 Care board meeting. The first item on the agenda is the executive director's report. Susan Barrett. Thank you, Chair Mullen. Welcome, everybody. I have a few announcements first regarding the schedule. Next week, June 10th, our regular board meeting, we do not have anything on the agenda at this point, so we may be canceling that, but we'll make that decision early next week. I also want to remind folks that on Monday, June 8th, we'll be convening our general advisory group for the GMCB, and that starts at 2 p.m. and the instructions and calling information is on our schedule for the month of June and on our meeting section of our website. You'll be hearing more about this from Sarah Kinsler, but we are opening a public comment period. It is posted on our website, I believe already, and that is on the vital FY 21 budget, which you'll be hearing more from in a moment. And that comment period actually has already opened from June 15th until June 15th. And then I just wanted to let folks know that the Green Mountain Care Board and its staff are working with the administration as well as the legislators as they work through their decisions on the up to $375 million in COVID relief funding. So this is a quick turnaround and important decisions to be made, so we have been providing those folks data as well as any assistance we can during this time. And that is all I have to report, Mr. Chair. Thank you, Susan, and just want to point out to everyone that Susan had a root canal this morning and is still here this afternoon, so great job, Susan. Thanks for your dedication. With that, we're going to move to the minutes of Wednesday, May 27th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, May 27th without any additions, deletions or corrections. Is there any discussion? Hearing none, all those in favor signify by saying aye. Aye. Any opposed? Okay, at this point I'm going to call off those phone numbers so that we can have a record of who was at this meeting. So the ones who do not show up with a name, I'm starting with 2505, the last four digits. Hi, Jennifer Follis, Museum Medical Center. Welcome, Jennifer. 743-8. It's a hand, Davis. Welcome, Ham. 5409. That would be Carolyn Stone from Vital. Thank you, Carolyn. Yep. 0043. Back you go and ask you a DRM. Thank you. 5058. Susan Greckowski. Thank you, Susan. 1042. Robin Alvis. Thank you, Robin. 1606. That's me, Kevin. Elena Baraby. Thank you, Elena. 7632. Jeff Thiemann with the Vermont Association of Hospitals. Welcome, Jeff. 3452. Rebecca Copan from Blue Cross and Blue Shield in Vermont. Thank you, Rebecca. 8913. Thank you, Rebecca. 8913. Christopher Shank with Vital. Thank you, Christopher. 7081. Eric Soltait with the ACA. Thank you, Eric. And I believe we have everyone else's name. So with that, I am going to turn the meeting over to Sarah Kensler, who will introduce us to the discussion on the Vital fiscal year 2021 budget. Sarah. Thank you, Mr. Chair. For the record, this is Sarah Kensler's record strategy and operations at the Green Mountain Air Board. Before Vital presents their budget, I'm just going to give a brief overview of the Board's authority in this area and remind us of the criteria that the Board has previously established for reviewing Vital's budget. As part of its oversight and policy-making activities related to health information technology and health information exchange, the Board is required to annually review and approve the budget of Vermont Information Technology Leaders for Vital Vermont's designated Soal Health Information Exchange Network. This authority came to the Board in 2015 and was first exercised in 2015 and the Board's oversight is intended to provide strategic direction and policy parameters. Note that in the past, the Board's responsibilities have also included review of Vital's core activities that the legislature removed in 2015. When the Board first began reviewing Vital's budget, it established four principles for review. First, the Board's process, the review process will be transparent and incorporate public input. Second, the Board will ensure Vital's proposed budget is consistent with Vermont's health reform goals, as well as the HIT plan, also known now as the HIE plan. The current HIE plan is available on the Board's website. Third, the review process must be timed to support and negotiating their contracts. And finally, any resulting Board decisions need to be clear enough to allow Vital to do his work and Diva to support that work with that preceded intervention. So unless the Board has any questions about this authority or these principles for review, I'll hand it over to Vital. Thank you. Thank you, Sarah, and that's whenever you're ready. Thank you. Thank you all for the opportunity to present our budget today and as well as an update on our current work. I'm Beth Anderson, the CEO of Vital and you have the full Vital leadership team on the call today. And if I just take a moment for them each to introduce themselves. Bob, do you want to go first? Yeah. Hi, I'm Bob Chernoe. I'm the CFO for Vital. Great to be here. Carolyn. Yeah. Carolyn Stone. I'm the director of operations for Vital. This is Christopher Shank. I'm the director of technology for Vital. Thank you. Just I'll point out you'll notice we're one fewer than normal. Andrea left the organization earlier this year and we have that position vacant unfortunately right now as you probably know from our budget material. So, as you know, the first item on our agenda is to go through our Fy21 budget for your consideration. Bob, if you can go to my first budget slide. All federal strategic plan has called for working to ensure organizational stability, serving as a credible partner, building new collaborations and expanding the value of the VHI. Fy20, Vital's work advanced those goals with our achievements including successful implementation of the consent policy in March with a strong process for public education starting work to expand the types of data we capture in the VHI including sensitive and Part 2 data implementing the collaborative services Phase 1 projects and selecting a vendor for the future platform to replace the HDM. Unexpectedly, as you can imagine, our work this year also was supplemented with the opportunity to work with Vermont Department of Health and responding to the pandemic and providing them data from the VHI to assist and ease some of their work which you'll hear more about later. The Fy21 budget which we are presenting today continues work towards these goals. Some of the key deliverables will include implementing the new data platform that we've selected continuing our work to expand the data types capturing the VHI has prioritized by the steering committee enhancing our outreach and education about the health information exchange both to providers on the public and as we expect continuing our work with VDH to help respond to the pandemic as well as to support some other pieces of their work that we've learned about through our interactions with them. The Fy21 budget was developed with an awareness of the changing health care landscape resulting from the public health crisis. As you have seen our projections for revenues for the Fy20 and for Fy21 are based on what we have called the worst case which projects that many of the projects that we have that require participation from health care providers will not be fully accomplished in Fy20. Further, we've included a negative revenue allowance for Fy21 of approximately $500,000 which will allow for any additional unexpected impacts to revenue as the year progresses and as we discuss our Fy21 contract with in all we project a balanced budget for the year after allowing for capital expenditures which are mostly associated with the future data platform. Looking beyond Fy21, vital is focused on developing a more sustainable business model which includes more diverse revenue sources. This planning is being adopted with an awareness that our participants have been seriously impacted by the pandemic and will affect our capabilities in that new model. Work is underway to define that model and we believe many of the initiatives currently underway will enable new and valuable services that we can provide to our participants to really show the value and enhance the behind. And with that I will turn it over to Bob. Thank you, Beth. As mentioned the potential impact of the COVID-19 pandemic has been a major part of our planning for both the Fy20 forecast and for the Fy21 budget. In the Fy20 forecast we are able to review the work scope in our current contracts and examine the degree of the impact with detail whereas with the Fy21 budget there was more uncertainty and so we have included as Beth has mentioned contingencies for revenue and cost in our planning. What we expect to see for Fy20 is shown in this chart. We expect impacts from COVID-19 in the fourth quarter as healthcare organizations focus on their primary mission of responding to the COVID-19 pandemic. We anticipate that connectivity projects such as interfaces are the most likely of our work scope to be impacted and have revised our estimate for Fy20 accordingly. There is a potential for the Fy21 budget to be able to support this new work scope but we have not included that in our estimate. Our overall revenue is projected to be $820,000 lower than the updated budget we submitted in January while overall expenses for Fy20 are projected to be $1.1 million lower. The reduction in expenses is due to the postponement of some cost and better performance on projects than we had estimated originally. This results in a modest positive balance in our change of net assets of $180,000 or 2.7% on sales. If you consider CAPEX essentially it is a balanced budget at $87,000 or 1.3% of sales. We will end the year with a strong balance