 Good afternoon and welcome to the Green Mountain Care Board Meeting. My name is Kevin Mullin chair of the board and I'm going to start today's meeting with the executive directors report Susan Barrett. Good afternoon. Thank you Mr. Chair. A couple of announcements. First next week we will have a board meeting. Other years it's town meeting week so other years we've canceled the board meeting for this week. This is an unusual time. I don't think folks are taking any time off to go anywhere. So we are in fact having the board meeting next Wednesday and the press release for next month will be out momentarily but just to update folks the topic of the meeting next week is a presentation by our hospital budget team on FY 20 hospital actuals. And I also just want to remind folks of an ongoing public comment period. I've mentioned it several times but we at the Green Mountain Care Board in with our partners at the Agency of Human Services have put out requests for public comment, public engagement. We've present on the potential next agreement with CMMI. So the information on that presentation that we had with the director of health care reform and Alina Barrett from our team given to the general advisories on our public comment website. I'd ask folks to take a look and if you want to share any comments or advice to the Agency of Human Services or the Green Mountain Care Board on the potential next agreement with CMMI we would appreciate that. And that is all I have to report. Thank you Mr. Chair. Thank you Susan. The next item on the agenda are the minutes of Wednesday, February 17th. Is there a motion? It's been moved and seconded to approve the minutes of Wednesday, February 17th without any additions, deletions or corrections. Is there any further discussion? Hearing none. All those in favor of the motion signify by saying aye. Those opposed signify by saying nay. Let the record show that pass unanimously. So next we're gonna revert back to the executive director and we're gonna have a presentation of what's been happening at the Green Mountain Care Board and it specifically relates to a recent submission to the legislature of our annual report and it's just giving the public an update on what we have been up to and what we look forward to being up to in the coming year. So Susan Barrett. Thank you again Mr. Chair. So I am going to share my screen and hopefully this will work. I announced earlier as having a bit of problem with my outlook. So I'm going to do that and make this into a slide show. Can you see my screen? We can. Excellent. And then I want to say up front, of course, of all days, we are expecting an oil delivery and I have two dogs. So I will usually I can mute but if I'm talking, it may be an issue. So just an FYI. We do need oil. So can't get around it. Thank you. So thank you for the opportunity to give an update on our annual report that as Chair Mullin said, we submit to the legislature per our statute every year. There's a lot of work that goes into the annual report and it's a really useful resource for legislators for us internally and I'm hoping for external parties as well. I want to start out by thanking a couple of people, which is always really dangerous because when you call out people, you're always leaving others out. So I'm just going to say this up front that Sarah Kinsler, who's our director of strategy and operations, as well as Christina McLaughlin, who's our health policy analyst, really took the lead in compiling this information. But everybody at the board worked on this. So it's a team effort and I also want to share that as I go through this presentation, we do have the directors on the line as well. So if we need to get into more of a deep dive, they are on call and ready to answer any questions you might have. So the first thing I'm going to do is to get a little bit of a background. I know the board knows what the Green Mountain Care Board is, but it's, I think, important to have a reminder of our background and how long we've been in existence and how we got here. So I'm just going to do a few of those slides and then I'll get into the results of 2020. So there you all are. This is the Green Mountain Care Board and me, the executive director. The board was established in 2011 as part of Act 48. It's a five-member board and the executive director. It's an independent board and each of you, as you know, have six-year staggered terms. So a little bit more about what makes the board unique. First, it's mission. It's built on the triple aim, but our mission is to improve the health of Vermonters through a high quality accessible, affordable and sustainable health care system. And there are three things, three unique things that make the board a very different entity than what is in existence in many other states. First, our transparency. And I'll be the first one to say this, and I've said this at the legislature. My job would be a lot easier if we did not have to work under the Vermont Open Meeting Law. However, I think the benefit that this, the fact that we are so transparent, the benefit to Vermonters, to the legislature, to the administration, to other stakeholders is immense. And although it is, you know, it's a lot of extra work. It's well worth it. And it makes me proud to be a Vermonter and to work at the Green