Yeah, I obviously would have some similar responses as Andrew had supporting OneCare and so forth, but just one other thing to touch based on access was the crucial piece and not only as far as developing the telehealth but also working with our members. Not all members have phones with video capabilities. So was audio going to work and how could we work with the members? And then also as the months continued in this COVID, working with our partners to establish which members are being treated, which members aren't, how can we also help with member education or provide rosters to our providers to say, these are the members that still need to get in or haven't been able to get in and how can we coordinate? So just kind of adding to Andrew's comments, but also to focus on how can we help the members too directly. Great. Thank you. And Alicia, do you have any comments or statements on this question? I think a lot of similar themes to those that have just been mentioned. I'll also just sort of note that if anyone's curious about the full complement of activities that the Medicaid program has been trying to undertake in response to COVID-19, we have a great website that summarizes all of the different things that have been part of the conversation, including ramping up some of the telehealth access and availability, waving some of our prior authorization requirements to ensure that there aren't any barriers to care, things like ensuring that there's continuous eligibility for Medicaid members. We're not redetermining eligibility for any Medicaid members at this time. There's been elimination of certain cost sharing requirements. And in addition to that, the Agency of Human Services has been working closely with the state on the implementation of a number of health care stabilization grant programs. So we're trying to help how we can in making some of the state's coronavirus relief funds available to the provider network at large. Perfect. And close to that website. If you want to send us the link, we can put that in our notes from today's meeting. If you'd like, put that on our website. Thank you, Alicia. So I'm trying to be equitable here. I forgot which order I was in between Georgia and Susan. So why don't I just turn to Georgia first? Was that right? Doesn't matter to me, Susan. Thank you. Susan, thank you. I touched on some of the impacts earlier. And I do want to pick up the theme that my colleagues represented, don't delay care. It's still a challenge. Immunizations, child well visits, getting back on track with lab draws. So it takes more than a village on that one. So thank you to the payers for pushing that and everyone else who has a mouthpiece to do so. In terms of things that have been beneficial, I have the benefit of working in New Hampshire and Vermont. And there's been a lot of amazing communication in both states. But the frequency of conversation in Vermont has been really well appreciated. That said, I think all of us are still drinking from a fire hose with all the information. Where are the rumors? Where are the truths? So anything to mitigate that is always helpful from anyone. And then the final piece is around workforce. I touched on this briefly in the beginning. But our staffing is not up to pre-COVID levels. Staff are out for, because they've got children who are virtually learning. Staff are out because they have to quarantine. And it's going to be a challenge for a while. And I also think that across our state, we probably have a lot of folks who have just left their jobs forever in the healthcare sector, be it in the dental hygienists or other folks who are front lines or folks who are close to retirement who've chosen to step off that treadmill. So I think that moving forward through the rest of the pandemic, really making sure we have the people to take care of our people, our patients and our residents will be really important. And again, appreciating the work that Green Mountain Care Board has done, leading a lot of those efforts. Seems like there's a lot of opportunity in that area. Thank you. You're welcome. Thank you. And Susan. I would echo a lot of the points that Georgia has made. In addition, I'll just mention definitely the telehealth coverage at Parity for both audio visual and audio only has been and will continue to be really key. For the independent practices, the Paycheck Protection Program, also basically I think is a primary reason why our practices are still open. Of course, the funds through AHS did help a number of our practices as well. So, but it's still a tough time, tough time for folks. And our workforce is getting extremely tired. And I'm sure Paul can chime in on this more personally. Yeah, if I could, I guess the one thing, and I'm sorry I was on taking care of family health care there, so I didn't hear everybody's comments. But one of the things is extremely inefficient to take care of patients now during this pandemic. Using the parking lot as a waiting room, for example, rather than your own and having so much more staff that has to call ahead and do screening. And it's very inefficient. And so there's going to be some deferred care and a real backup of the ability of people to get in for care. And we're already seeing that. We're trying to do our best to get people who are sick into the office rather than having to go to the ER. But it's, I guess that's my point, is a very inefficient. And any model that would include more substantial management fees for primary care that covers telehealth, rather than having it be fee for service and cover all the phone calls that are necessary, that you don't want to have to submit a bill for every time. And that was the kind of thing, a substantial management fee to cover all those non-fee for service components that go into care would be something that we really should look forward to. It's not the complete capitation because we will never move to that. We just can't in primary care. Everybody does things differently. But there's some good middle ground probably that we can come up with that supports primary care that's not so elaborate or complicated that it's cost more to apply than you really should, if that makes sense. That's helpful. Thank you. And I will apologize up front for the barking dogs. I think that's super helpful, all of you. Thank you for your answers to these questions. I think I'll turn it back to Chair Mullen and the board members at this time. I think this is a good opportunity to see if they have any other questions. And then I can go on mute for the barking dogs. Thank you, Susan. Great job moderating. And I'll relieve you from the barking dogs. And we'll start the board questioning this afternoon in reverse alphabetical order starting with the letter L to really throw everybody for a loop. So that will be board member Robin Lunge. Thank you. I never get to start because I'm right in the middle. So that's fun for a change. Yeah, so I had a couple of follow-up questions related to some of the discussion. I think I'll start actually with a question for Georgia. Georgia, you mentioned some of the federal limitations on taking risk and looking at how some other states are handling that. I'm wondering if you could just expound on that a little bit and also talk about if there's any activities that you would recommend or that you're participating in on the federal level that might move that conversation along. Thank you. So I'm going to answer by using an analogy that I am borrowing from Dr. Art Jones who is CMO of an FQHC dominated ACO in the Chicago area. So the way he explains what you can take risk on as an FQHC is with a birthday cake. So the cake part of that cake is the PPS and you can't take risk on the cake part of the cake. The frosting is all the other payments that you could take risk on. So in the Vermont market it could be care coordination payments that are above and beyond the PPS rate. It could be a specific substance use disorder program that you're operating. It could even be dental theoretically. So it's the services that are outside of the basic encounter type services. So then looking to what those opportunities are there's been some really great work in Washington, Oregon, Colorado, Illinois and a touch in Maryland to really focus in on this frosting and how you can look at that. So I think as I mentioned we had this good conversation earlier this week with OneCare. I would love more conversations along those lines. I perhaps shouldn't go as far as to say we should have meetings periodically with stakeholders so we're