sheet. Cash on hand is expected to be $2.9 million or $400,000 more than year and FY19. The major budget assumptions for Fy21 are the impact of what we have talked about of COVID-19 but also the negotiation of the Diva-CY21 contract and the third is the completion of the implementation of the new data platform by January 2021. This is a requirement of our CY20 contract. We see COVID-19 affecting the FY21 budget in several ways. For the remainder of the CY20 contract we see some projects being postponed and have assumed that they will not be shifted into FY21. We see this as a conservative position. Further we have scaled back the scale back forecast for CY20 as Beth mentioned represents really a worst case scenario in our view. Overall the CY20 contract has been reduced by around a million dollars with $800,000 in the FY20 forecast as a reduction and about 300,000 in FY21. We have also added as Beth mentioned a contingency line to revenue titled potential pandemic impact to revenue which reduces revenue by $517,000 or 6%. This is to address any of the potential revenue risk in either CY20 or CY21 or our OCB contract. As I mentioned the other large assumption in our FY21 budget was the need to estimate CY21 and this is necessary because the timing of the conclusion of negotiations for this contract will be after we have submitted our budget. We have based our estimate on preliminary discussions with Diva about the work scope and what collectively we should be focusing on. We expect to collaborate with Diva on the work scope and cost for their submittal to CMS in the June and July timeframe and expect to negotiate a final contract in the fall for signing prior to the new calendar year. However given the uncertainty of the contract we expect as in prior years to have to revisit the contract depending on upon how significant the differences between our estimate and reality. We may have to revise the budget in a similar fashion to the process that we had for this year for FY20. We estimated overall $7.2 million for the CY21 contract with about 45% or $3.2 million dollars to occur in the FY21 period. The overall contract is down about $1.7 million from what we've received in the CY20 of $8.9 million overall for the CY20 contract. This chart shows the magnitude of the contracts that make up Vital's revenue estimate for FY21. On the right hand side I've included whether the contract is awarded or estimated to give you an idea of the degree of risk of these projections. With awarded contracts the risk is really in realizing revenue is centered on the execution whereas with an estimated contract there's the added risk of actually realizing the funding as well as we've included as you have noted a revenue contingency which is the lowest line on this chart as a negative. The chart shows three years of expenses for Vital and includes FY19 audited results along with both the updated budget for FY20 which we submitted back in January as well as a forecast for where we think we will be for the year in comparison to our FY21 budget request. The significant areas of expense for Vital are labor which constitutes 40% of our budget. This is down from the forecast where it was 43% and significantly down from FY19 where it was 53% of our total cost. Our staffing is 24.6 full time equivalents. It represents an increase of one position and that is to support continued education and outreach. Our information technology costs represent 28% of our budget and our legacy V-High hosting expense represents 28%. These are really the largest parts of our cost structure. This also represents the first year that we will have both the V-High hosting cost along with cost for our MPI software the Rhapsody infrastructure and the data warehouse platform. I would be remiss if I left but I didn't address one of the board's questions regarding recruitment cost. Vital aims to complete our searches for new staff through traditional job posting and outreach and this is our first line of outreach. Some positions require specific skills such as a network security position or a service engineer and traditional searches can be unsuccessful in finding qualified candidates. In that instance we might have to work with a recruiter to fill a position where we have not identified a strong candidate through these more traditional means. Knowing that we have currently two key positions open we have budgeted for the possible need for a recruiter in our FY21 budget. There was also one other question regarding outreach and education and the question was whether Vital anticipated continued educational expenses and the answer is yes we do. We anticipate continuing public education related to the change in consent the state consent policy along with outreach in support of the goal to capture sensitive and part 2 data as well as general V-high education and outreach activities for providers. In conclusion on this page the bottom line for FY21 is that this is a break-even budget when CAPEX is included moving on to our next slide. This slide gives a view of the magnitude and proportion of our cost. You can again see that labor is the largest component of our cost and that IT costs are next at 28%. IT expenses include data security network expenses and software. Charit reflects Vital's FY21 staffing plan includes two open positions the director of client engagement and the network security administrator. The Vital team is a lean organization it is focused on meeting stakeholder requirements however we are some in some positions we are one deep. FY21 budget as I mentioned is one position which we anticipate starting in the third quarter of FY21 and that position is to support educational outreach. If you were to look back at Vital's head count further back than FY19 you would find that we are actually six full-time equivalents below where we were in FY17 we have been focused on maintaining a stable head count over the past several years and have only added positions to take on additional work scope where we see it is long term we use consultants to fill those short term needs when necessary. The FY21 budget is based on our current staffing our benefits plan is essentially the same as it was last year we have made an allowance in our estimate for the uncertainty with health insurance due to the COVID pandemic and direct rates over a four-year period the bars have four pieces those above the line are direct cost meaning that those are costs which are attributable directly to contractual work scope while those below the line are indirect cost as you can see that line has remained more or less in the same place over this four-year period Vital has worked hard to keep indirect costs in check over this period as you can see though the addition of collaborative services and future data platform projects have added to the direct cost of Vital and has reduced the indirect rate significantly as a small organization the changes in either direct cost or indirect cost have a large impact on the rate that is projected assets by category over the period of FY19 and FY20 and 21 here is to show Vital's financial resources that are available to us during these uncertain times the majority of our assets are quick assets such as cash on hand and accounts receivable and are highly liquid our current forecast for the end of FY20 is $2.9 million or 160 days this easily covers a projected estimate for current liabilities of $950,000 our budget for FY21 projects cash on hand at the end of the year to be $3 million or 138 days and this again will easily cover our projected liabilities of $954,000 in conclusion we believe this budget positions Vital to continue to execute on its contractual requirements and mission of using health information technology to improve the quality of care to enhance patient safety and reduce the cost to deliver health care I am going to turn over the presentation to Carolyn Stone Carolyn I should be saying the hospital is going to take this I think so, yeah I would just like to ask the board do you want to do questions on the this is my first time presenting the budget to you would you rather do budget questions before we go into the work updates or should we go through it all I think it would be easier to take them separately Beth it's a little bit different on remote meetings so we'll do our best at this and what I'm going to do is call on the board to drop off a medical order and see if there are any budget related questions I'm going to start first with member Yusufer Sure, thanks just a couple questions if you don't use the $500,000 that you have in the Revenue Reserve and the $100,000 that you have an expense contingency in 2021 if you don't need them do you expect those to be offset with additional expenses to drop to the bottom line? If I were to speculate I would say that they would perhaps drop to the bottom line but certainly if the situation improves in our financial situation I could anticipate that we would most likely try to take on additional projects that may not be revenue bearing and I do think some piece of that could be impactful to expenses some of the contingency was to allow for just the uncertainty and the CY 21 contract with SIVA not knowing so if we were to cut some of those revenues it'd be cutting it probably wouldn't be cutting deliverables for us or it could be increased deliverables for us so it's I don't think it's a one to one revenue expense OK and then you had a list of the fiscal 20 achievement goals and you obviously have goals coming into 2021 what area do you have the most concern about as you look to the budget for 21? Beth do you want to take that one? Sure I think if we were to say the hardest part is it's not a bad way it's just the timing of the negotiation of our contract with SIVA so I think we're pretty confident at a big