 Okay, good afternoon. It's one o'clock and I'd like to call to order the Green Mountain Care Board's October 12, 2022 Board meeting. First, thank you all for being here. I see we have all the board members present and the Executive Director, Susan Barrett. My name is Owen Foster. I'm the new chair of the Green Mountain Care Board. I started last week, and this is my first board meeting, so it's nice to be here. Also joining us is another new care board member, this Dr. David Merman. Mr. Merman, if you'd like, Dr. Merman, if you'd like to introduce yourself. I'm Dave Merman. I'm a practicing emergency physician here in Vermont. I've been practicing for about a decade in rural hospitals, academic hospitals, city hospitals. And I'm very excited to be part of the Green Mountain Care Board, really excited to serve Vermonters and promote the mission of the board. So thank you so much. Thank you, Dave. And before I turn to Susan, I wanted to thank on the record the care board staff and the other board members for working so diligently the last week and a half and even before that and getting David and I up to speed. We've been really impressed by the team and they've done the best they can to get us as much information that we can digest as possible. So thank you to the staff and the board and Susan for all of their work. And with that, I'll turn it over to the Executive Director Susan Barrett. Thank you, Chair Foster, and welcome to both of you. We're really looking forward to working with both of you and having a full board. It's very exciting. So I have a few announcements. First, some new open public comments and then an ongoing public comment. First, the board received the One Care Vermont certification on September 1 of this year and the FY23 budget from One Care Vermont on September 30. One Care Vermont will present their budget at a public board meeting on Wednesday, November 9 and the board staff will present their analysis on Wednesday, December 7. Public comment can be submitted through Friday, December 2 to be considered ahead of the Green Mountain Care Board staff presentation on December 7. By Friday, December 16 to be considered ahead of the Green Mountain Care Board vote, which will occur before the end of the year and is tentatively scheduled for Wednesday, December 21. There's a lot of dates here, a lot of information. It's all available on our website, but I'm just reading it off to you so folks are aware. The second public comment that we've opened is the board received Gather Healthcare Health ACOs FY23 budget on September 30 and Gather Health will present their budget at a public board meeting on Monday, October 24 and the GMCB staff will present their analysis on Wednesday, November 2. Public comment can be submitted through Friday, October 28 for Gather to be considered ahead of the Green Mountain Care Board staff presentation on November 2 or by Friday, November 11 to be considered ahead of the Green Mountain Care Board vote, which is tentatively scheduled for Wednesday, November 16. And then the board has an ongoing public comment period for anyone who wants to comment on the next potential all-pair model with the Center for Medicare and Medicaid and for innovation. Any comments that we have received or will receive, we share with AHS and the governor's office as they are leading the negotiations on the potential next model. Secondly, I'm going to announce a rate decision that the board decided on September 30 and that is the board issued its decision in order approving modifications to the 2023 Blue Cross Blue Shield HP filing. The decision in order is posted on the Green Mountain Care Board's website on the What's New page and on the filing page on our Rate Review website. And I'll also mention again that all of our open public comment periods are listed on our website under public comment. And then I've been announcing this for the last several meetings. I want to just remind anyone at the meeting today and anyone you may know who purchases their own insurance as an individual or a family that recently federal, a new federal law has extended and expanded subsidies that are available for those plans. So we encourage you or anyone you know to check out our website under premium tax credits where you can look at the information and it will link you to another website on the exchange for Vermont where you can actually see if you qualify. Even if you didn't previously qualify, we strongly encourage folks to check that out. And that is all of my announcements for today. I'll turn it back to you, Mr. Chair. Thank you, Ms. Barrett. The second agenda item today is the approval of the minutes from the board meeting of September 28, 2022. Dr. Merman and I did not participate in that board meeting. However, we have three board members who were participants. Is there a motion to approve the minutes from September 28, 2022? I'll move approval. I'll second. Is there any board discussion relating to the minutes from September 28, 2022? There is no board discussion. Those in favor of approval of the minutes of September 28, 2022, please say aye. Aye. Aye. That's three ayes and two abstaining and it's a unanimous approval of the minutes from September 28, 2022. Thank you. Susan, I'll turn it back to you. So, I wanted to just say a few words about our next presentation, our first presentation actually for the day that Marissa Melamed will provide. This is the first in a series of presentations that I've asked the staff to put together. As we saw, we have two brand new board members and board member Walsh is still in his first year. So for him, this is the first time he's going through ACO oversight regulation. So as we move through our calendar of events and regulatory activities, I've asked the staff to prepare some educational materials for the board so that you can hear this as a board and discuss this with each other and with your peers on the board. And I think it's a good way for everyone to be brought up to speed on our regulatory activities and really for the board to ask our staff questions on our work. So with that, I will turn it over while I can turn it back to you, Chair Foster, or I can just turn it right over to Marissa for her presentation. Please go ahead, Marissa. Great. Thank you. Welcome, Chair Foster and Dr. Merman. If you'll allow me a moment to project my slides. And then I'll get started. Is that showing up all right? I'll take that as a yes. Good afternoon. My name is Marissa Melamed. My title is Associate Director of Health Systems Policy. But my functional role at the Green Mountain Care Board is to direct the board's ACO oversight program. I came up to be the first staff member to present to the new board members because I direct the regulatory process that happens to be the first one that you'll go through this fall. So in addition, Board Member Tom Walsh did start after this process was completed last year. So three of five of our board members have not yet been through the ACO process. That being said, we thought you might appreciate some background and history on ACO oversight before we dive into the details of the submitted budget, which are posted if people want to start looking through those. That's Susan mentioned. I will endeavor to address some of your questions through these slides or at least facilitate your understanding of the process and the charge before you. So this is a broad and complicated area of review. So just remember that this is just the first time that we're going to discuss this process. And we have the next several months to work through these concepts and your questions as the regulatory review runs from October through December. So our goals for today are as follows one to give a brief background and history of ACO and ACO regulation in Vermont. That will include a very brief discussion of a complicated topic, which is what is an ACO and who are the major stakeholders. Also a brief history of the ACO concept and ACO regulation in Vermont specifically. Vermont, the Vermont ACO market and regulation is unique to Vermont. So there are statements that I'm going to make about ACOs in general, but also Vermont has a very unique health system