all learning at the same time. I think everyone including myself is scarred from some of the robustness of the SIM meetings. But that might be a step we want to take for example to have a joint learning opportunity in this area. And then in terms of what opportunities exist on the federal level we at by state are privileged to have a long-standing good relationship with the Bureau of Primary Health Care, the regulator of the fairly qualified health centers. And right now the Bureau is in the process of revising how some of its oversight of health centers is going to happen moving forward. It's reach R-E-A-C-H and they're looking to launch that somewhere between 2022 and 2025. We'll see exactly when that launches. And so we anyone really that have an opportunity to weigh in on the pieces and parts of that. All of that said that's you know you can modify some of the quality measures you could modify potentially some of the compliance obligations. But you know there's an underlying federal law that Congress passed right so that is directing HRSA to behave in a certain way with this program. And there's a very strong sense of making sure taxpayer dollars are well spent at the federal level and that this designation is really honored in that way. So happy to explore various things as they come along. As I as I mentioned I think quality the quality alignment could be a really great area because that could reduce a lot of tension potentially for everyone and also help get towards some of our goals in the all peer model. Does that get to your question. Yes thank you. Thank you. So I did want to turn to Susan Rizdin next to talk with you a little bit about your ask because to be frank it doesn't make sense. So what I think you are suggesting sort of misses the point that a rate a premium rate review process is about ensuring a is basically a projection. So it's it's not a guarantee that the medical trend will be in that ballpark. It's not a cap. It is literally just a projection based on data from two years prior claims data. So it is chewed up with reality in terms of what actually happens but it's not meant to be a rate setting or other like a provider rate setting or to direct provider reimbursements. So that a part that I find particularly confusing to be frank is that I'm assuming that if we use the statistics that our staff provided around our regulatory authority which is 15 percent of the commercial market the other 85 percent is self-insured employers I'm assuming that your payer mix in your practices may be different. We don't know. We don't have that data. So I guess my question is how if we are only looking at 15 percent of the the premiums we're only looking at 15 percent of the commercial population. So do you have different reimbursement schedules for the other 85 percent. How many fee schedules do your practices have. What is your payer mix. What can you tell us about margins days cash. You know these are all pieces of information that would be helpful in trying to be more directive around reimbursement but I don't think personally that the rate review process is the sensible place to go there. So I guess if you could explain your thinking a little bit more that would be really helpful. So to me it's a bigger issue or a big bigger picture to look at. You know we're I'm assuming that or presuming that the the medical trend that's based on claims data includes data from independent clinicians. Yet and that data is used to you know justify a rate increase and I understand that the rate increase is not an indication of provider reimbursement but it seems to me that you know it's unsustainable if you're increasing rates you're including independent data in the rate increase or the rate review process but yet there's no follow-up to see if where it goes on the other end. And I'm hearing from our clinicians that things haven't changed and it's not sustainable. Robin can I clarify one question you brought up was whether we have different fee schedules. We don't. So that 15 percent that that you're getting a fee schedule increase based on all those third-party payers the payers are third-party administrators work that the payers are doing. We get one fee schedule. There's no difference between whether it's based on an approved rate or whether it's being paid for on behalf of a third-party self-insured employer. So in essence whatever whatever they're using to to come up with that rate increase it's it goes across the board. It applies to you have more than one payer that you're operating right. Yes more than one payer but within that payer it's a single fee regardless of whether the employer is paying the bill versus the insurer paying the bill as an fully insured patient. Does that help. It does although it actually makes me more concerned about doing something or trying to do something in rate review because quite frankly it could very well result with you having additional fee schedules because our regular authority regulatory authority does not go beyond those that 15 percent. So I think the way to attack it is more on a provider rate setting model which quite frankly on the fee for service level is very complex and and I'm not sure. I mean I think you guys have to think carefully about whether you want to be regulated. I guess what I'm really asking more we're really asking more is is if the question can be asked. So when a rate you know proposal comes for for an increase of 10 let's say 10 percent that the question can be asked is you know how much is this going to providers and is it going to providers in a fair and equitable way. Yes right but the question doesn't make sense in the context of rate review because the question that we are trying to answer is what are we assuming medical trend might be going forward. So because we cap for provider reimbursement in the form of charges in the hospital budget process we can we can ask show us your work where you've taken our provide our regulated cap and that that is included in your assumptions. But I think it's the the question to me like we're not operating at a line level. And so unless we regulate the other entity the the data just doesn't it just doesn't work in that process. Okay that's that's helpful. I guess the question would be if if the Greenland Care Board doesn't have the ability to work within the line level who does and because it's a huge problem within our system currently so then and who does it fall under to because obviously we have some major forces within our current system like it or not that drive things not based on a free market system. But yet the independent practices it seems we are allowed to sort of float out there as if we're in a free market system. But there's nothing to help us on on the other side regulating the non free market parts of the system. And so we just put that out there for consideration of you know if the Greenland Care Board doesn't do it maybe there is some other means or mechanism to allow that to be looked at or at least regulated in a way that allows there to be some fairness and reasonableness and I don't know within equity to some extent within within the system because we don't we don't really have it now. And to me the way to regulate that is to regulate at the provider level like that would be the mechanism to do it which would mean we would need to collect data from independent providers similar to the data that we collect in the hospital budget process. I thought you said you're not looking at the actual payments to providers with the fees to providers within the hospital budget. We set a cap on charges in the hospital budget process. So that is the process that we do look at fees. We don't look at it outside of the hospital because we don't regulate those providers. So our mechanism for doing it would be to regulate those providers which would require substantial information gathering from whichever provider type we were regulating. So I mean I think that which you know we certainly hear from the hospitals that that's not a light ask. Yeah it's something I think we would be willing to consider. We would put our fees out there with what we're you know in terms of what we're being charging and what we're paying being paid. Yeah but what we would need to look at is not just your fees but also your financial structure of your organization your pair mix your days cash on hand your margins those sorts of other metrics that we look at. But in any case it's a larger discussion it would require you know quite frankly more staffing and and it's not