piece of the work like we know what we need to do to maintain the VEHA that's clear the implementation of the future platform project is a significant undertaking for us next year and that's a part of the contract and I think we're pretty confident in that piece I think it's the other pieces is I think we need to clarify you know we've learned a lot of lessons in working with the Department of Health and I think there are a lot of opportunities for us there and we're hoping we can have we're all in alignment about the additional work we can do and potential funding sources or you know this is an area where we may take on additional work that don't have funding sources but are just the right things to do and you know I think it's just getting clarity on our achievable deliverables for next year with SIVA and making sure that we have sources for them you know I don't think looking forward I don't think we have much more risk than we've addressed in this budget I think we've been very cautious and conservative in some of the estimates and the contingency we've allowed okay thank you and that's all I have for questions thanks Kevin thank you Maureen Member Pella thank you Kevin so I only have a couple of questions as I recall when the concept of collaborative services came into play coming into the the 2020 budget you know there was you know and the logic was very strong that you had I think three entities Vital, Diva and the Department of Public Health kind of heading in similar directions and it was more cost effective to kind of bundle those efforts together rather than do them separately but I'm just wondering kind of looking at your 2020 budget and the volatility that's there and moving into the 2021 budget is how during your discussions with the with Diva mostly but how are the savings from this collaboration being tracked and applied that's a great question you know right now I think we are just moving from with phase one a part of the collaborative services from a point where we're investing in those platforms to actually seeing some of the value and I know from Vital's perspective we're absolutely trying to capture metrics of what the improvements have been you know I think we do have to have some more and my understanding is that Diva as well has tracked where they haven't spent or where they are avoiding costs I do think we need to learn a little bit more from those platforms to know the full scale and scope but absolutely numbers that we we will be tracking some of it I do believe we'll be able to show cost savings or cost avoidance for certain and some of it will be in improved metrics where we've improved metrics which enables people to do better work with the data that we have well thank you for that I do think it would be helpful to kind of be thinking about that going forward because as you look at these contracts on your budget they're a big up but you know and certainly there might be offsetting savings in your budget but also Diva and the department of health and those are possibly downs and so when somebody looks at your budget at the top on its own bottom it's like well you've got the double digit increases here but what's behind the curtain is not being presented and so from a presentation point of view I think it would be helpful to keep that initial concept in play that this is being done to save money not to spend more money that's great people the other question would be that you know for example the board and I think all other state agencies are facing an 8% cut an actual hard cut and I'm just wondering if somehow that concept were to trickle down to you folks and your former director is probably the one that is most aware of this but is where would you go what is the is there any low hanging fruit in your budget that you would say this is what we would want to give up first that's a good question and we've definitely spent time talking about that again just looking at the uncertainty around us I don't think we have significant low hanging fruit I think the former director did a great job of streamlining the operation both from the staffing and the expense sides but if we were forced to look at cuts you know I think we've started some conversations about some lines where we would try to cut our goal I think as most goals would be would be not to have those in staffing levels initially we do have some consulting lines there may be some opportunity and and we to meet the deliverables that we believe we will be committing to we are as Bob mentioned a lean organization it would be hard to really meet those deliverables if we were to start cutting staff but that said as we negotiate the contract and the values and the deliverables decrease because of the lack of availability of funds we will look at what we need to do thank you Beth thank you Tom Member Lunge nice to see you again I just had a couple of quick questions when Bob was talking about the revenue there was a line that indicated you had $190k from other clients and I was just curious who those clients are and what type of work is included there if you don't mind I'm going to let Mr. Turnalf just answer that question thanks thanks Beth Robin that represents kind of a polygot of a number of different things the largest part is there are a number of contracts that we have for vital direct which is our direct secure messaging service and that represents about $123,000 of that $170 there is also a contract that we have with an organization a company called Patient Ping and they provide an event notification service that we provide an ADT feed to and that I believe was about $40,000 and then the balance will be interest thank you thanks and then you had also Bob in your overview mentioned uncertainty building in a contingency around uncertainty of health insurance I'm curious I don't recall if you purchase through Vermont Health Connect if you're self-insured or what's the source of your health insurance is I believe it does come through the exchange but we our broker is our policy is through MVP and you buy directly from them presumably well actually through a broker and really for us you know the risk is we have a high deductible plan will a lot of people go up to that threshold on that high deductible plan because you cover the deductible through the employees for the most part we do we flood the significant portion right yeah I'm sorry I'm sure you went over that in prior years but I can remember the details no quite willing to answer that great thank you those are my questions from the installer thank you Robin member Holmes actually my questions were asked and answered so I am good thank you great so I'm going to say public comment till after the second part of the presentation so that's whenever you're ready okay thank you Bob if you don't mind just going to the next slide sure we saw we take an opportunity and not spend a lot of time on it unless you want to but just to give you an overview of some of the work which we've been doing with the state in support of their pandemic response because I think it really is provides a good illustration of the value and the work that we do and why we have one of the reasons that we have something like this in place as I said in the interest of time I'll go quickly so Bob if you can go to slide 21 that might be a better place to go the work we're doing kind of falls in I'll go through three buckets but they're a little varied the first is really expanding access to patient data and the use of the patient portal vital access we the pandemic started we made a concerted effort to remind our participating providers that they have the portal available to them for access and that the portal was actually capturing and displaying COVID test results so it might be useful for them as they had patients or patients they might not know showing up we've also made a big effort to reach out to ambulance and ask fire teams across the state to educate them about the availability of the V-High for them often times or more often than not first responders don't have any patient data when they go out on a call and this now will provide them with the change in the consent policy and the availability of more data provide them the opportunity to really be a little more prepared going into response to emergency calls and I think a significant impact is the epidemiology team at VDH is using it to do data collection on patients who test positive they're required to do federal reporting into CDC and they were doing a lot of reporting by making phone calls to providers to collect the data and they've been able to actually complete a portion of a good portion of their data collection using vital access and not having to call providers and asking them to fill out one more form or answer one more survey so I think that's been great moving on to slide 22 we've done expanded our work to develop in our sped up our work to develop interfaces to both ensure test results can you go to slide 22 to ensure test results the COVID test results are in the V-High and available and that we are capturing results from new locations that are doing testing as it happened we're also working with VDH to build a feed to actually get the state labs test results into the V-High and then moving on to slide 23 we never quite got to 22 Bob are you changing maybe my computer's frozen Bob are you changing slides did we lose Bob we may have locked him occasionally we do have somebody get dropped Ben sorry about that I've been on slide 22 so is my video frozen it is not being shared we're still on slide 20 okay how about if I stop shit would you turn your camera off and see if that helps yeah that's what I was going to do great how about now no change hey Bob you may want to try stop presenting and then resume presenting okay that doesn't work I