 Welcome everyone I see that all five board members are present so I'm going to call this meeting of the Green Mountain Care Board to order. My name is Kevin Mullen chair of the board and we'll get started. The first item on the agenda is the executive directors report and I'll turn it over to Susan Barrett. Thank you chair Mullen. To start I want to announce that there's a slight change in the order of our presentations and on our agenda today so for your review first we're going to hear an update on the agency of human services workforce work plan then we will turn to the Vermont information technology leaders vital FY23 budget that will include a Green Mountain Care Board staff presentation and a potential vote then at approximately 230 we will hear from the department of mental health and they're going to provide an update on their work and priorities and then last we will hear on the accountable care organization guidance and also have a scheduled potential vote so just we will update the agenda after this meeting but we had to rearrange some of the order and I needed to announce that in terms of public comments ongoing public comments we have a couple first on Friday May 6th 2022 the board received and began its review of the proposed rates for major medical health insurance plans offered to individuals families and small businesses in Vermont for 2023 including plans offered on Vermont Health Connect the board is accepting public comments on these filings we started on Monday May 9th and we'll conclude that public comment period on July 21st at 1159 p.m. you can submit your comments electronically through the rate review website you can send them by email to gmcb.board at vermont.gov you can mail them to our address in Montpelier 144 State Streets in Montpelier or you can call at 802-828-2177 all of this information is located on our website under the rate review section also while you're there looking at if you want to check out our rate review website you can also see the filings and then also review the dates for the upcoming hearings which will take place on July 18th that week we'll also have a rate review public forum we are also have another ongoing public comment period and we are seeking public comment to inform a potential future agreement with the state of Vermont which includes the governor the agency of human services and the Green Mountain Care Board and CMS more specifically CMMI on an all payer model the board is encouraging that the public send in any comments you have regarding a next potential model we will share those comments with our colleagues at the agency of human services and at the governor's office and that is all I have to announce I will turn it back to you Mr. Chair thank you Susan very much the next item on the agenda are the minutes of Wednesday June 15th is there a motion so moved seconded it's been moved and seconded to approve the minutes of Wednesday June 16th without any additions deletions or corrections is there any discussion hearing none all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay but the record show that the motion carried unanimously so at this point I'm going to go to the first policy topic on the agenda and we're going to have a fascinating discussion and get updated on how the workforce plan is progressing to date and for that I'm going to introduce Ina Bacchus the director of health care reform Ina whenever you're ready you can take it away thank you chair mullin good afternoon how are you all today great good to see you better zady and sunny it's it is summer time now officially so it should be 80 and sunny I don't know what's going on I guess we if we got that in the spring we can't have it now and I wanted to absolutely take the opportunity to talk with you today about our progress with the health care workforce development strategic plan and to certainly share with you where the legislature and the administration together supported enacting components of that plan via uh s 11 which is now known as act 183 and talk through those new investments and scopes of work that have been created in that legislation and that are consistent with the strategic plan but before I dive into that I did want to talk about some other areas of progress with the plan that you're you may or may not be aware of one of the recommendations in the plan and that has been an objective for a number of years is to formally attach the work of the health care workforce development strategic plan to the statewide workforce development board and that has happened there is an advisory group which exists to inform and maintain the strategic plan as I think you know and that advisory group has become a subcommittee of the workforce development board and we are supported in our work by the workforce development board staff which is a fantastic collaboration and we've already found that by working together in this committee setting that we can bring that we're finding we're cross training bringing information that's relevant to the health care sector but perhaps is related to some more broad workforce development initiatives and ensuring that the health care advisory group is aware of those happening so one example of that is the worker relocation program and the additional funding for the worker relocation program and the policy changes that were also enacted this legislative session to expand or to rather not restrict the definition of the most high need worker or working types of jobs so I don't know if you're familiar with the relocation program and how it was running in the past but there were certainly dollars that were available for folks relocating Vermont to work but they were for high need occupations only and not all of the health care occupations were necessarily classified in that way so now there's no longer that high need classification which does open the opportunity for health care workers and as well as others with those funds so that's one place where we've been able to share information with the advisory group in this new structure and that's very exciting and so that I wanted to bring you up to speed on and we also as you know in the plan recommended that there be some investment to support recruitment and retention initiatives for the health care workforce in the near term and those investments were provided for in the budget adjustment act so not within the large workforce development board but rather earlier in the legislative session codified in the in the budget adjustment act and that program which is now dubbed the premium pay for workforce recruitment and retention program was a program that was open for eligible service providers for health and human service providers as established by the legislature it was open as an application for two weeks at the end of May the application closed on June 1st and our staff at the agency of human services are currently processing 141 applications for recruitment and retention funding through this program and we are anticipating and targeting the announcement of awards by the end of this month June and preliminarily um I think I'll back up and say that the act the budget adjustment act 83 it allocated 60 million dollars for the premium pay program for investments in health care and human services workforce recruitment and retention and initially slated 45 million of those dollars for a first round of funding that was and provided for program parameters established by the legislature meaning $2,000 per FTE for the qualifying and eligible provider types the second round of funding which was held back as 15 million would be for needs-based grants so a different process for determining um qualifying entities for investing and still in recruitment and retention work um we are we're still validating the requests but we do anticipate that there will be funding remaining in addition to the 15 million dollars for the needs program we anticipate additional funds could be directed for the needs-based program based on the 141 applications that are being processed now so that was the other piece that I wanted to be sure that the board understood as something that had been introduced as a concept and made a recommendation in the strategic plan and has been executed and is being in the process of being executed through um both the legislation and the staff's very hard work at the agency of human services so now I'll move on to walking through um the initiatives in s11 or act 183 and I will share my screen if that's okay or prefer yep somehow it wound up way at the bottom of my list and we can see it great so this is a basic chart um that describes the new initiatives in act 183 relative to the health care workforce and how those initiatives um may or may not have been reflected in the health care workforce development strategic plan and again I think that we see a lot of um alignment between the plan and the initiatives in act 183 or s11 the first initiative is emergency grants to support nurse faculty and staff and this is a two million dollar investment um that provides for interim grants to vermont's nursing schools over three years to increase compensation for faculty and staff and this um this investment um is something the plan acknowledges um that faculty compensation may be a barrier to increasing faculty staff for nursing education programs and this was certainly a topic among the advisory group that informed the strategic plan um the plan did not recommend um an investment or a grant program however the plan did create a work group to evaluate any gaps in compensation between academic faculty and practitioners so I acknowledging um that there is an issue with compensation and that compensation may be uh hindering um hindering nurses from working in these faculty positions and to identify possible solutions and make further recommendations so the that group the work group um has been convening and was convened I believe uh prior to or consistent with the legislative session opening by the office of professional regulation the plan um the plan asked that the office of professional regulation convene the group and there were reports out on the activities of the group um to uh to the legislature and so here we see um this grant program reflecting an issue from the plan but certainly um taking a concrete step beyond the plan the next um the next initiative in the workforce development bill um in section 21 section 21 creates nurse preceptor incentive grants and these incentive grants are for nurses employed by critical access hospitals in vermont to serve as preceptors for nursing students enrolled in nursing school programs here another issue that the plan um that the plan acknowledged um and provided for uh it certainly recommended that the work group that I just referred to also um think about and inform um the informed strategies to address the issue of there being enough preceptor slots available so that nursing students could obtain their required clinical time so again I think that some of the the work that this group the and those members of the work group which did include um faculty from vermont's nursing programs and those those individuals also were informing I believe the legislation um we see here a concrete recommendation in addition to those investments the director of health care reform or designee in the agency of human services is asked or required to convene a working group of stakeholders to identify ways to increase clinical placement opportunities establish sustainable funding models for compensating nurses as preceptors or hiring uh additional nurses to alleviate pressure on preceptors and this will be a new activity uh with uh report for additional um action in terms of improving the number of preceptor slots that are available um due January 15th another new grant program and opportunity that was created by the act is um a healthcare employer nursing pipeline and apprenticeship program 2.5 million dollars was appropriated to provide grants to healthcare employers including hospitals long-term care facilities da's fqhc's and other healthcare providers to expand uh partnerships with vermont nursing schools and create nursing pipeline or apprenticeship programs or both uh that would be available for training members of existing staff including personal care attendants licensed nursing assistants licensed practical nurses um to become higher level nursing professionals so acknowledging that uh many professionals may be ready to advance in their careers as they are currently employed but may need support um in in doing so and really needing to meet those um individuals where they are to support them in advancing in the career ladder this is a strategy that is um again consistent with themes raised by the workforce development strategic plan which included um developing and identifying strategies to streamline advancement through the nursing career ladder um and to allow for existing staff to uh further their capacity and skills as providers um so here the plan looked for there to be a convening of healthcare providers and higher education programs to develop and identify um a program and again uh the the legislation here goes goes beyond and provides an appropriation