a a light ask on your end or our end. But to me it's like if we're gonna get into regulating provider reimbursement the only way to really do that without running into a risk of problems among others is at the provider level. Yeah I just it's not to prolong it but I I would wonder if the Green Mountain Care Board has the ability just to say you can't charge more than 250 percent of Medicare. How do I know 250 percent of Medicare is the right level that's why I need data. Well yeah right. I hear you. Thank you. Thank you. Kevin I will leave it at that because I've probably taken up more than my time. So before we go to Jess if I could just ask a follow-up of Dr. Rice from what Robin's questions were asking. Paul I know you can't talk because the contract's probably don't allow you about specific reimbursement but I'm curious what the variation is between the commercial payers. You know I'm sure that you're dealing with the entities that we get to at least look at here in Vermont such as Blue Cross MVP and Signup but also you're probably dealing with that none and others and so I'm just curious what's the variation in your reimbursement from those commercial payers. Yes thank you. It's actually you know I can answer what they're based on rather than actually the fees but there is some substantial differences and I think you know for example I can say that for MVP we're paid on a percentage of Medicare. Okay so it's pretty straight. It's easy. You know what it's going to be. It's easy to change by just saying we're going to increase it by you know we're going keep it attached to Medicare as a percentage. Blue Cross on the other hand all over the map. It has no rhyme or reason based on Medicare or RVUs and so it's really hard to understand and it's even harder to understand how you how you change that from year to year. So there can be tremendous variation especially in the non-evaluation and management fees in other words the procedural fees from payer to payer. 100% difference you know 200% difference. No that's not no two times 100% difference. It can occur especially in those non-ENMs. Within the ENMs there's there there is pretty substantial variation as well. Thank you. So with that I'll turn to board member Holmes. Jess. Great thank you. Interesting conversation as always. Always learn a lot. I guess one of the things I would love to talk about is so it seems like we're hearing a little bit about fair and equitable reimbursement and in a survey that we did of providers independent providers a few years ago the independent providers reported that actually uncertainty of income was much more concerning than the level of income and in fact some other data that we had suggested that independent providers actually earn higher incomes than hospital employed providers. So it was the uncertainty that was a challenge among our independent providers in Vermont and so I guess one of the questions I had is why isn't there greater interest in joining one care Vermont CPR program where there is this you know it's capitated it's a stable revenue flow why isn't if one of the concerns or their larger concern is uncertainty rather than level why not join in a payment model that guarantees stability. Maybe that can go to Susan I guess that would make me the best person there. And I will look to Paul as well because they made the choice not to join one care but I can tell you that it does not work for every practice it really depends on the practice model whether or not it's beneficial. Some practices would actually lose money in that model and as I stated before it's you know it's a small percentage of the total patient panel so it's really not enough to change practice behavior but by and large our practices are interested in novel payment methods. Yeah yeah I can add to that and say that that's exactly true for our practice we did when it was offered to us the fully capitated model we did the numbers and we have a different style of practices practiced than others. We actually have a high frequency of visit in our practice we get people in the same day our primary care visits some of the payers have said oh you see a patient's too much that your visit encounters are higher than the average for primary care. I said well isn't that what you want? We do a lot of orthopedics in the office we do a lot of procedures we actually send fewer people out to specialists so yes we have a very high specialty sort of care within primary care and you get penalized for that in the program that they are offering. It more incentivizes you to send folks out to specialty care rather than keep them in your own practice and see them yourself and so we do a lot of outreach and get people into the practice you know we don't do phone refills for example at the annual need we say oh your meds are out you need to come in and see us and so we provide that level. I guess the other other thing is that the amount that was being offered is generally it should be for primary care you should be able to say oh that's a good amount you know that sounds like a good program and that's absolutely not clear for what what they're offering. So if it was good we would take it absolutely if it was good support for primary care there's no reason we wouldn't take it. And actually I was wondering if if Andrew and Matt might be able to respond to Dr. Rice's earlier comment about the only way to get reimbursement increases or opportunities for innovation is through one care so I didn't quite hear a response to that from the pairs and I'm wondering if there's some conversation we could have about that or hear about that. Sure this is Andrew I'm trying to get my camera back on it doesn't seem to be there we go. Well so I think I understand where the comment is coming from it's not it's not entirely accurate we we do have physician fee schedule increases built into our budget each year I understand completely that they are not as much or they're not as high as anyone would like. I think it's fair to say that we receive feedback from virtually every provider type and in a given year that they believe that that their reimbursement should be increased you know it's not only stress on independent providers you know we get we get we hear from most providers of mental hospitals, physicians, specialists, you know PT practices, Cairo practices, DME providers that that they feel like a reimbursement increases needed so that said we do increase reimbursement annually and we have for at least the last decade or so there have been times you know in my work with Blue Cross where that hasn't been the case where we've had to skip an increase for a year or two but that hasn't happened lately that said what has happened lately is that we have disproportionately shifted those increases to providers who are participating in in one care of Vermont and that's really been in the form of value-based payment to support the transformation that those providers have have committed to make so more dollars are are going through that model you know it is it is the most important you know reform effort that we have going on in Vermont and I know that those practices who are a part of it have committed to a huge undertaking you know in in addition to dealing with all of those sort of day in day out stresses that that Dr. Rice was describing they have to also find you know the time and resources to reorganize the way they provide care so so that's that's the reason that we made that choice and I think it's very in keeping with what really we've been working on you know for the last decade since we started the blueprint for health and really really recognizing that you know that transforming care is a complicated and and costly effort and people are are doing it off the side of their desk can be helped thank you really helpful Andrew I don't know if Matt you had anything to add to that but uh similar comments to uh Andrew as far as the investment in one care value-based type arrangements and then just to reiterate what Dr. Rice said earlier um MVP we do we do use CMS as our basis because we think it's just more transparent um if we base it off CMS and we can um you know look to adopt um their their code set their values and so forth so I think that's you know certainly more beneficial for the providers and easier to understand yeah helpful okay thank you um I guess my other question was really it's always so challenging to think about what is how do you define fair and equitable and and all of that so I guess um and one of the one of the things I think