can if worse comes to worse we do have the documents and we can just go to our website and follow along can you that look like it's being loaded Abigail could you take control of the screen and use them from the slide deck are you there Abigail thank you I'm going to stop presenting then while we're fixing this technical difficulty Beth like I'll throw a question your way so that we don't have silence in your first half year leading the organization what has been your biggest surprise hmm the amount of work that happened I think I had a sense of it and talking to I mean doing my you know research on the organization and talking to people through the interview process but the just the magnitude of the amount of work that such a small staff can get done and I know it's not a canned answer that is a totally sincere answer okay we have slide 22 up were you finished with that or oh I know I'm sorry I know one other piece I think I would like to point out here is work that we're doing in support of both the interfaces and the reporting that we are doing for the state has really involved validating data quality and you know we've worked we get data from all the hospitals across Vermont and that is largely the data that's being reported in is where we're providing data and they have been great partners in helping to test data and kind of clean up some of the data feeds to make sure we're doing complete and accurate reporting going to slide 23 additional work we're doing is more around reporting so we are working with BDH to automate some data feeds to them to meet some of their daily reporting needs and help them with some of their work to monitor resource usage across the state and hospitals so it's patients in bed like this day things like that again this is hopefully helping inform their response giving them more complete and consistent data and again avoiding what's currently a manual process of calling either calling for information on a daily basis or having the hospitals having to go into BDH's portal and upload or input data about this information and so I'm happy to answer any questions but I just I thought this would be it might be interesting for you to understand where you know the kind of scope of how the VHID data has been able to help address the pandemic response I also this is really a point where I would want to give credit to the vital team because they pivoted immediately as soon as the request you know we reached out the request came in and they've been working daily weekends to work with BDH and the team at ADS to get these data feeds in place to explore their needs help them to understand and build these feeds while not missing a beat on the other work that they're doing to meet our kind of day-to-day deliverable commitments. Thank you Beth are there questions from the board anyone just pop in because there's no point in calling on everybody on this section. I was intrigued by this is Jessica by the way intrigued by the emergency system services team reach out that you did and I'm wondering what the take-up rate was it's an interesting question initially I think there were a little this is my interpretation maybe not be fair but I think they were just overwhelmed with responding to the pandemic and so they were like this sounds great but we didn't really have time to engage and we've done some more targeted outreach in the past couple of weeks and they're very quickly we are getting a list of agencies that one where we've got training starting next week that we're onboarding a number of them and so I think once people on the ground are hearing about it and now that they've had a little time to kind of adapt I think they're really seeing the value of you know if nothing else knowing if you're going into a household and to pick up a patient but you know if they've tested positive or not let alone all the other information they can potentially have and if it's a diabetic we bring these things in type of response. Well then I mean at some point in your next update to the board or something it'd be great to see you know some kind of graphic of the provider take-up rate by area over time I think particularly and this is one of the questions I think I submitted out there you know now that the consent policy has changed and there's so many more records in the system the value of the system is somewhat greater I would expect the provider take-up rate to be greater so be wonderful to track by area what that take-up rate is and so this is an interesting one. Yep and I can I was going to answer that question with the next section but I'm happy to hit that now it's an interesting so we can definitely look at the vital access usage and it definitely started an uptick in March and then all the health care providers closed down sure and so it felt but the numbers given how closed down everything is the numbers are still pretty strong so well we I can't say that we see an increase they didn't drop nearly as much as if you look at the message flow that we have coming through for encounters it hasn't dropped so the same level so I think there is we can say that there is more usage with having the additional data in their role so hearing anecdotally from some practices and providers where they're using it more now to pre-screen patients so their staff will pull information out patients they know are coming in for the week or for the month or however long they look out so they're prepared when patients are coming in and again knowing that there's actually a better chance of there being data in there. Great, thank you. Any other questions from the board? Okay Beth, might as well keep going. Right and then you're done with me after this slide I promise. Abigail if you don't mind going to slide 25 thank you. I know this is a brief slide but I know we haven't talked to you since the consent policy changed on March 1 so I thought it would be interesting just to present some numbers on the kind of contacts we've had from patients so as you know that the change was March 1 technically it went successfully there was a lot of public outreach leading into that date as well as after the March 1 date and just some quick idea of what some of that looked like there was a series of three front porch forum posts that reached about 180,000 emails each across the month. We did 60 VPR sponsorship messages press release was issued by Diva that was picked up by numerous outlets. There was a story on CAX which was great which really seemed to get a lot of traction and a lot of response and there have been a number of social media posts across some of the different state agencies and some of our partners. As you can see we did see an increase in calls from individuals that's we could kind of track spikes to one of front porch forum posts one out or when the CAX story went on. Some calls were just people calling for information that's the first row, the 113 total we had people call to opt out once they learned what their options were and that's the next column which is 400, I'm sorry 35, it's kind of small and then we also have a few healthcare organizations still processing opt-outs but many fewer now so we do still get occasionally get opt-outs from patients when they're in for visits. In addition to these metrics we also know that through the end of March there were about 1600 visits to the consent website that was set up for the patient information and education. Outreach has largely slowed due to the pandemic and not thinking that this was an area of focus and now when our attention had been to slow it down we're going into summer but with the evaluation committee work and team we are planning to pick that up from late summer through fall and that will then coincide with the work the evaluation committee will do on the fall about the impacts of the outreach and who we've reached and who we still need to reach. Okay, are there questions from the board on the outreach or the opt-out transition? I had a question about your outreach thinking for next fiscal year 21 not only around consent but also around the Part B information and if you had sort of a rough plan there. So around the Part 2 and sensitive data we are working with Maureen Gilbert who did public engagement and education planning for the last three years work and so we don't have a set plan yet but we are working with her to develop a plan for what that looks like through the rest of the year. But I expect it to be as robust as the last one. Any other board members if not I'm going to open it up to the public for any public comments members of the public Abigail is this wide open or does anybody have to use star 6 if they're on the phone? We have not muted the audience so they should be able to talk as long as they unmute their phone. So if anybody has a public comment just unmute yourself and go ahead. We do have a few more slides for our quarterly update. Carolyn I think this is you now right? All right, yes it is. Thank you very much chair Mullen. So we wanted to give you an update on the collaborative services and the future data platform if you can go to slide 27. There were three pieces to this there was the universal MPI the interfacing and the terminology services and I'm happy to say that at this point all three of them are live. We went live in January with the MPI which has increased our matching abilities for our reporting clients over 25%. So they're very happy with their we know that one car is up around is over 95% now on their populations which they're extremely happy about. The only area we were not able to bring live on the provider portal was the provider portal with the but we do have a strategy to get this live within the next year. The interfacing engine has been brought live in early April at the Curious Innovation Center. This is run by the main