 Good afternoon everybody. My name is Jessica Holmes. I'm one of the Green Mountain Care Board members here. Our chair Kevin Mullen will be here soon, but I'm going to kick us off today. So welcome everybody. The first item on the agenda is the executive director's report. So Susan. Thank you. Thank you board member Holmes. Welcome everybody. I first I'm going to start with some updates to our calendar and some reminders. First on Monday, June 13th, which is this coming Monday, the board's general advisory committee will be meeting at 2 p.m. via teams. The focus of the meeting on Monday will be an update on the board's report on hospital sustainability that was released to the legislature earlier this year. And the recommendations from that report will also be discussing S285, which is now Act 167. And that law was created as a result of the recommendations from the Green Mountain Care Board's sustainability report. We're going to be asking the advisory committee for their input as we endeavor and work on the important work in Act 167. And we're really looking forward to working with stakeholders in Vermont and the folks at the agency of human services on that work and collaborating with them on it. In addition, as a reminder, we have a primary care advisory group meeting next month. This was just added to the calendar next week. Excuse me. That's on June 15th at 5.30. And then recently added to the monthly calendar is on June 22nd. The Department of Mental Health will be presenting to the Green Mountain Care Board on their priorities and some of the great work they're doing with our hospitals to address some of the wait times and issues in the emergency rooms and other parts of the healthcare system around mental health and how to address that. I also want to just briefly remind folks and I'd ask you to look at our website because we have several ongoing public comment periods. We'll be adding to them after today's presentation. We'll open, we're opening one up today on a vital's budget. So that public comment period will go until June 17th, close of business. And that will give the board time to consider these comments ahead of the staff presentation and potential vote on June 22nd. Also, we have an ongoing public comment period for the Accountable Care Organization budget guidance and the Medicare only ACO guidance will be covered today. And the certified ACO guidance and certification will be reviewed next week. Materials on this can be found on our website. And so also we ask that comments be submitted by Monday June 20th in order to be considered by the board for their potential vote on June 22nd. And then please look at the rate review area of our website. As a reminder, we received the qualified health plan rate requests on May 6th. We opened up a public comment period for those rates and we'll be accepting public comments until July 21st 2022 at 11.59 p.m. And please look at again that website for the hearing dates later next month. And then the last but certainly not least public comment which has been ongoing for quite some time is the request that the public share any comments they have regarding a next potential all peer model with CMMI. We are sharing any of those comments with AHS in the governor's office as they are leading the negotiations on the all peer model. And after that, all that, that's it. I will turn it back to you for never homes. Thank you so much. That's helpful. So the next item we have is the approval of the minutes from May 25th. So is there a motion to approve the minutes? So moved. Second. Great. Any discussion? Not hearing any. Okay. All those in favor of approving the minutes of May 25th? Please say aye. Aye. Aye. Any opposed? Not hearing any of that. So we can let the record show that we have unanimous approval of the minutes by the board members here today. Next up, we actually have the presentation of the vital fiscal year 23 budget. I believe Jess Mendesable, you are going to be kicking us off and setting the stage for us. So I'll turn it over to you. Thank you. Can everyone hear me okay? Okay. Good. I'll just go ahead and share my screen. Just have a few slides and for those who don't know me, my name is Jessica Mendesable. I'm a member of the data team with the Green Mountain Care Board and I've been working alongside vital this budget cycle to manage the process as the board reviews the budget. And so just to remind everyone, the board does have statutory authority to review and approve the vital budget annually. This was granted to the board in 2015 and was implemented in 2016. And the main focus here is for the board's oversight to provide strategic guidance and policy parameters through which the administration will operationalize via a contract between vital and the Department of Vermont Health Access. In April of 2021, the board established an annual budget guidance for vital. The guidance has not changed this year. So the budget submission tracks to that guidance. And there are four principles that the board uses during its budget review. The first is transparency, which is measured by compliance with the budget guidance as well as overall transparency for the budget process. We have a public and stakeholder engagement process, which Susan mentioned. So we'll have a public comment period following today's presentation. The board also has to ensure that the budget submission aligns with the health information exchange or HIE plan goals and ensure that the strategy and the priorities are consistent with the state's overall health care reform efforts as well as the health information technology plan. And finally, the guidance established that the board's review process must be structured in a timely way to assist diva and vital in negotiating their contracts each year. And so just Susan mentioned a lot of this. So just quick reference will open the public comment period today. I will present to the board on June 22nd and there'll be a potential board vote that day. If additional information is required or additional discussion, we do have a backup date scheduled for June 29th. So all of these materials are available on our website as well as historic materials from previous budget cycles. So folks are encouraged to go and look at that after the presentation. And with that, I will turn it over to Beth Anderson, who is the president and CEO of Vital. Thank you. Thank you, Jessica. I think Maureen is going to share our content. Great. I'll just get started while she pulls those up. Thank you to the board for having us here today to present our budget to you. As you know, the highlight for today will be our FY23 budget for the year starting July 1st. But we're also going to present to you some information about work we have ongoing and just progress we've made this year. The full leadership team is here with me, and you'll hear from all of them at some point today. So we have Bob Turnell, Christina Chouquette, Maureen Gilbert, and Sue Fritz. And I think we're presenting in that order. So Maureen, if you jump to slide four, please. What I'd like to start is just a quick update for you on our CMS funding. So you may recall from updates we've given previously this year. The state had submitted to CMS for the HIE to be certified as a component or a module of the Medicaid enterprise system here in Vermont. And we learned last month from CMS that that certification was actually granted for us, which is really exciting. We're one of the first HIEs to receive this designation across the country. And it's a really good representation of our work. It allows diva to continue to submit for ongoing operational funding of the VIHI under their work with CMS. And it also allows them to request an enhanced funding participation from CMS, which will make the state's match dollars go further. So I think it's a really great testament to our work. Just as a reminder, because it's been a while since we talked about that, certification really involved our identifying measurable and reportable outcomes that demonstrate the work that we're doing and kind of represent our goals as a state for the work with HIE and Medicaid. And they went around really three categories of work. So one is would be measures of direct care and care coordination. Another is a measure of public health and the support for public health needs. And the third is round value-based care on our work in support of that. And we will be providing updates that now for you going forward about what that looks like now that we've been awarded and we'll be presenting or calculating and presenting those metrics. We've also learned some more about shifts and Medicaid funding availability. So as we talked last time, we were here, HICEQ expired in the fall as we expected, unfortunately, and we were being funded through different Medicaid mechanisms. And we're learning more about what those look like and how they will impact our work going forward. So there is more of a focus on operational funding and as opposed to the previous work we've seen some investment more in development work. So you'll see that reflected in some of what we'll talk about today as we look to our 23 budget. And we've learned that unfortunately, CMS is no longer going to fund the creation of interfaces or connections between the HIE and healthcare organization. So that's connections that would get the data into the HIE. So we we realize that this is a big kind of gap our need for critical service for us really going forward. We're working with Diva and some other stakeholders to come up with ways to really address that gap going forward. And we'll be talking to you more about that in future presentations. So now before we start talking about our plans for 23, I wanted to just take a minute. I'm sorry, Maureen, next slide, please. I just wanted to take a minute to tell you a little bit about the work we've done in 22 and the current fiscal year and what we've achieved. So first is really our own outcomes based certification. Talk to you a bit about what that process was. But also that's changing a bit of the security focus of our work and formalizing some of our security. And Sue Fritz will talk to you a bit about that later in our presentation. But it's really taken us forward in some really good ways. We continue to expand our work with the Department of Health and support of their needs. That includes we've focused on developing a lot of new connections to get data for them around immunizations and lab results. We expanded the work that we do with them to be outside of COVID and really to help support their work around other reportable diseases and other data needs, which has been really exciting. And the teams have been working to design an integration between the immunization registry and the VHI, which will enable providers and healthcare organizations to have better point of care access to some of the immunization data that they need. Continue the implementation and enhancement of the collaborative services project and implementation of the new clinical data repository, which Christina will touch a bit later. We've launched a new clinical portal to replace the old one, which we're really excited about getting good feedback about. Maureen, I'll talk a bit about that. We did work with Diva to actually represent that we could ingest claims data and link it to the clinical data and have a more even more complete patient record, which included both their claims and clinical data. So that was really exciting capability for us. Maureen has spent a lot of time preparing a new patient education campaign and really go out and remind them about their choice and how their data is shared and what that means for them. You'll also talk more about that. And then finally, you heard a little bit about this in a written update during the year, but I thought it'd take the opportunity while we're actually in conversation to talk about some strategic planning that the leadership team and the board of directors did early in 22, that's guiding much of our work. So if we turn to the next slide, the strategic planning work really developed a strategic framework for us to use to guide our work in the coming years and really set a foundation for our work. And at its core, we set five strategic directions around the work. And I won't read all of the language on the slides, but just to hit the top points. It's really