Robin brought up was pair mix and so you know one of the things we know about commercial reimbursement are that they're generally expected or there's some hope that they're going to offset public pair reimbursements that may not always fully cover the costs right so commercial reimbursements may be a little bit higher this is the well-known cost shift and we know that FQHC's and hospital-owned practices take all commerce Medicaid Medicare um in some cases the uninsured and so how you know when we're thinking about just generally this is more of a philosophical question but when we're thinking about uh independent practices who have more latitude over which patients they serve how should pair mix impact or factor into commercial reimbursement for you know independent providers particularly if if an independent provider makes the choice that they don't want to accept Medicaid patients or they don't want to accept many Medicaid patients they have a low you know number of Medicaid patients that they're willing to serve how should I mean I guess this is just a question philosophical question should the reimbursement be adjusted for that so um it's a it's a great question uh Jessica it's not brought up very often um but independent practices are not subsidized to take care of those patients currently where the hospital and the FQHC it's they are and actually Medicare and Medicaid are the best payers for uh FQHC's um you know sort of in general there's nuances there but um there are least pay you know and and we pay taxes we're not a we're not a tax you know we're not uh you know a non-profit you know under that guys so we do have to pay pay taxes more um in that sense so we don't have the subsidies to take care of those populations if we got the same subsidies sure it would be easier to take care of those populations and not even have to consider it I would love for all and I think we all would love for everybody to be on the same fee schedules and on the same you know payment uh levels it would be so much better for for Vermonters at a whole as a whole I just have to quickly say um this concept of independent practitioners making more than those in in employed practice um that that that's that's not the it really have to go back to are they being paid the same per unit of work for the same amount of uh care and that's not true whatsoever um and the the big difference is in independent practice we are also the CEO the CFO we uh we we clean out our own toilets we paint our own walls we sometimes trim the grass um and all of that um is in what we take home so we might take home more but we're being paid as executives and maintenance people as well um so that's rarely considered thank you for that okay thank you that's it for me Kevin you're on mute thanks next we'll go to Maureen thanks um most of my questions have really been covered but you know a couple of things we haven't touched on is you know if the reimbursement the provider reimbursement schedules were changed to be parity you know what would the impact be on insurance rates so I mean it's just a question to throw out there we don't really know right it's not to say that you shouldn't be paid more I'm not saying that at all but it's just a matter too of saying if that reimbursement rate goes up the only way that's going to be paid for is through premiums by the by all the policy holders and so you know has anyone even looked at what kind of cost that would be so I guess that would really be just a question and that could be for either on the insurance side uh or for the providers if anyone has any idea how much that that could be so Maureen thank you I'll take a quick shot at that and we're we've never asked for for equity be equitable you know equal just just more accountability and fairness um there's probably very little justification anybody could give for being at you know 300 350 of medicare for anything but yeah here we are we're there for a lot of things in commercial rates um and um you know we typically are at in independent practice anywhere between 120 to 160 of medicare um for things but um so it's just there's seems to be no accountability currently for having this huge disparity um and I think the fact that we have huge disparity takes away from from the payments available to everyone else and so it's really a question of tamping down the the unreasonable levels and bringing them into into better alignment and accountability and transparency in some way not about equality right because I think you bring up a point there too with you know does go back to payer mix which is um in some cases when you say other payers are subsidized the subsidy is almost through the commercial rate right so if if we look at some of the payers um if medicare was 100 percent Medicaid might be at 50 percent and commercial might be at 200 right but if if someone has all three of those then the higher payment by commercial has to offset that they're taking those lower payers and if you aren't always taking the lower payers then you don't have that offset that you have to subsidize so some of the subsidy is just in the fact that you know if the service if they're paid out a certain amount across three payers they may actually be underfunded you know for Medicaid possibly Medicaid and Medicare and overfunded for commercial um and that's where that whole payer mix comes in and you know there is Robin and kind of pointed out any review that we would do um if it were our responsibility would really push into the profitability of of a practice and looking at those pieces right and understanding you know where where providers are making their money or not right that would become a lot more visible then and it seems in the past when we ask for any information just to help us to be informed we haven't been able to get that you know from private practitioners and and that that's the way it is right now and that's not to say that's that should change but if if we were going to be looking at some of those rate settings I think we would want you know full transparency on on all of that so just to add I mean it's a pretty big lift I mean because it's not like independent practices or franchise and how first does not gather this information either so I mean is the board prepared to look at um financial information for you know the 70 plus independent practices in our network pain no now I would say it's not that's not under what we're required to do right now either right so if it were something that we would be taking on we would need resources as well to do that it's just trying to lay out there making sure people understand you know what goes into to reviewing for rates that are approved for the hospitals for instance and things like that and I'm sure you you guys have sat through those in the past and and seen some of the questions but but this you know you know the other thing I would hope this does is you know there are a lot of private practitioners out there in the same position and you're talking to two of the insurance companies here as well you know and how you facilitate those conversations and work together um to to get paid you know equitably and you know some of these players like MVP is in other states as well so I don't know how those things compare but you know what you would hope you give you a vehicle to be able to talk to the insurance companies as well that's all I had Kevin thanks thanks marine tom thank you and I want to thank uh both susans for convening this uh let's get together um my my hope uh is that we're well my my we're not going to resolve anything here today but I think this is an important conversation to have one reason is what Georgia was talking about just a few minutes ago about the supply of health care providers in the state being diminished uh with the assault of the uh of the virus and you know as Kevin knows and as we all know that you know workforce in vermont is a is a difficult issue as it is and if we are losing providers um you know that are independent um then you know we're we're kind of a wind in the face of what we're trying to do um I'm not sure we're losing providers but I would just want to be sure that you know to to know um you know what the impact is so my my question will be first question will be for paul and susan but I just want to do a little preliminary on it in that you know for me I first met paul and susan at uh this health first event up at uh in waterbury um at the beginning of the year and uh at the end of the session there were some cardiologists that