um specifically for the agency of human services to develop an opportunity and we certainly will be looking uh to to the advisory group and representatives of the advisory group as well as providers uh to inform this this program as we go forward um we do have our preliminary work to do uh with all of these appropriations to ensure that they um are you know we have questionnaires and work that we need to do with the agency of administration prior to implementing any any of the programmatic activities because these funds are ARPA funds and need to be um and need to be dispersed consistent with uh the ARPA rules and requirements we also also a healthcare workforce data center um is established by act 183 the healthcare workforce development strategic plan recommended establishing a healthcare workforce data center and this provides for 750 thousand dollars to establish the center and also creates a full-time FTE for the agency of human services to um employ a healthcare workforce data center manager uh further uh uh limited three-year uh a limited service three-year position is created in the agency of human services by act 183 um to provide for coordination uh of the initiatives in act 183 but also those that are set forth in the healthcare workforce development strategic plan we're going to move on now to a large what a very exciting uh list of investments in um in scholarship and loan repayment opportunities these are two key areas where we made a lot of recommendations um in the healthcare workforce development strategic plan and as we continued in discussions and work in this arena um between the time that the plan was published and uh you know even beyond and into the legislative session we continue to hear very clearly from um current nurse nursing students recent graduates um of of educational programs in Vermont new to Vermont healthcare workforce that financial financial considerations were chief in their choice of where to work and where to seek um employment so we we see this um these investments in act 183 as really being critical components in creating a more competitive environment for Vermont to offer some financial incentive to live and work as a healthcare professional in our state um would you like me to pause before moving into the explanation of these new and additional investments in scholarships and loan repayment or or should I continue on so it depends on what you would prefer we could ask questions on everything that you've presented up to now or we can wait till the end so it's up to you how you want to do it I could go either way well and why don't we ask questions while they're fresh and I'll start off then um why just critical access hospitals for the preceptorship I don't have I don't have a good answer for you off the bat again this is something that the the the legislature pursued we didn't propose this um we didn't propose it and it does have a link to our plan um but I don't have I don't have an answer for you here about why it why it was just the critical access hospitals um I saw it coming together at the end and it seemed to be an attempt to help institutions that needed to help versus those that were big enough to afford it themselves and I just want to say that at least it's this one board member's opinion that some of the smaller hospitals were proportionately reimbursed more from the federal government due to the pandemic from their losses than some of the larger ones and I'll just leave it at that but I know it's not not yours so I just want to get it out there that that one seems strange to me the second thing that really raised some hair on the back of my neck was moving the oversight of this to labor and you were on the board back in 2017 and 2018 when we were trying to get labor's attention and bringing them to meetings to try to focus on this issue and we didn't seem to get that focus are you convinced that today you have their focus so I I think and I can't see you so oh there you are I apologize um I think that you're referring to the linkage that we made between the advisory group which is which is established in act 155 of 2020 that there be an advisory group to update and maintain the healthcare workforce strategic plan and and the linkage that we've made with that advisory group being an official subcommittee of the healthcare workforce or excuse me the workforce development board is that your question yes yes um I emphatically we are we're a subcommittee um of the board so we still like the convening of the advisory group is entirely um consistent with the advisory groups charge I chair the advisory group also consistent with 155 of 2020 so I wouldn't say that it I I don't view this um as you know creating oversight by labor I instead view it as incredibly helpful partnership and fusing of the expertise in the state of Vermont on workforce development broadly and well hopefully there's been an evolution but as a former member of the workforce development board for multiple years and this was going back quite a few years but I'm just I was concerned about um the lack of meaningful movement and maybe that has changed and in of course we wouldn't see it here um but hopefully that has changed well I certainly understand that the the board is is large and broad and that is why I think this subcommittee structure is particularly important because there are some targeted and specific investments excuse me and specific strategies that are very um unique to the healthcare sector and that's why as we work as a subcommittee uh we're working with a subcommittee that's comprised of those with expertise in the healthcare sector we are tied to though the resources and expertise that come with the staffing for the board and I do think with the workforce board and I think it's incredibly helpful and incredibly um it's it's I think it's a very good um well there was always incredible talent on the board it was just never utilized properly but that that could have changed it's been a lot of years um what commitment do you have from higher ed you've shown us the dollars that go to increased faculty compensation and the dollars that go to hopefully increase the availability of uh precepting but do we have a firm commitment from the leaders of our college system um to make sure this happens or are they too focused on what I think is this boondoggle of a combination of our state colleges well as I as I already as I should have said um at the outset uh with this with this legislation sort of newly hot off the you know presses and uh final here you know the agency of human services our first step as as I did describe is for us to really uh work with our partners at AOA um around the funding source for these investments and go through the proper processes that we need to in order to utilize the SFR and our ARPA and SFR funds appropriately and so that's that's our first step and then and then we get into the program design um and the grant opportunities and that's where we see you know the importance of partnership with those members of our partnership some with some who are members of the advisory group and can potentially provide some feedback on grant structure but certainly the programming is a piece that we will be working on next and the program design and the final question I had on what you've presented so far I was wondering if you could elaborate on the needs based on that 15 million is it the needs of the individual applicant or is it the needs of the institution it's it would be the need of of the employer um need need based based on yes employer not of not of the employee okay super those are my questions are there board members I have one question um you I mean as we know this workforce problem isn't unique to Vermont or hasn't been unique to Vermont and so you said that act 23 uh makes us more make say more competitive environment um but I'm just wondering if we we wake up a year and a half from now and find that other states have kind of paralleled what we're doing here in Vermont and that we really aren't any more competitive it's just that we've all moved in the same different you know direction and kind of raised the platform a bit so I'm I'm wondering if if there's you know any kind of ongoing way to really know whether or not we've made ourselves more competitive relative to our competitors that's a great question one of the and another area where we're looking to utilize our advisory group for feedback but where we've also built in with with the recruitment and retention program for instance and other states are investing in recruitment and retention uh as well so taking that as an example um there's quarterly reporting that is required for the recipients of the recruitment and retention and through that quarterly reporting uh we will be able to assess the impact of that funding through some um measurements and uh information that we'll be collecting and so with the program design that's how we've sought to understand the impact of of the dollars so that's one example and I anticipate with these other streams of funding that we will similarly be expecting reporting so that we can gauge the impact and when it comes to the scholarships and loan repayment programs um that those programs also should be evaluated for their effectiveness um certainly and that but that is a separate evaluation that when I'm talking about in terms of quarterly reporting related to um grant funding or the premium pay program thank you other board members I had a question about um the position I think it's great that you are going to have some help here that's awesome um and I was curious what level of a position you're thinking that will be um given you know obviously it's a three-year limited service the appropriation I'm assuming is just for the first year not for all three years so if you could speak a little bit to what you might be looking for and another great question and thank you for that question um we've also begun that work of thinking about you know if there's an existing position class for instance that um is applicable here that we can utilize so that we can quickly recruit and fill the position um and we are developing the job description and job duties for the position now um but you know at at a high level we're certainly looking for um an individual who is familiar broadly um with the various sectors in health and human services workforce for which we are you know particularly focused um an individual who's familiar as well I think uh with um with our partners in workforce development which definitely includes um higher education thank you to you to just you know kind of summarize we're in the process right now of developing um developing job duties and description for the position and going through the process that we need to go to in order to establish a new position and to recruit okay is there other board questions or comments up to this point hearing none you know why don't you just proceed okay so again uh the healthcare workforce development strategic plan uh recommended certainly increasing um scholarship funding broadening and expanding loan repayment options to more professional types and um there are a number of um there are a number of programs that are consistent with with this direction as established by act 183 the nursing forgivable loan incentive program and the forgivable loans are scholarships they are scholars you know they are forgivable loans technically but I think we can think of them as scholarships that are linked to service agreements so they are for uh scholarships for students who enroll in an eligible school and commit to working as a nurse uh in the state and who meet the eligibility requirements and there's uh an additional investment in this existing program of 227 uh thousand dollars um the vermont healthcare professional loan repayment program two million dollars is invested in this program and it broadens the program to include nurses physician assistants medical technician child psychiatrist primary care providers who meet the eligibility requirements a nurse faculty forgivable loan incentive program is created this was not an existing program previously this program is created for students who are enrolled in an eligible school and who commit to working as a member of the nurse faculty at a nursing school and who meet eligibility requirements the nurse faculty loan repayment program is also created newly by act 183 um same same basic um uh description of that program 1.5 million dollars um is appropriated for mental health professional loan excuse me professional uh forgivable loan incentive program and this program provides forgivable loans to students enrolled in a master's program at an eligible school who commit to working as a mental health professional in the state and meet eligibility requirements and finally one uh one million two hundred and fifty thousand dollars was appropriated for the designated and specialized services agencies to use funds for loan repayment and tuition assistance to promote the recruitment and retention of high quality mental health and substance use disorder treatment professionals and again um the plan the the workforce development strategic plan um uh does