for us to focus on our customers and their needs and their wants to tell our story to make sure people understand what the VHI can provide to them and what services are available to be the go-to partner for exchanging Vermont's health information, to build a learning organization, and to ensure sustainability of the VHI so that we can continue to do our work and deliver to the healthcare community here. All of this is really founded on what we've set out as kind of a security goal for us, which is really that all of our work is dependent on and must focus on the security of the patient data, ensuring the appropriate access to the data, and ensuring that we honor patients' rights and preferences. So that's really a long-term commitment of ours. And so this strategic plan, which is more of an internal to vital work, combined with the HIE strategic plan, which you are all aware of that you saw in November, really is jobs or priorities and plans for each fiscal year. And you'll see that represented as we talk about what we're looking at with the FY23 budget as well. So on the next slide, lays out what our actually calendar year 23 contract with DEVA is likely to look like. So this is based on our conversations and agreements with the team at AHS right now, which as we do every year, we have these initial conversations to inform our budget process, but this actually will not be approved by CMS until the fall. So welcome back to you when we have that final approval of the contract and let you know that that has happened. But what the thinking is is that the contract will be about $7.2 billion. And you'll see, as I mentioned earlier, this really reflects the transition away from platform development and implementation and really towards ongoing maintenance and operations of the existing platform. You will see that there is a bit of funding there for interfaces. We will not be using CMS dollars as mentioned for interfaces. However, the Department of Health wants to make sure that we can continue to at least focus on the interfaces that they need for labs and immunization data. So they will be using different funding sources to fund some of that work for us going into the next calendar year. There's also a bit of money for us to continue the integration of the immunization registry and the VHI, as I mentioned earlier. So I think this leaves us in a good place. I think the good part of the story is we had these conversations last year and we weren't sure what the CMS dollars would look like or how significant of a change it would be. I think we've been happy that we're in a better place and we thought we would be, but we'll be looking to the future to figure out different ways to continue to deliver new services and products for the healthcare community. So the next slide will lay out for you. As you know, Bob will be in a moment presenting the FY23 budget for you, which actually is a combination of work from our current calendar year contract, the CY22 contract and this new calendar year 23 contract I just presented. So just to give you a sense of what projects are represented in the budget we'll present, separate from how we've presented it from a contract year. The work that we anticipate will happen would be one, ensuring patients have access to their health data and delivering some of the new order called application programming interfaces or APIs that CMS and OMC are encouraging to be built so patients can use third-party apps, a thing like Apple Health, to get their data from the VHI. We'll be updating the platform to the newest standard of the FIRE, the fast healthcare interface resource tool and standard just so we are keeping current. We will continue some enhancements to the new clinical portal, which will deliver on some of the needs and wants of the healthcare community. We're going to continue working on our reporting and extract capability so we can continue to make data and data sets available to individuals who need it. So that's for work with Blueprint and one care and potentially others that might want data. As I mentioned a couple of times, the immunization registry integration will continue. We're also doing some strategic planning with the Department of Public Health over the next six to eight months to think about in addition to immunization registry, where are other opportunities for us to create our work to use the VHI to support their work to make sure we're not duplicating efforts and making sure the data is available where people need it. We're doing some work with Medicaid to help meet some of their interoperability needs. So the same way that we are trying to make patient data available through APIs, they also have that requirement to make the claims data available. So we'll be doing some work to help them in that work. And then we will be continuing as I mentioned to do interfaces for public health. Some activities we'll have that are represented in our budget but aren't necessarily aligned with the state or funded through the state contract. We'll be, you've heard this from us I think for a couple of years now really expanding our outreach and planning engagement. So making sure we're like talking with the healthcare community, understanding their needs and what their challenges are and opportunities for the VHI to support their work. We're finding our product roadmap as we have those conversations to make sure that we're delivering services that are actually valuable to them and that they want. And some of that will really be some exploring operas, some specific opportunities this year. And one is how do we get more of the VHI data into their health records directly so it really is at their fingertips at the point of care and not requiring other tools and access. And also a program with the NCQA to help with some of the supplemental data needed for HEDIS reporting that would be a really operational benefit to both payers and providers to avoid some of the manual data collection and extraction that happens now. So hopefully you'll be hearing more from us on those programs over the coming months as well. And so with that foundation I'm happy to answer any questions or to turn it over to Bob to talk you through the numbers. To board members have any questions for Beth? I have a couple questions but I can hold them to the end like we normally do if you prefer. What would you like? Up to you Beth. It's fine for me to hold till the end. So why don't we hold till the end unless Beth you feel like you'd prefer to answer questions? Not unless it's you know if it's something that would be helpful for you to have as a foundation to answer now happy to answer anything. Okay. All right why don't we hold unless somebody has a clarifying question and then we'll hold all the questions till the end. Good afternoon. I'm Bob Ternot CFO of vital and I'll be present presenting the FY 23 budget this afternoon. Next slide please. As we close out FY 22 we are forecasting better performance than planned as shown by the increase in net assets compared with budget and we believe that our balance sheet will remain robust through the end of the year. Next slide. As Beth has mentioned FY 23 really represents a year of transition as we complete development projects and we move from the legacy V high platform to the new data platform. Next slide please. This chart is a comparative of the statement of activities by year. The elements of this chart will be discussed in upcoming charts overall. The FY 23 budget has a positive change in net asset at year end and our cash position will be strong at the end of the year. Next slide. This chart details revenue by year by source and as noted the CY 23 value is an estimate and that's based on our discussions with Diva prior to putting together the budget. This value may change prior to award of the contract in the beginning of the new year but it is our best estimate with consensus with Diva program managers. Next slide please. This chart shows the portion of expense by type in the FY 23 budget. The largest items of the expense are labor at 35% software at 31% and outside support at 20%. In prior years outside support has been one of our largest elements of cost and again as we transition in scope that has gone down by about $200,000. Next slide please. Overall spend for labor related cost is less than a little less than $200,000 less than more than the FY 22 year-end forecast. This includes the creation of three roles but at the same time shifting two roles vacant roles to outside support for FY 23 and finally it includes a coal of 3% and a contingency for potential increased health insurance cost of around $20,000. Next slide please. This chart provides a detail on software and outside support. Comparing software support I mean software to FY 22 it is up $92,000 which reflects kind of a mix if you will of really capturing all the cost of some of the functionality which began in October of 2021 so this would have a full year of all the software licensing costs. As I mentioned outside support is down by about $200,000 as again projects draw to a close in this fiscal year. Next slide please. Vital is a lean organization and our continued staffing strategy has been to fill to not fill short-term specialized roles with employees but rather with consultants so we have held back on filling some roles with employees but rather we've gone out because the skills are specialized and are a one-time need. Any questions on that? Next slide. Indirect rates. Vital has worked hard over the years to keep our indirect costs in check. As a small company though small changes in volume and expense also will drive shifts in the rate. Next slide. Balance sheet. We project at the end of FY 23 that we will be in a strong cash position at the end of the year with 172 days of cash. Next slide. Finally vital plans on using some of its FY 22 surplus to support an internal effort to redesign the Rhapsody integration engine with the intent to improve the efficiency of this tool. So that concludes my portion of the FY 23 budget presentation. Are there any questions that I can address? I think maybe we'll just hold any questions until the end Bob if that's all right with the rest of the board. Very good so I will turn it over to Maureen Gilbert our director of client engagement. Thanks Bob. So I'm going to talk briefly about our development of a sustainability model. So Beth was talking earlier about the transition to new federal funding sources and shifts in the state's funded priorities and vital needs to continue to define a sustainable fee structure and by sustainable I mean sustainable for both vital and for its clients. And the goal here is to allow the organization first off to continue building new connections with organizations who want to submit data and to continue receiving data from organizations when they change EHRs which is a frequent occurrence. This is essential we need data in in order to make this this tool make the Vermont health information exchange useful to the health care community in Vermont and we're looking for our sustainability model to help support that. Additionally we know that the needs of health care organizations are changing all the time. Health care organizations whether they're defined as hospitals practices payers. We group a number of different types of organizations providing health care services under that heading and we know their needs are rapidly evolving. And in order to keep providing value to them it's important that we invest in customer led design and that we are able to implement new services to support actionable data for instance by providers at the point of care. So those are the key goals of our sustainability model and our ongoing development of of that certainly something that we'll be talking about a lot more in the in the months and year to come. And after that I'm going to move on to our program updates. I'm going to pass it for a minute over to Christina Chouquette our director of operations. Hi everyone I am Christina Chouquette I'm the director of operations as Maureen mentioned I might look familiar to some of you I'm pleased to be back and delivering the MedicaSoft overall project update. So to start where we are with the MedicaSoft project really can be seen as a period where we're fully transitioning onto the new platform from our legacy vendor hitting a period of stabilization onto that new platform and leveraging some of the great things that are available to vital and to our stakeholders on that new platform. So to begin we have rolled out our vital access clinical portal pilot that is the portal that is available to providers to access the data. It's using an API to actually hit the clinical data repository and present that data and Maureen will talk about that immediately following about that rollout effort. 