came to me and said we can't make it we haven't gotten an increase in x number period and we're private cardiologists and for me it was I didn't know whether that was true or not so it was a trust but verify kind of approach I took and I came back and I asked susan and kevin and just if could we do a little study um and the cardiologist gave us some codes cardiology codes that they use quite frequently and we uh and there were four of them that we ended up scrubbing and they were put into two columns one being a non-hospital provide cardiologists and the other being hospital aligned uh cardiologists and so for the four codes one code 78452 was found to be equal across both sets of providers at $114 for code 93306 the hospital was lower than the independent cardiologist $322 to $122 for code 92928 the um non-hospital was lower at $699 these are median median of statistics versus $1528 for the hospital related procedure and for code 93458 the median for the non-hospital folks was $309 versus $771 so well for hospitals so for me that wasn't defining but it was interesting that there is you know a lot of um variation out there and uh I visited the cardiologist and you could see from their office setting that uh they're living pretty much hand to mouth and pretty much stressed out you get you you could sense that so I'm thinking about that I'm thinking about our hospital review process which we as Robin notes we get into a lot of detail um but the scale of the hospital review is also a big scale um and then we go into the rate review process and we look at these medical trends and and you know those but you know I'm not I know that that's all proprietary information and we can't talk about it here but both ensures a kind of group information by hospitals some by individual hospitals or groups people that are in New Hampshire people that are um not regulated by the Green Mountain Care Board and I you know and you can see the independent folks in uh in in those groupings they're kind of separated out and so I you know I couldn't relate what I'm seeing through rate review to what I'm hearing from folks out on the ground in the independent circles it just you know there I'm I'm not going to you know reveal proprietary information but uh the the the the two were not aligned uh so to say and so this is a conversation I I hope you know that we can find some alignment and uh uh and but also keep in mind the scale of it uh independent providers are not hospitals are not of that scale um and if we are losing them because the you know the that the um the amounts that are in the uh rate review process for independents don't actually reach them on the ground that would be something I would want to know um and uh and to try to at least uh job own the insurers into you know uh paying a reasonable amount I I worry that we are losing providers I I haven't um you know and and also in terms of the pt folks I mean we all know the letters that we get from all the pt saying they haven't had an increase in 15 years so um I guess my question for Susan and Paul um you know is can you envision can you come back with a proposal that uh that you know uh allows the rate review process to get a a view into your world on a collective basis uh that um is isn't as overbearing as what we require of hospitals which is a full scrub quarterly reports tying out to audit and financial statements etc is there some middle ground we can we can find that that allows you folks to engage in the rate review process in a productive way but one that isn't overwhelming uh for you or overwhelming for the board you'll given given the scale of your uh your your piece of the pie the rate review pie uh that that falls to you um I I do worry that you know I I hope that there's a there's a way to resolve this because if we're losing providers you know because they're just kind of left by the side of the road and and we hear them but we don't act upon it then um I think that would be too bad but but on on the other hand there has to be a practical solution here where um uh you you know we can we can be somewhere in the middle so that's my question can can can you envision a process by which uh the the independence can can enter this discussion in an organized and deliberate way uh that's a great way to put it tom thank you for that um yes would be the easy answer but um it really depends on how extensive information is necessary um and it's going to be very difficult of course to compare apples to apples in terms of how our practices are even you know listed on a on a uh a balance sheet versus versus how a hospital is run or for instance you know how how uh physicians are compensated in a in a hospital system or even an FQAC versus uh independent community practice so um but yes I think I I think um you know providing the basic information from practices on on what their payer mix is what their um what their reimbursement is as a percentage of medicare perhaps um and um and and and those kind those kind of data points that and maybe the payers I mean the payers would probably have to free us up somewhat uh from our for our ability to provide you with uh you know what our fees are or our fee schedules are and how they're how they're derived Susan I was going to have the answer of we'll give it some thought and get back to you well I would also add to that um that that the the information that we look at in this this area with the insurers is proprietary and uh you know I don't know if some proprietary you know kind of you know proprietary arrangements could could be uh kind of crafted together that um allows you folks to convey information to us as to what is happening in terms of your reimbursement rates um in a even in a group way um or or benefiting from the proprietary process that you know that that that we have um we've just got to find a way to talk to each other um and and solve this problem um especially since you're not a hospital you're a small piece of the pie um and but an important piece of the pie and uh we need to pay pay attention to your problem in my view I think in terms of uh you know what Andrew had mentioned before um the the the rate increase from year to year for hospitals versus is not giving you the the actual fees but it's giving you the rate increases and for instance for our E&M um from Blue Cross we receive zero increase in 2018 and 2% in 2019 zero in 2020 and next year is slated for zero increase as well so for those four years of which we're about to enter another we have a two percent increase that's a half a percent per year and and I'm not telling you any fees but I'm just telling you what the percent increase in our E&M has been and again as Susan mentioned that's not sustainable because I know that the folks who are providing exactly the same type of care potentially um in other settings are getting significant increases in what they're being paid on those same E&M codes so um so we can maybe start there and then work towards you know substantiating those numbers amongst ourselves and working together on you know okay that doesn't seem right what more data can we then build on that and can I chime in here a little bit Chair Mullin go ahead um and Sarah Lindbergh might also I just want to clarify backing up to the data that Tom referenced where our team did do some analysis that was just on professional codes so and this is way out of my league but when you when you look at and as part of this discussion in different settings there's variations and so um I did just want to clarify that it is not comparing apples to oranges and part of the work that our team is doing with the validation on with our data as well as then leading up to our dashboard I know that the independent providers are part of those work groups so I'm wondering and I don't want to put more more work on our team but I'm wondering if Sarah Lindbergh and her team could follow up um through that group if that's if that makes sense Sarah and if it doesn't we could talk about it offline yeah sure so yeah we're just trying to to start make sure just validate information so how do the financials that we're capturing in the database compare with those that um providers are seeing versus those that the payers are recording in their financial records um and once we have a handle on that we can start to try and um you know crack a very tough nut in trying to see how a procedure performed in a hospital setting compares to one in a in a in a kind of outpatient non-facility owned setting which sounds like it should be really