landscape. It's ACO is very unique and our regulation is unique. As well, we're going to introduce the ACO regulatory framework to you. And which includes the statutory charge, the standards of review, so the criteria that you judge the budget against. And the monitoring and measurement framework that we are using and that's evolving for evaluating the ACO's budget. So this includes a discussion that was started last year around core competencies of high performing ACOs and outcomes assessment. We're also going to review the process in the timeline so to sort of orient you and in in time and space to this process. And we will conclude with a board discussion. And so a word a word about the discussion again since this is the first board meeting for several of you. I suspect that board members, especially new members are going to have questions or comments that are specific to how ACO concepts are applied in Vermont and how they're working. I definitely think you should ask those questions, but I'm not going to assess one cares or any ACOs budget or specific programs and their arrangements today. I'm going to try to sort of thread the needle between, you know, introducing you to this topic and and sort of the charge before you and what is actually going on in Vermont and in the specific ACO budgets because there will be plenty of time for that is the tip of an iceberg. So questions that are specific to the ACO submission should be asked during their budget hearings that are coming up. What I do want to do today is give you the opportunity to ask the kinds of questions that you're interested in things that you want to know about. And this will help the staff to craft our analysis. I may add some some commentary, but specifics of the budget will be discussed at the budget hearing where the entities themselves come before you and present present their budgets and programs. And the staff analysis will be presented following the hearing to aid in this discussion. I certainly do not do this by myself. I have Sarah Kinzler, Michelle degree and Russ McCracken who are ready to participate in the discussion at the end of the slides and help with areas where they have particular areas of expertise. We have a broad team that crosses green mount care board teams and areas of regulatory review to help us through this process. So I did something a bit challenging and that I opted to give you only one slide answering the questions. What is an ACO? There are concepts embedded in here that are entire slide decks themselves and we can, you know, work through those concepts as we go. But here's my here's my attempt at one slide to explain an accountable care organization to you. This slide and this presentation in general makes the assumption that the audience is already at least somewhat familiar with the concept of an ACO. However, it takes time and experience to gain familiarity with how ACOs work. And then there's also the specifics of how the ACOs in Vermont work. So in a nutshell, what is the problem that ACOs are trying to solve? Healthcare, actually, let me before I go there, let me read just read free of the slide so that we're all in the same place. So an accountable care organization is a group of healthcare providers who come together, join together to be responsible for the cost and quality of a defined population of patients. ACOs contract with payers to join value based payment models that reward good financial and quality outcomes. Value based payment models are a broad set of performance based payment strategies that link financial incentives to providers performance on a set of defined measures of quality and or cost or resource use. Like I said, there's a lot of concepts there. But in general, you have the accountable care organization, which is a separate entity and they have relationships and interplays with these three major groups, patients or the population, providers and payers. So in a nutshell, what is the problem that ACOs are trying to solve? Healthcare spending is increasing at an unsustainable rate. We're not getting better outcomes for that spending. What is the solution or the theory of change of ACOs? And that is that traditional fee for service payments are based on prices paid for services and payment is made per service. The incentives are based on volume, not outcomes. There is little incentive to coordinate care. The ACO model provides a mechanism for a group of providers to join together to care for a population of patients by participating in value based payments, shifting payment incentives from volume based fee for service to outcome or quality based. There are several models and a continuum of what those payment strategies are. These include pay for performance, shared savings, shared risk, capitation, or per member per month payments, PMPMs, fixed perspective or global payments. Again, all topics to get into and understand including what, which of these mechanisms are for which providers and what, you know, and how the ACO chooses to use these. But there's a broad set of strategies there. I believe that it will be important for us to discuss the theories of change embedded in the ACO concept, as well as the characteristics of high performing ACOs and the characteristics of ACOs in Vermont in order to assess the budget submissions. However, today we're starting with the basic concepts that ACOs exist. They exist in Vermont and that the state of Vermont has chosen to regulate them through a broad set of financial administrative and programmatic review criteria. The Green Mountain Care Board is charged with carrying out that review. And the scope of that review ranges from ACO programmatic and budgetary line item details, all the way up to the sort of ultimate question, are we achieving better outcomes for people and bending the cost curve. So, some basics about regulation of ACOs in Vermont. In 2016, the legislature assigned the authority to regulate ACOs to the Green Mountain Care Board, which is in Act 113. And the first budget review was in 2018. The aim of the Green Mountain Care Board's ACO regulation is to provide oversight and transparency into a major component of Vermont's healthcare system and to ensure alignment with the state's healthcare reform goals. The Green Mountain Care Board endeavors to give a balanced view into the ACO as an entity and its impact. And the level of review is based on the size and scope of the ACO. The Vermont ACO market in regulation is unique to Vermont, as I stated, but bears repeating. In conversation with other states and policy experts outside of Vermont, certified ACOs in Vermont are considered highly regulated when compared to other states. And they are subject to a high level of transparency and public scrutiny. For ACOs in general, maybe why is this different in Vermont? ACOs in general, they do not hold insurance risks, so they're not regulated like insurance companies. They are subject to data privacy and data sharing and antitrust regulation. I know of at least one other ACO certification program in Massachusetts. It's been a while since we've done a full sort of state scan on this regulation. But in general, ACOs in other states are not subject to the same level of budgetary and programmatic review. Okay, so one of the more frequently asked questions that we get about ACOs is what is in it for the major stakeholders? Why would you do this? Why would you join? How does it affect or impact them? These three slides represent the three sort of sides of that triangle graphic that I showed previously, patients, providers, and payers. So I'll give you the basics here. But this is also an ongoing discussion as we work through the review each year because the incentives, accountabilities, and impacts on patients, providers, and payers enabled by the ACO is what we're trying to assess here. So for patients, patients are attributed or assigned or aligned several terms to an ACO based on a methodology that's agreed upon between the ACO and the payer, the insurance provider. Attribution means that an individual is linked to the ACO generally based on the insurance coverage they have and the care they have received in the past. ACO, some