Mountain Care Board. So our regular decisions, as you all know, are made in public at these meetings, nearly all of our regulatory decisions with data evidence and staff recommendations. And these meetings are open to all the meetings are videotaped by Orca Media. That is not a statutory requirement. That is something that we do on our own. Most of the time they are videotaped. I think it's a little easier since we've been remote, but sometimes they cannot get a physical person to the to the meeting. And then the recordings are available online. We engage stakeholders, including the Office of the Healthcare Advocate, who we work very closely with. We work with other state agencies, regulated entities, and of course, most importantly, the public to inform our work. I talked a little bit about independence earlier. I'll just briefly say that the board is independent. So we do not report to the governor or to the legislature. We are truly an independent board. Our members are appointed, as I said, to six year terms. The advantage of this is that they span gubernatorial administrations. And then we have a system-wide view. The unique role of the of we have a unique role in Vermont's healthcare system, regulating the key industry players. We're driving reform efforts through our regulation and we evaluate our healthcare system. And then this integrated regulatory approach lets the board understand regulatory decisions that impact one another. And it also allows us to account for this in account for the cross system impact. I'll touch on this system-wide view a little later as we talk about our regulatory integration white papers. And Kevin or Mr. Chair, would you like me to just have folks ask questions as we go along from the board? Or do you want me to like do I can go either way? It's up to you. Folks, you're on mute, Kevin. I said, if someone has a clarifying question, they can ask it at any time, but otherwise we'll hold them till the end. Great. So the role of the board, I touched on this a little bit earlier, but this is on the left in the small bubble is actually our statutory charge. And that is the Green Mountain Care Board is charged with reducing the rate of health care cost growth in Vermont while ensuring that the state of Vermont maintains a high quality accessible health care system. In the larger bubble on the right is a list of our regulatory duties and some of the transparency work that we are doing and have done. I'm going to be touching on many of these things as I report out the results of 2020. And then just to sum up the system wide focus and what the board does. The board oversees innovative reforms that seek to improve quality of and access to care. The board contains Vermont health care cost growth and the board improves remodse ability to collect and evaluate health care data. And last but certainly not least key to our work is promoting transparency and understanding for the public. Okay, so now I'm going to get into progress in 2020. And these are the themes that I'm going to touch on for this discussion today. I want to say that our annual report is and there's a link to it at the bottom at the end of this presentation. It's on our website. If you can't find it, please reach out to Abigail. She'll make sure you get a copy. But I'm not going through every section of the report, but I am pulling out these key themes for an update for you today. So first the Green Mountain Care Report budget, then regulatory and internal response to COVID-19. Another theme from 2020 was reporting and monitoring of the Vermont's all-payer model, regulation, oversight and data. I'll discuss some legislative reports submitted in 2020. And last, as Kevin mentioned, I'll talk about some 2021 priorities. So first the budget, the board's actuals for FY 2020 did come under budget. This was primarily due to the board and the contractors deferred work due to COVID-19. It was also due to the Chair Mullen immediately after the state of emergency directing me to really just halt in terms of hiring or anything like that. We really took a very proactive approach to our budget. And Kevin, I don't know if you want to add anything on this slide. No, I think that the board has been level funded for four years straight. And we try to be ever watchful of the tax fair dollar, but it may not be able to last forever. And speaking of level funding in is an update to fast forward to where we are today. The board is level funded for this year, which is FY, I was get the FYs wrong 22. And we are in the process now of reviewing our budget with the legislature we've presented to House Healthcare that was last week. And then we have not been in front of the Senate Health Senate appropriation. Did I say healthcare? It's a House Appropriations Committee. And then we'll go into the Senate Appropriations Committee. That is the process. And then the legislature will decide on the budget as a whole. And we'll go from there. So the regular the response to COVID I have regulatory first, there's it's really two pronged. There was an external response from the board with our regulated entities. And then there was an internal response. So the first all covers the external response. So very soon after the governor announced a state of emergency, the legislature acted and passed Act 91 of 2020, which