 Good afternoon and welcome to the Green Mountain Care Board meeting. My name is Kevin Mullen, the chair of the board. Hopefully this afternoon's meeting will go much better than last week. We had a little bit of excitement as there was a nationwide Microsoft problem with teams and so the meeting was cut out halfway through. So after we do the executive director report in the minutes, I just want to give anybody that has an opportunity and wishes to comment on what we had been discussing at that point in the meeting, which was the quality results. And Michelle Degree, are you on the line? Not hearing Michelle. I guess the board members will have to try to do their best to help out with any public comments on that. So with that, I'm going to turn it over to the executive director's report, Susan Barrett. Thank you, Mr. Chair. And I think Elena should be on this call and maybe somebody could reach out to Michelle to see if she's on the spot. I'm here and I'm hanging Michelle, but I'm happy to answer any questions. Great. Thank you. And so thank you, Mr. Chair. I have a couple of announcements on public comment and then some scheduling reminders. First, we have two open public comment items right now. The first one we just started today and it's regarding the topic of our meeting today, which is the revised 2020 Medicare benchmark proposal. The public comment starts today, as I said, and it ends at noon on October 20th. We do have a potential vote planned for October 21st on this issue, which you will hear more about momentarily. And then the second open public comment period is on the draft regulatory alignment papers. And that comment period is open until the end of the month, October 30th. And if you have any questions, you can consult our public comment website or section on our website or reach directly out to Abigail. And the second item is just to update you on some scheduling, as Chair Mullen talked about in our last meeting, we had the technical difficulties. We were supposed to have a hospital budget debrief discussion following the quality results discussion. Due to scheduling, we are going to put that back on the calendar next Wednesday, the 21st. And we'll be hearing from the same folks who were lined up to discuss that last week. And that is all I have to report. If there aren't any questions, I'll turn it back to you, Mr. Chair. Thank you, Susan. The next item are the minutes of last Wednesday. Is there a motion? Still moved. Second. It's been moved and seconded to approve the minutes without any additions, deletions, or corrections. Is there any further conversation? Hearing none. All those in favor of the motion signify by saying aye. Aye. Those opposed signify by saying nay. So with that, I am going to give anybody an opportunity. I believe that Dale was the one that was making the last public comment. So I don't know if Dale finished that public comment or what. But I do understand that Michelle is also on the line with Elena. And although we don't have the entire panel, we certainly welcome public comment on that discussion. Would anybody wish to make any public comment? Hearing none, we'll get in right into today's business. And the next item on the agenda is I'll be turning it over to Sarah Lindberg for a discussion on the Medicare benchmarks. Sarah? Okay. So is everyone able to see my screen? Not yet. No, we can't. Okay. Okay. Wonderful. So thank you for taking time for me to speak with you today. Today I am coming to you because we need to talk about the current year, the 2020 Medicare benchmark, which we proposed and voted on at the end of last year. But due to the public health emergency, requires some revision. So our objective today is to look at those, review what we mean when we talk about a Medicare benchmark, because the benchmark as it exists today can no longer really be considered appropriate due to the effects of the public health emergency. And given that there is ongoing uncertainty about how the rest of the year is going to play out, it is our opinion that the appropriate methodology would be using a retrospective trend factor for the current performance year. If we were not to submit this revision to CMS, they do have the authority in their participation agreement with one care to just revise it on their own and not involve us. So I think that this change will happen whether we do this revision or not. And in the spirit of the agreement, it would behoove us to make this revision accordingly. So moving on to slide three, just as a reminder, there are lots of different financial targets that we talk about with the all payer model. Often when I'm talking with you, I am talking about the all payer model financial targets. And that is a contract between the state of Vermont and the Centers for Medicare and Medicaid Services or CMS. And that's where we get our all payer growth limit of 3.5 to 4.3% from 2017 to 2022. There's also a Medicare specific financial target in that agreement. But that is not what I'm here to talk to you today about. Today I'm here to talk to you about an agreement between CMS and one care Vermont called the Medicare participation agreement. And that set annual prospective targets or benchmarks for the spending of Medicare beneficiaries attributed to one care Vermont. So these are the lives who one care is responsible for in the current performance year. Now the contract, the all payer model contract does give us authority to propose these targets for approval to CMS. And that's the process that we tend to do in December proceeding a performance year. I should say November into December proceeding an upcoming performance year because we try to set the targets in a prospective manner. However, turning to slide four on COVID has really put a wrench in the works of anything prospective. And so Medicare has acknowledged a lot of these problems and