key points here. ACOs must notify patients that they are attributed, but it's not something that you necessarily sign up for. Attribution does not change your insurance coverage or your plan design. Attribution does not restrict freedom of choice to see any provider. However, insurance network restrictions still apply. So it's all based on what your insurance arrangement is. The patient or the person's sort of agreement is with their insurance company still. Attribution may, however, provide enhancements, increased access to care coordination, or other programs or values that the ACO provides. So as the definition stated, an ACO is made up of a network of willing providers. Providers may join an ACO in order to participate in the value based payment arrangements and population health programs that are offered by the ACO. Providers could be a hospital, hospital system, independent providers, specialists, community based, skilled nursing facilities, home health and hospice, designated agency, federally qualified health centers, ambulatory surgical centers, etc. Participation can allow access to ACO negotiated payment arrangements with payers, which can provide more predictable payment streams or pay for care that may not be covered under traditional payment structures, fee for service, can also require or may require providers to bear risk for cost and quality of care. Participation allows access to ACO resources, which might include data analytics, population health management programs, enhancements, waivers, or other transformation support. And participation can promote collaboration across the continuum of care and community based services. For payers, payers contract with an ACO in order to bring more providers into a value based payment arrangement. It shifts some accountability for cost and quality outcomes to the ACO and it can lessen payers risk. If successful, this would improve the health of the insurer's covered population and over time reduce overall cost. Example from chronic diseases. So ideally it would shift some population health activities, care management and utilization management to the ACO and providers to streamline patient experience and lessen insurer, excuse me, lessen insurer administrative burden. So to orient us in history here, how long has this concept been around? So the term ACO goes back to a 2006 meeting of the Medicare Payment Advisory Committee or MedPAC in 2008. The concept was scored favorably by the Congressional Budget Office at the federal level. In 2010, the ACO model was included in the Medicare program through the Affordable Care Act. In 2012, the federal Centers for Medicare and Medicaid Services launched the Medicare Shared Savings Program and the Pioneer ACO Program. And then kind of zipping ahead through the present ACO implementation continues to grow through both public and private payers and different provider organizations. So goals were set during the first Obama administration to transition Medicare lives into a value based arrangement. The concept has been supported by both parties and through several administrations since then. So in short, the concept has been mainstream for about 10 years. The ACO or Value Based Payment Models are the current models of payment reform that we're operating within, not just in Vermont, but nationally. So here's an ACO, a brief history of ACO oversight specific to Vermont. So from 2014 through 2017, Vermont had shared savings ACO programs for three payers, Medicare's national program, and similar programs for Medicaid and Blue Cross Blue Shield of Vermont with three ACOs. In 2016, Act 113 charged the Green Mountain Care Board with oversight of ACOs. In 2017, the board adopted Rule 5.0, which established standards and processes to certify ACOs and annually review, modify, and approve their budget. In 2018, the Green Mountain Care Board certified one ACO, one care Vermont, and completed the first budget review of that organization. This was also performance year one of Vermont's all payer model. In 2021, after doing this for several years, we started working on some program improvements. So one is that the board adopted guidance for Medicare only ACOs. So one care is the only certified ACO in Vermont, but not the only ACO operating. And we needed to adopt sort of a general guidance for new entrants in this space. As well to improve our regulatory framework, the Green Mountain Care Board reviewed the core competencies of high performing ACOs, which led to recommendations to enhance the board's regulatory framework. One note here, in general, places where I put links in these slides, I recommend for people that are new to this process, this is highly recommended reading to give you sort of context. Obviously, the rule and the statute and such are required. And some of these other presentations and things give you some background on where we've been on our journey of ACO regulation so far. In 2022, the Green Mountain Care Board reviewed Medicare only ACO operating under Medicare's direct contracting model. That was our first sort of new review. That was Clover Health. And we will review a new entry Medicare only ACO and the shared savings program for 2023 that is gathered health. As Susan mentioned, Clover Health is no longer operating in Vermont. So sort of where we're at 22 and beyond. And we as a team are continuing to work to include the ACO core competencies and ACO performance benchmarking. So our sort of measurement and monitoring approach that we've been evolving. We're continuing to work that into the regulatory framework this year. ACO oversight will evolve with any future all payer model agreement. There's sort of a tie that part of our charge here is to align those things. So as we move from this base of sort of the extension agreement to any new agreement, the oversight will necessarily evolve as well. We're working to sort of generally standardize our guidance, particularly for Medicare only ACOs now that we've seen two new entrants in this space. And to get even more level detail, we have been working on our transition to using the adaptive financial reporting database for ACO financial reporting. This is the same system used for hospital budgets. This should improve our analysis as well. So there have been some really good program improvements over the last couple of years. Okay, so moving into sort of an overview of the statutory requirements. So the Green Mountain Care Board's oversight of accountable care organizations consists of two things. There's certification and budget review. So we try to be clear about who is required to go through what process and where the kind of lines are because they can be a little gray. These regulatory processes overall sort of in plain language include a review of programs and investments to facilitate the shift to value based care investments in health improvement activities. Tools and analytics to support providers and improve health care quality and reduce unnecessary costs. ACO administrative costs and alignment of ACO strategies with Vermont's all payer model goal. So the certification piece of it. Certification occurs one time following the application for certification and then eligibility verification is performed annually. So each year we look and we see does the ACO continue to meet the requirements of certified ACOs in Vermont. Certification applies only to ACO seeking, Medicaid or commercial contracts. Medicare only ACOs are not required to be certified. That's partially because they are subject to, you know, particular Medicare requirements are sort of outside of our jurisdiction. Certification ensures that ACOs seeking to receive payments from Vermont Medicaid and commercial payers have the systems in place to do the work that's required of an ACO. Budget review in a nutshell all ACOs operating in Vermont are subject to budget review. There's a threshold of 10,000 lives. That's Vermont lives that defines the scope of the review. The review of ACO budgets occurs annually, usually in the fall prior to the start of the budget program year of January 1. Payer contracts and attribution are finalized by spring of the budget year and the ACO submits a revised