um again recommend broadening and expanding loan repayment to more professional types members of the board any questions or comments sure this is tom walsh uh thank you you know um it i noticed with all that you presented it's about um retaining people who are already working in the in the health care field and bringing people in and i'm hoping that with the data center and the data coordinator that you that you highlighted that they'll all be also be some efforts to look at what we can do in a shorter term horizon the development of a workforce um education training that's all kind of long term um so what are some shorter term things um that maybe we could do to help support a workforce that um was feeling exhausted and burnt out uh before the pandemic um also when i first started uh i'm trying to get my head around workforce issues in vermont i was interested to try to understand how many physicians we need how many nurses we need and the best way to look at that is by rates like what how many physicians do we have per 10 000 or 100 000 citizens and i was surprised when i looked at that that vermont for years now has already had more physicians a higher rate of physicians and a higher rate of nurses than most other states and so i i wonder if um there'd be some effort to try to learn why other places have of how some other places have avoided the backlogs and delays and coordinated coordination difficulties that we've had with fewer doctors and nurses that i may have a better answer to that tom but one of the things that in vermont when you take a look at um licensed uh uh doctors it's a little bit deceiving because we have a lot of people who maintain licenses but don't practice full time and so um that could be part of the answer but you may have an even better answer to that yeah i think that that's that's particularly true uh kevin given that people may come here uh to retire but the the partial fte particularly in academic medical centers that's true everywhere most clinicians who are in academic medicine medicine have time carved out to do research so they're not a full fte so a lot of the a lot of the differences in the way people structure their time are true in other states it's not unique to vermont um when the va medical center was looking into its workforce difficulties i learned about the concept of internal demand how organizations structure themselves internally how they utilize allied health professionals how much what's the amount of time between a visit with a doctor the inter visit interval those types of things um those are all things that can be worked on right away and ease the burden on existing staff um and of course if we're not looking at any of that we're looking at a long horizon fix of bringing more people in to a system that's just not that may not be working terribly well for those providers so adding more um it just may not be the answer that we're looking for the full answer that we're looking for i think it'd be good to see some things in these plans that we're trying to learn from other places that are able to serve their population with fewer resources so that's all thanks anything on your end dina or should i proceed i i i certainly um i certainly appreciate and think that that is a is an important line of inquiry and is it is one also that um i think with some of the modeling that's been um looked at in the past um and in past as past products of healthcare workforce development strategic plans that we've tried to anticipate how team-based care may change the need um for a workforce and uh how um different compliments of providers work together to provide and i do think that it's important to continue looking and understanding those developments and they are also i think there's you know kind of evolution ongoing in terms of um the practice of clinicians and how they meet needs i do think however um that there's you know critical staffing shortages today that also make it very difficult for organizations to contemplate how to reorganize care and how to work in team-based care because they can't they they aren't able to meet the immediate needs of of patients i mean not a patient but they're they're not able to meet the immediate kind of demand for services today as as we're aware um so i think they're that needs to be considered as well i do think there's a very near term stability uh piece that we certainly focused on with some of these recommendations and and where the legislature also uh acted yeah i i agree with you and and i i think the um trying to think about what we can learn and may do differently um can be a shorter term uh solution when um focusing on education and recruitment can sometimes be a longer term okay other board comments or questions so i i just got oh go ahead no go ahead because i already asked one before i'll follow you okay no worries um so you know just a quick question maybe can you just remind me how long the commitment is to work um in vermont after you know receiving a free of the loan or as part of the loan repayment program um in the in the new rule or in the new law i believe it's consistent with the the previous construct and that for each year that uh scholarship let's say scholarship is offered that the year that there is a year of service in turn okay and the way the programs function now you can quote you can qualify for multiple years of scholarship for example okay thanks and then i guess the other question is will the i'm just wondering where who's going to be doing the an evaluation of all these multi-pronged approaches to improving increasing the pipeline and you know recruitment and retention is there um some sort of plan in place in terms of you know what will the date will the data center be contributing to that will this come from the person who is hired to work with directly with you who's going to be evaluating the impacts of all of these um new programs to see what's working what's not how do we tweak it where does that live i think the data center with time serves um a purpose there certainly because we would who the data center will be bringing together multiple pieces from across different entities to inform the picture and our understanding of the workforce and so with that um you know those are inputs into an evaluation uh with the data center bring that together but um i don't want to oversell either and say that we've committed to a evaluation that um you know is a full blown evaluation across all these areas but i but i also as i stated it's important to us to be able to track and understand the impact of the program so as we've been implementing the the programs to date which is the recruitment and retention program we are asking for information so that we can understand um impact that that work i think is something you know certainly that the person in the coordinating position would be tracking would be tracking so it may seem like that's something that in the position description either for the data center or for the coordinating position might be helpful to add is some sort of background and evaluation um just to to have at least that possibility thank you for the update really helpful and it sounds like some exciting programs coming down the pike okay tom so my question was the other side of the coin of jess's first question which was uh what if somebody gets these grants for uh or these forgivable loans for a three-year period say and um and then they fall in love with somebody who's got a job uh in montana and so they skip out on vermont what what are the um what are what are the penalties or what are the burdens or um should somebody default on one of these forgivable loans was the the service obligation has to be um has to be met in order for their the loan to be forgiven so um the service obligation is that and i don't want to i don't want to misrepresent um the exact program of the program and that's something that we could come back to you with more information on um my colleagues in the department of health and collaborating with a heck on one side in terms of loan repayment collaborating with vsac on the other side in terms of the forgivable loans um operate those programs so i don't i don't want to misrepresent but just at a high level the the architecture of the forgivable loan is that you know it is only forgiven if the service obligation is met i understand that i understand what through a heck and a vsac is to experience with loans and so there must be some mechanisms in place that work for these institutions that i i assume are adaptable to this situation but you always worry about it um you know yeah um so that was my question okay any other questions or comments from the board i just have one more which is um obviously the legislation and the funding is going to take priority since that's uh you know those initiatives need to get off the ground but i was curious if there are things um in the work for strategic plan that are not included in the bill that um you expect to continue to focus on or whether those will be paused while things get up and running from the legislation and the funding for the for the new programs just a little bit curious about the venn diagram between the bill and the plan and what's not included in the bill yeah that's a very good question i do think it's a it's a very high priority for us to recruit um for these positions because there is so much between you know the plan as you've all noted previously is very it's comprehensive it's broad there's a lot of work across across a lot of areas and i think will very much benefit benefit from dedicated staff um to implement and coordinate those activities so um in the near term i do think that's where priority uh lies i did fail to mention and it is included um this is included in the bill so it's not you know that part of the plan that's not in the bill but there is also work for um uh the board i believe collaborating with department of labor in the supply and demand modeling activity um so my apologies that is a recommendation in the strategic plan and i'm i'm sure you're well aware of it and um and how the board is thinking about that work but i did want to say that so um yet i i appreciate the question robin and i do think that in the near term there are a large number of new initiatives new programming and fund sources that are are important for us to be in compliance with as we execute the programs and that will be the focus in the near term make sense thank you okay anything else from the board if not i'm going to open it up for public comment does any member member of the public wish to comment on the uh workforce strategic plan walter thanks kevin uh tom walsh was kind of thinking along the lines that i have that i was so i won't be won't rehash that but i did have one question more of a generic type question one of the most common denominators in all the workforce development plans was eligible why does everyone have to be eligible kind of like you're starting a class society who's eligible and who isn't but that was just my question i see that as a problem right away from someone who has had to be eligible before and other guys's walter i think some of some of that you know is in how i summarized the work and that and the description of the eligible types is is certainly included within the legislation so that it's describing the the different types i think we you know uh do intend that certain funds are um are available for the health and human services sector in particular and need to put some parameters around those funds i think they're otherwise we would risk um oh i'm sorry chair mullen you i think you usually like to direct the answers to the question no that's fine i know i would have directed it to you anyways i'm i'm i'm not i'm losing i'm losing my edge in the um in the conduct for the board meetings um uh so so you know there there does need to be some parameters around the funds there are um you know i think then there are some uh in the system who might not be licensed as a healthcare provider who may view their services as healthcare for instance that may not be a health or human service and we certainly would want to you know be able to understand that the dollars are are being directed to um legitimate health and human services provider types as established in the legislation alter i hear a cough are you okay i hope so i need cpr i'm in the right place right yeah i don't know how we would do that but we'd have to check on your eligibility oh walter there are limitations to telemedicine for sure someone would call 911 right yeah we would call 911 yeah unfortunately i don't know if we would have your address to give them well send a doctor send a doctor over kevin okay is there other public comment hearing none ena i want to thank you for the update um this is something that um is so um so important this work and uh we appreciate uh being kept up to speed and we understand that uh you'll update us on uh yes and hopefully uh getting feedback from so my hope is that future updates um will be led by perhaps the healthcare workforce coordinator um certainly with my with my supporting role but um certainly like to introduce you to another person as soon as we're