90% of the interfaces which is now as of today 93% of the interfaces that needed to be moved from the legacy platform directly to the new platform that transition is underway and we are focusing on getting that done in the June-July timeframe. We have selected and are in the process of finalizing a contract with our results delivery and direct messaging vendor and the announcement is it will be with Health Catalyst who was our legacy vendor. I think we're all surprised about that decision but at the end of the day after coming down to three vendors in the running it really came down to Health Catalyst has two really solid services that we already know that our clients are already using it was the least disruption for our clients using those solid services especially with results delivery knowing that that vendor was able to integrate right into the EHR and support the current workflow that many providers have really tipped the decision in their favor and so we are signing a one-year renewable contract with them so that will allow us to also determine what do our clients needs back to what Maureen was saying really having this customer led design what is it that they would need a year from now and where is the market for us to either renew or to consider another platform. The reporting database once the clinical data is stored into our clinical repository it then moves into the reporting database and that's what we have used to deliver the two blueprint extracts to date successfully delivered to blueprint extracts to date and we're working on fine-tuning the performance and availability of that data looking forward for when we can provide views into that data and some self-service tools for our stakeholders to use in addition to extracting data and then we have some really exciting projects underway for fall delivery and Beth has already touched upon the patient API so that would enable Vermont patient to actually have access to their own data using a third-party application and we're working with our state counterparts in order to leverage some of the existing infrastructure if possible for identity management and authorization for Vermonters to access that data not listed here is also working with the Medicaid interoperability to enable Medicaid patients to also have data so we're working with Medicaid to share the data for their API needs and we're working on a technical design for the social determinants of health to enable data ingestion using the gravity project as our framework we're putting together a repeatable process to be able to ingest that data and have it available for use as needed and lastly we're working with the Vermont Department of Health in order to implement bidirectional immunization query and and retrieve technical design it's two phases the first phase will be to integrate with the immunization registry so that providers would be able to access and view the immunizations that are in the registry themselves and then phase two would be the ability to present forecasting information so when a provider needs to know what immunizations need to be administered and when they would have that information available as well so really exciting things happening on the medica soft front and at this moment i'll turn it over back to Maureen thanks Christina sure all right so Christina and her team did a tremendous job standing up the vital access provider portal this is something that we did in really close collaboration between the operations team the engagement team the technology team and our clients so Christina mentioned a pilot that we did earlier and we talked a little bit about that last time we were here we are now rolling out to to users beyond that that pilot group that rollout began on april 19th and it continues in waves we're doing it in a way that requires the least disruption for for the organizations where vital access is used so we are reaching out directly to users we are certainly letting leaders at the organizations know about this and asking for their support and encouraging the transition and encouraging use but the first step is this outreach directly to users inviting them to activate their new accounts building awareness of education resources and encouraging use of the portal got live trainings happening regularly we have a learning hub with a user manual quick videos recorded webinars and more and our support team has been working hard to define an approach to to supporting user needs and answering user questions and has been in fact getting a lot of user questions and answering a lot of user questions they're a great resource for our users from those users we've heard really positive feedback about the new interface and the data that's available there hearing that it's more intuitive more like an electronic health record organized in terms of the clinical data that's needed at point of care and there was important new data sources in there like immunizations for interest for example um there were some questions um from the board in reviewing our materials about how the rollout is progressing it's progressing steadily um we are seeing steadily increased um patient chart queries in the new portal and steadily decreased patient chart queries in the old portal and I am thinking next week is the point when it crosses over but the lines are converging and I think we're about to see more use of the new one than the old one we're also going to be doing a big push to get everybody um to make that transition before we do finally close out the old portal and then we'll we'll develop plans for ongoing support of use and ongoing user user feedback mechanisms so that we can continue to evolve this tool to meet user needs the next thing I wanted to talk to you about is our patient consent education I feel like every time I've been here since I've taken this job I've said hey you know we've had to put this on hold because of the pandemic or the next wave of the pandemic um and the recognition that there are a lot of health messages out in the world and a lot of very important ones we think now is the time to be relaunching our patient consent education efforts um doing direct outreach to vermoner's this will begin this month um there will be paid placement on facebook instagram and youtube sort of brief pre-roll videos and the goal here is is building views and awareness so it's not actually asking anybody to take a very specific action but we just want to build awareness of health record data sharing and make sure people have access to um opting out should they should they choose to or um in in most patients in the case of most patients we find that when they learn about this what they want to do is they want to stay in and they want to keep sharing their record this will supplement ongoing education by participating organizations and we continue to support that through a toolkit of resources for our clients and we will be reaching out to um partners both um clients and um community partners including the ones who were part of the original um opt out switch um consent education and letting them know about the resources so that they have the opportunity to um post repost share this content that we've developed to help support um education of vermoner's about health data sharing so there are folks in the in the audience today who can expect to hear from me on this and with that i'm going to turn it over to sue fritz our director of technology thanks moring um so i wanted to bring to you a little update on our security um program here at vital there's so much to talk about when we talk about security but i could don't assume the rest of you want to spend the rest of the afternoon with me so i took some high level bullet points but also welcome you to ask any questions if you had them um the the big bullet points that i brought to bringing you today is is kind of the culmination of security assessments and tests that we do so in january we finished up our are we did a penetration test with a third party vendor that was mostly successful successful there were absolutely no critical vulnerabilities and everything that was noted was um um mitigated in in the follow-up session that we did with the vendor during february we uh conducted disaster recover tabletop tests this was kind of an escalated effort that came as part of the cms certification funding normally we would be doing that disaster recovery testing every year but this one was a tabletop test that we did during the at the request of cms during the 90 day feedback period we met with each of the vendors we ran through the disaster recovery playbooks with them um kind of half um mocked the exercise by saying okay this is how i would perform this step each member of the team would perform the step maybe show show um the steps on the screen to the rest of the team um that type of thing we do plan to um go through follow-up these tests with full-blown tests as the life cycle continues here um but the tabletop tests were were a good practice made sure everybody understood what their exact um role in the disaster recovery um was and um highly successful um another thing that's now part of the cms evolution that we have going on here is this concept of system security planning so we have a really robust security program following the nist 800 you know 53 or the nist cfs platform but as we move into the new funding sources through cms our framework for doing security has to change and one of those big pieces is a system security plan which is a very formalized thorough document that outlines every single security control that you have across your infrastructure so we uh started by creating the overall overarching policy for creating and maintaining that system security plan um as it's not only something that vital needs to do but it's something that each of our vendors need to do and then we need to combine it together into a combined system security plan so we wrote that basic high-level architectural policy to guide the process and in the upcoming months we will start digging into actually pulling together the system security plan itself um and then finally just now we are finishing up our annual security assessment which is um our partner sitter just like that's coming in to that has come in um assessed our security program as it sits right now and is finalizing um that assessment and we have a workshop next week to uh review it and um um update our uh security planning for the next year um so in a very high level set of steps that's basically where we are right now thanks sue all right so i'll take um take the mic back just one more time and walk you through our quarterly metrics and i'll focus here really on the the notable changes um to these metrics so each time we present to you or share a report with you we talk about the number of patients opted out of the vermont health information exchange wanting to make sure that that some patients are continuing to opt out as a signal that that option is clear to people um we know that it's most people's preference to stay in but we do want to honor the preference of opting out that rate did go down a little bit in the period between march and april and this is due to a large new um set of patient information that we imported into the vermont health information exchange mostly historical data from a large covid testing laboratory so anytime we get a really big group of new patients um it tends to decrease the opt out rate a little bit from where it was historically next up is um queries of vital access by organization type and here we're reporting on the legacy vital access portal you can see that most um the the biggest user is a federal state agency um and in this case vdh makes up the most of that number um you also see good use at hospitals um and in independent practices one of the questions that that you all had which i didn't touch on earlier was um who do we think will continue to or