 upon us to start and I'm going to call the meeting to order. Welcome to the Green Mountain Care Board meeting and I'm assuming Abigail you're going to try to create a list of everyone who is participating. Do you need to do any type of a role? Yes please whenever you're ready. So I would proceed if you want me to call it off or do you want to? Okay well why don't you take down the information. I see all five board members on the call, Executive Director Barrett, Patrick Rooney, Richard Watson, here, Orca Media Physically, Dean, Michelle Degrave, Lynn Combs, Mike Barber, Amarine Averjali. So I'm going to call off the last four. Kevin, it's hard to hear you. Hard to hear me? Yeah, I think you are leaning away from the computer. Okay, I'm going to call off the last four digits of a phone number if you could just identify yourself for the record. 9-0-0-6. Kevin, it's 9-8-0-6. It's Mike Fisher. Oh, thank you Mike. I can't hear you Kevin. I was just going to say that I recognize the next number being our office. So the one at that is 50-50-50-50-50-50-50-50. Thank you. 0193. I have statistic from the State Auditor's Office. 263. The Tower of Whiteism in Vermont Public Radio. 0043. Thank you. 6376. More quads for a minute. Private edition. 2505. Jennifer Collins, E.V. and then at the center. 4191. Living Green Vermont Association of Hospitals and Health Services. And 5001. Julia Schall at the Health Graduate. Did I miss anyone? Yeah, this is what they've become a whole channel. And anyone else? Okay, the first slide on the agenda is the Executive Director's Report, Susan Merritt. Thank you, Mr. Chair. And thank you, Board and folks on the line. I want to start today by first making an agenda change. So on today's agenda, item number 2, FY 2021 Hospital Budget Guidance, potential vote. We are taking that item off of the agenda. And then the second thing I wanted to reach the board on is H742. This is the COVID-19 emergency bill that is over in the Legislature. It passed out of the Senate yesterday. And it is, I know it was discussed in House Appropriations today, but I don't know when it will be taken up by the full House and there might be folks on the line who may know that so we can call a friend on that or they can text me. But I know it's being discussed as I said this morning in House Appropriations then this afternoon. But I'm not sure if it's the full House. So it has not passed the House yet, but we expect it to move very quickly. So I had sent an email to the board earlier today and these are public documents for folks on the line. They're actually accessible through the Vermont Legislature website. And what I wanted to do to start is to review the COVID-19 bill as H742 as I said. And the purpose of this discussion would be for the board to understand what's in the bill generally and then specifically around our duties and regulatory duties at the board. And then have a discussion about how we go forward in this new world of COVID-19 in terms of triaging what we need to do in terms of contingency planning and making sure that our regulated entities can do the job they need to do to get out and help patients right now. So does that sound good and clear to everyone? And do the board members have that email that I sent earlier today? There are two items on it with two links. Yes. Okay. So I'm going to start with the first item and I just want to thank Jen Carby from Ledge Council over at the Legislature. She summarized the bill and then she also has the second document that I sent to you is a summary by each section. We won't go through that one, but I'm going to just go ahead and read this because I think it's a really good summary and it will give you board a general idea of what's in the bill. So the amendment to H742 recommended by the Senate Committee on Health and Welfare would enact a number of provisions designed to provide administrative and provider flexibility in responding to the COVID-19 pandemic. It would allow the Agency of Human Services and the Green Mountain Care Board to waive or modify certain regulatory processes and requirements as appropriate to prioritize direct patient care, allow flexible staffing, and preserve provider sustainability. It would direct the Department of Financial Regulation to consider adopting emergency rules to expand health insurance coverage for helping insurance coverage as a typo and reduce out-of-pocket costs related to COVID-19 diagnosis, treatment, and prevention. Modifiers suspend deductible requirements for prescription drugs and expand access to and reimbursement for health care services delivered remotely. The amendment would permit patients to refill their maintenance medications early, would allow pharmacists to extend prescriptions for maintenance medications, and would allow pharmacists to substitute a substantially equivalent prescription drug if a prescribed medication is unavailable. It would allow recently retired Vermont health care professionals and health care professionals licensed to other states to deliver health care services to Vermonters using telehealth as part of the staff of the licensed facility or under a temporary license. And would allow the Office of Professional Regulation and the Board of Medical Practice flexibility to waive certain requirements during the state emergency. The amendment would also expand health insurance coverage for telehealth, including requiring coverage for a teledentistry and