HIE and terminology services went live in late April using the term Atlas solution provided by Curious Innovation. Next slide. The second phase of this on slide 28 is the future data platform and in 2019 we started the vendor selection process with review and evaluation of many vendors and ended up with many stakeholders who are listed here and ended up selecting Medicasoft in February as our vendor for our new data platform. After this we moved into contracting. The contract was signed on April 22nd and then we started our implementation activities and a bunch of requirements discovery sessions and stakeholder engagement plan development and I'm happy to say that on Monday we got approval for an HIE subcommittee that's going to help provide some strategic guidance from the HIE steering committee aspect over this project in addition to numerous stakeholders who will be involved in this project and we're meeting here sometime coming up in June and our implementation sprints with the vendor have already started we're in the middle of sprint one right now so things are moving along very well we're targeting January 2021 go live of this platform and this will replace what was the Vermont clinical registry and replace our vital hdm our data warehouse next slide actually two slides we're going to move into our quarterly updates and as Beth mentioned and everyone is well aware on March 1 we changed the statewide consent policy from opt-in to opt-out and conversely we've also flipped our metrics so that now we're reporting the number of patients that have opted out and you can see that this is for our overall population the number is low but from anecdote 11 talking to other HIEs that are also opt-out states we actually have a higher opt-out rate than some of them do so you know I can infer that the education and outreach that we did is somehow getting the message across that people are aware that they can opt-out and are choosing to do so when appropriate for themselves but we'll continue that education as we move forward next slide point of care utilization this area is usage of data within the VHI and this shows two mechanisms one through vital access our provider portal and one through cross community access which can be accessed either usually through their own EHR but access is the same data source and you can see in March the opt-out consent changed and March was half the month was a big reduction for us in volume of encounters but yet we saw our usage go up and the things that we're attributing this to is the consent change having more data available we've heard anecdotal evidence that there's providers now more willing to use the tool because they can get data on virtually all of their patients as opposed to only a fraction of their patients the other thing is that the Veterans Administration who pulls from cross community access is now able to get a lot more data with the consent policy switch they also switched their policy to an opt-out so between the two we've seen a big uptick in usage and then I think the other place that the utilization started to spike in March was as Beth mentioned epidemiology is starting to use the tool to access patient data instead of calling providers next slide the other way one of the other ways that people use data within the VHI is we do provider results delivery and this is delivering lab tests into provider EMRs from the hospitals or commercial labs and you'll see that the volume dropped off some with a number of encounters dropping off at the same time but we are able to deliver COVID tests we are able to deliver normal tests and people find that this is a huge service we have about 541 providers that were receiving results in March and we'll be tracking how this goes throughout the rest of the year clearly next slide the other area where we do have a lot of work that we do is with interfaces and the connectivity criteria that you annually get to review as part of the HIE plan we have a target of 85 interfaces for this calendar year we had completed 23 at the end of March we are definitely working with the designated agencies and others to define mental and behavioral health data connectivity criteria for this new data type we did present our recommendation to the steering committee Monday and that will be going back for final approval I believe on the 22nd of June so we are working a lot in that area and we will tackle any updates to the physical health connectivity criteria in the fall and then present that as part of the steering committee overall as a package as part of the HIE plan to you in the fall the one area as Beth mentioned that have been affected is some of the interface projects that we do have actually been identified as new needs and been accelerated and some have stopped due to the COVID-19 pandemic but we continue to work with Diva, ADS and VDH and other agencies throughout the state to support all their data needs in responding to this crisis and we are prioritizing those interfaces that will have the most impact as part of our work next slide the last area I wanted to talk about was meaningful use and security risk assessment this is a consulting area and while we had some pretty good uptick in March we definitely will be seeing lower numbers as providers are not as available to are not in the offices as much to do some of this work but we continue to offer that service and make sure that providers we work with Diva and the Medicaid program to make sure that anyone who needs needs help in this area can get it and that's the end of my quarterly update and I'll hand it off to Christopher for the technology update thank you thank you Carolyn and good afternoon everyone it's been a few months since our last update so today I am pleased to share some of the progress of our security program next slide Vital recognizes the magnitude of being responsible for healthcare data in the state of Vermont as such we have developed and maintained a thorough and sound information security program we continue to be positioned very well but we also understand that information security is and will always be a changing landscape therefore we are committed to constant improvement through continuous analysis and updates at the end of 2019 we finished rolling out a secure corporate password manager to all staff completed documentation of system interconnectivity and completed a full system security review of a key hosting partner in January and February we completed our annual full vulnerability scan onsite assessment and implemented an information security management system that is now monitored 24-7 by a local security operations center in addition to implementing the security operations center through March and April we performed a recovery test of some key backup infrastructure rolled out new end point security and have exercised our work from home contingency plan with great success the results of the scan and assessment highlighted our strong security posture the third party security analysts remarked that many of the security focus projects completed by vital such as implementing a full business impact analysis and onboarding a managed security operations center our achievements they rarely see in an organization our size I'm very proud of the work that we have done and thank you for allowing me to share our progress with you today I look forward to sharing more with you in the future Super, so board are there any questions on either the quarterly update or the technology update Hi Kevin this is Tom I just have a quick question that it was referenced that the patient matching for the ACO is at around 95% which sounds like a good number are there any other comparative entities which you have numbers to kind of give some context to that ACO number? Anecdotally within the realm of HIEs 80% used to be considered the average ONC has given everyone a challenge to get to above 99% nationwide but very few have been able to get there um you know the challenge is knowing the known population you're capturing um especially across all the organizations so I think that we're well above where we were I would say that we will continue to try and get higher with ONCARE if that's possible um we now have a state-of-the-art tool that's using some of the new technologies that are allowing enhanced matching capabilities so we look forward to trying to get to 99% um with them over the future but that's a very lofty goal ONC did a challenge and I'm not sure anyone made it to the level that they wanted well thank you for that Will will not make perfection the enemy of the good yeah compared to the 60 to 70% where we were I can say ONCARE is much much happier that they're getting a lot more data um and it really improves patient care all around so it makes the reporting more robust if we can attribute the right data to one person instead of having multiple duplicates or not being able to match them at all thank you is there any survey whatsoever of those who opt out for their reasons no not that I'm aware of we just if they've wanted to be out sometimes they'll share that with us we have not made a point of asking for a reason because we don't want to make them feel that there's some reason that they have to give so I know anecdotally have just said I don't want my data shared anywhere I'm worried about my identity being stolen I'm worried about databases being hacked in general so and others have potentially conditions that they didn't want shared so but most of that's just anecdotal okay other questions from the board just a quick one what would you all say is the best way to quantify how close we are to the goal of one health record for every Vermont I'd say we're getting much closer with the new MPI you know I think the challenge we will face is getting all of the data right now