 The first item on the agenda is the Executive Director's Report, Susan Barrett. Thank you. So, a couple of scheduling updates. First, we do not have a meeting next week that will be for July 4th, so we are canceling that meeting. I also want to remind folks that we have a very busy July, and so please consult our website with our upcoming July meetings. And just as a reminder, we have our Rate Review Hearings, which are being conducted on Monday, July 22nd, and Tuesday, July 23rd, both in Room 11 at the State House. We are also conducting a public forum on Rate Review, and that is located in the Council Chamber's Memorial Room at City Hall in Montpelier. A couple of other announcements. First, I wanted to introduce folks to a new member of the Green Mountain Care Board team, and that's Elena Barube. She will be the Director of Value-Based Programs and ACO Regulation. She will not be presenting the team today because she just started on Monday, but she's catching on very quickly. Elena comes to us from the Department or the Agency of Education, where she was the Manager of Finance for Special Education. She also has background in academia and corporate finance, so I welcome Elena. Okay, I'll turn it over to you after that. And then also just wanted to let folks know that this week, was it just yesterday? I think it was yesterday morning. The Rural Health Care Task Force met, and that was per Act 26 of last session. The legislature asked that a group of identified participants to ask them to come together to evaluate the current state of rural health care in Vermont and identify ways to sustain the system and to ensure it provides access to affordable, high-quality health care. I am pleased to announce that our own Robin Lunge was nominated as the Chair of that Task Force, and so she will be working along with the group to make sure that we have a report back to the legislature in January of 2020. And if you have anything to add, you can, Robin, or you don't have to if you don't want to. No, I mean it was an organizational meeting, so we got ourselves organized, and we'll have many more meetings to come. Perfect. And Mr. Chair, can I turn this over to our general council, who will announce a rate review decision? Sure. Thank you. So on Monday, the board issued a decision disapproving the 2020 Association Health Plan rate program filing submitted by Blue Cross Blue Shield without prejudice to refiling, so they can refile that filing at a later date when it is not appropriate to do so. And that's the decision. I have nothing else to report now. Thank you. The next item are the minutes of Wednesday, June 19th. Is there a motion? It's been moved and seconded to approve the minutes of Wednesday, June 19th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? Thank you. We have a very short agenda today, so we welcome Marissa and Melissa to join us down the front. Can you take it away? Thank you. Good afternoon. My name is Marissa Melamed. I'm here with Melissa Miles, and we're back today to present to you the final 2020 ACO budget guidance and certification eligibility form. We began development of the 2020 guidance in mid-March with internal review of last year's ACO budget and certification guidance and review process. The guidance is reviewed and adopted annually by the board to assist the public and the regulated entity by providing our current approach to or interpretation of the statute and rule. The guidance development process includes reviewing the questions, data collection tables, and budget submission from last year in incorporating any required statutory changes or process improvements. In addition to our internal review, we consulted with OneCare and the Office of the Healthcare Advocate to inform the guidance. We presented the draft guidance at the June 5th board meeting. We reviewed public comment and we're here today to present any updates or changes and recommend a vote to adopt the guidance for the 2020 ACO budget submission. So our agenda today is pretty simple. I'm going to go over the 2020 certification eligibility verification form and we're going to review the public comment and changes on the budget guidance and recommend a vote on the guidance. So we went over this June 5th, but to review the Green Mountain Care Board has the regulatory authority to provide oversight of accountable care organizations with two different mechanisms, certification and budget review. After initial certification, which happened in 2018, the yearly review is to verify ongoing eligibility under the criteria in Rule 5. The yearly review of the ACO's projected budget is where we look at their network, payer contracts, budget, and population health programming. Then through reporting, we monitor the ACO's activities related to the budget throughout the year and we collect updated policies and procedures related to certification. So the guidance is developed under this authority and the standards and requirements by which we review the ACO's submission are set forth in 18VSA 9382, GMCB Rule 5.0, and the all-payer model agreement. So for a review of annual certification, we annually review the One Care's eligibility for certification by asking the ACO to complete a form, identifying material changes to policies, procedures, programs, organizational structures, provider network, health information infrastructure, or other matters addressed in the 10 certification sections of Rule 5.0 that are on the slide. And the annual eligibility review is our opportunity to ask the ACO to attest to material changes and verify that we have received the latest documentation. So this year, we were able to more closely align the timing of the certification form with the budget guidance. There were no changes to the certification criteria this year. So last year, we brought this form to the board for a