who uses the portal rather than getting their data in their ehr and also um what do we expect to see for portal use over time long term use the portal so um this is a good look at the types of organizations that that use the portal right now we don't have an option for viewing vermont health information exchange data in your ehr with two exceptions one is results delivery which is very specifically a provider order to test and is getting a result back um the other is e health exchange queries of the portal that happens are queries of the vermont health information exchange that returns documents so large summaries of a patient's health history um and that is used right now by the va do d and uvm we are actively looking right now at options for making um access to vermont health information exchange data easier from within organizations electronic health records and we think that there's going to be the most interest in that um at hospitals possibly at fqhcs um perhaps at independent practices with um sophisticated it programs and the ability to invest there we think vital access is going to continue being essential um the actual web portal is going to continue to be essential to many other organizations including um the vermont department of health including emergency medical services which do use um the portal today smaller practices we get quite a lot of reliance on the portal from for instance on naturopaths um so smaller independent practices um alternative and complementary medicine practices there's a a range of types of organizations that are apt to be users of the web portal in the long term rather than ingesting data into an ehr this is vital access queries by month um the the drop that you're seeing here is not yet the drop in uh it's not related to the launch of the new portal because that would really begin the full rollout in april that drop reflects decreased vermont department of health use and decrease engagement with the portal around covid specifically so really this is a good news story we have seen lots of interest from vdh and lots more use in using it for for other purposes we're actively exploring um permitted uh health um public health purpose use of the um the portal and so there's a diversity of uses um that we expect ongoing from the department of health but it's not going to be the volume that it was during covid and i think that's something we can all be um grateful for and then you will see at the bottom a use of the new provider portal and what you see there is a use in february and march when we were piloting march was really when the pilot was in full swing and then um in april piloting and then launched beginning april 19th so what this story is for me this is about um our commitment to piloting and getting user feedback um and building that into our new tool this chart shows queries of the vermont health information exchange via e health exchange primarily from the medical center and the va and do d results delivery by results type this is a fairly consistent story from what you've seen all along so um primarily laboratory results some radiology reports and some transcribed reports or notes sent into electronic health records to 599 providers right now are receiving results in their electronic health records through the vermont health information exchange and then this is who's relying on results delivery and this is very clearly our federally qualified health centers and our independent practices who are using this to get results from hospitals mostly and that's all so i'll stop sharing now and ask if anybody has questions about the presentation great thank you so very much um i guess yeah i'll open it up to any board questions i'll go ahead and jump in hi everyone this is robin um so i had a couple of questions related to um the future planning around funding which i know as you stated in your materials it's premature to go deep on right now but i thought it might be helpful to just kind of uh share some of my questions now and um so that you as you're developing information you'll have this in advance so i think for me what would be super helpful in thinking about this as we move forward is understanding in more detail how the shift in cms funding impacts core services and operations so in for example prior budget presentations and potentially even in the hie plan there's graphics that sort of show the core services um that we as a state were we're trying to really focus on with vital um and so having an understanding of which of which of those things are still able to be funded under the new cms uh rules and which are not you've obviously given it a good example today about the interfaces so for example with the interfaces what would be helpful to understand moving forward is before it was funded x amount for y amount of interfaces i know you actually typically exceeded your uh your minimum so what you were typically able to do with current staffing so that kind of gives us that gap obviously some of that might be the public health interfaces so that needs to be backed out but really getting just using that as an example um for each area that where there's now a funding gap from the state understanding that with a little more depth um so that we can so that we have a better understanding of what kind of private sources might be necessary to support that interfaces i think is obviously a necessary area sensitive providers aren't connecting there's no data and without the data there's really no point not to put you find a point on it but um so and i think i did raise this issue in the hie planning uh approval in the fall that i do come at the funding from thinking about vital as a really as a public utility model and so um i am particularly interested in understanding the private funding components um because i want to make sure that we're maintaining that the appropriate public utility components so um so i think for me what would be really important is making sure that we're building in checkpoints or ways that we can we can stay informed on that um because part of what we have to assess is how this compares to the hie plan and then when we get the new hie plan i would assume that that will have some more information about public versus private funding in that balance um so sorry to talk at you so much but i just wanted to kind of share my thinking so that as you're getting more information you can be having that in the back of your mind um so that was really the major point that i wanted to just express um and let me just look at my notes real quick yeah no i think that really covers sort of my major area of interest um moving forward to make sure that we really have an understanding of how that funding change will impact your work and um how to ensure that we're uh appropriately looking at that before anything is implemented yeah that um i won't answer your questions but just to respond um that it's really helpful to understand how you want to think about it and that is um that is how we've been kind of trying to ground the conversations that we've been having with the team at dmna hs is really looking at the plan and the foundational and what's changed so we will absolutely come back and try to frame it in that same way so it makes sense and and it's clear going forward thank you great any other board members tom or tom do you have questions uh i have a couple i think they're easy ones but um if we could go to slide 12 if you could put slide 12 up almost there there you go so just a couple of line items here that caught my eye and uh they might just be issues of of of moving work you know forward from the 22 to 23 etc but i'm looking at network expenses and seeing the variance between the approved budget and the year-end forecast and that variance on network expenses is a is a 39 decrease and i'm just wondering what drives that and right below it moving to um occupancy um that decrease is a 37 decrease and just wondering you know what's behind that bob do you want to take those or do you want me to um if you want to take them that great um i mean certainly the occupancy tom uh that reflects um the impact of our move from the chase mill which we affected in um march of this year actually february to um Blair park in wilson we went from a 7 000 square foot um office in the chase mill to 1500 square feet um and that had um really a material effect on on our occupancy cost so that's a that that that that's a an embedded reduction and that that that will stay going forward um it i guess i think for the near future yeah i think for the near future that is our intent we're working remotely i'm not saying that there isn't a point in the future where we decide a different hybrid mixture of onsite and remote won't change but our intent for now is is for this to remain correct and in terms of i'm sorry go ahead i'm sorry uh in term of in term of network expenses um that the shift that you see is um the increase in um data security expenses associated with um the cms certification between uh the two years okay okay okay um and then i think a little bit later i don't think we need to go to the go to the uh the page but there was uh there was a screen that talked about two um positions were um moved to out um outside support so sound like you had two ver vacancies internally and um you've moved something moved to outside support and yeah just wondering uh what that was about we have um two positions one being a database um an analytics focused role and one being a sub programmer with some very specific skills with some of our tools that we did have um individuals leave during the year um and given where we are in the transition from the old platform to the new platform and really trying to build up our skills and capabilities on the new platform we've decided that filling those roles at least for the short term next you know eight months or whatever makes more sense for us to pay for really skilled consultants to help us think about what we need to do and what our going forward looks like then with the intent of defining the job descriptions that we need as permanent staff after that and we don't think we'll need the same level of skills for the long term so i certainly didn't want to bring expensive people in and lay people off in in a year and so it's really to help us transition gap this transition on the platforms and learn what we need to do and two other quick ones um relative to kind of the the patient consent education and i've asked this before and i still worry about it um we have uh are kind of you're building into our your capabilities the uh social determinants of health and um i have yet to see a list of what those data points are and so i'm wondering when you go out to talk to patients about consent what will they be told about um you know the the progress and the kind of inclusiveness of um social determinants of health as to what those data points are that will be added to what what you make available sure so i think there's two ways for us to think about the social determinants of health or two types of social determinants of health we should be thinking about one is the um social determinants of health that are collected by health care providers where the information is collected by health care providers so that might mean for instance a hunger vital sign screening that many primary care providers are implementing now that's shared just like all of the rest of the information in the medical record um we are are certainly working on how to share that information back out um because it's a little less standardized than for instance a blood pressure reading um i think we can do more to let folks know that all of their medical record from their primary care and their hospital visits are are potentially shared um including those i don't know that there would be an expectation of that type of thing being left out um i think where the question gets um harder and where we need to do more um thinking and engagement going forward is when it's social determinants of health collected somewhere else besides a doctor's office and we um are right now christina talked about the work to plan for technical ingestion of that type of data um i think there is also work that needs to be done around data governance um when it is appropriate to share it with the health information exchange when it is appropriate for the