budget. So there's a little bit of a bifurcated process because at the time of our review, which is prior to the start of the performance year, the ACO is still negotiating and finalizing their contract. So they give us their budget based on their best estimates and assumptions. We review that budget. And then once those contracts are finalized and attribution is finalized, they submit to us a revised budget and we review it against what, you know, what their assumptions were. And then we have sort of the set budget that they're operating under for the year. The board monitors ACO activities and performance throughout the year to ensure compliance with their requirements of budget approval. We refer to these as conditions and to ensure that the ACO is operating as required under the all payer model agreement. The ACO standards of review are here and again, you'll want to check out these links to get the specifics. I'm not going to go through all the criteria today, just sort of point you to where to look. We do walk through the criteria or work through the criteria with you as part of the review. So the standards and requirements are set forth in 18 BSA chapter 220. Section 9382 also Green Mountain Care Board rule 5.0 and in the all payer model agreement, specifically under rule 5.405 the board considers any benchmarks established under the rule. The criteria listed in section 9382 of which I've provided at the end of this presentation. We have about 16 specific or 16 criteria on that we're that we're looking at when we review the budget and then as well the elements of the ACO's payer specific programs and any applicable requirements under section 9551 or the Vermont all payer accountable care organization model agreement between the state of Vermont and CMS. So we're required to look at, you know, to sort of align those under this process, as well as the broad statement of any other issues at the discretion of the board. So that's why it's helpful to understand what is important to board members when assessing entities and the ACO shot the burden of justifying its budget to the board. So I'm just going to refrain from describing the ACO specific models today in any way because they will come before you and present their budgets and their programs to you. Okay, so here's a brief overview of the certification process for ACOs as I mentioned before all ACOs that accept payments from Medicaid or commercial insurance must be certified. One certified ACO must annually submit a form to the to the board to verify that they are continuing to meet the certification requirements and describe any material changes to any matters addressed in the certification sections of the rule. The following are the sections of rule five that cover the requirement for certification of an ACO. And the board does not need to vote on the certification updates unless there is an area where we feel they're not continuing to meet the requirements. And so then there are these 10 areas of the rule that we review for certification. And we will go through those when we, you know, with you as we complete their certification review for this year. Okay, so this is the ACO oversight perpetual calendar year over year, maybe sort of oddly starts in June. But I'll start where we are now, which is October to November. So they've submitted their budgets. We're in the process of reviewing those submissions. The ACOs will present their budgets at hearing later this month and in November. And as well what happens at the same time is that the ACO and the payers present or the payers really based on their contracts with the ACO present their prior year results. So a tricky thing about this is we have our feet in, sorry, Michelle degree you said this the other day three canoes sort of each different the prior year the present year and the budget year. So they will present prior year results in November as well so that you can see those results as we are reviewing the budget year submission. That will all be October to November in December. The board publicly deliberates to approve modify or deny the budget and and hold a vote and the program year starts on January one. In the spring time is when the ACO submit their prior year actuals and their final contracts and attribution for the current what will be the current program year. So we do have a revised budget process that happened in the spring time. And then over the summer, we, we update the guidance. So the requirements that they will need to submit for their next budget review. And we also work on monitoring measurement and enforcement review of the previous year's budget order. And then they submit certification in September, and we start our review all over. Finally, a specific calendar to to this year and where we are right now. And green there is today. Just the first tip of the iceberg introductory presentation for you on October 24 gather health will present their budget to the board. And you will be able to ask their questions and hear about their, their model on November 2nd. We are planning to present a staff analysis on gather. We tried really hard to fit all of these things in. This is the first time that we're reviewing to ACOs at the same time. So this is a tight, a tight schedule. There's the hearings are set, but potentially some of these dates could move. So we're attempting to work through gather, which is shorter and has a smaller scope and then shift to one care so that you can hopefully keep your review, you know, on one ACO at a time, as much as possible. The one care budget hearing is scheduled for November 9. And then later in November, we're going to kind of walk you through the ACO, the certification process that applies to one care only. And if, if ready, you could vote on the gather health budget in the November on December 7, the staff will present our analysis on the one care Vermont budget with, you know, potentially, or historically we've done this vote the week before Christmas. We're going to vote on the one care budget. However, we do have until the end of the year. And then again, there's ongoing monitoring. And throughout throughout the year. I want to just about the end of my presentation here. I just want to make a note about discussion and then a quick note about some of my resource slides. I suspect that board members, you know, are going to have a lot of questions as I mentioned before. So this, this is an opportunity to, to ask some of those. And we will either note them for our review or point you to resources or, but, you know, I'm interested to hear thoughts so far. A quick note about my resource slides that I'm not going to go through. This is a kind of a flow chart of how of the sort of requirements of who's who's subject to what review and what type of guidance documentation we produce. So that might, you know, might be helpful for reference and points you to the statutory citations. We also, as I mentioned, have the 16 criteria here in case you just want to have them handy. And then we try as much as possible to define our acronyms and jargon that we use. We don't make this more difficult to understand that it needs to be. So that that concludes my remarks. I'll turn it back to you, chair posture. Well, that was extremely informative and helpful. I recognize that probably took you a lot of time to put together. It had a lot of value for me. And I'm going to turn it to the board to see if there are any board questions. I have a couple myself. But why don't we first go to board member lunch? Thanks. I'm good. This is my seventh rodeo. So I have no questions. Ms. Holmes, do you have any questions or comments? I don't. Lots of rodeo action here, too. But thank you. And thank you, Marissa and team for putting that together. I think it was really comprehensive and helpful. So thank you. Mr. Walsh. Thank you, chair. And Tom's fine. No honor or fix needed. Marissa, thank you. That was very helpful. I appreciate it. I guess. Maybe this, I'm sure they'll be further discussion, but I'm wondering from this presentation. The. Will there be further discussion of the levers we have available as regulators to. To make changes to enforce changes. For example, if