for health care services delivered using stored forward means. And the amendment would allow the Commissioner for Children and Families to use additional funds from its fiscal year 2020 appropriation for the childcare financial assistance program to help childcare programs at risk of closing due to financial hardship. So that's a general overview of everything that's in the bill. I want to direct your attention to a second email that I sent out, which is the language specific to the Green Mountain Care Board. And I'll move over to that, but first I want to see if there are any questions at this point. And I may have been getting some updates on where the bill is. I heard my phone dinging, so let me check. Any questions? Yep, Mike and Sher did. He my picture. Thank you. He understands that the COVID bill is going to be moved through the full house at this time. So I'm assuming today. That's the latest and greatest. And before I go over to the other language, I just want a shout out to Jen Carby and Nolan Langwell and other staff over at the State House and the legislators for working so hard on pulling this bill together in such short notice. And I also want to provide a shout out internally to board member lunch, who is very instrumental in helping us craft language that will help us do our work and ultimately help our regulated entities get through this crisis. So I'll direct you to the language. That's the second email I sent today. So I want to go directly to I have to find it myself. So bear with me. I have it up Susan if that would be helpful. That would be awesome. Okay, so for members of the public or those on the phone, the green mountain care board language if you go to the House calendar for today on the legislators website. We are section five of each 742, which is on page 1824 of today's House calendar. Yeah. Well, Robin is doing that as I will read through the language, but really the goal as I said at this discussion is to have just to hear from you board on where we need to go next. And if there are certain requests from staff, we have several members of the staff on the line listening in to make sure that we can research the information for all of you to make decisions that can help us get through this crisis. Great. So do you want to do you want to read through it and then we can we can talk about it together or what do you think is the best way to go forward to see this. Okay. Sorry. When I when I share my screen, I can only see my screen. What what the section does. Okay. Yeah. Yeah. And that's the start section, not the other side. Okay. Yeah. That sounds great. Thank you. Go ahead. So what this section of the bill would do is provide us the green home care board with the ability to wave or permit a variance from administrative rules or other guidance during the state of emergency and for a period of six months. Following this combination of the state of emergency. The purpose of doing that would be limited to maximizing direct patient care, safeguarding the stability of healthcare providers and allowing for orderly regulatory processes that are responsive to the needs related to the pandemic. And it would cover all of our regulatory processes. So if the language is obviously not intended for us to take a normal process and have it the way it was totally unrelated to the crisis, but it does give us flexibility related as long as there's a connection and a need related to the pandemic. And I also have just flagged. We want to make sure we update all of you on open meeting law requirements currently. Like today. Needed in our office because we need to have a location for the public to come to a public space to hear the meeting. There is language, I believe in the Godox committee coming out of the Godox committee and in another section of this. I believe it's a part of the COVID response where they are going to wave that requirement. So we'll be watching that to make sure that that's included. Initially, we did have that language in here, but Jen Carby recommended we wait to see if it's included somewhere else. So we're that we're all covered as a public board. And that language is indeed past and different levels. Okay, great. And Susan just as we've had a couple of these meetings so far. And has anyone come into the office. Not that I am aware Kevin was there last week and Janine is anyone there today. Nobody is here. Okay. No, it was just good to know, right? Yeah. Even though we kind of did a task to pass. Yeah. Board meetings. And I think everyone is, you know, understanding. Not to be near each other. It looks like everyone's awesome. Thank you, Maureen. Do you want to add anything? And was somebody else going to say something? I really don't need to add anything other than the reason why we dropped the potential vote on guidance is pretty self-evident. And it would be inappropriate to even spend time talking about that, knowing that everything is going to have to change. So I think that this is something that will sail through the house and will be signed by the governor very quickly. More importantly, it's been very hard getting details out of what was agreed to in Washington and a lot of hospitals and others are on the edge of their seat, waiting to see what type of financial relief they will have as they see most of their revenue dry up immediately. So that's something that we're going to have to be keeping an ever vigil on the eye out for anything that