health information exchange to share it back out and what sort of um patient consent uh needs to be honored there and then how we communicate with patients about it i think there's a lot of work before we get to how we communicate with patients about that second type of social determinant of health does that answer the question uh yeah i mean it's clearly a work in progress but i just worry that at some point in time the you know um we went we went you folks went through a great job of um getting people going from opt uh opting into opting out um that whole transition i just worry that you know that the social determinants health will become a surprise to people as opposed to something um and and unnecessarily surprise but just that it's not something that that it's it's a new piece of new set of data out there that that uh isn't isn't ingrained in the system at this point in time just to worry and one more question you don't have to go to it but i will go to for example on so i'm not looking at you now i'm looking at this chart on on slide 30 where you have legacy um queries by organization type and i'm wondering in terms of kind of growing your portfolio whether within those organization types you have um captured a certain portion of them and whether or not it's possible to leverage growth by having the portion that you've engaged with um uh communicate to the portion that that that aren't aligned with you to kind of you know grow the totality of your engagement with those types of of organizations yes absolutely and there's there's two ways that we we do that um one is by um every time we go to an organization that is looking to increase their use or where we think there's opportunity for increased use we look for clinical champions so we either find ones if they're already there or ask people to to try it out and see how it's working for them and then become the evangelists for the tool um because nobody listens to how do i say this uh doctors listen to other doctors a lot more closely than they listen to me and that's as it should be um so we um really do look for clinical champions the other thing is that we um we have very clear guidelines for use treatment payment operations within that there are a lot of new um use cases ways to use the tool that are being discovered every every day um so for instance there are hospitals that are using this to do um patient matching work to help clean up their own records because we have a little bit more information than than they do about past addresses for instance um there are hospitals who are using this to help verify that it's appropriate to give a proxy access to a record and those are things that um sometimes they're they're discovered by somebody in one hospital or practice or organization and then we can bring that as an idea to other ones and say hey have you thought about this this use so absolutely there is opportunity for growth within each of these organizations and we look for champions and we look for new uses and help spread the word well thank you very much i just want to applaud you all for the kind of progress over the years in terms of the budget presentation and that you know i'm finding it crisp and clear and uh and also successful and so it's um it's just it's it's uh it's good to have you before us and i think you're doing a great job thank you this is uh the other time um the the the new um tom if you will and so um i've just got a couple questions and some of it you can just tell me if i'm off the mark on what you're aiming to be um doing um but a couple things that came up from listening to the presentation um the kind of first and simplest the the last few slides that you showed that showed utilization over time um that was just for like the last year and um in future presentations showing longer horizons would be helpful to me um but beyond that i'm really interested in the medical soft part of the presentation and the work with health catalyst um i'm i i don't think it's very familiar but i'm quite familiar with what they they do and and i was wondering if um you could say a little bit more about there was a comment that it was somewhat of a surprise to land with them again and i'd just like to understand that a little bit more um what was uh what were the deciding features with with using them yeah i can do you want me to take that bet or do you want to start can i give a piece of context and then let me fill in the details is that okay because tom i um i'm gonna give you a little bit of background that you probably don't have because we haven't presented live in a while um is we are transitioning from our full hie clinical data repository platform from the health catalyst system to the medical soft system which is a fire native platform so a very different technical capability for us and and so we have been looking at some of the components that we had with health catalyst to see how we replace some of the components that work off of that platform so just so you understand the context for those comments and then i think christina can talk through some of the details yeah that's exactly right and so um after moving toward this new platform we went out to market to find out who could provide the best results delivery and um web mail his product for us and obviously health catalyst was still interested in maintaining a relationship with us and two other vendors that we compared and it really did come down to at the end of the day although we moved to the medical soft platform because of its fire capabilities and modernization to be able to um have apis on top of that data and extract the data easily we still really came down to the conclusion that all along we did have two solid results delivery and his choices um and having a conversation with health catalyst and where they're heading with some of their products in those areas was was intriguing to us and and really that tipping point was the least amount of impact to our clients who are already happy with those services right why change horse is midstream and that direct integration into the EHR so those were those were really the critical points thank you for that and some of the kind of the emerging um tools that work through api and through these type of vendors um i wonder if there's been discussion if you've had discussion about incorporating patient reported outcomes that um if you're talking about engaging with patients whether it's with consent or with shared decision making collecting any type of of general health perception in patients over time and then being able to provide that to clinicians um when they arrive for their appointment is that something that you all have talked about at all with your services or am i missing the mark with what you're what you're doing i think we'll all have a piece of an answer here but no it's i mean it's definitely something we're talking about we're talking with um some of the providers previously within some of the hospitals or the larger centers like thinking about wearables both the wearables they send patients home with as well as the wearables patients choose to have like a fit bit or something and and how do we think about that data and incorporating and i don't have answers for you today except to know that this is on the radar and things that we are absolutely talking about perfect yeah it's it's even um simpler than like the the wearables just asking there's some good evidence it's not quite old but it's been replicated a bit just asking an individual how's your health today how is it compared to six months ago and that question about six months ago if the patient reports they're feeling their health is declining that's a very powerful indicator of they're they're not doing well and bringing that information to providers can can help with the the hot spotting and assessment assessment of rising risk in a patient population and adding that with the social determinants of health information is is a really powerful thing for clinicians that's what when I was seeing patients were always trying to build this type of capability and having the individual's perception of their health their neighborhood characteristics you know being able to answer a question a provider being able to um query a data set with questions like what proportion of my patients with diabetes have an a1c level greater than nine so they're quite sick um and have not been seen in the past six months who live in a food desert area with poor transformation if I add that in that they're telling me they're feeling sicker that's a person that's likely to be admitted and have undergo very expensive care and if I can intervene earlier I can save that admittance but having tools that present that type of data to me is difficult and and requires a lot of interface with integration the type that you're describing so that helps me understand another piece that it can be really powerful that health catalyst I know had done a lot of work with and it seems to have gone away and I don't know why but they had a cost allocation tool that could be used by provider systems a service line cost allocation tool that helped a provider system understand their cost of caring for an individual with a condition and and that is a really powerful piece of information as well um because most of our conversations are around charges and reimbursement and people are afraid that if they're not being reimbursed what they've charged they might be losing money but it's not until they understand their cost that they can make a difference most places don't have cost allocation tools so if there's a system that um we can we can bring those tools to people that could be helpful again I don't know if that's part of your purview that or what you're interested in doing later on but with the technology that you outlined it's possible I'll say and somebody again the rest of the team can comment like this is something we haven't heard much about but as I mentioned very as just a bullet point earlier something that we really do intend to do this year is much more outreach and engagement with the healthcare organizations to understand like what they want to achieve so it's something we can ask about and and and listen for whether they're wanting tools like this and if there's an opportunity that is helpful with value-based reimbursement when there's a set amount a capitated amount or a bundled amount the cost allocation tool helps the organization understand their cost of care to be sure that their costs are below the capitated amount so they maintain their margin and without those type of tools they can't really do those calculations so a way to bring that service and tool to um providers especially smaller ones um is is very powerful that makes sense thank you well thank you and great thank you tom are you set yes okay great thank you um you know I just one question um and then I want to definitely open it up for public comment if there is any but you know I think about so much that we can learn from COVID and from you know going through this pandemic and in many ways you know the critical need for data during a pandemic and you mentioned um you know bdh was thinking about other potential public health uses and I'm just wondering if you could speak a little bit more about what those potential uses might be where we might go what we learned I can I think we can mention a few things and just um but to set the foundation is we are actually um working to identify a consultant with really experience in this work of integration of what what's possible with hie and public health to help us do some strategic planning so really to push us and help um raise some ideas but thoughts that come I mean some are very straightforward using that we mentioned a bit using the provider portal for some of their other work where else is some of that data useful um even just other reportable diseases because COVID isn't the only thing that happens um things like electronic case reporting um and surveillance so you know if we're getting the data in a timely manner can we help identify trends that otherwise require manual reporting or and timeliness of that reporting um it could be um better integration with some vital records right now we get the death registry data and make that available but there may be some other opportunities birth birth things like that um and