we were to ask. An accountable care organization in Vermont. To provide us with data on the outcomes of the patients that have been attributed to them. But then they were not able or did not. Deliver the outcome information. What recourse. Does the board then have. Yeah, so we have very broad authority to ask for the information that we want to know and put conditions or requirements on the ACO. So. We will. Our review will include a discussion of levers that you have. And recommendations that we have for, for those levers or how to use those levers. So that certainly will be a part of the. Of the process. What is challenging with ACO oversight. Now again, this is your first, not yours, but. The board members first process. It's, it's different than some of our other regulatory processes in that with rate review or hospital budgets, you're actually approving a number. A trend and there's a or a rate. And there is a sort of a piece of that with ACO oversight, which is actually a little bit outside of what I'm talking about today. I'm not going to go down there, but with the ACO budget specifically, there's not a very specific number that you are approving. So identifying those levers. And what the board can affect and how you want to help impact or what you want to regulate on is is is tricky is challenging with ACO because there's not a. We don't boil it down to a specific number. So we will certainly talk you through that. In terms of enforcement, that might be a good rest question. We can either save it for later, but he's, he's more of the authority on enforcement than me. That's, it's, it's fine. I've got a lot to learn. I look forward to learning from you from you all. So thanks for this presentation and I'll look forward to more in the future. Dr. Merman. Yeah, thanks a lot for the presentation is is really helpful. There's two areas within ACOs that I've been thinking about that I would like to know more about. And I don't know whether or not these are things the board would regulate, but I think it's good for us to think about. And one is the quality metrics that are used within ACOs and how, you know, how those are chosen, how those are measured and how those are impacted by the ACO program. And my, my, my bias in that is I, I guess I'd like to have quality metrics that really matter to individual patients and families that are, that are in those metrics. So do you know if you could comment on how the quality metrics are chosen and how those work? I'll make a, I'll make a quick comment and then I'll, that might be enough or I'll see if Michelle wants to add because she's our quality expert. My quick comment is that is that there are contractual quality metrics within the, the payer and ACO contracts, which they, which the payers will report to you on in November. And another, I think I mentioned my timeline, that's another presentation that will happen. I think at the moment scheduled for November 21st, where the payers come in and report on their quality metrics for 2021. So the prior year. I think that's kind of the, I think maybe the first place that you'll see it in terms of how they're chosen. That is also a really big, really big important and complicated question. I'm not sure if there's like a way that Michelle wants this to to sum it up or we can leave it and say, it's a really important question and and we will talk about that as we go through this process. I think that's a really nice summation. I think the only thing that I would add is that given that different payers serve different populations of Vermonters, their measures are different for reasons that make good sense for the populations that they cover. So for example, in a Medicaid space, you're going to see a lot of, you know, children and adolescents and things, whereas you likely won't see those types of measures in Marissa, you are now showing all of us again. Yeah. In, you won't see that so much in the Medicare space so there are places where they differ, but for good reason and I'll just flag that and then I think Marissa's right to let the payers really talk to you about how they go through that decision making process but also recognizing that from the set of each of those individual payer contracts, a lot of the measures have remained the same for reporting and kind of consistency purposes. Marissa, can you stop sharing your screen? Yeah, I'm not entirely sure how that happened. I'm trying to get it to stop. It was showing my presentation and it switched to this which has never happened to me before. I apologize. That's okay. I think I'm hopeful that that's a close enough answer for now for you, Dr. Merman, and if you have more questions as we sort of work through the process, I'm happy to have those conversations with you, but I think it's a really great question to have with the payers when they come in in November or with one care at any of their hearings. If I could add a tiny bit to that and Marissa, I think if you click the little X in the box right in the middle that you will not be sharing anymore. So historically, Vermont has worked hard to develop aligned measure sets across payer programs as much as possible both to make sure that we're aligning the incentives that providers have and that we're minimizing the measurement burden wherever we can. So as Michelle pointed out, there are really sensible differences that recognize kind of the payers populations that they're serving. But there was a significant stakeholder process in like 2013, 14, 15, 16 to align the measure sets as much as possible that were being used in the commercial and Medicaid shared savings program with the measure set that was being used for the Medicare shared savings program and then later transitioning to developing payer measure sets that aligned relatively well with the all payer model measure set which was developed with at least some stakeholder involvement informing that. Robin, maybe you went off mute before and want to add to that because Robin was quite involved. I think you did a great job. I was my only suggestion was going to be that we it might be helpful to cover some of the history that you just covered. So thanks Sarah. Happy to. And I actually now I've gone off mute and come back again. I also just want to say that that effort to continue to develop and maintain aligned quality measure sets is still ongoing. Michelle degree participates in a lot of that work that happens kind of across state of Vermont entities and across stakeholder entities. To develop those aligned measure sets Vermont program for quality and health care VP QHC recently recently ran a stakeholder work group that you know worked on kind of the continuation of that. What I what I see is kind of like a forever project of continuing to develop and update and refine aligned measure sets. I think it's a really interesting area because what we choose to measure, you know, has so much impact in one, you know, the burden of trying to figure out how to measure it and the complexity of of the measurement. But then to that's what we'll choose to, you know, evaluate and manage and and view our progress. So it's, you know, it's kind of one of the big crux is a value, I guess. One of the other questions that I have and I don't know if this is really specifically an ACO question, but it's sort of an impact of ACOs, which is and maybe Marissa, you, you might be able to speak to this from other ACOs around the country, but how do hospitals. And what are some experiences the hospitals and how they look at productivity of providers when they switch to an ACO format for reimbursement. You know, the sort of the crux of the fee for service model is our views relative value and it's which is essentially a value that's assigned to an amount of work that's done in the hospital that's kind of a complicated old system that has a lot of issues but is sort of what we've been using for a long time to evaluate productivity. I'm just curious how if you know of systems outside of the area or in Vermont where hospitals have moved to a different system to evaluate productivity and thus value within a health care system. Yeah, it's a great question off the top of my head. I, I