offered us and many other parts of state government, some flexibility. And for us, it offered the flexibility for us in our regulation. And it allowed our GMC be regulated entities, that flexibility as well. And I'm just going to go through this list, but I'll give you some specific examples. So we were able to issue new guidance for CNN applications related to COVID-19, and waiting the need for new for review of certain projects. So, you know, if you remember back to a year ago about there was did we didn't we were in a position where we we were potentially needing field hospitals and hospitals were potentially going to and did break down walls and have to set up places for potential surge. Luckily, we avoided that, but we needed to make sure that the regulated entities and the state could move quickly to adjust to the needs of the of the frontline providers. The second is continuing. We continue to monitor hospital solvency and and we were able to issue new hospital guidance leaked. I think it was in April that we did it maybe March. We significantly streamed line the the guidance in order to reduce the regulatory burden on the hospitals. And then in addition, we delayed the hospital budget submission due dates by about a month, if I recall. And the we also were amended the one care Vermont's 2020 budget order. And that was to allow the redirection of resources and funding toward frontline provider providers. And then also to extend the reporting timeline to allow the revisions and accounting for delete delays in the availability of information. Obviously, folks were not going into doctors offices and claims were not being processed as quickly. So that was one of the reasons we did that. Also we delayed the Green Mountain Care Board's insurance rate review decisions by a week. And then last but certainly not least, our data team was able to assist the state as they looked at responding to COVID and to identify in cases with our data separately, not related to Act 91. The board and our AHS partners worked with our federal partners at CMMI to request flexibility and additional funding for providers participating in the all pair model. Importantly, both for the board as well as for regulated entities that despite all these challenges, the board completed all its regulatory duties. And I really want to send out a thank you and a kudos to our frontline regulated entities. I know it was quite a year and it still continues to be quite a year. And then there was an internal response that I'll share. This was really our operations at the Green Mountain Care Board. So the board quickly transitioned to remote work for our staff and to all remote board meetings and hearings. Most people know where our physical location is. But if you don't, we are located in Montpelier and we are right next to the Wynuski River. And there are oftentimes where the river either gets an ice dam or jam. I think it's a dam. I think and there could be flooding in the winter or flooding from raining in other parts of the year. So we in our internal operations in our business office was had put together extensive planning for an emergency situation and the ability to work from home. So we implemented those plans. I believe it was we were just talking about this earlier in a meeting Friday the 13th of 2020, that the governor ordered that everyone was to work from home. And we did that and I haven't been back since. So it has, you know, there have been hitches in terms of some some processes, but all in all, the transition has been pretty seamless. And then also the remote board meetings and hearings that we're doing right now. I want to call out Abigail Conley, who is the executive assistant to chair Mullen and is so much support to all of us. She took a lot of energy and put in a lot of work behind the scenes to make sure that people could understand how to get on to teams and how to present on teams. And so all of our meetings and hearings have been really accessible. Literally, I'm going to knock on wood because I don't want to jinx it. But there was one time where teams went out nationally and we lost our connection. But that was the only time that we have any issues. And then I wanted to silver lining here is that we've been able to welcome Vermonters who might not otherwise be able to travel to Montpelier for these meetings. And there have been, I think there's been an increased ability for others to attend our meetings who may not have been able to when they were held in person. And then a note on the teams platform that we use that it offers a lot of accessibility for disabled folks with disabilities. So for instance, it has a closed caption feature. So if people need that, they can turn that on. And it's another enhanced way to communicate. Kevin, do you have anything to add here? I do not. Okay. So moving on to monitoring and reporting on Vermont's progress in the all payer model. So COVID-19 obviously presented challenges in the third year of our model. But it also confirmed the benefits of these that move away from fee for service to predictable fixed payments. So early in the model, early in the pandemic, excuse me, as we remember, there were literally that nobody was going into hospitals, no one was seeing their, their providers in person. And what was a lifeline for many of these