I you know I I do think like as we really dig in and engage with the teams we'll identify some new opportunities I will say like we've you it's been really um exciting as we have these you know as public health as they get their hands on these tools and see the data the things that they come up with on the thoughts that the teams have once they see what's possible so I think we'll probably surprise ourselves with some ideas that come out of this great so many promising uses to hear about that unfolds um I think at this point are there any other board questions everybody feel okay rough just one other um one other area um that occurred to me as as I was listening to others ask questions um in terms of this you had mentioned the social determinants of health bill that you're working on uh for fall delivery I'm assuming that's uh using the diva contract money from um like the existing CMS funding scheme right so I was just curious about how and again this this can be for future not right now but I know that in the past we in the hie plan there was a discussion around different uh potential data sources to be combined in addition to claims and clinical social determinants obviously being another um so when you're thinking about the funding issues moving forward um having us have a good understanding of how that is changed or not changed like does that count as maintenance and operations or does or not would be very helpful as well um and then the last um question I had is we had asked a question about being able to get a better understanding of um the reporting that diva is now being able to do with the combined claims and clinical and I know that you had indicated in your answer to the question that that material is currently confidential and there's no way to de-identify so I think my question really is more for our legal team whether there's some way we can ensure for confidentiality but I think it'd be just super helpful to have a concrete for us at least understanding of what that might look like um so our team is working on a way of presenting it to you so maybe you don't have the data but you have the structure to at least understand right might be in the file which might be at least a first step for you as well so great we'll come back yeah okay thank you very much that's it thanks jess oh yeah you're welcome um so I guess at this point I'd love to open it up to public comment if there's anybody from the public that wishes to make a comment walter jessica hello walter hello jess it wouldn't be a board meeting without public comment from walter so please the stage is yours put that into the record jess uh thanks to tom and tom pretty much said what I had on my mind so I won't bore you with that but I just have one quick question um the use of consultants consultants are usually more expensive than regular employees are so I'm nervous about that and as someone who's paying the bills ie you know as a person who's paying the taxes and the fees and all that that's going into vital I'm concerned about that because they are consultants can come in very expensive and they're not always right on so that makes me nervous and when you use consultants more instead of employees that's also chinsing people out of benefits too yeah so that's yeah it's a very valid concern I appreciate you bringing it up we we have tried to be really um thoughtful where we use consultants and we use them where we know we have a very specific skill need for a short period of time where we wouldn't want to hire someone and have layoffs or set bad expectations so it's really to help us complete projects where we just need more hands for another six months or nine months but it's not a long term or end or where we need someone who has a skill set that we either don't need long term or can't afford long term but really need them to help us make our work successful and then near term we really do try to be very careful and another thing just as we do contract with consultants they are very often more resources and not kind of the strategic big project consultants and we do go through a competitive RFP process to identify them to to make sure that we are getting value for what was what we're engaging them for how do you measure the value we look at it that's a great question I think we look at a couple things it's not always just cost or the cheapest consultant right that's not necessarily the best way to do it so we really do a pretty rigorous vetting of their skills references from other types of work they do both understanding what types of work they've done and getting references on the work that they've done and really holding them accountable for clear and measurable deliverables along the way on the project to make sure we're meeting our needs and goals great how are you holding them accountable all right go ahead Jess fine the next one well no that's okay Walter Walter but um yeah Beth if you have an answer to that question that'd be great if there's a way that you can address the accountability of the consultants yeah you know our contracts do have out clauses so if things are not going well we can end an engagement or ask for a different person to be put on a project if the person that's assigned does not have the right skills that we need great thank you Beth I appreciate that Walter do you have any additional questions I yield the floor Jess to someone else I'll shut up no we appreciate your questions no we appreciate your questions Walter they're always good and informed anybody else I haven't thrown me off the board yet anybody else have any public comment or questions at this time all right I am not seeing anybody raising their hands so at this point I want to thank you all for coming and sharing your budget update with us again I think as Jess Mendesville mentioned we have a public comment period that's open until June 17th I think that's right at that point you know we're going to be hearing from our staff on a recommendation and we will have a vote on this budget coming up hopefully June 22nd if not it'll be June 29th so that's the plan so thank you very very much we appreciate Beth and team for coming today and I hope you have a great rest of your afternoon thank you for having us yeah thank you so actually next up is the first of a two-part sequence on ACO guidance and so Marissa and team I think at this point I'm going to turn it over to you all good afternoon thank you board member Holmes members of the board my name is Marissa Melamed I'm Associate Director of Health Systems Policy with the board and I'm going to introduce this afternoon's presentation I have several colleagues here with me today that are going to help present this first part of the of the FY23 ACO guidance so I'll be joined by Julia Bull Senior Health Policy Analyst and Michelle Sawyer Health Policy Project Director for several sections of the presentation and then our staff attorney Russ McCracken is available to help us with legal questions let me go ahead and the presentation going for you all right is that visible looking good okay great so the agenda for today's presentation is three-part an overview of the ACO guidance process for fiscal year 2023 we're going to give you a preview of the certified ACO guidance and then we're going to review the draft for the Medicare only so I'm going to explain the difference between those two processes but the board has two different types of ACOs that we're looking at that fall under different statutory criteria they've been done at different times in previous years and this year we're aligning the process to happen all at once so we want to make sure it's clear what type of guidance that you're looking at so that's outlined here on this slide the board both reviews budgets and certification for ACOs all ACOs operating in Vermont are subject to budget review the statute outlines a threshold of 10,000 lives that defines the scope of the review so it's a little bit more in depth for larger ACOs and there's a little bit more discretion on the criteria for smaller ACOs so the piece of guidance that we are looking at is referred to in the rule as the annual budget review manual we we tend to call it the ACO budget guidance and there there's two types of budget budget guidance which we will go over with you for certification only ACOs that want to accept payment from Medicaid or commercial insurance must be certified and if ACOs plan to be in a Medicare only program they're not required to be certified so for certification we have something that's known as annual eligibility verification or for short the certification form and the authority that lays this out is 18 BSA 9382 and the Green Mountain Care Board rule five so everything points back to there and we try to be specific where we can on on what areas have authority on what items we're talking about so we created this visual for you this year to help clarify how we um figured out what type of guidance we needed to develop so on the left hand side there are ACOs that fall into the category of accepting payments from Medicaid or commercial insurance this can also include Medicare there's one ACO operating in Vermont that fits this category that's one care Vermont so certification is required and we annually develop a certification form budget review is also required so we would look at the size of the ACO in this case the ACO over 10 000 lives and so the board is required to consider all standards and processes established by rule 5.0 so we are developing the guidance consistent with those requirements and we refer to it as the certified ACO guidance on the right hand side there are ACOs that plan to accept payments from Medicare from a Medicare program only currently there's only one ACO operating in Vermont in this category that's Clover Health Partners that we review the budget for the first time for 22 so certification is not required again there's that threshold of 10 000 lives that ACO currently is under that threshold so the Green Mountain Care Board can consider the standards and processes that are most appropriate just to properly size that review so for this type of ACO we've developed the Medicare only guidance that's reviewed and approved annually by the board so today we're going to focus on the draft of the Medicare only guidance but I'm going to give you a preview of next week which is a little bit more detailed certified ACO guidance and then as a reminder the standards and requirements by which we review the ACO submissions are set forth in the statute and the rule as well as the terms of the all-payer ACO model agreement for which we're now in an extension year under that agreement and specifically under rule section 5.405 the board may establish or may establish benchmarks sorry under 5.402 and then review the the budget with you know with those benchmarks considering those benchmarks so we'll talk about that a little bit more all the criteria that's listed that number two is sort of the area that you can have more discretion at for the smaller or Medicare only ACO and then again elements of the all-payer ACO model agreement and the sort of catchall of any other issues at the discretion of the board this slide may be somewhat familiar but it outlines the overall approach to ACO oversight for the coming budget year so we have gone through a process or we're in the process of stakeholder review and feedback in internal collaboration we also include public and board member input from from these meetings or public comment we're driven by these four priorities which we developed last year in which we're continuing to this year I think they're you know kind of long-term priorities that are still relevant and that is that the guidance and the review is sort of looked at in this framework of you know overall we want to understand ACO financial and quality performance over time we want decisions an analysis to be data driven we're always looking for regulatory alignment and understanding how these entities and the regulation of these entities interacts and we're working toward having more standard reporting and templates including metrics and definitions so that's the reason for sort of generalizing the guidance instead of saying like this is one care guidance or this is clover guidance where we're trying to make it clear that this is general guidance that applies to any ACO that fits this