don't, but I will say that the board is in a really unique position to sort of explore that because you do look at hospital budgets and regulate hospitals. You know, when I showed that triangle, you know, you have insight into payer rate setting and hospital budget so the way that the dollars sort of flow between these entities and what sort of impact they have and how, you know, how that money works once it gets to that organization is, you know, you do have some lens into that through the board's regulatory processes. Certainly something we want, you know, we want to sort of help you explore and I, you know, particularly appreciate your perspective sort of operating within that system of being a provider to understand how that works when it gets to the providers in terms of other states, I'd have to think about that or research a little bit and get back to you. Certainly happy for any of my colleagues to add to that answer as well if they'd like. I can jump in with a tiny bit more. I, there are definitely examples although I wouldn't want to name anything specific right now and kind of misspeak their for sure examples of provider systems shifting toward like a fixed salary model and kind of non RVU based physician compensation. So we can ask we can ask around to get you some examples of of of how that looks. The thing that I want to highlight is like taking a step back. Our process has our process is looking like I think of this as four tiers. It doesn't work as well to talk with my hands when I'm on screen so we've got like a couple of different tiers of relationships we've got you know the payer and the ACO. Our process gives us great visibility into that relationship. We've got the ACO and the provider entities so like the entities that the provider that the ACO is contracting with. So a hospital that decides to be in the ACO provider network where we don't have great visibility is the relationship or through this process but we have much more visibility as Marissa saying through the hospital budget process is how a hospital does chooses to pay its individual clinicians. And so I think like we we are as staff are talking about kind of how all of those relationships. Impact the care that individual people receive from our health care system. But it takes it it takes a couple steps to get to get down to that level and we we don't necessarily get to see it all in one process. Do you have something to add. Yeah, thanks. I don't that's a really good question Dave and I'm not familiar with any research on changes in productivity of the providers within a facility when an ACO is launched. But some terms that come to mind that I have seen research on there are spillover effects that happen when the changes that occur in the because of the formation of the ACO spillover into the way that care gets done throughout the organization. So there may be if we were to search spillover effects from ACOs, we may find some productivity information in there. I'm just, it's not at the front of my head. And there's also the other term that gets used in consulting land quite a bit is the foregone economic contribution, which when you reduce utilization of attributed ACO members, which is the point you're trying to keep them healthier. And reduce utilization those changes in your organization spillover into the non ACO organization parts of the organization where you're still being paid fee for service. So you're you're losing an economic contribution there because of the formation of the ACO. So there have been research into those areas. But I'm not familiar with anything specific about the productivity of providers. I think it'd be hard to tease out. And my question is actually more about the measurement of the productivity as opposed to the productivity in the sense that like productivity measurements are classically in this RVU approach, which is very it has certain biases as to what it thinks it's higher value or what not it thinks, but what it attributes to being higher value. And if there's a way to measure productivity with a different lens on value. That's a hospital level, you know, thing and not so much a care board level thing potentially. I don't know. I mean, Sarah, you know, there's maybe other ways to look at that that Sarah mentioned. It's just an interesting question that I have that I would it would be nice to be able to provide some resources to hospitals if we had insight into it. I agree. Dr. Merman anything any other questions you had? Great. Marissa, I just had a couple I see under rule 5.402 the board can establish benchmarks. Has the board established any benchmarks? Yeah, great. That's a great question. So we use benchmarks in several different ways, which sometimes gets a little confusing. I think what we're talking about here is that the board can establish certain to use a different a synonym targets or benchmarks or something that that the ACO has to hit. That's sort of separate from the benchmark setting that's done under each payer program in terms of their total cost of care benchmarks. So the benchmarks we're talking about in that in that guidance are Yeah, specific other specific sort of budgetary or programmatic targets we want to hit. And the answer to that is that until this year we had we hadn't actually set any in this year's guidance that the 23 guidance for the first time we did sort of dip our toe into that this is sort of an attempt. Like I said, there's no particular number you're approving this is sort of an attempt to be like can we define benchmarks or numbers. And in this year's guidance we did put in several benchmarks that we wanted them to consider and they were around investments in something called or what was called the value based incentive fund, which is variable quality payments to providers. The second benchmark was around. So I'm going off the top of my head consistency with the board's approval of rates in the in the rate review process, which is kind of a standard condition that we've issued. And the third one is around targets for fixed perspective payments, which is a complicated issue we did we did not set a particular target, but that's been an ongoing discussion. And we required some reporting from the ACO around this in sort of an attempt to set a benchmark so the answer is that we have sort of dipped our toe in benchmark setting. And we will and we will talk about that as we go through the process. It's been challenging to define what those benchmarks should be. Hopefully that helps. Thank you. The only other question I had was relating to the risk cap that the board would approve. Is there any guidance or benchmarks at the board in evaluating whether or not the risk cap is high enough or too high? So good question. So the risk cap and the risk, the risk model again is a sort of a significant area of review in our budget. I think I would have to reserve answering that for now. If that's okay. But to say that it is a it's a it's a required it's a required part of our review. Do we have set sort of guidance on how we do that. I think, no, but we'll walk you through it. I think please do. Yeah. For a minute. So the risk cap issue has evolved over time significantly because of COVID. So prior to COVID-19, the board used a couple of different ways of analyzing whether the risk was too much or too little. So we required an actuarial certification, for example, where we had the ACO in this case one care hire somebody to perform that and then give us verification that the risk was appropriate for the model with COVID. Quite frankly, a lot of the risk models no longer made sense because of the pandemic and things, things so unpredictable. So that hasn't been something that's been highlighted the last couple of years because of COVID. So I think, Marissa, you could pull together some of that historical stuff from the early years and that might be helpful for folks. Thank you. Thanks for having that helpful. Yeah, but the COVID factor has been significant over the last couple of years. So sometimes I forget that that has that has sort of impacted our review in ways that we, you know, didn't necessarily set out when we first started doing this. At this time, I'd