able we look forward to that so thank you very much so next we're going to uh turn to um the vital fiscal year 23 budget and i'm gonna turn the meeting over to jessica mendizaba jess hi thank you mr chair i'm gonna go ahead and share my screen um just a second so um thank you again um for the record my name is jessica mendizaba and i am a director of data management at the green mountain care board today i will provide an overview of the board's oversight authority related to vermont information technology leaders or vital which is vermont's designated sole health information exchange network i will summarize vital fiscal year 2023 budget submission which was presented to the board on june 8th and i will provide a staff recommendation for the board's consideration so as part of its oversight and policy making activities related to health information technology and health information exchange the board is required to review and approve vital's budget annually this authority was granted to the board in 2015 it was first exercised in 2016 the board's oversight is intended to provide strategic guidance and policy parameters this is a summary slide of vital's f y 23 budget submission all the detailed documentation can be found on the green mountain care board website vital's revenue includes state funding through their contract with the department of vermont health access as well as the department of health the f y 23 revenue reflects project work that's shifting into f y 23 from previous years there's also non-state funding and um this reflects a decrease uh in f y 23 of some program fees and um and some other non-state contracts vital's major expense categories are highlighted here and reflect additional staff positions as well as some contractor work to support shorter term projects and we see a slight increase in software expenses to support operations there's also a built-in contingency of a hundred thousand dollars so the budget review criteria which i did review very briefly prior to vital's presentation is here again um for your reference um the criteria was established in the budget guidance and approved by the board in april of um 2021 the guidance includes four principles for use in reviewing vital's budget which are listed here and i will review these in more detail along with the staff assessment in the following slides the first review criteria is transparency transparency is measured by compliance with the budget guidance and overall transparency of the budget process and staff find that vital has complied with the budget guidance um the budget guidance was submitted in a timely manner including all requested components vital also responded to board member written questions about the budget in a timely manner and actually addressed those uh answers in their presentation to the board the budget narrative and all the financial documentation as well as the most recent audited financial statements and the irs form 990 are posted to the green mount care board website and we have a link there for you the second review criteria is that we have public and stakeholder input so um staff have found that vital presented at the june 8th board meeting as we've said and responded to questions from board members in the public at that time in addition we did hold a special public comment period from june 8th to friday june 17th and we did not receive any written comments during that period the third review criteria is that the budget align with the health information exchange strategic plan goals the updated plan was approved by the by the board in november of 2021 and that's also available on our website the criteria specifies that the board will not direct the technical details of vital's work or the details of vital's contractual relationship with the state staff find that the budgeted activities will advance the goals of the 2021 update to the hie plan and those are to create one health record for every person to improve health care operations and to use the data to enable investment and policy decisions staff also find that the budgeted activities will advance the goals of the hie plan by providing the following services which are foundational services exchange services and end user services these categories reflect the office of the national coordinator for health information technology framework which the state's hie plan relies on the budget submission includes a table which is referenced here which categorizes vital's revenue sources and major projects by service category the fourth review criteria is alignment with the vital and diva process and so um our review has to be structured in and timed in order to assist vital and diva as they negotiate timely effective agreements each year staff have worked with diva and vital to prepare the timeline for this year's review to ensure that we are in compliance and we do not conflict with the federal contracting requirements for the agreements in addition staff will ensure that written decisions resulting from this budget review are sufficiently clear so staff recommend approving the vital fy 2023 budget as presented with the following conditions in addition to reporting requirements outlined in the budget guidance quarterly reporting should include updates on vital's work to design a future financial model that would diversify revenue sources vital's strategic planning process and progress continued work on integration of claims and clinical data in the vihi and continued work on consent including patient education the second condition is that vital will comply with mid-year budget update requirements as described in the board's annual budget guidance so um that is my recommendation are there any questions from the board on vital's budget or the recommendation do any board members have any questions okay maybe you could reverse to the uh motion language i don't have a um motion prepared uh draven are you prepared uh yes can you although actually i'll just pull up the staff i'm so sorry i'll i'll reshare no it's okay i have it up um so i would move that we approve vital's fiscal year 23 budget with two conditions um that in addition to the reporting requirements outlined in the budget guidance quarterly reporting should continue to include updates on vital's work to design a future financial model that would diversify revenue sources vital strategic planning process in progress continued work on integration of claims and clinical data in the vihi and continued work on consent including patient education so that's one condition the second condition would be to comply with mid-year budget update requirements as described in the budget guidance is there a second second it's been moved and seconded before i open it up to public comment is there any discussion from the board hearing none i'm going to open um the discussion on vital's 23 budget for public comment does any member of the public wish to comment at this time hearing none i'll ask one more time if any board member has any further discussion and i just want to i just want to go ahead just quickly add that over the last two or three years i think vital has done a very good job and and under some stress uh you know moving from opt in to opt out went smoothly um the role that vital played in the pandemic in terms of the lab reports and all that that was wasn't on their screen you know originally uh went very well and so it's just fun to be in the public sector and see an organization that's getting its job done quietly um and and and thoroughly they've come a long way and it was very refreshing also to see the regional news so kudos to uh beth and the team at um vital but i do see ham davis has some public comment now ham or maybe his hand is up for no reason ham did you wish to offer public comment yes i haven't covered i just was muted i'm sorry i'm not sure this is the right place but but uh what i've sort of looked for consistently especially uh between vital and um the uh and um in one care of amont and the uh and and the whole system i spend the ages age the system is whether or not we can start to see some numbers that really make sense in terms of of uh of of quality systems in the the quality measures in the system if we look at member back when not when not those consultants came in on october 27th of last fall um the the um there was a lot of stuff in there the pqi that showed very great differences in uh in quality between one hospital and another hospital service area um there were um there was information brought for what that a certain amount of some of the care in the system is not needed etc etc one of the quest things i think is most important in vermont and i've never seen and i and i i i've heard that exist but i've never seen i don't know whether it's in vital or where it is but and that is the question of revision surgery okay so that if so that in if you get a if you get a an operation in mass general um and it doesn't go well then you may need to go back to a different doctrine mass general but if you if you have a if you're in a especially in a smaller hospital if in vermont if you have a bad result from a surgery you're not going to go back to the same hospital that may be the same doctor you're going to go to a different hospital usually one either in burlington and handover in boston or in some other place is there any way we can get the data actual data on revision surgery in vermont because i think that's one of our biggest expenses is is stuff like is is complicated surgery so i'd agree that's one of the biggest expenses and i did see that beth you popped up on the screen were you um going to answer this question or i i i just wanted to be ready to answer any questions that came up out of public comment so happy happy to try if you would like me to but not specific to this one um yeah yeah i mean i think that's a great question and from vitals perspective like we are not doing the analytics on the data at this point where we really have been focused on getting the data and getting good quality data that can be used by our partners to do this type of analysis and analytics and we do work closely with the acl um department of health um the blueprint programs to make that data available for them to do the work and the analysis so it's not something that we specifically have looked at because it's not really within our kind of mission for our work at this point so i i'm not sure um if vpqh is on or not but they're usually here do you know if they're doing some work in this area uh kevin oh there we go kathy hi how are you um it's uh this is kathy solton from the executive director at the vermont program for quality and health care and um to answer ham's question um i i think that's um certainly on the horizon for our organization um the very thrilling news of the regional collaboration uh takes us that many steps closer to making that type of analysis um a more routine and um hopefully productive of you know process that could benefit everyone from being able to see you know not just the volume and utilization but the quality outcomes and you know we're being able to identify opportunities for improvement exists so um you know as i said i'm i'm thrilled to see the collaboration that's coming that that's been an item that's been on my whiteboard for a while now so um i think the answer to your question ham is um yes hopefully sooner than later okay is there any further board discussion before we vote hearing none all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay let the record show that the vital 23 budget was passed unanimously so i do see that we're ahead of the uh 230 meeting i wonder if it might make sense to adjust the agenda and move um the aco guidance up next because we had uh susan i think we promised commissioner haas it would be 230 is that correct yes that's correct and um i would just i don't know how long that agenda item is going to take and i don't see them on the line yet we did say 230 i just didn't know if it would well if it appears that it's going extremely long i'll figure out a way to uh have an intermission to the aco discussion so at this point i'm going to turn the meeting over to marissa melamed marissa hi thank you chair mullen members of the board um i'm not sure we'll be able to get through the whole thing in um 15 minutes but maybe the the presentation and um but we can we can manage that no problem i'm going to go ahead and present the slides okay well again good afternoon my name is marissa melamed associate director for health systems policy uh this is part three of the board's review of the fy 23 aco budget guidance and certification form um today on the agenda um we did receive some public comments so we'll start with that um there are a couple of updates to the two guidances that were reviewed uh last week so i will go through those um there is some time for questions and public comment and then uh there's some suggested motion language and a potential vote if you're ready to do that and the most recent version of the two guidances are posted with today's board meeting materials so those are clean copies of the uh the guidance sort of the final draft um that we're discussing today so for a summary of the