these categories and we want to review them in a standard way just so happens there's only one in each category and then the outcome of this work so far we have for the past this is now the second year that we've issued an ACO reporting manual as allowed in the rule and that outline sort of standard reports that we've identified over the over time that we want year-over-year to help us monitor the the performance of the ACO we did finalize and issue the report for FY22 and it was posted on our website on May 27th so if you're interested in the types of reports that come in throughout the year from the ACO these are these are you know the expectations and templates for those reports are in the reporting manual and then the other outcome is the finalization of the guidance for the coming budget year which needs to be approved by July sorry June by the beginning of July by the end of June and so that's why we're starting that that process now and the timeline the the 2022 timeline for development of the 23 guidance so again May has been a development month even even prior to that really but we've worked more closely with the stakeholders through the month of May including the ACOs you know reaching out to the ACOs are meeting with them about guidance requirements as well as the office of the healthcare advocate today we will be presenting the Medicare only ACO guidance draft next week we will present the certification form and the certified ACO budget guidance draft with the potential to vote on June 22nd so we can issue that by the end of the month as you're ready to do so and as Susan mentioned at the beginning of the meeting there's a special public comment period on these documents and development which will run from today through June 20th so we can get excuse me public feedback prior to that vote so I'm going to move from process into giving you this preview of what the certified ACO guidance is going to look like for this year and some of improvements that we've made so this slide illustrates some goals that we've been working with over the past couple of years to improve the guidance so on the left hand side these are continued goals from FY 22 that were developed through debrief processes we feel as though these are mostly still relevant and we've also made improvements and will continue to do so so we've considered to we've continued to consider these goals as we've been in the budget guidance development phase this year so that's streamlining information requests across regulated entities so working closely with the hospital budget team as well as rate review because these these three entities interact closely to make sure it's clear how we are breaking out and presenting information across processes and aligning them to rule five trying to emphasize the data over the narrative and improve many of our data collection templates we've done a better job separating out information requests so what we want you know we want the budget to be really focused on the budget what are the factors and assumptions that are going into creating a budget for 23 versus just ongoing monitoring of how things are going so that's why we've been developing that reporting manual prior to the guidance for the second year row we're still monitoring considering the impact of of COVID-19 and the you know last year we talked about 2022 being the final year of the current APM agreement however that since been extended so we're now you know still working under that agreement in an extension year as we look toward 23 and last year at this time you heard a presentation from consultant Michael Baylett on core competencies of high performing ACO so we have been using that as a framework to under you know to to sort of focus what we want to look at with the ACO and also as kind of a benchmark against you know their own identified core competencies or core capabilities through their strategic planning and process it gives us you know something to to benchmark against as we consider you know the story that they that they tell us about their their priorities and how they're setting their budgets and such new this year for FY 23 in our discussions internally and with stakeholders we're looking at I mean a clear crosswalk to rule five so you know clearly linking why we're asking certain things to requirements we've spent a good deal of time removing areas of identified duplication and streamlining questions and I wouldn't say that this duplication is happening because of sloppiness a lot of it is because there's a lot of overlap you know the the ACO you know several different contracts that come together to them formulate their program so we may have been asking similar questions from different perspectives and I think we've been able to identify where there's overlap in those in those questions and how to make it clearer and perhaps reduce some duplicative work or narrative we've also been looking really closely at how to incorporate performance benchmarks and more prescriptive guidance as allowed in rule five section 402 so this this has shown up in two ways one you'll you know of course from the 22 budget order that one care is working towards implementing an ACO performance benchmarking report that you know should be reported to the board later this summer so it's not in time to sort of incorporate that reporting into the guidance in any way but you'll see that we we're going to present a section where we sort of provisionally look at what we might do with that information in a future year so that we can get set up for that the other piece of this is the ability for the board to say proactively like on the front end in the guidance we would like to see a budget that that meets these sort of conditions up until now conditions have always sort of ended up at the end like oh we review the budget and then we say oh great we want you to do this but there are some things that the board may say look we want to we want your board of managers to create a budget that meets these requirements or if you can't explain why because these are priorities that we've identified over the years so again we'll talk a little bit more about that next week but that's something that we have been looking at and may have some proposals on so I'm just going to give you a preview again of what the certified ACO guidance looks like with some of these changes that I've talked about so these are the sections we have added two sections but I think we've streamlined the questions in each so I don't think this adds questions necessarily but makes them more clear so section one the executive summary we just changed the name to clearly caught in an executive summary and then we want a high level overview of what is in the rest of the of what is in the rest of the submission sections two and three we streamlined the content of what's in those or we've narrowed it down to to the basics of of the provider contracts and then who is contracting with with one care or the entity and are there any changes to those base contracts same thing with the payer contracts section though you know we understand that some of the particular the payer contracting information has to wait to the spring so instead of having this be broader like what are your provider programs and what are your payer programs we're just calling this section contracting and we've added a new section five which is called network program and risk arrangement policies and this is where we are instead putting this all into one category and saying like look you have contracts with providers your contracts with payers please talk to us about the programs that you now develop through policy at the ACO level you know that these contracts enable one care to implement and that was able to reduce some duplication of questions the budget sections there's not necessarily a change there to the to the format same thing with quality population health model care and community integration that we've done some editing of the questions which we'll talk about next week we've created a new section called evaluation and performance benchmark so we've taken all the evaluation questions and put it into their own section because that seems to have been important enough to call it out instead of having evaluation questions be peppered throughout and then the section on the performance you know what we're going to do with the performance benchmarking information will be here as well so just by way of example what we've done for each section is make provide a clear objective what is the you know what is the point of the section clearly lay out what data we're collecting or what source documents like primary source documents we're collecting and then what narrative we need in order to explain that data or those source documents so we've created an outline kind of like this for each section and that will be in the more detailed review we've also we want to make it clear you know what what we were what we are asking for in each section and why we are asking for it so for this section one you know the executive summary should have a brief you know summary of each of these aspects which you'll then read about in more depth as you go through this submission so an update on the strategic plan changes the provider network payer programs what are the attribution estimates the two budget looks that we've been working with for the past several years and recently talked about in our revised budget presentation and then the overall changes to network programs and population health and the care model for 23 and evaluation how they're looking at evaluation for 23 lessons learned plans for the future and a summary of the ACO performance benchmarking results to date so that brings me to the end of the preview of the certified ACO guidance I'm going to pass it over to Julia who's going to review with you the Medicare only draft guidance perfect thank you so much and nods that people can hear me perfect thank you always want to check the technology wonderful we can go to the next slide Marissa so I know Marissa just covered this chart but just wanted to reorient since we are covering two different types of guidance today everything I will be covering is specific to the Medicare only guidance and again just to really briefly walk through how we got here this is guidance for ACO's that only accept payments from Medicare which is why I will keep saying Medicare only again and again throughout this presentation and in this case the guidance we've developed is for Medicare only ACO's that have less than 10,000 attributed lives within the state of Vermont and because of that size the standards of review are those that the board deems appropriate whereas if the ACO had been larger than 10,000 lives or if at any point that happens we would broaden the guidance to be all of the standards within rule five and again this guidance is not for any particular ACO but applies to any ACO that fits the criteria which in this case follows the right-hand side of this chart we can go to the next slide and just wanted to give a bit of background today there we go thank you probably just a delay on the slides so wanted to just sort of reorient the a bit of history on this guidance so as you will remember because it was not too long ago we just reviewed the budget for Clover Health Partners FY22 budget and this was the first time that we were reviewing a Medicare only ACO and in this process now with the guidance it is the second time that this guidance is coming before the board and again as you know any Medicare only ACO will have a participation agreement with CMS so there are a lot of elements of the program that you know and the ACO's operations that are specified in the CMS requirements and that is something that we've been trying to keep in mind throughout this guidance process as we have learned more about how Medicare only ACOs operate and again for further background last year when we were reviewing Clover's budget they were participating in the direct contracting model and this model is being sunset by CMS and replaced with the ACO reach model starting at FY23 so while this is the second year of ACO or Medicare only guidance that the board is looking at this will be sort of a new year in terms of the program that we anticipate the ACO participating in and the reach model has a number of new requirements