like to open up to public comment unless there are any other board questions or comments. And for public comment, if you could please use the raise your hand function on teams. I'll try and call on you in the order in which your hand is raised. I'm not sure I've ever done this before, so bear with me. I see Mr. Walter Carpenter has his hand raised. Please go ahead, Mr. Carpenter. Oh, and Walter is fine. No need for the mister. Informal is best. I wanted to say to Owen that he's my fourth Green Mountain Care Board chair. I've been with the board since its creation and helped to create it. I'm on the advisory committee. Anyway, make it short. Thanks to Tom and Dave for their questions. That's what I was thinking throughout this presentation. And thanks to Marissa for that overview. Sometimes, even though I've been involved with this for so long, it's still almost impossible to grasp because it is so complex. And that to me is one of its vast problems. As a patient and someone who almost died from our private insurance system, I keep wondering why we need this whole ACO thing in there because it adds another layer of complexity. I mistrust words like accountable and that sort of thing, like affordable, because they generally are words that they cover under. But in any case, as a patient, I also, when we talk about payers, we always say like the insurance companies, public and private are payers. They're not payers. They're middle people. We are the payers. And I'll leave it at that so others can shoot forth. Walter, thank you for your comment. It's really nice to meet you and thank you for your involvement and your participation throughout the years with the care board. You're my fourth director. I'm a survivor, Owen. Given the length of my term, I hope you have many, many more. Next, I see RH guest with a hand raised. RH, could you please identify yourself for the record and please go ahead. Hi, thank you, Chair Foster, Robert Hoffman. Some questions and comments. Obviously, the board's under no obligation to reply, but if you choose to. Dr. Merman is an employee of UVMHN and as well as UVMHN being the sole owner of the ACBO that is the single partner to the all payer model agreement. I would suggest this is a clear conflict of interest. Will Dr. Merman be recusing himself from budget deliberations related to this ACO? Again, no obligation to respond, but I put that there for your consideration. Next, since the 2019 budget round in fall of 2018 in response to public comment, this board has assured the public that its single all payer ACO partner would provide a summary of investments to date and its return on investment. But my understanding this was subsequently determined to be an activity that would be pushed out and finally performed at the end of the APM six year run of year zero through five. Will the board be working with its ACO partner to provide the fiscal summary of to date return on investment? Those investments total roughly $250 million in administrative support and programmatic support. The public would call upon this board to include to this end something conspicuously absent to date. A year over year reporting of utilization rates by hospital and payer for primary care, specialist care, ambulatory care, ER, ED and inpatient care from year zero through most recently available data. The APM agreement was premised upon an increase of the right care at the right place at the right time. As far there's very little other than the norc report available demonstrating that specialist rates were in decline as were annual well visits. No, no return on investment summary would be complete without this information. In 2011, former Green Mountain Care Board Chair Anya Wallach wrote publicly that the value based programming being discussed by all of you today, many years later, would allow Vermont to execute on what she called in her publication a quote audacious goal of bending the cost curve without limiting access to or quality of care. This board through the annual hospital budget process delivered on its role to cap annual hospital growth. This was most recently confirmed by Dr. Joseph Paris and his hospital budget presentation stating that the board has been singularly effective in bending the cost curve and sees no indication that the ACO takes credit for any of that. The ACO whom Ms. Wallach now serves as chair for was meant to deliver on her audacious goal. Instead, hospitals as we're all aware become extremely insolvent under the weight of annual caps on budget growth. Dr. Broomstead CEO of the largest system controlling two thirds of hospital spending has recently been on the record saying the consequence of this is unfortunately they will have to limit access to care and won't be able to staff up to optimize the value of care that their wholly owned ACO promised it would deliver on. He ignores that promise wholly when he makes these statements. Research now emerges that not only has Vermont become sicker, but that we're still hundreds of middle aged individuals have likely died due to delayed care. This board owes it to the public to reassure the public that ACO non performance as a counterparty to the all pair model agreement did not play a role in care rationing described by Dr. Broomstead. Finally, perhaps most importantly of all. Listen elements work with its single APM ACO partner. Was she merely remiss during the last ACO budget process or deliberately withholding information to satisfy rule 5.0 section 5.403 subsection six. The ACO has an obligation quote to report information on actions investigations or findings involving the ACO or its agents or employees. This information I will suggest is conspicuously absent from its current certification submissions. This board should have been aware since summer of 2020 that the ACO is in fact engaged in illegal action of a very serious nature. Alligations which get at the very heart of whether or not the ACO is honored its obligations to this board. The public has a right to be kept abreast of this action and for the Green Mountain Care Board to address to what extent this action compromises transparency and accountability for the ACO, which the most recent installed chair represented to the public he would be certain to deliver on an accountability and transparency. I would suggest that effective immediately the board should demand submissions be updated to include information satisfying statute 5.0 section 5.403 section subsection six. This is absent and the public demands to have access to what information is available regarding extant legal actions facing its singular ACO partner. Thank you. Mr. Hoffman, thank you for your suggestions in your comments and your participation. Do any board members have any other comments or questions before we move on to the next agenda item? Ms. Millman, thank you again very much for your time and putting that all together is extremely helpful for all of us. At this point, I'd like to move it on to the prescription drug technical advisory group discussion which will be led by Christina McLaughlin, our health policy advisor. I'll note that Ms. McLaughlin in my transition has taken on multiple hats to help ease my entry here and I thank her for that and I'll turn it to her. It's been a pleasure. There's been a lot of change and we're all working together, so happy to help. Christina McLaughlin, health policy advisor here at the board, and I also staffed the prescription drug technical advisory group as part of my work. So I'm just going to share my screen. The presentation is also posted on our website. If folks are interested, move screens around because I'm running the meeting and presenting. Okay, so moving to slide two, I just wanted to provide some background as to why we are here today. So first and foremost, the board has the authority to establish advisory groups as needed to carry out its duties. And as folks may know or remember, we have a primary care advisory group to which we've kept after it had sunset and legislation and kept that using this authority. And all the way back in May of 2020, the board had discussed in a public meeting forming a prescription drug technical advisory group