we're missing big chunks of the data so it depends on how we define one health record for every Vermont you know with the data we have we're much closer now with the new MPI because we can say with a defined population like one care we've been able to say for 95% of their patients we have one record for them so the bigger challenge is do we have all of Carolyn Stone's records in the MPI? I don't know because there could be places I've gone you know I'm of that example but there could be places I've gone for care that don't contribute data to the VHI so that data will be missing until we can get it into there and really have a comprehensive record I guess to some degree that's my question how do we sort of start to understand what's missing so that we know you know people who are seeing providers but the providers aren't contributing those records to the database and or don't even have electronic health records for their patients how do we start to understand what's missing well I think I was just going to say I think that the HIA steering committee is starting to try and tackle this and starting to try and identify priority data types that they would like to bring into the VHI and the next priority data type have been the part two or the sensitive data that is a key part of people's whole health care you know you have the physical health side and the mental health side and that you can't just look at a person with physical health only or mental health only and that you need that combined some of the other areas that the HIA steering committee is considering is social determinants of health data or claims data and trying to really get all of the pieces that clinically they would need to be able to treat patients holistically so we look to the HIA steering committee for you know guidance and help in prioritizing that those types of data and to your point too I think there is a challenge and there has been a challenge because we don't necessarily know all the practices that are out there but I think some of how that's been addressed is in work with some of our partners with a one care or blueprint and they can identify the practices that they work with and have some of those conversations about getting hooked up so it does help to at least identify some of the opportunity or else doesn't force them to participate and many will you know not want you for different reasons practices you know provider that's been there forever is retiring in a couple of years doesn't see the value things like that but at least it does and Caroline you know better than I do at least introduce us to things we might not have known about otherwise thank you other questions from the board hearing none I'll open it up again to the public for any comments hearing none Beth, Bob, Carolyn we want to thank you very much for an excellent presentation and again the public comment period is open on vital team for the presentation today Susan or Abigail can you tell me until when June 15 sorry it's June 15 I have barking dogs in the background thank you Susan so again we'll take any public comment up until June 15 and really want to thank the vital team for the presentation today thank you for the time thank you and we're going to switch over and talk about the accountable care organization budget guidance and I'm going to turn it over to Elena Barabee thank you Elena hello okay so I'm going to share my screen let me know when you can see that we see it's loading but it's not quite there yet there we go okay great so Elena Barabee director of value based programs and ACO regulation so today we're going to talk about the 2021 ACO oversight process so budget guidance and certification eligibility verification so at a high level I'll go through the background the statutory authority and then these two separate processes and then outline some next steps for your convenience all the materials posted to the GMCB website and are located on the ACO oversight page so some background GMCB established guiding priorities for staff so regulatory integration and reducing the administrative burden on our regulated entities especially in the wake of COVID-19 the legislature passed Act 91 so this has kind of been emphasized by many stakeholders so in response we set up some goals specific to our ACO oversight processes we would we hope to streamline information requests across regulated entities for both ACO and hospitals because these things kind of play together we break out information requests across processes categorically to ensure that we're still meeting our regulatory requirements so we emphasize data over narrative where appropriate and reconsider timing of certain information requests so you might see some things that have been historically included in budget so we move to another section called monitoring also to be clear about when some of this information might become available due to you know certain operational processes etc so hopefully that will all help get a little more clarity this year and I apologize I have a puppy making noise in the background the statutory authority 18 BSA 93 82 and rule 5 distinguished between two processes ACO certification and ACO budget so certification happens the first time an ACO applies to be certified in Vermont and then each year goes through ongoing eligibility verification so we don't re-look at everything we just look at changes over a prior year and make sure that they're continue to be eligible and the budget is an annual process and looks I shouldn't say different but we tweak it to whatever entity is submitting their budget for review the standards and requirements by which we review the submissions are established by 18 BSA 93 82 as well as the rule and the all pair model agreement something to keep in mind as this is how we kind of tie ACO oversight to some of our other work at the board this is a list an outline of the structure of the rule guiding certification eligibility verification and this should look familiar to you the high level sections require us to look at legal entity governing body leadership and management solvency and financial stability provider network population health and care coordination performance evaluation improvements patient protections and support provider payment and health information technology so making sure that the ACO has policies procedures organizational structure infrastructure in place in order to actually deliver some of the these things so this year in 2021 there are no significant changes to the form we simply updated the dates and then there are no new criteria this year outlined by the legislature so it's pretty standard over prior year and just some reminders you know it's posted on our website that we issue it to one care of Vermont by July 1st 2020 along with the budget guidance and we expect it to be completed and submitted back to the board honor before September 1st so I'll pause there and see if you have any questions but this one should be pretty easy to get through any questions from board members hearing none go ahead and proceed Alayna okay great so the ACO budget guidance so as we kind of mentioned before we hope to simplify questions and reduce redundancies there were a lot of areas where the level of question kind of overlapped in nature and we got a lot of the same kind of response so we tried to clean up what we were asking just to make it more precise and clear about what exactly we were looking for we clarified any references to the ACO versus the broader all-payer model which is the agreement that we hold at the state which is separate and apart from this ACO oversight process we separate content necessary for budget guidance first of all monitoring as I mentioned earlier and then we really want to make sure that we're relying on data and allowing staff to analyze that data rather than just getting the narrative and we think that will also reduce the administrative burden for the ACO we understand a lot of changes will be occurring due to COVID-19 but we need to understand when changes are being driven by COVID-19 or other factors that might be at play so that will be apparent throughout the document and then we want to understand implications of ACO participation for our hospitals especially in light of COVID-19 so in summary we hope this will increase transparency, reduce administrative burden and help both the board and the public understand how the ACO plans to adapt this operation given COVID-19 and the reduced ability of hospitals to take on financial risk. We have now eight sections so we tried to break apart some of these sections so in part one reporting requirements we have the ACO information and background ACO provider network, ACO payer programs, total cost of care and risk management, the budget which is the financials that meet and then you know their quality population health model of care and community integration initiative and then we have section eight which we postponed for future years but we would really like to tie the all-pair model questions there's some all-pair model specific questions we would ask there. Part two is now ACO budget targets and then monitor which we will explain as we continue. So in the introduction I just wanted to point your attention you know it reiterates our statutory authority and background but then outline you know these things that we need to think about in light of COVID-19 so many standard and otherwise relevant questions may not have meeting given COVID-19 and so we kept them because we think they're important but we've grade them out and italicized them to indicate that they're not required for 2021 but we want to make sure that everyone is aware that this is something that we expect to ask in the future and then you know while estimates on utilization other perspective factors