specifically related to ACO governance as well as a larger focus on health equity and we linked in the slide here to a CMS graphic that has a really nice just breakdown of a lot of the key elements of the new reach model so on the next slide for further background I wanted to just take a minute to cover the sort of the beneficiary experience as it relates to the ACO reach model and most importantly keeping in mind that the model is an agreement between CMS the reach ACO and the providers who are contracting with the reach ACO so it doesn't change or limit a beneficiary's access to services or providers and the ACO does not have any control about where a patient seeks care or whether a patient sees a provider that is part of the ACO's network so to be even more specific again beneficiaries are still in traditional Medicare they have access to the entire traditional Medicare network their alignment to a reach ACO does not affect their out-of-pocket costs or the premiums that they pay for traditional Medicare and it does not affect their use of supplemental insurance it's really a sort of behind the scenes payment model as it relates to providers and not an upfront impact on beneficiaries with the exception of the fact that if a beneficiary is aligned to a reach provider they might have access to additional benefits that are called enhanced benefits in the context of the model so on the next slide um similar to what Marissa covered with the certified ACO guidance we wanted to cover sort of our thinking and our goals to updating the Medicare only guidance this year so as we look to FY 23 we had a few goals in mind that dictated our approach and in terms of goals the focus of the budget review was twofold first transparency to shed light on the operations of Medicare only ACOs with fewer than 10 000 lives in Vermont and secondly a focus on the GMCB's area of jurisdiction again with that framing that CMS does dictate many elements of these programs and keeping in mind the size of the ACO under this guidance so with those goals as our framework our approach to updating the guidance particularly given that this is the second year of the guidance and the first year of the reach program was first and and similar to the the certified ACO to really be focused in our questions specifically for the Medicare only ACO to narrow the focus to budget specific requirements including the removal of questions that are more appropriate for the certification process and importantly that the board and staff did not rely on during last year's budget review and secondly to update the questions and the appendices to reflect our improved understanding of Medicare only arrangements including what CMS requires versus what the ACO has flexibility to design in their program and I also wanted to thank the HCA for working with us and providing input on this draft so with that on the next slide we have links to where folks can find the documents that I will be referring to today everything lives on the the board meeting page of the website but the slides if you get there have links to the different copies we have a red line copy as well as a clean copy they're just different views of the same thing if you don't want to look at too much red and then the appendices which is an Excel document where red is used to denote things that were changed from last year and again as Susan said we have an active public comment period through June 20th and then just a quick key anything in bolded blue represents changes as we go through the next few slides so we have one slide per section so I will just be going through them in order and then have Michelle help with the last few but the first section is called ACO information background and governance the main change to this section was removing submissions that fall under certification and that the board and staff did not rely on in last year's budget review specifically these were in question four removing the submission of bylaws operating agreement or equivalent document and question five the conflict of interest policy and with all of that said again there are still questions in the guidance that get at specific information about ACO governance and the reach model also has new governance requirements and then additionally in question five we added a clarification to to clarify that the question was referring to executive leadership compensation which was just sort of a cleanup clarification because we had asked a follow-up question last year so just sort of codifying it if this year's gotten um section two the main change is the addition of appendix a2 and when you look at the red line copy you will see a lot of track changes in this section but it's really just cleanup specifically questions one and two there's a lot of text that we had both in the narrative and the appendix and realized that it would be simpler to just keep that information in the appendix so when you see stuff being cut in the narrative it's only because that same information is covered elsewhere and because this is year two of the Medicare only guidance we added appendix a2 which asks the ACO to summarize provider network changes and reasons for provider departures if there are any and then based on some of the follow-up questions we asked last year we also clarified question four so more clearly get at whether the ACO has plans to expand their network in Vermont and their related recruitment and network development strategies so just making that question a little more robust based on some follow-up that we did last year section three is about the ACO payer programs there were no major content changes but very similarly to section two there's a lot of red markup again because the text was in both the narrative and the appendix and we wanted to keep it in the appendix but remove it from the narrative and we also changed the layout of appendix B to make it more reader friendly just from horizontal to a vertical layout so it'll look different but all of the questions are still the same and additionally in question five again just to sort of clarify the language we we changed it to say for all measures in a question about quality as opposed to having a long list of all of the measures and so just adding all to capture it but again the cuts that you see in red are not substantial changes the next section section four is the ACO budget and financial planning section there were no major content changes in this section just some small updates specifically in question two we added a funds flow chart to summarize the different types of funds and this was actually just a chart that clover created in their submission to answer our questions last year and we felt like it was just a nice way to summarize the information so we wanted to sort of default have it as as the best way to answer the question and additionally we cut part of question two because the same information was better covered later in that same section under question five and otherwise all the other changes in section four were just small text changes to reflect the FY 23 so with that I will hand it over to Michelle to cover the next few slides perfect thank you Julia so section five covers model of care and community integration there are a total of seven main questions in the section and like the other sections of the guidance we work to improve questions in an effort to prompt concise clear and comprehensive answers the primary updates were around the questions included on the slide so questions one and two were updated to align with the budget section of rule five previously there had been parts of these questions that had incorporated requirements of ACO certification but given that the Medicare only ACO is not required to be certified these certification requirements were removed in addition we ensured that all aspects of the vegetarian review requirements were included in these questions for fiscal year 23 question three was in addition to this year's guidance to better capture any health equity efforts being made by the ACO given that this is a requirement of the reach model we anticipate that will receive an insightful answer questions five and six were updated this year in response to our experience with last year's questions the staff found that the previous versions of these questions had resulted in responses that required additional follow-up questions so we're hopeful that these updates will prompt complete and clear answers regarding the matters at hand and finally question seven was added to the guidance this year it was a question that had arisen in follow-up last year so the ACO is asked if they benchmark performance measures against similar entities and if so how the information is used next slide please so the final section of the guidance is section six which covers the Vermont all-payer ACO model agreement scale target ACO initiative so no changes were made to this section it includes three different tables regarding scale financials and quality measures next slide please and then this has been reviewed earlier in the presentation so I won't go through it but take home message is that any potential vote on this guidance is slated for June 22 so no action is required today of the board we can go to the next slide this concludes our presentation and I'll hand it back to you board member Holmes great thank you so very much I just I want to say I'm probably on behalf of the whole board but certainly my own opinion is that I really appreciate all the hard work that you all did streamlining the process trying to reduce the you know the guidance trying to reduce the duplication and actually ensuring that we have all the data and information that we need to make decisions so very much appreciated I'll just kick it off actually with just one question or actually really a comment in terms of the the health equity question I think health and health care disparities often focus on race and ethnicity and the question actually highlights race and ethnicity there and I just wonder if we should expand that health equity question to include socioeconomic status disability status sexual identity orientation and really with respect to Vermont although it's just this you know the morality or the geography location of where people are in their access to care and their health outcomes as related to where they live so just a thought to broaden that health equity question a bit but I really appreciate everything that you all did here so I would love to open it up to other board questions and does anybody have any or is this just so thorough and clear that nobody has questions I do not have any questions I thought it was very thorough and clear and I liked the red line copy so I could see clearly what changed I like the red line copy because there was a lot of red line great okay well it sounds like we don't have any questions from the board I'd love to open it up to public comment if there is any at this time Sam go ahead from the HCA hi everyone good to be with you I just wanted to briefly thank the ACO team for the opportunity to work together on this I think that you landed in a really great place in showing that we can balance reducing administrative burden I think and overlap with a lot of valuable questions that get at data criteria and evaluation that are really important and I agree with your point member homes about expanding the definition on health equity I think that makes a lot of sense but yeah I just wanted to thank the group it was a great collaboration I look forward to doing so more in the future great thank you Sam any other public comments or questions I am not seeing any so with that I guess thank you Mercer and team we look forward to obviously we're gonna have part two next week and as always we welcome public comment on this and any issues particularly this special comment period will be open till I think June 20th if I have my date right is that right Mercer yeah okay all right well I think with that we are set with our kind of substantive parts of the meeting so is there any old business to come before the board today is there any new business to come before the board today no is there a motion to adjourn it's a load second all right all those in favor of adjourning please say aye hi be opposed no all right we are set for the day and I hope you all have a great rest of your afternoon thank you all