comes out of there. We did see in the last bill some dollars that went out to FQHCs and that's reassuring, but that's nowhere near enough to help them through the financial morass that they're in right now either. So we all have to just stay tuned and we all have to slap our hands when I do something like that and scratch my face. I saw you doing it earlier too, Susan, so we all have to be better. And with that, Susan, did you have more for your report? Whether we have this discussion now or we continue it at a further board meeting, that the board members are starting to think about this flexibility which we likely will receive and how we triage our work. I don't expect any decisions today. We can talk a little more about it now or we can move on and bring it up at another meeting. But I just think that it's very important that the board and the public understand this bill and the flexibility that we have. I also, to your point, Kevin, understanding, I think we'd be dueling barking dogs, Kevin, understanding what's available at the federal level will be essential. And I will just say from, I think this is well known within the board and our staff, our number one priority right now is making sure that the hospitals are financially stable. And we are working with the administration and with VOS to provide information to them to make sure that we can really understand how we can help these hospitals. And I think that federal legislation that you mentioned, Kevin, is going to be vital, obviously, to getting them and all of our healthcare providers through. And I'll just say one other thing. I wanted to say it up front. We just want to thank all the healthcare providers out there. I know there are folks on the line that represent healthcare providers, but we know every day they're going in risking their own safety to try to get us through this crisis. So thank them and all others who are out there, grocery workers and other essential folks who are doing what they need to do to service all of us. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, March 18th. Is there a motion? So, Maureen, I think I heard you move it. Is there a second? Second. Okay. It's been moved and seconded to approve the minutes of Wednesday, March 18th without any additions, deletions or corrections. Any discussion? Seeing none, all those in favor, signify by saying aye. We do have to vote roll call. All right. Go ahead, Mike. Member Holmes. Yes. Member Pelham. Yes. Member Vomich. Yes. Member Youssefer. Yes. Mr. Chair. Yes. Thanks for keeping me on my toes, Mike. So with that, I do want to make a commitment to the public that the board, despite being given these changes in statute, are going to do their utmost to make sure that there is complete transparency and openness to the public. Hopefully, everyone in the public is learning how to deal in this brand new world. I realize that not everybody has the ability to do Skype, and that is problematic. And the reason why these types of things are normally not allowed, but given the unprecedented circumstances that we're in, it is a time to make sure that we all keep our social distance and protect the spread of this and try to flatten the curve, because that's what's going to allow hospitals and providers to be prepared for us if we do in fact need their care. So just very grateful to everybody's patience as we go through this, and very grateful that so far we have been quite successful in conducting. This is our second board meeting by Skype, but we did a COIN hearing this morning that I thought went over very, very well. And thank goodness for technology. And even a decade ago, we wouldn't have been able to probably function the way we're functioning now, and we're just very grateful for that. The next item on the agenda is the discussion of the emergency COIN guidance and procedure. So Mike, I'm going to turn it over to you. Thanks, Kevin. Everyone should have received that, and it should be posted on our website under the meeting materials for today. Does everyone have that, or do I need to share my screen? I have it and read it, but I don't have it here on my screen, but I don't think I need it. Oh, for members of the public, could you share it, Mike? Sure. Great. Okay. How do you do it? Oh, great. Thanks, Abigail. And Mike, it is posted on our website as well. I just checked. Yeah, but it was on and it's off again, so whoever's controlling the screen, there we go. Thank you. So this is a document that I drafted last, finalized it last week early this week. If it proved it would establish emergency review procedures applicable to certificate of need applications for projects that will support or enhance the state's ability to manage the current public health emergency. You know, I don't have a presentation here really, but be happy to kick off the discussion. You know, I think given that we're under a declared state of emergency, given the, you know, continuing the steepening of the growth curve for new COVID-19 cases, I think it's pretty evident that both public and private health care facilities throughout the state are going to be thinking about what they can do in the immediate future to manage and expect the surge of infectious patients. And while health care facilities are considering how best to respond to this crisis, my sense is that there's a desire on the part of the board to not have CEO interview be impediment to swift action that will meet pretty