comments that we received we received two public comments they were both on the medicare only aco guidance that was presented originally on june 8th we provided a summary here the board has received those comments they're also posted on the website um they um included concerns about uh beneficiary impact and uh just just a note there as we've described in the staff analysis um and in in this in some remarks um as part of this guidance being attributed to an aco that's in a cms or a medicare program the the reach model which was previously called the direct contracting model um that does not change or limit the beneficiaries traditional medicare benefits access to medicare providers or costs so they are still in a traditional medicare program um the the reach and the the or the previous dc model are agreements between providers um and the the reach aco or direct contracting entity um and it does not change the beneficiaries um benefits or enrollment in traditional medicare only um the the other was around concerns about private companies involvement in medicare um and so under the statute and rule the board's authority is to review and approve or modify an aco's proposed budget and the board must work with the parameters of the medicare programs set by cms um the guidance which is what you're approving today um does cover elements of the budget review that are in 18 bsa 93 82 b um it doesn't recover other statutory requirements so we do look at all statutory requirements when we do the review um but we're just focused on the guidance today so notes on the f y23 medicare only guidance or updates into the original presentation there was some discussion around the health equity question uh and it sounds like uh the the consensus um was to keep that question broad and just list um how is the aco addressing health equity concerns um under the assumption that that is going to include uh uh racial disparities within the health equity concerns so we did update that question to respond to to that discussion and we aligned it with the other guidance with the certified aco guidance as well so this is one change that was made and the new question is in blue below that's the only change to the medicare only guidance since the original presentation for the f y23 certified aco budget guidance there are a couple of updates one was some suggestions by board member homes to edit the total cost of care accountability strategy by uh by hsa questions and the edits to that question are in blue and it was to add um the term avoidable utilization um to to make this question a little bit more specific to try to get a more specific answer um there's also the addition of that last sentence there to cite specific examples and where possible quantify the aco's direct impact on reducing avoidable utilization and or low value care and low lowering total cost of care and specific hsa i also actually combined there was an a b and c here um in looking at it again a and b were pretty uh similar it was the first question there under a and so i just i put the question all together into one sub bullet because sometimes when the aco answers they divide out each sub bullet and i thought this would give a more concise answer so that is the change there and again that's based on conversation that was had at the previous meeting and then this is the companion question that's in the medicare only guidance around health equity so we aligned the questions here and kept um the the question to be broad um around social determinant um data we made one edit here as well based on uh some feedback and internal discussion again similar to the hsa total cost of care accountability question this was just to be really specific that we want the aco to answer with some examples so we added and provide a couple of examples of how it has improved quality to the question around evaluation of the quality improvement program finally in part two of the certified aco budget guidance around setting targets and benchmarks we proposed to you two targets for the f y 23 certified aco guidance one around the vbif or other pre-funded clinical quality incentive programs one around the commercial benchmark trend rates which are consistent with either decisions the board had made previously or conditions that are generally in the order that we want to make sure that the aco is considering when they create their budget we had some discussion around setting the fixed perspective payment um target um and we did decide after discussion after that discussion to add a third um budget target for the guidance um and it's it's number three there in bold and it reads the aco shall endeavor to meet or exceed the target proposed by the aco and approved or modified by gmcb staff in accordance with one care vermont's f y 22 budget order condition 3a for the portion of the f y 23 commercial payer contract revenue in the form of fixed perspective payments so just a couple of remarks around this um so again setting targets or benchmarks in the guidance is something that we haven't uh done before that we've been working towards doing to give um the aco more specific guidance when they're actually creating their budget around what we want to see in the budget so they can bring that to their board of managers when they're putting their budget together as opposed to you know conditions that we impose on the on the aco after the fact under the review now the conditions in the budget order if i'm if i understand correctly and legal well we'll correct me if i'm wrong but our our sort of more binding in terms of enforcement guidance is guidance we're saying this is what we um want to see um and then the the actual sort of order and the enforcement comes in the in the budget order so uh given that we did decide it makes sense to put in that we want to see um you know a target around fixed perspective payments in the guidance so we've added that in um the um the reason why we didn't put a specific target in here is because um it's uh it's it's sort of semantics we've required some additional reporting from them around the methodology um and the reasons um or yeah the methodology around how those targets were set and the staff wants to see that reporting before we say um this is the target that being said um if the board wants to put the target in of 23.9 percent that that one care has proposed um you can do so um we just were interested in waiting to see that reporting that's coming in but the way this is written and the way that the FY 22 budget order is written um we are still able to impose that target or you know set it as as something that we want the ACO to strive to meet and then explain to us why they did or did not meet it when they turn in the their budget submission in October um so hopefully that helps clarify what I what I don't think was clear last week is that we hit already we already had language in the budget order um around uh FPP target um this just more clearly brings it forward to the guidance um which I think is is helpful uh for the board and for the ACO to have when they are are creating their budget um so it looks I may have already said what I had on this slide um but that reporting that I'm talking about that's due in July it requires more transparency around the calculation um of the of the baseline and target and it also requires a little bit more of a detailed report around reconciled and unreconciled FPP which their original report doesn't include and then this is the second point there is the language that's in the budget order already um around um specifying the target so um depending on how much discussion or questions um that does bring me to the end of the presentation Russ with our legal team put together the suggested motions there would be two motions one for the Medicare only guidance um and one for the certified ACO guidance which includes language around the target um you'll see that there's some bracketed phrases in there which you would include if you have any additional changes that you want to make today um that I have not spoken about that the you know the board um decides on so I will leave it um at that uh Chair Malin you can decide how you want to proceed I think you're still on mute trying to be efficient with time and I'm blowing it okay so uh board members do you have any questions hearing none is there any member of the public who wishes to offer a public comment oh Tom go ahead yeah I I do have a question I just want to get this and this kind of uh solid in my in my understanding here that um I think that and I've said this before but I I'll repeat it repeat it briefly now is that the commercial FPP is a big deal um and uh when after five years of the all-paramodal effort you know we're only at we're still at 98% commercial payment um through fee-for-service and 2% or less through fixed perspective payments and you have the ACO saying and this is a quote the pivotal first step in managing overall health care cost growth is to transition the health system from one rewarded by volume to one that rewards cost effective and high quality care so in my mind um the the one care is kind of an intermediary a very important intermediary and um but we're kind of losing ground um if you look at their 22 budget order um the external process including fee-for-service increased by 91 million dollars 22 over 21 which is the 11.6 increase in the fixed perspective payments uh only increased by 38.6 million dollars so there's to me in my mind there's a distinct contrast between the statements of the value of fixed perspective payments um to health care reform and what we see in reality on the ground after a number of years so um for me uh the ACO presented a number for 2023 for commercial at 23.9% and I just want to kind of make sense that that that is what this language language is establishing that we're not going to go back um I mean I worry about this language about the staff review that just becomes another platform to people argue over FPP and defining it etc etc when when the um underlying foundational structure of FPP is not being supported um so uh so that's my simple that my concern is a macro foundational concern that we aren't focused enough on pushing commercial FPP um that that's my concern and I just want to know when I read percentage of payments in the form of FPP set in accordance with the FY 22 one care Vermont budget order and in that budget order commercials at 23.9 so is that is that my what I can take home take to the bank so the recommendation that we have put forth here as staff I'm going to go back to the actual recommendation um does not set does not establish the 23.9% as the target it says that um the target will be the target that's proposed by the ACO and approved or modified by GMCB staff so the the the 23.9% is the proposed target by the ACO um they've presented that several times the staff has not done the has not completed our review in order to approve and modify so um I think that you as the board if you wanted to um you know the target is set is set by the ACO I think um if if you wanted to um endorse that if the board wanted to endorse that you could um the staff wasn't ready to endorse that target um because frankly I think it's um quite aspirational which which might be fine for a target but we were looking for a little to to complete that reporting to see if we could understand what we if if if there's a different number that might be the right number but that being said if the board wants to add a specific target at this time you can what this language does it says that that there will be a target that's endorsed um we're just waiting for some additional reporting well I worry I I do worry as much as I respect our staff um and the ACO staff we're very very talented people I do worry that this conversation can go on and on and on and on and in the meantime uh time the clock is ticking we can see that we're only at 2% FPP you know in on the private side now um we've kind of nearing maxed out on Medicaid and maxed out on Medicare in terms of attribution there you know we are far down the road and that that uh the commercial payer is the biggest payer across all of them and uh we don't have a we don't have a target I for me personally I'd be willing to say I'm going with the 23.9 percent for 2023 because that would be a huge step forward um if if if if that reality could unfold if 23.9 percent of commercial payments were via FPP on reconciled um I know that's not going to happen the reality but but I'd rather have a target there where the system is failing against that target um and so there's uh an ability to kind of push the target more aggressively as opposed to having an ongoing discussion about what comprises the target when if we even got anywhere near 23.9 percent it would be a home run so that that's that's that's where I'm at. Tom as I try to figure out uh whether I should go and put an intermission here and go to Commissioner Haas do you have alternative motions that you're going to make or? Well I'm just not quite sure this is the right venue I I mean if I were to make an alternative motion I would change the word endeavor to use best efforts to kind of elevate it a little bit more and I