has offered some flexibilities to a lot of different programs. One of them is that any expenditures associated with a COVID-19 episode is excluded from the ACO's accountability. So it is removed from their total cost of care. To date that's about $1.3 million for beneficiaries attributed to one care. And statewide it's $2.5 million. And we expect to remove those costs from our statewide total cost of care which we'll talk about another day. Another flexibility that they've offered is that any shared losses that's associated with the time period of our public health emergency are mitigated. There's a little bit of a complex formula but the upshot is that there essentially won't be any downside risk to the ACO in 2020. It's going to be a because we know now that the public health emergencies at least extended into next year. We feel really confident that any downside loss is really not a concern for 2020. And finally the flexibility is they're saying that while we usually insist on a prospective trend factor given the uncertainty we would recommend using a retrospective regional trend for these financial targets or benchmarks. And turning to slide five I just want to remind you about kind of the core components of how a financial target is set in the Medicare program. It's got three principal components. There's an estimate for historical experience. There are the number of prospectively aligned beneficiaries and then there's a trend rate. So in for 2020 you had elected to use a trend rate of 3.5 percent but that is the factor that we're really talking about revising in this proposal. And instead of using that guess of growth that we would have expected this year we're suggesting that we use the actual growth from calendar year 19 to calendar year 20 to account for all the uncertainty. And if you look at slide six you can see that expenditures really took a dip in response to the public health emergency. In Vermont we've been relatively fortunate compared to some other states in that most of these declines in expenditures have to do with people not taking care instead of seeing bumps in costs due to the system being overwhelmed or excessive COVID costs. But as you can see in April of 2020 costs were about half of what we might have expected in a typical year. I'm sure this is all a near and dear to your hearts having just gone through the hospital budget review process but these are just how it's affected Medicare as a payer. And if we look at that on slide seven on a per person spending so if we look at statewide so all of Vermont people who we think would be eligible to attribute to this ACO program and we can pair their monthly expenditures in January through May you'll see again that costs were about half of what we would have expected in April. They're starting to rebound in May and in June they're starting to converge again so we think if the recovery continues to be as successful as we are seeing now that probably the rest of 2020 will look similar to 2019 however that's a big if it's hard to say what might happen and that is causes a lot of confusion and uncertainty for both the ACO and Medicare. So basically the slide eight lines out the meat of the proposal there is a draft letter that we would like to send to CMMI for the board to review prior to voting but essentially we would like to wait until we have three months of paid claims run out for Caledare 2020 so that we would have expect that to have that available around April of 2021 and we would see how the comparison population in 2019 compared to the actual aligned beneficiaries in 2020 and use that actual trend rate to recalculate the benchmark and then once we have that number it will be the board's job to make sure that that target still fulfills our duties as outlined in that all-pair model agreement and we want to place specific emphasis on section 8B21A which says that the Vermont Medicare ACO Initiative Benchmarks should incentivize high quality care promote efficient care and support improvement in the health of aligned beneficiaries and essentially what we're saying here is that we don't want to set a benchmark that would put any risk on providers to continue to provide that high quality care so we want to make sure that we know the benchmark today is too high but we don't want to risk it being too low with this methodology so in partnership with CMMI we would do that calculation and assessment to see that we still think that the benchmark is appropriate and finally I want to be clear that we would still add on the advanced shared savings as it was originally included in the benchmark and so that was 8.4 million dollars that has already been distributed to the ACO and as ordered by the Green Mountain Care Board the ACO has already invested those funds to support the blueprint for health in SASH and so we believe that these programs definitively have been evaluated to show that they help further the goals of the all-pair model both in terms of quality access and cost savings and so I believe that you know in particular the the network participants have some concerns about the the risk of having to pay that money back and we at the Green Mountain Care Board and our federal partners you know we are we're very mindful of that and sensitive to that fear and we you know will assess the results of the benchmark but this money is is added on it's not part of the performance risk so this won't be a change per se but we just want to make sure that the federal government is aware this money has already been spent and that the one care didn't really have any discretion in that spending so that's going to be part of the you know the review when the benchmark comes back and I would say that this amount assumed growth it assumed a growing trend that maybe won't be won't be possible given the COVID emergency so we just want to you know be sensitive