vote because there was three new criteria that we needed to review in 2019 that we did not in 2018. This year, the board does not need to vote on the form because there's no new criteria. The form is substantially similar to last year in that it asks for changes to policies and procedures. It includes 15 narrative questions on specific criteria that are related to certification such as governance, mechanisms for obtaining consumer inputs to inform the public or other consumer protections, updates to informatics, platforms, and attestation on the antitrust guidance that the board issued and compliance with the new criteria that we reviewed last year. So the form is now completed. It's posted on our website under 2020 ACO budget and certification. We've done a little work on the website to make it a little bit easier to navigate and find materials and we're continuing to work on that process, particularly in this interim time between issuing the guidance and receiving the submission. The form is now posted, but it will be formally issued to OneCare on July 1st along with the budget guidance. And then we've asked that the form be completed by September 1st so that we have additional time or we have the month before the budget submission to review the certification. So just a reminder of what we presented June 5th. This is an overview of, I'm switching now to the budget guidance. This is an overview of what is in the budget guidance and we are going to highlight changes that we made from what was presented June 5th to what we have posted now as our recommended final guidance. And I'm going to turn that over to Melissa. Thank you, Marissa. So as Marissa mentioned, we shared the FY20 ACO budget guidance with the healthcare advocate in May. They provided feedback on the guidance which we worked to incorporate. In follow up, they submitted a public comment on June 17th that can be found on our website. And of note, they provided some questions for our staff in those public comments as a result of the meeting that we will be responding to and posting to our website when they're complete. They also requested the option to submit questions for OneCare to answer simultaneously when OneCare responds to GMCB's FY 2020 guidance in October. And we have agreed to this and those questions will be received by the Board mid-July and also posted to our website with the guidance. So now I'm going to review the two comments that pertain to your approval today of the FY20 budget guidance. And they can be found in section 5, which is the ACO quality population health model of care and community integration initiatives. So this is question 3. And I think I'll just read the question to give you some framework. So how have OneCare's population health investments supported transformation and care at the local level? This includes the complex care coordination program, Rise Vermont, the regional clinical representatives and other initiatives directly funded by the ACO. The ACA's suggestion was please note in your description of each initiative which population health program investment budget items it pertains to under Appendix 5.4. So if you'll recall Appendix 5.4 is where all of the population health investments are listed and how they tie back to the criteria in Act 113 as well as a description of them in the total dollar amount. So we agree with this. We had already worked with the HCA on the last sentence which is that if you're providing support other than financial, please describe because OneCare provides both, sorry, but OneCare contributes through financial and also non-direct financial means including they have clinical consultants out in the community, technical assistants and the population health investments. So we agree to what the HCA suggested but would like to offer modification to replace it that you will see underneath. So for each program list the population health investments referenced in Appendix 5.4 that the community or OneCare is using to support the program. So we would expect that if OneCare lists any of these, any initiatives they would then also tie those investments to them in the qualitative written portion of our guidance. This is an evolving program as we understand and maybe, you know, we will continue to refine some of these questions. This question was worked on a bit this year to be able for OneCare to be able to fully describe all that they're doing in the community. So secondly on question nine, by payer in line of business, provide an analysis of your most recent annual ACO quality reports for measures. In addition provide results and analysis for the measures included in each payer contract including the quality scores, benchmark and percentile for each payment and reporting measure for 2018. The HCA's suggestion was to add in for any previous years for which information on the measure was collected and then back to our question then and results of patient or provider surveys. Describe how these results have informed the ACO's programs and model of care including the ACO's annual quality improvement program. So we, you know, in talking with staff and also with the board, we accept the HCA suggestion but have a modification to it to be able to tie the analysis to how the results from their previous years are influencing their quality improvement initiatives and also their programs that they're developing. So we do acknowledge that there may be some statistical limitations to comparisons so which we've asked OneCare to acknowledge. So in conclusion the staff recommend that the board vote to approve the guidance as presented June 5th, 2019 with the recommended changes to section five questions three and nine presented June 26th, 2019 today. So now we'd like to offer it up for board questions please. If there are any. Question to the board. Any comments from the board? I