after the House Health Care Committee proposed the idea during the 2020 legislative session. As we all know, it was a busy time 2020 during that period that we were very much into the COVID-19 pandemic. So the discussion at that May board meeting of 2020 just focused on whether we could take on this work with existing resources and staff. And the board felt strongly about supporting this or convening this prescription drug technical advisory group. Even though the board does not have the authority over the cost of prescription drugs, it is consistently a major cost driver and our health insurance rate review and hospital budget rate increases at the board. So moving to slide three, the board first convened the prescription drug technical advisory group way back when in December of 2020. Currently, the group consists of 12 active members, including representatives from the Attorney General's Office, VOS, UVM Health Network, Blue Cross Blue Shield of Vermont, MVP Health Care Pharmacists, the Health Care Advocates Office, other state agencies, plus a GMCB staffer, which is myself, and a designated board member, which has most recently been board member lunch. And then moving on to slide four. This is a high level overview of the group's work. As mentioned, the group convened at the end of 2020 and held public meetings in the winter and spring after that and then decided in the spring of 2021 through the spring of 2022, convened two subgroups, one specifically focused on affordability and the other on PBM regulation. And the groups met during that time. And then in the summer of 2022, those subgroups had adjourned by then, and then fast forward to now in the fall of 2022. The prescription drug technical advisory group reconvened in a public meeting to discuss the future of the group's work and ultimately decided they would like to continue working as a group and continue however it may be with that work. So we'll get into that, but I just want to go over some of the work that came out of that group. This is very high level. There was a lot of work, a lot of folks involved in a lot of meetings, so I had no way want to downplay how much work was involved. But on this slide, number five, I just wanted to outline the recent legislation that related to the groups and really the subgroup work. So while the PBM subgroup did not have a consensus on Act 131, also known as H353, an act relating to pharmacy benefit management as a group, the bill did address many of the issues related to that subgroup's work. So while that passed, it did not specifically come out of our subgroup, but a lot of folks separately had commented on that in the legislature. And then although the two bills that did not pass were more related to the subgroup's work, specifically the affordability subgroup, although they did not pass, they were drafted from that work and recommendations. You'll see the first bill here, S-243, did not make it through because the Vermont Department of Health testified they did not need a bill to pursue the feasibility analysis outlined in that bill and assured the legislature its intent to perform the research with or without the legislation. So that was kind of tacked on to the wall and did not need to be addressed. And then S-193 there, an act relating to strategies for reducing prescription drug costs for Vermonters. Again, that came out of the work and recommendations from the affordability subgroup. And there's a link there for folks who would like to read more, but essentially it directed certain state agencies to explore strategies for reducing prescription drug costs for Vermonters and directed AHS to coordinate with the Vermont Resource Center to provide info to the public regarding the availability of prescription drug financial assistance programs offered in Vermont. So again, while these did not make it through, a lot of work went into it and perhaps the work moving forward would be coming back to specifically S-193 and seeing if we can move that through the legislature next session. And I will not go into Act 131, it is quite a big bill. Folks are interested they can reach out, but it is linked there. So with that, all that information and background, I just want to move to the final slide, slide six, to ask the board members here for discussion really. Would the board like to continue the prescription drug advisory group, knowing that the group itself would like to continue the work? And if yes, which board member will like to staff the advisory group moving forward. There's going to be no votes today. This is mainly discussion and we probably will not actually decide on which board member would like to staff it as we all know and have talked about. We have two very new members and one also pretty new member. And so I think that today we just want to discuss this and I will bring it back to the group and we continue this discussion and wrap it up at a future meeting sometime soon. So with that, I will just stop sharing my screen. And first question I'll go back to is, would we like to continue supporting this group at the board? Thank you Christina. Are there any board members that have any reactions or comments or questions for Christina? I'll happily jump in. Oh, go ahead Robin. I'm going to jump in. Since I've been working with the group for the last couple of years, I think it's been a very dedicated group of volunteers who've been coming together to work on the issues as Christina said they largely don't. The types of discussion doesn't interact directly with our regulatory authority so it has really taken the form of a group that kind of comes up with some policy ideas where the affordability group kind of ran into trouble is that they needed cost estimates that really are not cost estimates that are within our purview or that that group could do so we needed to involve other state agencies and that was a bit of a challenge. So that's just to give really more color commentary around what the groups have been working on and why it's legislatively focused as opposed to Green Mountain Care Board over, you know, regulatory focused. I think it's it's been a good productive group and I would certainly support them continuing if since they all seem really interested in doing so I would however love to pass the baton to someone else to work with them. And Miss Holmes. You can call me Jessica Owen. I, I was just going to echo, you know, more or less what Robin just said I think that if the group is willing to continue working on these important topics I think that we should support them. You know, some legislation has come out of their work and I think some future legislation might and certainly, you know, it would be helpful probably at some points to hear from, you know, updates from that group, particularly maybe as it relates to prior to hospital budgets when we're hearing about the increasing pharmaceutical drug costs and just having their perspective on some of that would be helpful. And I think that's one of the two staffs that I think, you know, from my perspective I think we've got, you know, we're a weekend to two new board members I think we have to allocate figuring out how we're going to staff lots of different projects moving forward so I like the idea of of waiting to figure out how things all shake out to decide who's doing what. But if we're voting on whether to continue the group I absolutely support it. If any other board members have any comments or questions hearing none I'd like to open up to public comment. And again please use the raise your hand function seeing none will move on and Christina thank you very much for your presentation and for that background. Next agenda item is old business and new business is there any old business to come before the board hearing none is there any new business to come before the board. Motion to adjourn. So moved. Second. Second. All in favor please say aye. Aye. Any opposed. Motion carries the meeting is adjourned and I'll just note it's one of the most beautiful days in Vermont you will get this year so I hope that people get a chance to get outdoors and enjoy our gorgeous foliage and the beautiful day. Thank you everybody. Thank you.