prime providers and, and I think predominantly some of the independent providers we heard anecdotally were these fixed payments that they were getting if they were participating in the all payer model. So it really laid bare the the shortcomings of the fee for service model. In addition, the board looked at revisiting the methodology we use to develop the Medicare the 2020 benchmark to more accurately reflect utilization 2020 is going to be a very difficult data year in so many ways. And we recognize that and our partners at CMMI recognize that. So in December, the board also voted to propose the use of this new methodology and developing the 2021 Medicare benchmark. And then that will also include approximately 8.7 million to the benchmark to continue investments in blueprint for health and SASH programs. And this is a look at the reporting to CMS that the state both AHS and the Green Mountain Care Board does regarding the all payer model. This has been a bit fluid as well because of the pandemic. Much of our data, especially around quality comes from the Vermont Department of Health. Obviously they have been tied up with the pandemic. And so there have been delays. I also want to highlight that in June of 2020, we did issue our scale target report. And that that report initiated a warning letter from CMMI on the state's scale target progress. But in response, and I'm just going to go to the next slide, one of the key things that came out of that was that the the the agency of human services announced the all payer model implementation improvement plan. And they issued this in November 2020. Oops, I think someone might not need to be on mute. I think I hear a little one. Hope they're enjoying the presentation. Some kids are off this week. Oh, that's right. That's right. So the agency of human services issued a plan this plan in November of last year for improving the performance in the all payer model agreement. It has four categories of recommendations. One is focused on state and federal work to maximize agreement framework, to reorganization and prioritization of health reform activities within the agency of human services, three evolving the regulatory framework for value based payments and for strengthening ACO leadership strategy. We did have a presentation from the Secretary of Hs and the director of health care reform when this plan was was launched and the link I'm sure they have a link on their website. We also have a link to this plan on our websites. So GMCB oversight and regulation oversight and data. I am going to summarize this is a lot of work in one page, but and I again, I suggest if folks want a deeper dive, they definitely look at the annual report that lays out a lot more information in here, but this is just really a sound bite of our summary of the regulatory work for 2020 at the Green Mountain care board. First hospital budget review for FY 2021. So system wide increase in NPR of 2.7% for was approved versus the requested 3.3%. And I should say net patient revenue. I'm going to try not to use acronyms. The board established we did average increases in hospital charges of 5.6%. And the board expanded sustainability planning to all hospitals. This was also required later in the session at the legislature by Act 159 of 2020. In terms of health insurance premium rate review, the board reduced rates requested by the insurers by approximately $20 million, including $18.8 million for plans sold through Vermont Health Connect. For certificate of need, the board reviewed five CON applications. There are another five proposed applications that fell outside of the statutory jurisdiction parameters of the board. And then ACO oversight. The board approved one cares FY 21 budget with 17 conditions. The board expressed intent to incorporate a new requirement in the ACO rule. And that is that executive compensation be tied to ACO quality and financial performance and that work is being done right now. In terms of data, the board the board's data team increased access to the cures and buds through improved application processes trying to streamline those and make them a little easier to access. They created standard reports and analysis ready files and published the first phase of the health resource allocation plan. The data team also explored ways to improve race and ethnicity data and claims. And then I talked a little bit about this earlier. And again, I urge folks to take a look at these papers. These are the regulatory alignment papers. They that this white paper series looks to improve the board's ability to make decisions consistently across regulatory processes and ensure appropriate assessment of regulated entities in a reformed payment and delivery system environment. We're really trying to take all the levers that we have and align where we can. So it sounds easier, easier said than done. But the white papers really look at that what that process could be and what some of the issues are to doing that. This summer, we heard a presentation from Sarah Kinsler. And in the Green Mountain Care Board, I'm sorry, this summer, they were released in discussion drafts for the first two white papers. And these focused on exploring the board's regulatory processes and the connections between them and their current state and potential changes to the