think I might get rid of the language that has our staff review the methodology because that to me creates a platform for people to keep arguing over the number and I would just you know think it might be beneficial to get rid of the platform you know given um given the uh where we stand with FPP and and the commercial payer. So if I offer anything would be two things change endeavor to uh best efforts um which I think is a little bit stronger language I I know that the ACO can't wave a magic round and make 23.9 a percent happen um and then I'm I guess I'm still insecure as to what the staff review is going to lead to and if it's just going to be something that sucks up a lot of time and we already have a good solid number you know in the 22 board order at 23.9 I'd go with the 23.9 um and just and just move on as fast as we can. Okay I think we're close to um at least finalizing uh what might be the motion so I'm going to continue with this just for a few more minutes and see where we go and so I'm going to open it up for public comment on the ACO guidance. Is there any member of the public who wishes to offer guidance at this time? Does any member of the public wish to offer comment at this time? Sam Davis. Thank you Kevin um I think this uh uh Tom Pelham has really made this point over and over again I think it's critical I think it's critical to do that um and I agree with him that that what's really the real risk here in a certain sense of bureaucratic sense is that we just keep babbling about something and never nothing ever really happens um one of the things I would ask is that I think it's just set up as a proposition I think that the attention to the ACO to make this happen is completely misplaced the ACO has no power whatsoever to compel any um payer whether it's a private payer, a government payer, any other payer, any kind of payer to participate in a fixed price contract that has to be it has to be a decision by it has to be a decision by the payer to want to do that and on the other side you have to have a decision by individual hospitals to agree to live under a fixed price contract so I would just say that the that that that this chasing the ACO around is just not going to get anywhere if I've got another minute can I make another point Kevin or do you want to stop as long as it's about the ACO guidance yeah um the yes uh well uh okay I'm not sure about that it's generally about it yes here is here it is uh if the single most important piece of data about what's actually happened is the Dartmouth Health Atlas every policy person that I know and the serious person in the policy biz agrees with that rock solid and what that rock what that shows is that the is that the UBM health network because mainly because it's an academic medical center with a whole different financing structure for its physicians okay is very very very low and you've got very high cost per capita in the hospital service areas for other for the other hospitals I mean way way way more okay and so if you look at if you just look at the if you look at what the percentages are it's a Tom's point Tom Pelham's point if you look at that the UVM help not just the UVM MC itself is half of all the care in Vermont half okay and it has very low this lowest cost per capita in the service area and that's also that's also backed up by the BR the Berkeley research group PQI data that you've got in October so I would just say um in this to get in to get in a to get the kind of participation that Tom Pelham wants is going to depend not on you on ace on the ACO at all it's going to depend on the the determination of Blue Cross in real life okay to say that they want that kind of a contract I would just guarantee you that if Blue Cross asked you uh one care of Vermont to design a fixed price contract one care would do it why wouldn't it okay is there other public comment is there other public comment Walter thanks Kevin just a point I'm I agree with Tom Pelham's points and Ham's point as well I just wanted to say that Blue Cross etc are not payers they just are middle people who disperse it we are the payers so it's almost like asking us to be in a contract okay is there other public comment is there other public comment is a board member prepared to make a motion at this time I'll I'll go ahead and make a motion unless Tom Pelham you'd like to but before that I just want to comment on Tom and Marissa's comments so regardless of what we change in that in the guidance it does not change the budget order and the budget order has the staff looking at the targets and approving or modifying so taking that language out of here doesn't change the process that we that we established in our budget order last whenever it was December or January so I just want to make that clear because this is the guidance it's not the budget order so where I am with this is I like the addition of adding the third target I however would prefer to see what comes out of the staff analysis before picking a number because my recollection of the reporting that we've gotten to date is that I didn't feel comfortable that those numbers were real and while I don't disagree that setting a target you can choose to be aggressive I would like to know that it's somewhere within the realm of reality and not just throwing a dart on a dart dartboard so just where I personally am is I I'm fine with changing endeavor to use best efforts I agree that is a little bit stronger I think that's a good change so I would that's that's where I'm at in terms of sort of the discussion around the FPP target so I can go ahead and make a motion unless Tom wants to make a motion or if other people want to comment I don't know how you want to handle it Kevin Tom did you wish to make a motion no I mean if if Robin wants to make make a motion with best efforts in it that's that would get me halfway I know that I'm not going to get all the way there so my feeling here is that you know at least at least we have systematically worked in the 2021 budget order to get the ACO to kind of commit to giving us targets they gave us targets and when we encase them in the 2022 budget order and I just don't you know I worry that that our staff language will end up quibbling with the ACO over methodology and months and months and months will go by but I'm not going to be on the board in months and months from now so but I do want to at every point possible make this a serious concern because it is fundamentally a serious concern that I sometimes wonder what would the rate increases that we're being proposed now by the carriers at 12 and a half percent and 16 percent look like if we if if if Bromstead who was a willing partner had a willing partner at Blue Cross Blue Shield and they had implemented fixed by prospective payments two years ago I think we'd be in a different place so I'll let Rotward make the motion and hoping she puts best efforts in it at least it's something okay thank you Thomas do you have something to add I did yes if I may thank you I just wanted to offer one more comment that might help if any board members are still not sure I think there's two ways to think about it you could set a target an aspirational target like like robin said or to ham's point you could set anything you want you could set it at 50 percent or over 50 percent which is you know where Medicaid is at or Medicare if you include their AI PVP or you could set a target or or wait to set a target that's more realistic and that's that's I think that's kind of the decision and I think the the target that they set is kind of somewhere somewhere in the middle so I think you could you know the board could the board could set an aspirational target or you could leave the language as it is and allow staff to sort of finish our more our technical review or I think I think you know accepting that the target has already been proposed is kind of something in the middle of that so in case that helps to think of it those two ways that's my comment okay robin are you prepared to proceed I am so first I'll move that the board adopt the fiscal year 23 budget guidance and reporting requirements for Medicare only non-certified ACO as presented by the board's staff is there a second second is there any discussion hearing none all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay let the record show that the motion carried unanimously robin I move that the board adopt the fiscal year budget guidance and reporting requirements for Vermont certified ACOs as presented by the GMCB staff today specifically including the fiscal year proposed budget targets for minimum funding of BBIS commercial benchmark trend rate consistent with ACO attributed population and GMCB approved rate filings and setting a percentage of payments in the form of FPP set in accordance with the fiscal year 22 budget order with the change that the word endeavor be struck and use best efforts be included in lieu of endeavor second okay is there discussion hearing none all those in favor of the motion please signify by saying aye aye any opposed please signify by saying nay let the record show that the motion carried unanimously thank you Marissa and next we're going to turn to an update from the Department of Mental Health and we're going to hear from Commissioner Emily Haas commissioner whenever you're ready and if we could take down the other screen perfect welcome commissioner thank you thanks for having me today I'm also joined by Deputy Commissioner Allison Crumpf Samantha Sweet who is our mental health services director and then our interim policy director Nicole Dostadio so I'll just do a brief overview of current priorities for DMH we'll also highlight some initiatives that have gone into action over the last several months and then highlight some gaps that we've identified in the system and we can go from there that sound like a good plan it sounds great okay so Nicole if you don't mind moving us to the next slide thank you so for folks who who don't know or haven't seen the department's vision 2030 this came out of some work that occurred right before the pandemic where we engaged stakeholders across the state in several town hall style meetings to really look at our system of care and develop a vision a 10-year vision for 2030 so that's to advance the and so Allison and I both came on to these positions about a year ago and we continue the work around vision 2030 with the department so advancing the goals and ejection and objectives of vision 2030 for a coordinated holistic and integrated system of care for Vermont we are looking to expand access to community-based services enhancing intervention and discharge planning services to support for monitors in crisis we're committed to workforce development and payment parity and completing our mental health integration work highlighting in action area number four I'll mention the implementation of mobile crisis DMH has testified a couple of times around the Rutland mobile response stabilization pilot that has been operating for about the last year maybe 10 months out of the Rutland area and we've seen some success with that pilot program and we'll be looking to continue that as well as but as expanding that into four other for other areas of the state we're also looking to align our provider incentives so DMH has included performance measures in the provider agreements with our designated agencies to incentivize providers to move individuals through the system of care so when somebody is no longer meeting hospital level care that there is action towards discharge also taking a look at where crisis assessments are occurring with a primary focus on those occurring in our community setting versus an emergency department setting and then also a follow-up after a hospitalization stay for mental illness and that's both for youth and adults this is Samantha I have the next slide and my apologies without my voice I've been fighting a cold for a couple weeks now so let me know if you can't hear me telepsychiatry so DMH was able to secure a hundred thousand dollars for telepsychiatry services with the intentions to use these funds for critical access hospitals that do not currently have psychiatry in their emergency room quickly after securing the funds at DMH we learned that PPQ was awarded one million dollars through senator Leahy's office to establish a Vermont emergency telepsychiatry network PPQ partnered with DMH and VOS to create a survey to go out to all hospital emergency rooms to learn more about what equipment they have what are their needs who currently has psychiatry available in the emergency room along with several other important questions the survey was completed about two weeks ago and DMH is meeting later this week with PPQ to review the results of that survey and our intention is that for our hope is that survey will be able to help guide us in the development that needs to happen the allocation of the resources and to establish a process our goal is and I think I said this as we're getting but I just want to say this again our goal is to make sure that everybody in emergency rooms has access to mental health services and specialty just like any other healthcare crisis that goes to the