easy but unfortunately I think it's going to keep us busy for a while can I jump in here with a question Kevin sure go ahead Jess um I'm actually this is more directed towards Andrew and Matt but I'm wondering you know we have the rate review process and then we have the hospital budget process that happens after the rate review process and we've in after the hospital budget process actually had conversations about should we follow up with the carriers to understand after the hospital budget process how did the decisions we made in the hospital budget process flow through to um changes within within the reimbursements for say inpatient and outpatient and maybe imaging or some big broad categories and understanding how it actually manifested the the commercial rate increases that we allowed how it actually manifested through the subcategories of the hospitals with a follow-up with um the carriers and so I'm just wondering if we expanded that and at the end of the year would it be proprietary um to also ask for a breakdown just of an aggregate what was the aggregate increase in inpatient you know increases outpatient imaging and then independent maybe FQHCs but and then independent primary disparities this big broad categories so we could see how the the increases manifested themselves across all of the kind of big bucketed areas is that too proprietary is that too uh confidential in terms of contract negotiations is there a way to aggregate it up to share that information yeah I think if we aggregate that data across those categories that that would not be um that wouldn't be violating any contract that we've executed with anybody um we would you know want to keep that you know within the green mountain care board I think at least initially um you know but um it's certainly analysis that we can do there there are some limitations of course because uh we don't know exactly what goes on with hospital reimbursement um so apples to apples can be a little bit tough there but I I think we can we can share what we know yeah because that might be helpful I mean I think that's what we're trying to understand here right is how you know how do these rate increases flow through the system in the various component parts so it sounds like from at least Blue Cross's perspective that would be some version of that could be shared and Matt I don't know how you feel about the MVP side of things but I mean I think similar to Andrew I mean I think it's possible but certainly um I have to have the tagline that I'd have to run it by our legal department just to make sure we're in compliance with our contracts and depending on specifically the questions asked but we can definitely look into that one of the things that has always frustrated me um in a number of our processes including um hospital charges is that we don't really um get the luxury of seeing um how they compare against each other as opposed to just talking about a percentage increase so I'm this question is for um Alicia Matt and uh Andrew um do you benchmark against your peers um so for Medicaid do you look at reimbursements compared to other states when you're making decisions and for the commercial payers um do you benchmark against other commercial payers across the country to see if your reimbursements are way low way high just right um Alicia we'll start with you you've been awful quiet and thank you for the question um I think for a lot of our methodologies we do try to key off of Medicare's reimbursement both their approaches to structuring the rates and we try to understand what we are able to pay as Medicaid relative to what Medicare is paying currently so an example of that is for our professional fee schedule um for primary care services for the last several years um Vermont Medicaid has paid 100 percent of Medicare's rates for those primary care services we're trying to maintain that level of 100 percent for Medicaid if we can we also try to do that benchmarking for other methodologies where there is an appropriate Medicare equivalent in some instances Medicaid pays for services that Medicare doesn't necessarily cover and so in those cases we do try to compare ourselves to other sources in particular we look at other Medicaid programs nationally but more specifically we try to look at Medicaid programs within the New England area and so that gives us a sense of where we are relative to our peers and in particular neighboring state Medicaid programs thank you Matt Andrew uh this is Matt um it's actually similar for MVP that we do use Medicare as our as our base I mean we are in the we are in you know all product lines you know the main ones of being Medicare Medicaid and the commercial product lines so we do use CMS as our benchmark and follow a lot of the CMS requirements on coverage guidelines and services I can't get into specific rates but that we do use CMS as the basis do you think you get to the just right or I mean I think I think MVP is very competitive in our regions we actually we look at all our regions specifically you know what we're paying primary care hospital based etc so we obviously try to maintain that competitive competitive advantage and um you know that's that that's a goal we have to report to our customers our employers thanks Matt Andrew yeah we also look primarily at um well the two major sources of information are government payers and then the direct feedback we get from our network providers I can't tell if my camera is on or not sorry it hasn't been on all day um all we do is hear you Andrew okay I can see myself I'm sorry about that um you can I can yep wow all I see is a blue ring it must be what part of the state you're in I'm on failure black wall uh yeah so we we look at uh Medicare certainly even though we have a proprietary fee schedule we benchmark every fee on the fee schedule against Medicare and then we also look at what what's going on with Medicaid in Vermont a generation ago or more it was common practice I think for health plans to sort of benchmark against each other in the commercial space but that's not something that that has been done for a long time because I think there were concerns about about collusion for price fixing so really we keep our focus on what's going on with Medicare maybe most importantly what we're hearing back from providers like I said we have we have a lot of discussions with providers across the community each year about what's going on with their practices how work is changing um and how reimbursement works or doesn't work in certain situations and all of that factors into our our management of the fee schedule and then you know of course what's going on with members and clients as well um you know it's very important to keep in mind that and I know you all know this every dollar um you know that that we spend um to pay for care is is dollars that are supplied by our members or uh the businesses and organizations across Vermont that purchased our product so it's a it's a real balancing act so Andrew follow up to that um and I'll just focus on you because I know that uh Matt's company contracts with um another um national player for their um out of state network but you're part of the the blues network and being part of that is there ever any um comparison by regions of reimbursements no no the only thing no you know we see what um we get blinded data every year that shows us relatively how much um each payer pays in each state so I can see for example that the Blue Cross plan in Arkansas uh pays the third most or the first most but I can't see who any of the other payers are and I can't see um what they pay only what what their ranking is um but otherwise I did at all if you're um a higher payer um for things and then others around the country or you get ranked but it doesn't really matter um not by the association but but as Matt said you know we we answer to the customers who are are you know counting on us to help them finance healthcare so every every customer RFP we've ever received has asked us to explain our reimbursement so that we can be compared um you know to the other the other health plans that that clients are considering so in in that case we we can be penalized um you know by the market for paying too much or too little for services um we have had clients express concerns you know over the years about both of those things yeah I mean I think of it like as a Vermont or we have so many snowbirds and and uh if they were going to uh another state that was paying so much more than healthcare was here then obviously