may be more volatile we still care about you know all the input to the budget and so expecting the ACO to be able to explain those even if it's you know ranges or they have to put confidence intervals around some of that information and the expectation still stands across all sections you know I had to mention earlier when changes are due or you know significant changes over a prior year or due to COVID-19 or other factors and then we really want to understand you know the role of the ACO in stabilizing the healthcare system you know FPP has been cited as a valuable sorry fixed perspective payment excuse me have been cited as a valuable mechanism to provide predictable funding to providers especially during COVID-19 when providers can't rely on utilization to drive revenue and volume so in order to cover their fixed cost so we really want to understand what they're doing to expand that or to help providers if it's not fixed perspective payments if there are other mechanisms we can take into that a little further so background information on the ACO so this section is pretty much the same we just cleaned it up and reduced some redundant tables value proposition and business model challenges and opportunities and objectives for the budget development changes to provider network payer programs administrative operations and key assumptions made during development so we're looking just for a high level summary which is kind of the key takeaway from the rest of the submission section 2 is provider network so network development strategy challenges and opportunities for 2021 network recruitment network data so provider network including provider type and program participation details and we have a separate table for the provider list which is just a more detailed version about provider network and then we want to understand their provider context so we would want to see copies of the proposed provider contracts and explain any payment strategies and methodologies and their contributions to the goals of reducing cost and improving quality we also want to understand you know any new or expanded incentives for strengthening primary care and strategies as I mentioned before related to expanding FPP adoption across providers section 3 payer programs explain changes across their portfolio payer programs new or terminating programs changes to existing programs and if they are implementing any non-scale target qualifying programs why and then again you know about their fixed perspective offering how are these amounts calculated and what mechanisms exist to ensure that these amounts are not too high or too low we would also like to see copies of the contracts or proposed payer contracts we understand that these actual payer contracts will not be finalized and signed until the spring but it would be great if we could have a preview to that to the extent possible or understand what's being held over a prior year in a similar fashion and then we would like an update on the Medicaid expanded geographic attribution methodology that was rolled out in 2020 I think it was a very new and innovative idea so we'd love an update on how that is working and whether and when we will know if it makes sense to expand that and I just wanted to remind everyone that we're not doing a programmatic review but trying to understand how the ACO programs impact their substance B program alignment and meet the goals of our all payer model and then where it intersects with duties of the board other duties of the board for total cost of care so this is more data centered now than it was in previous years so we're asking for total cost of care by payer by HSA for the prior current and the budget year and then there will be a series of questions that help us understand the ACO's role in assisting HSA's kind of meet those targets or not and I think we can all understand reasonably that 2020 will be a challenging year and I'm not sure if we've grade that out I don't think we need to spend much time there as you know utilization is much lower and looks very different than in previous years so trying to understand that is going to be a challenge for everyone but we do want to know what assumptions that the ACO used in developing their 2021 budget section 5 risk management this is at high level we're looking for ACO risk by payer and any payer specific risk mitigation strategies risk by payer by risk bearing entity which in this case ACO has chosen the hospitals as their risk bearing entity and then any specific risk mitigation strategies that the hospitals are following so this is where we have some hospital level data that we're asking for but as was mentioned in the hospital budget process it would also be good to have these data from the hospitals at a later point in time which may be more up to date and then we also have a summary of shared savings and losses for the prior current and budgeted year and their actual and expected distribution methodology so we need to know kind of how performance is going to affect prior year performance will affect their future year budget because at any given point in time we're kind of juggling three years of this of activity section 6 so this will look much the same we have made some additions here so we'll continue to collect projected and budgeted financial statements income balance sheet cash flow we've added budgeted sources and uses documentation so that's understanding how the revenues are really clarifying how the revenues are funding particular expenses which I think we've kind of deduced but what's not super clear previously PMPM revenues we've added my payer details of hospital participation and risk and then another new one is management compensation I didn't say new it's more detailed than in previous years so for gross we want all gross compensation or positions with gross compensation over $150,000 and then we want all the positions associated with or all the leadership positions where their gross compensation is over $100,000 and then the budget narrative would include explanations of any significant variations over prior year particularly their revised budget which they're coming to speak to on June 24th and we would also expect discussion of any expected gains or losses their rationale for such or to the extent that they are proposing a break-even balance what they expect to do with surplus or reserve moving surplus or you know in another way what does that interplay with reserves section 7 quality population health and model of care in community immigration initiative this was a particularly complex section so we tried to break it out more precisely so now we have model of care quality, improvement in clinical priorities population health and payment reform care coordination and care navigator integration of social services childhood adversity and all-payer model quality and population health goals so we thought this would allow us to kind of break out these specific items and look at look at them in more detail so questions across topics are generally you know what is the progress to date including any HSA level statistics we'd like to understand methods, metrics and measuring impacts and then you know any proposed budget year objective section 8 are the all-payer model questions so you know we'd like to ask additional questions related to the ACO's goal in meeting or helping the state meet goals under the all-payer model but given COVID-19 you know we didn't think this should be the focus of the presentation in the budget submission we really think that we should focus on how the ACO is adapting to this new world and you know especially when it's hard for hospitals to invest at the level that they have been in prior years so we will revisit these questions once we have a better understanding but we hope that you know they will continue to discuss their role as it relates to the all-payer model so the ACO budget target so we used to have a section called you know the financial benchmark and while that is one target here you know these are the updated data there are other targets that we could set before the ACO submits their budget to give them kind of some you know goals to work towards as they develop their budget so at this time you know previously we've had more precise detailed information on you know setting the benchmark but this year as you understand it fluctuates we still have to meet our threshold or come under our thresholds under the all-payer model but I think how that gets executed is still being discussed even with our federal partners so I will continue so other targets and benchmarks as I mentioned before we will likely establish benchmarks later in the process so we've discussed administrative expense ratio population health ratio metrics for the ACO to hold their budget again but in future years it might make sense especially as things stabilize and hopefully at some point they will that it might make more sense to specify some of those things up front part three so we added a section for revised budget which I think was missed in an earlier slide but basically we wanted to call out specifically the items that will not be ready by October 1 and that we expect in the spring but are a part of the budget submission process so final attribution by payer provider copies of all payer contracts details of any six perspective payment that may be negotiated and clarified you know when the payer contracts are finalized and then an actuarial opinion that the risk bearing arrangement between the ACO and payers are not going to threaten the solvency of the ACO finally part four monitoring so we're still working on this and this we expect to be a document a companion document for the budget guidance but it will really be its own own document and it will outline what the deliverable is