evolving needs. So as Susan mentioned, the bill, it looks like it's going to pass probably this week. This enacting its current form is going to allow the board to waive or prevent variances from state laws relating to among other things, CEO interview. But this bulletin is really looking at what can we do within our existing authority to expedite projects or the review of projects that will meet this kind of evident need. So that's the context. It's building off of existing emergency review procedures and authorities in our current statute of rules. And I think I'd like to have the board discuss whether this is the right information, whether this is the right process, the right timelines. But there's also a question about assuming the board gives this authority to waive provisions of a statute of rule. So do you even want to review CEO and applications for these types of things or would you rather just get some basic information from and not review the least redundancy during the emergency. It had to go through point by point, but that's basically waived the need for review and issue and specificity of need for a period of time. So until the public health emergency is lifted and then the continuation of those projects, if they were going to continue would need to come through CON, kind of that last paragraph would still be in place. So I don't think you'd want emergency projects that are not reviewed to continue indefinitely. But I want some sort of information up front about generally speaking what are you going to do and what's the cost and go ahead and do it. And we just want to know and then if you're going to continue this after the emergency needs to come through CON, that's what I was envisioning potentially. If I could jump in, Robin. So my preference would be to approve this as a stopgap measure because we, if we want to waive or modify anything from here for CON, like as Mike said, either waive, see another or deem certain types of projects approved prior even to notice or something like that. We're still going to need to issue some sort of a bulletin or other written guidance, which needs to be approved by us in order to waive. So, because it would still need after the bill passes, we would still need to do some sort of process to have a legal kind of parameters set out. And I think this gives us an immediate process just in case anything comes up in the next few days to a week, depending on how long, you know, when the bill gets signed and how long it takes to develop some written documentation around that other, you know, any additional process in the next few days. So that's kind of how I was thinking this might work. Just because even when we have the authority to waive it to actually waive it, we need to vote to waive it and we need to know what we were waiving. So that does require further process. Other thoughts. I just wanted to let you know I got a couple of texts from folks that they're trying to figure out whether there's a quorum on the floor, the House floor. So that's fair. I think they're just trying to get the numbers, just so you know. Didn't they divide them out so that they're not all on the floor? I'll keep you updated. That doesn't help it, Susan, though, because what the real question is, has the administration statement that they would sign off on it immediately? I believe that we've heard repeatedly that there have been conversations between the two legislative bodies and that this would be okay with what the Senate passed, but I just want to make sure that there's not any hiccups. I think that Robin's right that this really should probably be dealt with today as a stopgap measure and obviously things are changing on a daily basis in front of us. So other members of the board, thoughts on this document? I support voting on this as a stopgap measure. Yeah, I do as well. I mean, it's pretty skinny. All it requires is a letter and we have a 24 hour oral turnaround time. So, you know, I think it's fine as a stopgap measure. Would someone like, well, before we do that, going to open it up to public comment. Any member of the public who wishes to comment? I'm from the Vermont Association of Hospitals and Health Systems. We support this immediate procedure for a CON. We have hospitals who will need approval immediately. And we've looked at this policy and we support it. Thank you, Devin. And please assure your members that we will not get in their way as they try to provide the best care to Vermont. Other members? Yeah, this is Howard at VPR. I would just request that somebody read out the motion before it's voted on if possible. Certainly. Is there other public comment? Kevin, this is Mike Fischer. I apologize. I just came back on. And so I missed. Is this something I missed? But the topic I may want to take a high. But I had asked you a question, but you weren't on the line. Basically, I was wondering, we're hearing that the House and Senate had agreed behind doors that the House would pass this language that passed the Senate. But I'm curious if there's been any statement from the administration on whether or not they will sign it immediately. I don't have any inside information on that. Okay, so the next item, Mike, is we are discussing and I'm really glad that you're back on the line because we want to make sure that you have a chance to comment on this. And that is this bulletin that is would provide us with a stopgap measure as we wait for