would make a motion if you're ready for a motion. I'm sure we'll do a public comment on that. I move that we approve the guidance as presented on June 5th, 2019 with the recommended by staff changes to section five questions three and nine as presented today, June 26th, 2019. Is there a second? Second. Okay, moved and seconded. At this point we'll open it up to public comments or questions. Yes. Thanks. First I just wanted to thank Phyllis and Marissa for working with us and for working to incorporate some of our feedback in this draft. And I just wanted to note that we, on the first point, we do believe that the change that was made addresses what we were looking for. On the second point, we don't believe that it does, but since we will be submitting questions to be included with the guidance, we can ask for the information that we're looking for in our questions so we don't see a problem with it being done in that way. The only thing I did want to note is, so the information we are looking for is year over year quality data. And the way that it's currently written, the data that's being requested is only for the current year. And then one cares asked to kind of narratively describe how pastors have informed their quality improvement programs so that we do think that's important information to include, but having the actual data to back it up we think is essential so you can expect to see that in our questions that we'll be sending. And then so one of the questions that we also included in our comments that was a question for the board staff is related to the board's position on year over year quality information and how the board plans to kind of look at that information so that's something we're looking forward to hearing more about what we do as we respond to those questions. So my understanding and maybe you all correct me, we have the results from prior years. So it's not the fact that we don't have the results because we're not asking them to repeatedly give us results that they already have. We're asking them to describe how they're using the results from prior years that we already have in their programming for this year. Is that more or less correct for the advocate yet? Yes, that is correct. And as we start to look at the author and model results there are some NCO author and model measures in there that we will also be examining through time up to 2022. Other comments or questions? Yes, Susan? Susan Aronoff from the Vermont Developmental Disabilities Council and I didn't submit comments because I thought that the guidance collected both the quality performance data from all of the payers and all the programs and the financial performance information. But in looking back over both the comments and the materials for today's meeting and the conversation I was having with a colleague I was able to point out and it was in one of the slides that was just discussed where you collect the information about past quality performance. But I couldn't find anywhere and if you could point it out that would be great and if it doesn't exist it would be a comment. I know it's outside the comment period so take it for what it's worth. But that as they submit their budget if one care could provide what their performance was in Blue Cross it's the only place we get it. We can't get it from the Medicare website or from Diva. So Blue Cross financial performance, the private ones financial performance and Medicare and Medicaid. I know Medicare results might not be available till whenever but as soon as they are available and if that could be cumulative because I think that I understand your point that they submit stuff so maybe you guys already have it. But just as a researcher trying to find stuff it is really hard to look at year after year performance when you can't access the data in any one single place. Because the Green Out Care Board has the affirmative duty under the state action doctrine to not give any ACO the safe harbor of being able to engage in price negotiations or whatever unless, unless there's a benefit in savings and cost to the population. I would think the Green Out Care Board should be looking year after year to see are we saving any money for the population yet or slowing the curve and is the quality improving yet? So I would think you guys would want this year over year information easily accessible too and it just isn't right now. I kind of respond to that in part and I would also comment if they have additional comments. So this year we did add in section four of the ACO budget and financial plan there are questions six and seven so for their first year being in the all care model in 2018 we've asked them to put down what their total shared savings and losses were and provide a qualitative and quantitative summary of that shared savings distribution plan for 2018 as well as a quality with hold question providing a quantitative and qualitative summary of your quality with hold distribution plan for 2018 as well we also have a table that we've asked them to fill out back to 2017 which would show shared savings and losses both from 17 forward up to 2020 I believe. Yes, I thought. The table is by Payette. Other questions or comments from the public? Seeing none there's a motion on the floor from for the board to approve the guidance as presented June 5th 2019 with the recommended staff changes to section five questions three and nine which were presented today. Is there any further discussion by the board? If not all in favor signify by saying aye. Any opposed? Thank you, Marcia, Melissa. Thank you. Is there any old business to come before the board? Seeing none is there any new business to come before the board? Seeing none is there a motion to adjourn? Second. All those in favor signify by saying aye. Aye. Any opposed? I might have just set a record. Thank you.