and the timeline for its submission to the board and then I think we would like to discuss which pieces should come before the board or which can simply be reviewed by staff so we can go into more detail about process board processes that relate to those items but some of the topics that will be subjects of that document will be presentation of prior year performance so last year the ACO and the payers came before the board to discuss quality and financial outcomes from the prior year and this coincided with the budget cycle so we would expect details of that to be included in this document tables submitted through the budget process for which actuals are required so we received quarterly financial statements and to make sense of their other standard standard materials delivered on a standard basis we would like to see that in here data on HSA level performance so on an ongoing basis we would like to understand how the ACO needs to see what the data that the ACO and HSA see and just understand they have a pulse on what's actually going on on the ground and then I think part of this analysis will be in previous years we've asked the ACO to comment on all-payer model performance on total cost of care but we really think we need two pieces of information here we need the all-payer model statewide metrics as well as the ACO specific performance so we're putting these two things together and then having a discussion about the ACO's role in helping the state drive down the cost of care while maintaining quality and finally information on ACO's complaints, grievances and appeal process for enrollees and providers and this is not comprehensive it's just kind of examples of pieces that may have shown up in the budget but we think are more of an ongoing conversation alright so I tried to highlight some of the intersections of this work with other regulatory processes so certainly the hospital budget process in terms of the fixed perspective payments of the percent of NPR risk related to total cost of care performance, reserves related to the reconciliation of fixed perspective payments versus fees for service for the Medicare contract only hospital participation fees and then any other hospital payments they received to support infrastructure care coordination and other initiatives rate review which is you know very hot topic right now and then QHP rate service and input to this ACO budget the all payer model as I mentioned before the ACO contribution to our all payer and Medicare total cost of care as it really you know in proportion to scale and then population health quality outcomes scale we do have requirements for scale under the model and then our we have GMCB authority to modify the Medicare next generation or to make suggestions for modification to the Medicare next gen model so as some next steps GMCB staff are still reviewing some of the tables for efficiencies we think we're pretty close but you know I think it would behoove us to maintain some flexibility you know as things develop we might want to change the way that we collect certain things you know due to COVID-19 and we just want to be flexible there but I think these are pretty close you know one thing is with everything going on you know our legal team internal legal team would still like some more time with this document because we move pretty quickly with everything else going on but we do have the potential vote for June 17th on these materials and then July 1 is when we would issue both the ACO budget guidance and certification eligibility verification form and then September 1 is when certification the form would be required and then October 1 is when one care would submit their budget and as I mentioned before these materials can be found on our website and that brings me to the end of the presentation do we have any questions? Thank you Elena any questions from the board? This is Robin I had one small question Elena when you mentioned on the table if you had mentioned maintaining some flexibility in case some issues come up related to COVID are you anticipating wanting that after the vote or are you just meeting in the next couple weeks pending a final decision? Yeah I'm hoping that any significant changes would happen before the 17th would be helpful to think about delegating authority for us to just make them last minute tweaks and if it was significant we would certainly want to come before the board to explain any significant changes but yeah I would hope that it's mostly in place before the 17th Thank you Other questions? Yeah this morning I just have a couple comments one first thank you Elena team for all the work hard work into this I know you've been sending us drafts and taking comments and it's been very helpful just a couple things in section 5 when we talk about risk management maybe asking as well if there's been any changes or are they contemplating any changes to the allocation of risk to the risk bearing entities because I think that's something that really could be considered in the future I don't know if you want to put that in the second Yeah when we talk about the risk that's allocated to right now it's the risk allocated to hospitals and the methodology of the risk whether there have been any changes or whether they're contemplated any changes to that allocation methodology Yeah so I think if that's not clear in the guidance we'll make it clear that is certainly something that we want to understand Right okay and then in section 6 in dealing with the management comp really I think what's more important is how they come up with the salaries and what benchmarks they use for those ranges Sure I think we could add a question Yeah I think that's Yeah it's really that's really important is just what's the process that they use to come up with salaries for specific positions and if they have any benchmarks Elena this is Jessica just to take you back on Maureen's point I think you could pull some language from the hospital budget guidance because that's what we do in the hospital budget guidance is we ask the process for determining compensation and what benchmarks are used so symmetry between the two might be helpful Absolutely yeah thank you And that's all I have thanks Any other questions One question The ACO is in a very unique position relative to healthcare the healthcare system they deal with providers they deal with insurers etc and you know from that position I would think from time to time they would see things and maybe this kind of relates to slide 23 you don't have to go back there but they might see things that would be helpful to making the system more effective even though it's kind of outside of their direct purview and I'm wondering and one of the ideas or thoughts that struck me was in the last years ACO budget process it became clear to me that ACO staff didn't appreciate the benchmark plan that is the foundation for all the QHPB plans they just didn't know about it and didn't know that the one that we have still now goes back to 2012 and so I'm wondering if in their budget process there is a point or should there be a point where their good ideas the things that they see out there where the system is inefficient get communicated and not that they can do anything about it but that they don't stay so in their own silo that they don't mention it to us or to other players out there so that's just the thought that they are in a unique position and see a lot of the complexity that exists out there whether it ranges from the benchmark plan to payer mix et cetera et cetera and I'm just wondering if we should formalize or do you think we have a process by which those insights can be shared yeah I mean I think certainly we can ask a question that asks them for any insights they might have I think that's kind of the hope with adding a greater emphasis on data is that we will be able to see and identify trends and you know share insights but I think certainly asking for their innovative ideas can certainly not hurt that's it for me thanks thanks Tom other questions from the board or comments I just have a comment Elena and this is for you and your team you know we as Vermont have been regulating hospital budgets for decades and we've been regulating ACOs for a few years and so this process of building an ACO budget process we've been working on it for a few years but it's still relatively new and I just want to say I really appreciate all the thought that you and the team put into really thinking about eliminating redundancy and streamlining the process and focusing on data for the purposes of clarity and taking into consideration board comments but also public comments on all of this and I just think this is a great you know piece of work here and trying to do all this and so I just want to say I appreciate it thank you and I appreciate all the input that we've gotten you know it certainly wasn't just you know the two of us putting our heads together we relied you know the HDA provided comments and one care provided some comments and certainly all the board members and you know we're excited to see what public comments shows but really I think the goal here is to make sure that we're increasing transparency and making things simpler to understand so thank you Jeff and everyone who's helped out okay anyone else from the board hearing none I'm going to open it up for public comment any member of the public a very quiet group today thank you Elena thank you all take care okay is there any old business to come before the board hearing none is there any new business to come before the board I heard a sigh but that was it so with that is there a motion to adjourn so moved second it's been moved and seconded to adjourn all those in favor signify by saying I I any opposed thank you everyone have a great rest of the day