the legislation to go through on emergency CON applications for COVID-19 projects. So hopefully we wanted to make sure you had a chance to weigh in on this as we're taking public comment before a vote to approve this bulletin 002. So Kevin, I think I'll just comment on a very high level saying that I appreciate and support the board's actions to be able to move with appropriate haste. And the HCA will absolutely follow the board's lead on sort of level of review on all regulatory tasks in front of us. And we are interested in continuing to stay up to date on the actions but are in support of the efforts that you are undertaking to be able to move fast. Thank you, Mike, and thank you for everything that you're doing. Is there other members of the public who we wish to comment on certificate of need bulletin 002? Seeing none, Robin, we've had a request for your motion to be read by VPR if you could read your motion slowly so that he gets it. Absolutely. I move that we approve certificate of need bulletin 002, which provides a procedure and guidance for emergency certificates of need applications to respond to the COVID-19 pandemic. I'll second it. Okay, thank you, Jess. Is there any further discussion from members of the board? Seeing none, Council Barber, could you please call the roll? Yes, member Holmes. Yes. Member Yusfer. Yes. Member Pelham. Yes. Member Lunge. Yes. Mr. Chair. Yes. Let the record show the certificate of need bulletin 002 passed unanimously from the board today. Mike, do you have other items for the board? Not that I can think of. Okay, at this point in time, is there any old business to come before the board? Can I ask a question, Chairman? Yes. State your name for the record since I don't know who it is. Yeah. So this is Howard at VPR. At the last meeting, one of the board members talked about the statutory requirements of the board to collect some kind of budget information. And since you put the budget discussion off earlier in this meeting, I wonder if you could talk a little bit about, is that just until you learn more about what is needed? I wonder if you could talk a little bit more about why you didn't discuss the budgets and what we might expect concerning next year's budget. Thanks. Sure. So basically the legislation 742 that was discussed would give us some relief from existing statute as far as the process. And what is necessary is that hospitals put their total focus on gearing up and ramping up for the COVID-19 pandemic that's in front of us. And it would be inappropriate for the board to be taking them away from that core mission. So if you remember Howard at the previous meeting, we decided to suspend the non-financial reporting requirements. What we can't say at this time is what this year's hospital budget process will look like because we don't know when we will peak in Vermont and when hospitals will have the resources to properly understand what the effects of the pandemic are on their budget for next year. And a whole bunch of myriad of other associated questions that would come into the budget process. So it seemed illogical to proceed with guidance that really was drafted in a pre COVID-19 world. And we know it's going to have to change. So until we start to have a better handle on when the numbers will start to subside, it's very difficult to put in place a budget process for 2021. And so this by not taking a vote today, we're basically saying that taking a vote today would just be a waste of people's time and create uncertainty for hospitals. In fact, that they may believe that they have to adhere to the existing timeline that's in that guidance when we know that in all likelihood that timeline needs to be scrapped and rethought. So at this point in time, what we have asked is the staff at the Green Mountain Care Board to come up with different scenarios on what the budget process would look like for 2021, which is the fiscal year beginning, getting 10-1-2020 for hospitals in Vermont, and there will be a number of different scenarios that will be thought through. And as we have more information on what the full impact of this pandemic will be on the hospitals and what type of relief will be available for them and what type of relief will not be available for them. Then we can come out with a set of guidance that's more realistic and more in tune. And the one thing that we keep hearing from hospitals is for a request for people that really mean well but are really taking up the resources dealing with questions that takes them away from their focus on the immediate problem that's at hand, which is fighting this pandemic. So does that answer your question, Howard? I appreciate all that, but I'm trying to understand, again, under statute. I mean, do you need to get a budget in place by say July 1, even if it's just two numbers? These are projected expenses and revenue or does statute allow you to put the whole thing off? Just a little clarification on that, on what exactly does need to happen before next fiscal year starts? So under existing statute, there are very firm dates. It's our belief that 742 will pass, and that will give us much more latitude. And so until we know for sure if that's going to pass, it just doesn't make sense to be voting on something today here in towards the end of March that will probably change in just a few days. And Howard, this is Robin, just a clarification. The dates and statute are a decision by September 