emergency room so our goal is to get the services in the emergency room very quickly have that available for consultation or for medication prescribing whatever the need might be to move over to 988 so currently Vermont is providing statewide coverage 24-7 to the crisis prevention lifeline currently the centers we have two centers in Vermont and they are providing follow-up mental health support to anyone that has the history of suicidal ideation or anybody that has expressed any current suicidal ideation or has any risk factors and I'm sure you have heard in the media effective in about a month for July 16th the 10-digit suicide prevention number will be a three-digit number 988 and as you will see on the slide there will continue to be free and confidential tech support by texting VT to 741 741 so we are excited about 988 and there's a lot of work going into that currently to make sure that we are ready for July 16th. I'm going to talk to you about a little bit about suicide prevention so again I'm Allison Crump I'm the deputy commissioner and when we look at suicide prevention and why it's important one I'll show you on the next slide some statistics but also when we see the list of folks waiting for emergency departments waiting in emergency departments for placement the whole thing even if I'm not going to eat at all um ham if you could mute yourself I believe that was you no problem ham I'm hungry too so we get the list of folks waiting in emergency departments and most days the majority of folks particularly with youth are there for suicidal ideation that tends to be and it's been increasing over time it's been increasing with youth before the pandemic and it's really been exacerbated by the pandemic so we're grateful that there's some additional funding coming our way once the big bill was signed that came with a package of suicide prevention funding so we've only had a very small piece historically we've grown that this coming year and there's a lot of initiatives to go with that so you may have heard about zero suicide that's a public health approach it has pieces to it that include training providers how to treat suicidality it includes educating schools and includes assisting emergency departments if they want to screen it it's a very large umbrella so some of the funding will go towards expanding zero suicide in the state some of the funding is to support 988 which the man that just spoke to also we look at where are our most vulnerable Vermonters and for a period of time older Vermonters were dying at a higher rate in Vermont than other states and so we do have a program that goes out to homes to serve older Vermonters with mental health needs and we're looking to expand that with some additional funding and lastly that funding is going to go towards a director of suicide prevention for the state of Vermont up until now we haven't had any position focused on suicide and the funding's getting larger there's a lot of federal opportunities and we want to be able to prioritize going for those and then you having somebody who can implement the other two pieces you should be aware of there's a larger effort with the we received a CDC suicide prevention grant in 2020 and we I say we but it's technically the Department of Health and we're partnering with them and it's been a really great opportunity to look at how do we maximize syndromic surveillance how do we dig into some of their population health expertise and work together and that's a five-year grant that the goal is to reduce suicide both mortality morbidity by 10 percent by 2025 and lastly I'm going to name the governor's challenge governor Scott requested that we sign on as a state to the national effort called the governor's challenge to reduce suicide deaths for service members veterans and their families Vermont is a very large national guard population and when you include their family members and you include veterans and other service members this is a very big target population for which has a higher increased risk for suicide so we're excited about that we signed on just about a month ago and half the governor's office support and then this is the staggering data that will tell you why this is so important we've had an issue in Vermont for a long time we've been higher than the national average for over a decade but last year in 2021 we lost 142 Vermonters to suicide which is intensely and notably higher than we have in the past so we're really feeling an imminent need to address this issue okay I think it comes back to me so another area action area eight is our commitment to workforce development and payment parity I'm sure that you've heard it's well known the workforce shortage and crisis that Vermont is experiencing across our health care system so I'll focus this specifically around the designated agencies and special service that special special service agencies workforce recruitment and retention so around December DMH was able to give out about two million dollars for workforce retention that went directly to the designated agency system we're also leading a workforce development subcommittee and beginning to do some work to develop a peer support credentialing program in order to expand the available workforce to respond to mental health needs and then I think folks are probably aware there was an increase allotted to the designated agency ssa system for July 1st and part of that is obviously to support payment parity and retention I'll highlight also the peer workforce development initiative which is a $30,000 grant to support the initial stages of a peer support credentialing program and so we'll be holding or hosting a series of stakeholder working sessions to develop recommendations to present for access to peer support services the department of mental health is fully committed to having a peer support initiative and credentialing process to provide those needed supports for other mantras in need here's the graphs to highlight some of the vacancy challenges specific to the designated agency and ssa's so as you see around December they reached the highest level of vacancies at around 1027 which is substantial as we moved through the winter months into the spring and some additional money and raises were given to those staff we stop we saw their vacancy rate start to decrease we'll be getting some updated data around their vacancy rates in the coming weeks but we're hopeful that folks are continuing to be able to hire permanent staff and we'll keep working to support those agencies and moving forward other things I'll highlight this is around potential integration so we have an initiative with the secretary's office to expand hub and spoke our first our first focus of that is increasing access to mental health services at the hubs and so being able to have those providers serve folks in a more comprehensive and integrated way additionally dmh in collaboration with Vermont care partners in the national council are working through a policy academy around ccbhcs or certified community behavioral health clinics those are very similar to an fqhc we're in the early stages of that project right now there are expansion grants available that the designated agencies have applied for I think nine of the 10 have applied for those expansion grants ccbhcs have been successful in states that did not expand medicaid we're obviously vermont did expand medicaid and so we're still working through to see if that's a model that can be beneficial for vermont at one point there was also an enhanced reimbursement rate for four agencies that became certified that enhanced rate is currently on hold but we'll see if there is a change in that direction on a federal level so we'll continue to work through that ccbhc project and like I said we're we're in the early stages of that policy academy so we heard there was some interest in payment reform and value-based payment models and so we wanted to just give you a quick summary of where the department of mental health is at regarding payment models we made a huge shift in 2019 away from fee for service um for a large portion of our medicaid programs um we moved we took the fee for service we put it into a prospective payment model that included a value-based payment aspect and so the goal there was to provide some more flexibility on how clients are served and um when and where and then create some incentives towards um quality that the da's also were on board with as well so we had lots of working meetings came together and tried to align on um you know some some metrics that everybody agreed should improve the system and so taking that major step which again we found it to be very stabilizing during the pandemic to have them on a prospective payment model versus fee for service it allowed this the system to maintain some stability in a very unstable time we i wanted to highlight the mental health integration council because that was a legislative charge that said hey vermont we have laws on the books that said you need to have integrated mental health and health care and yet we're really not there yet and so we're asking for these specific leaders to come together and start to take some action steps towards more integration so that's a place where we're taking the steps that we have made through payment reform and add bringing them to the table with others that includes one care includes uvm health network it includes the blueprint for health um it has other state members it has blue cross blue shield um and so the goal was to really gather and and start learning from each other and see where we can align and remove barriers so in example as last month we had the uvm health network come and talk about their aims model um and what they've done so we can learn and ideally you know understand if you did have some interesting mechanisms for how you pay for things because that's where a lot of us stumble is we we can envision what we want but then we've got these silo payment structures um so that was one we also have had national speakers come in and talk about things like um you know whole health integration um and whole health models and so we're a year in july will be our one year anniversary where we're going to be meeting to talk and summarize what we've learned and talk about what we want to accomplish in the year to come and the next slide is just an example of one of our value-based or two of our value-based payment measures um thinking about why we would want to do payment reform and what we want to incentivize access to care was towards the top of that list and so we brought in measures that um looked at whether or not once you make that phone call and say you want you need help how many people are given a face-to-face contact within five calendar days I will tell you once COVID hit we quickly had to change that face-to-face to include telepsychiatry so it does now um and then we also have a second metric to say okay you got your first appointment which is often where you decide what you need then how long does it take for you to actually get that service that you know you agree that you needed and so that's the second um they're sort of not in order here but that's the 14 days within assessment so we've set a target for that and we'll be looking at we use real data to then reset the targets and we're in that process now. Thanks Alison um so I'll take an opportunity to highlight some gaps that you know we continue to focus on in addition to all of this other work and I'll preface this that these four topics are youth focused not necessarily adult focused and that's because over the past year and we know what's likely ahead of us with youth needing services or needing timely access to care we have seen those numbers increase over the last year and that need increase over the last year we've seen um youth who have complex medical and psychiatric needs be delayed care uh because our system just wasn't able to appropriately serve them so I'll highlight youth inpatient capacity um folks are where all of the youth inpatient capacity for Vermont is at the Brattleboro Retreat um they are challenged when it comes to youth who also have a significant um medical or a complex medical issue that also needs hospitalization and so um we need to diversify um and make sure that there's access to um inpatient care for youth um who can also appropriately serve and treat those medical needs so we are posting an RFP today um to gather bids um for a youth inpatient facility um our unit so that will should get posted either today or tomorrow to push that initiative along additionally we have a team of care managers that meet every day that take a look at who is uh youth who are waiting for um inpatient care youth who are waiting to be discharged from a hospital level care as well as youth who are needing access to crisis beds or intensive outpatient or therapeutic foster care um the whole gamut of our community resources and we know that there are significant gaps um across our system for access to residential care most of our residential programs have been out of state historically uh the COVID COVID pandemic along with an already looming workforce shortage has really impacted the