that's driving up our cost of care so I just would think that it would be reciprocal in that respect so I didn't know if there was any type of natural check and balance on what's happening around the country but it doesn't sound like it no and generally though I will say that the blues plans tend to have very competitive reimbursement and I think part of the reason for that is because we provide a very high level of service both to members and providers um and that has typically um you know translated into very strong relationships with with provider systems great thank you um before I turn to the public is there any further questions from the board hearing none I see that um Susan Gutwin had her hand up for a very long period of time so first of all thank you for your um patient sharing and go ahead with your comment or question thanks um I've enjoyed listening to the conversation and I'm encouraged to hear the board include independent providers in what they feel is their purpose of approving um rate increases and I'm especially thrilled that the discussion of you um and Tom has gone into okay well how do we how do we go about doing it and um I would love to be a part of future discussions I do not see us in the same category as a hospital so the logistics of getting regulation in place cannot be compared to the hospital we could group ourselves um and and frankly we really just don't have as much going on if you look at my balance sheet and PNL you can compare to the hospital you know one takes a wagon the other takes you know just a a folder so um uh and to look at salaries the cost where's the money going in independent practices versus hospitals and looking at the percentage okay uh if we're getting this amount in revenue from our insurance payers what percentage is going towards towards the profit of the business and generally that goes to salaries um if it's an independent practice so there are ways to look at how reimbursement rates that the board approves has its outcome and and the fairness I think will be apparent once there is a system in place to take a look at it so I'm I'm thrilled that today feels like a Friday to me I want to celebrate that I feel for the first time that there's an interest in including independent providers in in the health of the health care system and then the one other thing I just wanted to question is did everybody see the 60-minute story on a Sutter hospital in northern California? I think that we have similar behaviors here in the state of Vermont and um I can I can remember one of the statements was well that they get what we pay them because they ask and of course it's not a hundred percent but certainly what they they ask for in large part is coming through the insurance payers to them to grow and to consume um independent providers so if we don't want to do this in the state of Vermont now's an opportunistic time to take a look at the health of our independent providers thanks. Thank you Sharon and just for those who weren't aware there was a piece on 60 minutes this past Sunday so if anybody wanted to review that they could probably go online and and see it from this past Sunday it wasn't interesting piece Sharon thanks for bringing that up um is there other public comment? Hey Kevin this is Walter calling in from the phone go ahead Walter and then I'm going to call on Dale and then Rick so go ahead Walter. Okay thank you Kevin uh first of all I do say I want I really enjoyed listening to this conversation I can't get on the Microsoft team for unknown reasons but I enjoyed listening to this seminar it's a good one I just want to comment on it make a couple comments on some of the things brought up here tonight number one was the comment that this healthcare system is not a free market system healthcare should never be considered as a free market system uh it's public good second is the comment about value-based care what is the meaning of value-based care and that was a good one because a couple days ago I went to the doctor and I got 10 minutes and I was done now is that value-based or is that not considered value-based in and out wham bam thank you gone reimbursed hit up medicare um and a third concerns Robin's point that she made earlier about regulation and I almost think that is the key in this multi-payer confusing crazy system with all its jar with all its jargon that you don't know exactly what it's talking about you know what is value-based care what is all payer etc etc etc and I think Robin was right on with that point is that what is needed and then is much much more regulation of this system and I know it's a huge task involves the legislature and so on and so forth but anyway I just wanted to agree with her about that and it as a patient it's so confusing to have to go through all this because you're bounced around between insurances you know you you make too much you're kicked off Medicaid then you go back on the private insurance and then you're kicked off Medicaid and you go into an office and you get 10 minutes or 15 minutes and then suddenly you get a bill that says you may owe this or that you know and that's kind of the way I look at all of this because you can talk about reimbursements you can talk about value-based and how people are getting paid and so on and all that but at at the bottom it's the patient and all of us who are paying for this and it is the patient that is the one that we serve whether you're an advocate an activist a board member a board staffer a physician a nurse whatever and to go into a place and I drove 40 miles for this and to get 10 minutes you know and that's typical it's not atypical it's typical it's rush you in and rush you out so that's what I'm getting at so it's the regulation it's what is value-based care and who determines what is a value-based care and it's that health care is not a free enterprise system and thanks again for this I enjoyed it thank you Walter next we're going to go to Dale Hackett and Rick Dooley you're on deck Dale yes thank you very much I did find this very interesting very well done compliments to all of you um and boy it really is a complicated topic um I made my head spend how many years over I've been following this um but you touched on some topics that are very dear to me and happen for years so I just want to comment that when it comes to reimbursement fees example I have hearing aids because I don't hear well and while I'm thankful that Medicaid covers them it was startling when I they stopped working and while I'm due for a new pair I couldn't get these fixed and one of the reasons is one I'm due for a new pair but two the reimbursement cost for fixing them is more than the private practitioner gets reimbursed and I hear these stories so often where it's like well if we I send them out I'm going to have to pay some of my own money because the reimbursement fee isn't going to cover the repair costs and I'm thinking to myself anybody that's got hearing aids that is going to be chilling news to them because you think about more as a service needed if you've got the hearing aids it's like a repair service and the idea of oh am I going to have to pay to get them fixed that increases my cost and we aren't talking something that's cheap the other thing that I hear in all of this and think about is the service is non-included for example reimbursement fee like when I go to a neuroarthbologist what is their reimbursement fee to pay for that visit to pay for services needed the writing of the prescription or certain tests that need to be done but what isn't going to get covered is the glasses at which point I'm handed a prescription and I'm out asking the place I go to to get the one or two prescriptions filled if they can find me a lab reasonable in price where I can pay for my glasses my glasses can cost more than eight hundred dollars a pair and I'm asking them to shop for something that is three hundred dollars a pair and that's going to end up being my fee which means I often can only afford one pair of glasses so I heard like in these conversations where people were talking about being paid 250 percent of Medicare reimbursement rate and that always leaves me puzzled when I know there's also reimbursement rates that don't even cover the cost and there's never there's never a cap on that it's like how how can you pay less than the atrial cost it especially if it's going to fall on the back of the consumer to cover that cost this doesn't make any sense to me I'm trying to talk about something that is just so complicated how they