15th with a written order by October 1st, which is the hospital's fiscal year. So there's still some time, but typically our process would start in May with the non-financial reporting and in July with the financial reporting with hearings in August. Right. And so those numbers, so those dates you gave me, even if they're very, very, very reduced budgets, you have to accept something from the hospitals by those dates, even if it's again just two numbers. Well, as Kevin said, if H742 passes, it would give us the authority to waive those dates. So then we could shift the dates to a different time period if that makes sense, or we could, you know, that's the scenarios that the staff has to think through is what would make sense to do. Okay, great. I appreciate it. Thank you. Are there other members of the public with any comments or questions? Okay, is there any new business? Go ahead. This is Mort Wasserman. Mr. Mullen, are you looking for general comments about the procedure or just about that particular question? At this point, Mort, I would take any public comment that you wish to offer. Okay, well, I'd just say you folks are doing a great job as are folks in the legislature. There's a lot of mention about hospitals. I hear less about primary care, especially independent primary care practitioners who are under tremendous financial stress right now. I don't know if, from a standpoint of what the board does, if it's in a position to help those folks, certainly actually Blue Cross Blue Shield is changing rules and Medicaid is changing rules. And some of the other insurers have been less helpful. There's telehealth now being paid for. Telephone triage is being paid for. There's all kinds of exciting stuff going on. I just would like the board to keep the primary care community, including all the people who work in those primary care practices and clinics, some of whom are completely independent of hospitals, just to keep them in mind. Absolutely, Mort. And the reason why the discussion was focused on hospitals today is because we were talking about elimination of an item from the agenda that dealt with setting guidance for hospital budget processes. As you know, we don't set any budget for any primary care office in the state unless they're owned by a hospital. And we've been dealing with a number of public comments that are coming through our normal public comment portal on the board's website dealing with exactly the issue that you've highlighted, not only from members of the public, but also from providers themselves. And it is more than just Blue Cross Blue Shield that has made things more lenient as far as their coding for telemedicine and telehealth. And those are the type of things that are being addressed throughout state government and especially want to give some praise to the Department of Financial Regulation, who's been reaching out to example workers comp carriers to try to make sure, again, insurers have had to deal with the new reality just like everybody else. So as they have struggled to get everybody working remotely. In some cases there has been a little bit of a delay in getting reimbursements out to providers and DFR has done yeoman work and making sure that they understand that that can continue and these payments have to go out and done in a timely manner. So, there, I don't think there's any segment of society that's going to be left untouched from what we're going through with COVID-19. And what's really sad is that frontline providers, as you mentioned, are seeing a huge drop in revenue as anyone other than someone that believes that I shouldn't say anyone but a great percentage of anyone who whose medical questions are unrelated to COVID-19 is cancelling their appointments and probably rightfully so as we try to socially distance. And so, we understand that this is much more than just hospitals. And unfortunately, as far as relief that the Green Mountain Care Board can give, it's very little to those providers since we have no regulatory authority over them. I'm sorry. I wonder if more could state his name please for the record. My given, sorry, who was that who made that request? That was BPR. My real name is Richard Wasserman. I'm an emeritus professor of pediatrics at the Medical College and a former employee of Health Network. My nickname is Mort, and that's how I often am referred to. Thank you. And I do appreciate, Kevin, what you had to say, but just keep everybody in mind because there may be points of contact where you can touch on this. Thanks. Thank you, Mort. Other members of the public hearing none is Ernie Newp. Yes. Mike Fisher here. I don't know exactly what kind of report I can give about actions at the state in the Vermont House during this hour, but they've they've run into their typical bumps. Well, these are untypical times they run run into bumps and they're trying to figure out how to move. I think is what I can tell you. Okay. Thank you, Mike. Okay, is Ernie New Business to come before the board? Is there a motion to adjourn? So moved. Second. Thank you. Mike Barber, if you could call the roll. Member Pelham. Unmute yourself, Tom. We'll go. Member Youssefer. Yes. Member Holmes. Yes. Member Lunge. Yes. Member Pelham, looks like you're off mute. Member, let's just. Fine. Yes. Yes, there you go. Yes. Thank you. Thank you, everyone. Thank you. Good social distancing. Lots of lots of hand washing and be safe. Bye. You too. Bye. Bye. Bye.