to that assumption with whatever the benchmark comes back at so that's a high level overview of the letter to the federal government I'm happy to talk about any questions or concerns you have about the letter at this time questions for Sarah hi Sarah did we lose her hello hello here okay hello can you hear me okay I can hear you um can you go back to slide six please uh yes I can I think I can as the little engine says yes there is slide six not yet for me but you're getting there slowly there you go um so I'm just wondering um obviously the pandemic is an extraordinarily unusual event so you know this effort certainly makes sense to me I'm just wondering what the you know a guard rails might be around um a recalculation of the benchmark because you can look at of September and October where there was no pandemic and there's a 14 point differential there um and so I'm just wondering kind of from a statistical point of view what might might be a range around the benchmark as opposed to uh a precise calculation uh that's a great question and uh we we floated the um I'm gonna turn my camera off because it's looking wonky uh we had asked our federal partners about the possibility of such um guard rails and I think that the the the fear on their side is that it's just so much uncertainty that they didn't feel comfortable documenting any specific number in writing uh but I would say that it looks like um even if uh we were to have an increased utilization um there's I I don't see a chance that we would get up to the former benchmark uh so I think if I were a betting man I'd say we're probably looking at about a negative five percent trend rate um when the year is over but um there's still a lot unseen um just a couple more um are there um I mean we faced this issue in the hospital budget process and generally hospitals kind of trended up you know off of information through February and I'm just wondering are there any complications uh if if a different methodology is applied to this benchmark um so I think that's a great question uh and that's we're actually grappling with that for sinking through the 2021 benchmark so is there a way we can have something that's truly prospective given this uncertainty with a little bit more experience and perhaps an opportunity to revisit um that estimate a little bit into 2021 but I do think that uh for 2020 uh any any other substantial change to the methodology might be something that uh would have some time and resource constraints associated with it if that makes sense yeah I I'm just I'm just worried about you know the two different processes being on a different platforms um and and whether and maybe it doesn't make any difference at all but I'm but alignment always favored over non-alignment so that's that's why I asked the question sure the tricky thing is that um you know the hospital budget is based on you know care that the hospital delivers so whoever shows up whereas you know this is a measure of where of the people wherever they get the care and so there's some even more variability there so for instance I'm keenly interested in if we have a market difference in our snowbird uh behavior uh due to this event so that would mean that you know there'd be kind of um probably less spending just because compared to the prices we're seeing for care sought down in Florida um it tends to be lower um costs uh when people have their care in Vermont so you know I think there's just even more uh variables at work with this um kind of um people behavior aspects that um it's certainly a factor in the hospital budget but might be a little um easier to to project to Ella I shouldn't say it's easy none of this is easy it's just a it's a different um it's a different yeah it's a different now it's one of one of one of trying to do the best you can situations uh final question is are there other states going through this with CMI uh obviously you know there are different um health care reform activities in other states is is this um you know a shared uh I mean it's not just from I do you know of other states that are going through the same same process sure I think the most um close example would be the next generation aco program and they are using this retrospective trend so that's another kind of point in its favor is that um that's what the next gen aco program is doing they are planning to do that again in 2021 but um we and our federal partners are in agreement that we would really like to try to figure out something truly prospective for 2021 to help with um predictability and stability for our health care providers thank you anytime other questions from the board or comments maybe just a quick question Sarah um this is Jessica can you just remind me uh who the reference population will be in 2019 um that you're going to use to calculate that um you know the trend rate obviously the 2020 will be the attributed lives in 2020 can you just remind me who they will be in 2019 the reference or yep so that would be the um folks who would have attributed to the aco in 2019 using the 2020 network so we have a fake performance here that we use and that way we're able to capture the expensive end of life care that we know will hit a cohort of Medicare beneficiaries okay thank you so it's not the actual attributed in 2019 it's the would have been attributed in 2019 if the 2020 network were the same in 2019 correct yeah there is there's quite a bit of overlap I'd say about you know I I don't want to speak off without reviewing it but uh there's quite a few people who are in both those populations but it's the people who die that are um really important to incorporate in that um estimate sure okay thank you so much no problem other questions or comments from the board this is Robin I'll just say this makes um sense to me I think we all when the pandemic hit recognized that it was