throw this around it works out for them and the balance sheet at the end of the year some get paid more some get paid less as far as the services what they negotiate but just a reminder sometimes that comes back to the consumer as the consumer picks up that difference and that really staggers us because we aren't talking cheap in terms of what can be thrown at us and so one I'd love to see a cap where it's like nothing is covered in cost that's below the actual cost two keep in mind there's also services that aren't even included that are part of the overall package so you're negotiating reimbursement costs on a package that's not even complete I'm referring to like my glasses you'll get half the service but the other half you're stuck with that's going to be your cost so it's not even a complete package hopefully that comment made sense and this overall discussion that's so complicated thank you Dale appreciate it Rick Dooley sure thanks very much to the Green Mountain Care Board so I have just a couple sort of comments on the first is in terms of reimbursement year to year with Luke Ross and again not revealing anything proprietary I you know I looked at our numbers before this meeting and I have almost identical numbers to fall in terms of our year to year increases that would be you know zero then two percent then zero then zero over four years so so I presume they're both looking at the same data and I'm suspicious that if we did this for other independent practices that we find the same thing so I'm a little puzzled you know by Andrew's statement that you know each year there's a percent increase each year maybe it's just specific codes you know but I looked at E&M codes that make up probably 85 percent of our of our payment stream here so so I'm not sure how those numbers come into being I do think the idea of having the insurers provide some of that insight you know even aggregate data saying here's what went to the independent practices last year out of that budget that was approved I think is is a great idea I think so we can say okay yeah here's and here's where the money is as at least flowing and what impact it had I think in terms of the idea of independent practices sort of having a say in in rates or anything of the sort or and I forget how it was worded something about you know essentially saying that the insurers did have their sort of finger on the pulse of independent practices and had a had a good feeling for healthcare you know providers across the state I'm not sure that's entirely accurate I would I would say in conversations I've had you know with colleagues in different practices there's not really a sense that the insurers sit and talk with independent practices I think pretty much it's here's what the fee schedule is here's what we will pay you for this year and I don't know that anyone's had a lot of success saying well here's how our costs are up and geez we need more money and there's been a back and forth that really hasn't happened on a regular basis and maybe it should and maybe that's one of the roles of the Green Mountain Care Board has helped facilitate you know if you shine a spotlight on some of this and help facilitate some of those conversations understanding that you only regulate that 15 percent of the market totally understand that but certainly facilitating the conversations and and you know bringing them up into light of day as much as we can given the yoga and strength I think would be helpful and the third thing I wanted to just point out is that you know I'm I'm entering my quarter century mark in primary care since I started practice so it's you know I've I started at a time when capitation was the you know going to save us all and then we went back to fee for service then we just sort of mixed capitation model and now we're into this alternate you know alternate payment model so so I've kind of seen it all come full circle and each time I'm told the same thing each time it's oh we're going to invest in primary care and we're going to bring down costs and and but as I look at the numbers and I look at our you know increases over the years I don't see an investment in primary care something for my practice and for other independent practices I see more shifting of money going to the hospital each time those rate increases are approved I see the vast majority of that money shifting to the hospital and I see primary care getting shortchanged each and every year time and time again so I just want to sort of implore the agreement on care board to understand that maybe we can't regulate our way out of this but maybe we can have some conversations and just really talk about how to stop that trend of all money going to hospitals you know primary care and independence sort of sitting on the sidelines and picking up the scraps those are my only only comments thank you so much thanks rick and just a little feedback we had a presentation this morning on a new england states consortium report that looked at primary care reimbursement for the six new england states and what they reported was that vermont as a percentage of its spending in the medicaid program is doing great compared to their peers but maybe commercials a little bit behind their peers so if you get a chance to watch that recording rick i think it would be something that would interest you and thank you for your service and primary care we need more primary care doctors thank you i'll take a look thank you other members of the public hearing none i uh want to thank every member of the panel it was a very interesting conversation and i especially want to thank our executive director she's right that she and i had a conversation with um susan that uh kind of was the uh the fruit of having this panel this afternoon but after that i delegated or dumped depending on how you want to look at it all the responsibilities for this afternoon on susan barrett and she did a great job so thank you susan and um with that is there any old business to come before the board kavin can i chair melin can i just say one quick thing about just a item and thank you for the compliments and i also have to uh thank abigail connelly who assisted greatly in putting this all together in the panelists um but thank you very much um i do just see uh as a follow-up and i just wanted to get consensus from the board on this that um i was planning on following up with andrew and matt to see if they could um provide maybe a template of what they could produce in terms of that aggregate data um on fqhc's infusion outpatient independence um so that is an action step that we'll go ahead and take at the staff level and i just wanted to to just make sure you are aware of that and you know in in uh agreement with that next step can i make it just a slight tweak to that or just that i think that's great and i'm just thinking that since given where we are we're trying to move towards health care reform would be helpful if that in that template if there was a breakout or an account of rate increases that were going towards providers that were undertaking you know delivery system reform and to the degree that some of that rate increase may be going towards investment and transformation that's you know that would be helpful for us to understand um in you know to andrew's point about uh why there may be rate increases for delivery system transformation um so i think thinking about that template would be really helpful and we'll learn a lot from it um to robin's point earlier what we can do with that information is going to depend on a lot of information that would have to come from independent providers about you know financials and things like that but i think just understanding the rate increases and where they're going will be helpful what we can do with it i think is limited by the information that we have about independent providers but thank you okay is there any old business to come before the board hearing none is there any new business to come before the board hearing none is there a motion to adjourn i'll move second tom moved to adjourn with morine seconding um all those in favor signify by saying aye aye those opposed signify by saying nay thank you again everyone have a great rest of the day and uh best wishes for the most joyous of holiday seasons even though it uh may be a little bit more isolated than a normal holiday um we are getting close to a time where we can spend um with others and we all just need to be patient and get there so be safe and have a great holiday thank you you too