timeline to improve alignment. In the fall, September, the white papers were presented to the board. And there was public comments through the end of October. The final versions of both of these papers are expected to be released in early 2021. And those really helpful public comments are being incorporated into the papers. And then I'm going to list out these annual reports, excuse me, legislative reports that we submitted last year. The many of them are annual and they're per our enabling statute, but some are some are unique to last year. So the impact of prescription drugs and you can see the asterisk asterisk indicates reports that are submitted annually. So this is an annual report. This is shows the impact of prescription drug costs on health insurance premiums. The rural health services task force report board member lunch put a lot of work in with a lot of work from stakeholders looking at the issues around rural health care and many of the recommendations in that report were used like in telemedicine bills in I think they're even talking about audio only coverage for remote health care. So really this this report was very valuable. The other report which which this was a unique report 2020 was the primary care spend report, Michelle degree on our team, as well as worked with others in the stakeholder community and other agencies to create this report. The cost shift impact report. This is also this is an annual report and it looks to measure the impact of the cost shift on our our health care environment. Also the GMCB 2019 annual report, which we're discussing today that is a report that is submitted obviously annually. And then also the 2018 Vermont health care expenditure analysis. Note that this is typically delayed. We have flagged this with the legislature just timing on data and resource staff resources typically means that this report is produced later spring as opposed to January. So we're working to tweak that due date this session. And then another annual report is the billback report. And that's submitted in September. And one last slide. Priorities in 2021, these priorities are not in any specific order. There and it's really hard to really focus on, you know, there's so much work to be done, but it is important to focus on on specific priorities. And this was a list that we put forth in our budget as well. So first ACO oversight, all peer model implementation and all peer model 2.0 planning and engagement with our partners at the agency of human services and the director of health care reform. So that work continues. It's a very important work. And again, as I mentioned at the beginning of the meeting, I'd urge folks to provide any comments or after looking at the information on our website, any advice on going forward with a potential second agreement, we will we will be working very closely with our partners at AHS and they will be taking the lead in the design of this model potential model. So I urge you to comment on that and we will share those with them. regulatory integration. We talked about this is a key focus. It has been it was last year it continues to be this year. And that work is integral to our future work and how we can integrate our regulatory levers to accomplish our mission and our statutory charge. Transparency, data and vCures, we wanted to we want to continue to expand access to and the usability of our healthcare data resources. We continue to work on ways we could look at in increasing recent ethnicity data and claims as we as I said before, we're working on those areas as well. And then the health resource allocation plan in 2018 Act 167 was passed. And that amended the requirements for the HRAP or the health resource allocation plan. The board continues to work on the HRAP. We've made significant progress. And we are creating the HRAP in a different form than it's been created in the past where it was more static. We're making it more dynamic as a series of reports and to support and improve regulatory decision making, both at the board and other state agencies and for the public. Healthcare workforce is a really big focus for the board. It impacts our regulatory decision decisions immensely. And we see the impact of shortages, both in the hospital budget process and the and the impact to hospitals in having to hire traveling providers, as well as other parts of the healthcare landscape. And I will call out our primary care advisory group that is about, I think it's 11 11 or 12 primary care providers who have been working tirelessly to support primary care in the state. And they have been very influential in passing last year, they were able to testify up at the state house to talk about the impact of healthcare workforce shortages, especially in primary care. And we're able to get each 607 passed, which was a scholarship fund set up for primary care providers. So that's a that's a huge issue. And then hospital sustainability, we I touched on that earlier. We are working with the Vermont hospitals on sustainability plans. I will say, because of COVID, we've we've taken a break off for the hospitals, we continue to work internally to look at some data and to work on those plans. But we are very mindful of the burden of COVID and the vaccination programs that especially the hospitals are taking right now. And I