ability to access our out of state residential um park care partners um we know that we have ongoing waits for intensive outpatient services for youth um and additionally uh we know that there is a significant um gap in the availability of therapeutic foster care so we'll be engaging in conversations across um AHS on how to bring back a stable therapeutic foster care system for here in Vermont so I'll highlight those gaps DMH team anything that I missed that you want to add to those I think the only thing I would add is that RFP specifies that we are looking for inpatient capacity in places that can offer the co-occurring you know psych psychiatric and medical support great thanks Alison Sam anything to add from your lens no I don't think so I think you covered it really well um just to drive home the point of how much manpower staff power go into the care management team really looks across the state is who's waiting for an inpatient bed who's ready to come breaking down all of those barriers to keep the system moving um if that doesn't happen then the backup to the emergency room is just uh amplified yeah and that's why we made the point to put these other levels of care on the list because those are the things that are needed in order for someone to leave and so without that discharge we don't have access Kevin you're on mute I know our slideshow is not showing anymore but the last slide was a thank you um so we're at the end of the road for that but happy to um answer any questions you might have so actually commissioner I was starting to thank you um but as usual I forget to unmute myself um I just wanted to say that you and your team are doing incredible work and it's not easy work and I want to thank you um for all Vermonters for the work that you're doing each and every day and if there's anything that we can ever do to assist you we want to be there for that and you know we've had some conversations about maybe what's the best way to um utilize the money that UVM isn't able to put into adult beds and I look forward to that conversation continuing just to give you a heads up we will be sending a letter to UVM tomorrow and asking for their input on this topic as well because we need to move forward we can't just keep saying that the problem exists in emergency rooms which is the absolute worst place for care um we need to do whatever we can do within the the stark reality of limited resources to try to fix this so thank you I don't have any particular questions but I just really wanted to thank you and your team with that I'll pass it to my other board members I'll just go ahead and jump in and echo the thank you it's really helpful for us to have um a grounding in your larger goals and priorities and have a a better understanding of the areas that you're working on um you know so that we can make sure that we're doing our part to consider mental health issues and integration as we're proceeding with our work so I also didn't have any questions the presentation was very thorough and helpful thank you any other board members no I guess I'll just pipe in echoing thanks as well um and I'm sure you know from the conversations that you've had with chair mullin I'm sure you understand the the perspective that we often see is around the eds from our in our hospital budget process and so you know I've been on the board now seven years and I've been hearing about the borders in in the ed for a long period of time um adults as well as children um obviously and so to me I think you know I I hope that there's you know continued conversation around you know adult inpatient um as well and you know we are you know receiving certificate of need requests for major capital expenditures to redesign eds to basically be able to accommodate the borders it's expensive we hear about workforce challenges around you know um the the the care that's um or the the episodes of care and the ability to care for the patients that are struggling with mental health and the need for sheriffs and sitters and all of this and so to the degree that you know we can keep the lines of communication open between dmh and the board around these topics I think it would be really helpful especially as we're heading again into hospital budget season any things that you are doing um on your end and you've certainly alerted us to many of these initiatives that you have now that will mitigate some of what we're hearing about um in the eds I think would be really helpful just as we're thinking about hospital budgets and the need that they're expressing for the mitigation strategies that they have and also you know the the challenges that they face in um having patients in their um inpatient that actually really should be in a mental health setting and so it's occupying beds that you know you know that I know you know all this but I'm just saying we're hearing it from our end so anything any strategies and priorities that you're going to be emphasizing that will help mitigate that will help us you know informing us in terms of our hospital budget process so a thank you I know it's hard work thankless work so I will at least be one of three people today to thank you that's much appreciated thank you back for your work I'll just highlight that that's why you see a lot of our initiatives not necessarily focusing on inpatient capacity it's a given that we need to diversify from the retreat um that we need to integrate and have medical facilities who can appropriately serve folks who have co-occurring um psychiatric needs and medical needs but you'll see a lot of our efforts if not almost all of them really targeting those folks before they get to the emergency department so thank you very much for having us here today much appreciated well it's been our pleasure and uh under our our rules and policies we always open it up to public comment so if no other board member has any comment at this time I'm going to open it up to the public and I see that ham davis has his hand raised ham thank you Kevin um this is obviously one of the most difficult issues that we have one of the it was it rose originally because of because p chelman the five decided to only replace half of the beds the uh really the heavy-duty psych beds that were lost and Irene um but they but it seems to me that this in a certain sense this issue is really easy there isn't any money this most single word mentioned in all of that presentation was the word gap okay and so what what I so what you're really looking at and I think people ought to really get real about this is on the one hand um the uh there's no way to clear those there's no way to clear those eds I've seen as many I've heard as many as 90 people and the uvm in the uvm emergency room that simply can't be moved there's no place for them to go and they're having huge problems with that a nurse got beat up the other day it's going to be it's so it's a horror show every way you every way you look what I think you we need to see and I would hope that the agency or the or this board or somebody would would lay out these absolute numbers so that at least we can see where where we're headed on the one hand there's an there's an irreducible minimum of new capability new a bit new beds new uh places to put people to keep people that is going to have to be paid for by state government just forget it and it's not you're not going to get it you're not going to get it without that we need to know how much that is what the what this what the professionals really said what is the real gap what do you need for actual new new money and new purchases and new facilities that would be paid for by state government and by bond issue if necessary and the second thing is you have I think you had a meeting here with brumsted about two or three weeks that I can't remember when it was given but it was recently and what he told you he he doesn't begin to have the money to do this not even close he does not only have the money not to build it he doesn't have to build the money to run it which because it would lose the fund so so that sits right in your board that's in it so so you could what we need to do is have some looking in mirrors here thank you thank you ham is there other public comment hearing none the important question going back to you ham is were you able to eat it all or not I'm sorry we heard you say you weren't going to be able to eat it all during the previous conversation so we're curious if you were able to eat it all or not I don't know I've got way too much trouble with eating I'm sorry just giving you a hard time ham and that's okay you're entitled Kevin okay just got to teach you better control that mute button you have the exact opposite problem that I have I mute myself too often and you don't mute yourself enough I'm going to do it right now watch okay okay thank you commissioner and team from DMH really great work and we appreciate it thank you thanks so much so next I'm going to go to old business of the board and I'm going to call on Mike Barber and to set up for Mike I just want to say that we made a decision a few months back I'm not sure how many months ago it was now they all seem to be rolling together but the board designated Robin and I to be the negotiators with the federal government and AHS for the work on the existing and next models and with my leaving whether it's in two and a half weeks or a month and a half whenever that is it only makes sense that we have continued continuity not only on the all-payer model but also on sustainability in those discussions with AHS so I'm hopeful that the board can move today to replace me in those discussions with Jessica and I'll turn it over to Mike Barber thanks mr chair so you set it up pretty well I don't really have much else to say other than I have have drafted an order obviously I can't make a motion but I had drafted an order that would essentially revoke the previous delegation which was dated December 30th 2020 and holy mackerel I guess it was a few months ago it's been a bit and then and then delegate authority to whomever you choose delegate the board's authority to negotiate with respect to the all-payer model agreement and any subsequent agreement and then in addition as you said pursue the activities required by s285 act 167 regarding hospital sustainability and all-payer model agreement development so I can share that to help you guys with that if you think that'd be helpful I think it would be I mean I think the board understands that there has to be continuity on these hugely important issues so it just makes sense we can't violate the open meeting law because we can't have more than two board members together at a time unless it's an open meeting and so it makes absolutely no sense for me to keep going and then try to provide the feedback to the the new chair which I'm more than happy to do and anybody can call on me at any time in the future don't worry about that but I just think it makes so much more sense to have a board member who's going to be here throughout the process in those conversations so Robin is there enough there for you to make a motion well I feel a little awkward making a motion to delegate authority to myself so I would prefer I'm happy to continue doing it of course and well maybe Tom could make the motion since that might be the best way to go does one of the toms wish to make a motion sure Robin will tell me what to say I recommend you read what Mike Barber has put on the screens starting all right delegating authority to okay so I move that pursuant to 18 vsa not 93 74d the green mountain care board here by delegates to board members Holmes and Robin the board's authorities to negotiate with respect to any amendments or modifications to the all pair model agreement and any subsequent agreement and and pursue activities required by act 167 2022 related to hospital sustainability and a subsequent all pair model agreement including community engagement payment model development and regulatory design the delegation of authority to negotiate with respect to the all pair model agreement and any subsequent agreement does not extend to the gratification of or execution of any of an agreement okay tom w can you second that that can do great is their discussion by the board hearing none I will open it up for public comment in case any member of the public wishes to comment at this time hearing none is there any further board discussion I'll just say that I'm gonna officially change my name to just broaden I think uh when Mike uh drafts the official uh thing it will definitely have both your full names okay all those in favor of the motion please signify by saying hi hi hi anyone opposed please signify by saying nay let the record show that the motion carried unanimously does anyone have any other old business to come before the board is there any other old business to come before the board hearing none is there any new business to come before the board hearing none is there a motion to adjourn I move we adjourn second it's been moved and seconded to adjourn all those in favor of the motion please signify by saying aye aye aye any opposed please signify by saying nay thank you everyone and have a great rest of the day