going to create a lot of uncertainty and difficulty in terms of setting benchmarks moving forward as well as budgets so um thank you for a very clear presentation you're welcome Sarah when would you need action by the board on this uh it would be ideal to have a vote uh next week so that uh we can get approval from our federal partners in advance of the next one care Vermont board meeting in November so that they can vote and um sign a contract that reflects this um all these flexibilities not just the retrospective trend but also um removing the COVID costs and the mitigation of the downside risk so we really need to get this posted for public comment as soon as possible yeah I believe the public comment period is currently open for this so uh we welcome public feedback the only other thing I wanted to chime in with um and I apologize I forgot to say this earlier is um I I appreciate also um taking a look at those blueprint community PMPM community health team and cash payments that are in what people call the advanced shared savings um given that that was a specific request by the state from the federal government that we that we'd be able to maintain Medicare participation in those programs and that that Medicare participation be able to um work the same way that it had been working as well as um be trended which it hadn't been prior to that so I think given the situation um I'm I really like the idea of being able to maintain that amount even even if we're adjusting the benchmark because I do think that the community health teams have been working remotely and so um you know that work I I think was maybe less impacted from some of the pandemic since it's the type of work that could be done easily more easily through telemedicine etc. Absolutely and I would just say that um our federal partners um have not had any uh criticisms about that program or or desire to um cut the funding I think it's just that um because it is part of the savings calculation it feels a little bit riskier to the network um than maybe it did last December. Sure I mean there's been a lot of confusion about that I think from the beginning in terms of how that works um and uh the other thing I was going to suggest you may have we may have already done this but since we do have the federal evaluation showing savings for blueprint and staff I wonder if maybe we should post links to those on our website I know you referred to it in your PowerPoint but um those are publicly available if people weren't interested in looking at those. We can put those up Robin thank you. Any other comments or questions from the board? Hearing none I'm going to open it up for a public comment. Is there a public comment? Mike Del Treco. Can you hear me now? Yes. So just to clarify this presentation that Sarah just went through is to revise the methodology on how you will recalculate the benchmark. It doesn't really talk about any new benchmark today is that correct? Correct we wouldn't know the new benchmark until about April of next year. Correct we'd have to have at least the three months of run out Mike to set that. Once the methodology is finalized however we will be able to get reports from our federal partners to help track where we're doing well how it stands to date. We are hoping to get our next sense of that towards the end of this month and those are reports that are also shared with OneCare. Right so that you you tipped my next question which is three months of run out but if it's a retrospective look on trend you know how are you going to marry those two things together to develop the new benchmark because you know the sooner we know this the better and I understand the challenges you're facing so just just clarifying questions and that's all. Thanks Mike. Other public comment? Other public comment? Any other public comment? And again we do have an open public comment period that's posted to the website and we will be taking any public comment so if you think of something later or in the next few days please provide us with that public comment. So thank you Sarah I think this was very very helpful uncertain times but it's clear that it's better that the state of Vermont takes action rather than just letting the feds go ahead and take the action on their own. Yeah thank you for your time. Thank you. Is there any old business to come before the board? Hearing none is there any new business to come before the board? So I'm going to take this opportunity I know it's probably not her last meeting because I believe that she's still working through the end of this month but many years ago I had the opportunity as a legislator to work with a member of the administration that always came into our committee and gave us the information and the facts and was clearly an incredibly hard-working state employee. She left in what I would call went to the dark side and became a lobbyist after that and then a few years back she left that role and went over to work for MVP and it's been a pleasure working for her as she really has been the Vermont face of MVP at least during my tenure on the board and so Susan Gorkowski we're going to miss you we're jealous that you're retiring but we do want to thank you for your many many years of service in the healthcare arena and wish you all the best in the future so thank you Susan. Well and thank you Kevin I'm not sure I'm going to go away totally I'll probably still call into your meetings just out of curiosity but thank you very much it's been my pleasure. Thank you. Congratulations Susan. Is there any other new business to come before the board? Hearing none is there a motion to adjourn? So moved. Second. It's been moved and seconded to adjourn all those in favor please signify by saying aye. Aye. Aye. Those opposed signify by saying nay. The meeting is adjourned thank you everyone have a great rest of the day.