think that is that the rest of the slides are additional information listed titles here. And you can go through the slides for the additional more in depth information. So I will stop there. So with that, I'll open it up to board members for any questions of Susan. I just like to add that I think Susan and staff have done a great job of presenting you what we do do and the complexity of what we do do and the ability to be fast on our feet when something like COVID comes along and be very supportive of the folks that we work with without work within the field. But one thing I'd like to emphasize or two things that I'd emphasize is one is that we we don't have aren't by and large a command and control entity, you know, where we regulate the entire environment that we're trying to affect. We do have some influence over hospital budgets, relatively less influence over influence over insurance rates. The ERISA folks, for example, it's not something that we cover. There's many providers out there that we don't cover directly. There's others that are across our borders like Dartmouth Hitchcock and the hospitals in New York, et cetera, providers. And so we're in a position of trying to leverage what we do have in order to achieve system wide improvements in quality and cost effectiveness. But we don't have the kind of span of control. I think that some people think we have. So it's an issue of leveraging, you know, the the domains, for example, that the legislature has allowed us to to engage in. And the other thing I would say is I think that we're kind of at midstream. I mean, I've only been on the board three years, but I look back and, you know, to all the work of the folks that that did that were there now, and that were there before me, and getting all of the policies in place, the legislation in place, the procedures in place, so that we can do what we do. And, and even entities like the ACO that didn't exist a few years back. But I would have to say that all of that is substantially in place now. I mean, as we transition from 2020 to 2021, you know, and it's the issue of leveraging the ACO, leveraging our rate review proceed processes, leveraging hospital budgets, you know, to, you know, to affect the change that we're looking for, we, we and, you know, we don't have direct command and control, we've put into place the infrastructure that gives us some points of leverage that hopefully will be in influential. But there's no guarantees. And we're still a work in progress. And I think that's important to for people to understand. Thanks, Tom. Really good point. Other members of the board. I just want to say great work to the team. Very clear and succinct. Anyone else from the board? I'll just ditto that echo the same sentiment. Thank you all. Same for me. So if we could get whoever that is to mute themselves, that would be great. So Susan, thank you very much for the report. And at this point, we're going to open it up to the public for any comments or questions that they may have of you. So public comment. Well, I'm glad that Jeff, you raised your hand because I did not want Susan to get off that easy. So I was like, Fair enough. Thank you, Mr. Chairman. And thank you, Susan, for the presentation. Really excellent recounting of what has been a pretty fascinating year for all of us. And thank you to the Green Mountain Care Board, board members and staff for all the work. And, you know, I think we really appreciate the collaboration and the flexibility that was offered to help us get through this unexpected and unbelievable set of moments that we've been managing. So we just really appreciate that and the flexibility that's been offered. You know, hospitals share the same goal as the GMCB, which is better care at a lower cost. And now I think to emerge from the pandemic smarter and stronger. So I think the rest of this year in 2022 are offer are going to offer us a ton of new challenges, some of which we know and some of which we don't. But I think if we continue to kind of work in the Vermont spirit of staying together and being collaborative and listening to one another will be in good shape. So that's what I wanted to offer. And thank you, Susan, for the presentation. Thank you, Jeff, for those kind words. And also I want to express our thanks to you. I see all the hospitals continue to step up further and further to make sure as we get more vaccines that they're getting in people's arms. So keep up the great work. Other members of the public. Well, Susan, I guess this will be a short meeting. And again, thank you to everyone on the Green Mountain Care Board staff. We know that we've asked you to do a lot under tough circumstances. We've left some positions open, and we've asked everybody to do more. And in some respects, I think that our productivity actually increased by working remotely as people focused squarely on the work and realizing that, you know, how important it really is. And so thank you to the staff. Thank you, Susan. And with that is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? Don't move. Second. It's been moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Those opposed signify by saying nay. Thank you, everyone. Have a great rest of the day. For those who are in the sun like we are in Rutland, get outside and get some fresh air.